PCOS – Obesity The Present Day MenacePCOS – Obesity The Present Day Menace

EpidemiologyEpidemiology

There is an epidemic of Childhood obesity in the world

From 1963-91 -Doubling of the incidence of children with BMI of more than 95th centile

Overall scales are going up. Children with the same BMI centiles are now heavier

Genetic shift unlikely. Profound environmental effect

There is an epidemic of Childhood obesity in the world

From 1963-91 -Doubling of the incidence of children with BMI of more than 95th centile

Overall scales are going up. Children with the same BMI centiles are now heavier

Genetic shift unlikely. Profound environmental effect

DefinitionDefinition

Weight centile alone is useless as it does not consider height

Height for weight is better but does not differentiate between increased muscle or fat

BMI reflects the degree of fat content best

BMI = Weight in Kgs / Height in m 2

Weight centile alone is useless as it does not consider height

Height for weight is better but does not differentiate between increased muscle or fat

BMI reflects the degree of fat content best

BMI = Weight in Kgs / Height in m 2

Obesity is not overweight.

Obesity is excess body fat

In adults

BMI > 25 is overweight

BMI > 30 is obese

In children

BMI > 85 centile for the age is overweight

BMI > 95 centile is obese

Obesity is not overweight.

Obesity is excess body fat

In adults

BMI > 25 is overweight

BMI > 30 is obese

In children

BMI > 85 centile for the age is overweight

BMI > 95 centile is obese

DefinitionDefinition

Lab methods Underwater weighing

DEXA

Air displacement plethysmography

Skin fold thickness

Bioelectric impedence

Not useful in clinical practice

Country specific BMI charts Should be prepared and then 85 and 95

centile limits should be used

Lab methods Underwater weighing

DEXA

Air displacement plethysmography

Skin fold thickness

Bioelectric impedence

Not useful in clinical practice

Country specific BMI charts Should be prepared and then 85 and 95

centile limits should be used

DefinitionDefinition

BMI Centile ChartsBMI Centile Charts

Definition and EpidemiologyDefinition and Epidemiology

Increased prevalence is now seen in countries where the major problem used to be malnutrition

Now obesity is caused by poor food choice and decreased activity

Indeed we are seeing this more and more commonly in urban areas in India !

Increased prevalence is now seen in countries where the major problem used to be malnutrition

Now obesity is caused by poor food choice and decreased activity

Indeed we are seeing this more and more commonly in urban areas in India !

Tracking of ObesityTracking of Obesity Three crucial periods determine the

chance of obesity during adulthood Gestational period – Infant’s of Diabetic

Mother’s have higher chance of becoming obese at 6-10 years and persist into adulthood

Adiposity rebound - Early adiposity rebound was related to parental obesity and persistence of obesity in adulthood

Adolescent period

Three crucial periods determine the chance of obesity during adulthood

Gestational period – Infant’s of Diabetic Mother’s have higher chance of becoming obese at 6-10 years and persist into adulthood

Adiposity rebound - Early adiposity rebound was related to parental obesity and persistence of obesity in adulthood

Adolescent period

Childhood onset obesity

Has worse prognosis than adult onset obesity

Associated with

High BP

Increased risk of cardiovascular morbidity

Insulin resistance and dyslipidemia

Lipid profile reveals

High triglyceride levels

Low HDL levels

Visceral fat is most metabolically active

Childhood onset obesity

Has worse prognosis than adult onset obesity

Associated with

High BP

Increased risk of cardiovascular morbidity

Insulin resistance and dyslipidemia

Lipid profile reveals

High triglyceride levels

Low HDL levels

Visceral fat is most metabolically active

Tracking of ObesityTracking of Obesity

Sequel of ObesitySequel of Obesity

Obese children have . . .

2.5 times risk of having high BP

8.5 times risk of being hypertensive adults

Increased left ventricular mass

Higher chance of being insulin resistant

May develop Type 2 diabetes as early as 6 years

Obese children have . . .

2.5 times risk of having high BP

8.5 times risk of being hypertensive adults

Increased left ventricular mass

Higher chance of being insulin resistant

May develop Type 2 diabetes as early as 6 years

Functional ovarian hyperandrogenism

Restrictive airway disease

Obstructive airway disease

Snoring, Sleep apnea, Right ventricular hypertrophy

Heart failure

High incidence of asthma

Functional ovarian hyperandrogenism

Restrictive airway disease

Obstructive airway disease

Snoring, Sleep apnea, Right ventricular hypertrophy

Heart failure

High incidence of asthma

Sequel of ObesitySequel of Obesity

Gynaecological Consequenses Of Obesity

Gynaecological Consequenses Of Obesity

PCOD- Hair-An syndrome PCOD- Hair-An syndrome

AnovulationAnovulation

AmenorrhoeaAmenorrhoea

D.U.B.D.U.B.

Fibroid UterusFibroid Uterus

Fungal InfectionsFungal Infections

InfertilityInfertility

PCOD- Hair-An syndrome PCOD- Hair-An syndrome

AnovulationAnovulation

AmenorrhoeaAmenorrhoea

D.U.B.D.U.B.

Fibroid UterusFibroid Uterus

Fungal InfectionsFungal Infections

InfertilityInfertility

Evaluation of Obese YouthEvaluation of Obese Youth

Family history

SMR, acanthosis and striae, goitre

Blood pressure

Cholesterol, Blood sugar and HbA1c

Liver function tests

Family history

SMR, acanthosis and striae, goitre

Blood pressure

Cholesterol, Blood sugar and HbA1c

Liver function tests

Evaluation of Obese Youth - Endocrine tests

Evaluation of Obese Youth - Endocrine tests

T3, T4, TSH

Cortisol

Dexamethasone suppression test - Low dose

1.5 mg/m2 of Dexamethasone given at 10 p.m.

If short metacarpal, cataract etc. then Ca, Phosphorus, PTH

Bone age

T3, T4, TSH

Cortisol

Dexamethasone suppression test - Low dose

1.5 mg/m2 of Dexamethasone given at 10 p.m.

If short metacarpal, cataract etc. then Ca, Phosphorus, PTH

Bone age

TherapyTherapy

Dietary restriction

Increase physical activity and exercise

Reduce sedentary behavior

Modify behavior

Change of life style for the whole family

Reduce TV viewing and computer games

Dietary restriction

Increase physical activity and exercise

Reduce sedentary behavior

Modify behavior

Change of life style for the whole family

Reduce TV viewing and computer games

Intensive Therapies - IndicationsIntensive Therapies - Indications

BMI > 95 Centile and one medical complication ( co morbidity)

Co morbid conditions include

Dyslipidemia

Disorders of glucose metabolism

Hepatic enzyme derangement

Hypertension ( Systolic or Diastolic)

Pseudotumour

Sleep apnea

Orthopedic problems

BMI > 95 Centile and one medical complication ( co morbidity)

Co morbid conditions include

Dyslipidemia

Disorders of glucose metabolism

Hepatic enzyme derangement

Hypertension ( Systolic or Diastolic)

Pseudotumour

Sleep apnea

Orthopedic problems

Intensive Diet Intensive Diet Calorie intake 2400 to 2940 KJ per day

Aim is to induce a weight loss of 0.5 kg per week

Protein sparing modified fast (PSMF)

2520-3360 KJ/day

1.5 -2.5 g/kg of IBW / day of high quality protein

Carbohydrate 20-40 gms/day

Does not lead to cardiac arrhythmia as was observed earlier

Calorie intake 2400 to 2940 KJ per day

Aim is to induce a weight loss of 0.5 kg per week

Protein sparing modified fast (PSMF)

2520-3360 KJ/day

1.5 -2.5 g/kg of IBW / day of high quality protein

Carbohydrate 20-40 gms/day

Does not lead to cardiac arrhythmia as was observed earlier

Not prescribed for more than 12 weeks

Risks:

Cholelithiasis, hyperuricemia, hypoproteinemia, orhthostatic hypotension, halitosis, diarrhea

PSMF produce rapid weight loss in the short term

In the long term does not seem to be superior to restrictive diet programmes

Not prescribed for more than 12 weeks

Risks:

Cholelithiasis, hyperuricemia, hypoproteinemia, orhthostatic hypotension, halitosis, diarrhea

PSMF produce rapid weight loss in the short term

In the long term does not seem to be superior to restrictive diet programmes

Intensive Diet Intensive Diet

PharmacotherapyPharmacotherapy

Limited data available in children and adolescents

Medications reducing energy intake

Fenfuramine

Phenteramine

Diethylpropion

Sibutramine

Limited data available in children and adolescents

Medications reducing energy intake

Fenfuramine

Phenteramine

Diethylpropion

Sibutramine

LeptinLeptin A hormone secreted by adipocytes in relation

to lipid content

It is a peripheral signal to the hypothalamus of inadequate food intake but NOT of Satiety

Leptin deficiency causing obesity is VERY VERY RARE

Leptin therapy to Leptin sufficient adults is not very impressive in terms of weight loss

No studies in children are available

A hormone secreted by adipocytes in relation to lipid content

It is a peripheral signal to the hypothalamus of inadequate food intake but NOT of Satiety

Leptin deficiency causing obesity is VERY VERY RARE

Leptin therapy to Leptin sufficient adults is not very impressive in terms of weight loss

No studies in children are available

MetforminMetformin Stops hepatic glucose production

Reduces insulin resistance

Several studies have shown impressive weight reduction in dosages varying from 500 mg to 2 gm per day in children of 8 - 14 years

Side effects

Nausea, flatulence, bloating

Diarrhea, Vitamin B12 deficiency

Lactic Acidosis - Rare

Stops hepatic glucose production

Reduces insulin resistance

Several studies have shown impressive weight reduction in dosages varying from 500 mg to 2 gm per day in children of 8 - 14 years

Side effects

Nausea, flatulence, bloating

Diarrhea, Vitamin B12 deficiency

Lactic Acidosis - Rare

Contraindications

Renal failure, creatinine > 1.4 mg/dl

CCF, cardiac and pulmonary insufficiency

Liver disease

Contraindications

Renal failure, creatinine > 1.4 mg/dl

CCF, cardiac and pulmonary insufficiency

Liver disease

MetforminMetformin

No medications are approved for

use in children in routine clinical

practice except Leptin in Leptin

deficiency children

No medications are approved for

use in children in routine clinical

practice except Leptin in Leptin

deficiency children

Bariatric SurgeryBariatric Surgery

Limited experience in children and adolescents

Balloons placed in the stomach are shown to be ineffective

Jejunoileal bypass is not done now due to high complication rate

Roux-en-Y gastric bypass (RYGB) is performed now

Limited experience in children and adolescents

Balloons placed in the stomach are shown to be ineffective

Jejunoileal bypass is not done now due to high complication rate

Roux-en-Y gastric bypass (RYGB) is performed now

RYGBRYGB

Post op complications are many (8.5%)

Post op mortality is 1.5%

In a recent study by Strauss - Adolescents were treated with bariatric surgery

90% lost > 30 kgs and co morbid conditions improved

Complications include iron deficiency, folate deficiency, small bowel obstruction

Post op complications are many (8.5%)

Post op mortality is 1.5%

In a recent study by Strauss - Adolescents were treated with bariatric surgery

90% lost > 30 kgs and co morbid conditions improved

Complications include iron deficiency, folate deficiency, small bowel obstruction

This is the only treatment with evidence that it can induce sustained significant weight reduction in adolescents who have severe obesity

Can only be recommended to those with highest morbidity

As Strauss concluded: “Gastric bypass remains a last resort option for severely obese adolescents”

This is the only treatment with evidence that it can induce sustained significant weight reduction in adolescents who have severe obesity

Can only be recommended to those with highest morbidity

As Strauss concluded: “Gastric bypass remains a last resort option for severely obese adolescents”

Bariatric SurgeryBariatric Surgery

Education and awareness programs for parents are required to prevent adolescent obesity

At risk individuals can be identified with BMI curve

The mainstay of treatment is diet, exercise and behaviour modification

At present no medicine is routinely used in clinical practice to prevent or treat obesity

Education and awareness programs for parents are required to prevent adolescent obesity

At risk individuals can be identified with BMI curve

The mainstay of treatment is diet, exercise and behaviour modification

At present no medicine is routinely used in clinical practice to prevent or treat obesity

Take Home MessageTake Home Message

Concept – Dr. Duru ShahConcept – Dr. Duru Shah

Contributors

Dr. Suvarna Khadilkar

Dr. Vaman Khadilkar

Contributors

Dr. Suvarna Khadilkar

Dr. Vaman Khadilkar

Editors

Dr. Sangeeta Agrawal

Dr. Reena Wani

Editors

Dr. Sangeeta Agrawal

Dr. Reena Wani

We acknowledge the efforts of our :We acknowledge the efforts of our :

Coordinators :

Dr. Sangeeta Agrawal - Central

Dr. Narendra Malhotra - North

Dr. Hema Divakar - South

Dr. P. C. Mahapatra - East

Dr. Uday Thanawala - West

In bringing the FOGSI YOUTH EXPRESS to your city.

Coordinators :

Dr. Sangeeta Agrawal - Central

Dr. Narendra Malhotra - North

Dr. Hema Divakar - South

Dr. P. C. Mahapatra - East

Dr. Uday Thanawala - West

In bringing the FOGSI YOUTH EXPRESS to your city.

This Youth Express has been possible through an educational grant from

This Youth Express has been possible through an educational grant from

Charak Pharma Pvt. Ltd

CIPLA Ltd.

Emcure Pharmaceuticals Ltd

GlaxoSmithKline Pharmaceuticals Limited

Glenmark Pharmaceuticals Ltd.

Metropolis Health Services (India) Pvt.Ltd.

Organon India Ltd

Roche Pharmaceuticals Ltd.

Sandoz Private Limited

USV Limited

Wyeth Limited

Charak Pharma Pvt. Ltd

CIPLA Ltd.

Emcure Pharmaceuticals Ltd

GlaxoSmithKline Pharmaceuticals Limited

Glenmark Pharmaceuticals Ltd.

Metropolis Health Services (India) Pvt.Ltd.

Organon India Ltd

Roche Pharmaceuticals Ltd.

Sandoz Private Limited

USV Limited

Wyeth Limited