PCOS – Obesity The Present Day Menace

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PCOS Obesity The Present Day Menace
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Epidemiology

• 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

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Definition

• 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

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Definition

• Obesity is not overweight.
• Obesity is excess body fat
• In adults
• BMI gt 25 is overweight
• BMI gt 30 is obese
• In children
• BMI gt 85 centile for the age is overweight
• BMI gt 95 centile is obese

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Definition

• 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

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BMI Centile Charts
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Definition 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 !

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Tracking of Obesity

• Three crucial periods determine the chance of
  obesity during adulthood
• Gestational period Infants of Diabetic
  Mothers 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

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Tracking of Obesity

• 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

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Sequel 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

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Sequel of Obesity

• Functional ovarian hyperandrogenism
• Restrictive airway disease
• Obstructive airway disease
• Snoring, Sleep apnea, Right ventricular
  hypertrophy
• Heart failure
• High incidence of asthma

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Gynaecological Consequenses Of Obesity

• PCOD- Hair-An syndrome
• Anovulation
• Amenorrhoea
• D.U.B.
• Fibroid Uterus
• Fungal Infections
• Infertility

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Evaluation of Obese Youth

• Family history
• SMR, acanthosis and striae, goitre
• Blood pressure
• Cholesterol, Blood sugar and HbA1c
• Liver function tests

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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

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Therapy

• 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

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Intensive Therapies - Indications

• BMI gt 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

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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

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Intensive Diet

• 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

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Pharmacotherapy

• Limited data available in children and
  adolescents
• Medications reducing energy intake
• Fenfuramine
• Phenteramine
• Diethylpropion
• Sibutramine

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Leptin

• 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

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Metformin

• 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

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Metformin

• Contraindications
• Renal failure, creatinine gt 1.4 mg/dl
• CCF, cardiac and pulmonary insufficiency
• Liver disease

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No medications are approved for use in children
in routine clinical practice except Leptin in
Leptin deficiency children
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Bariatric 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

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RYGB

• 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 gt 30 kgs and co morbid conditions
  improved
• Complications include iron deficiency, folate
  deficiency, small bowel obstruction

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Bariatric Surgery

• 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

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Take Home Message

• 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

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Concept Dr. Duru Shah

• Contributors
• Dr. Suvarna Khadilkar
• Dr. Vaman Khadilkar

• Editors
• Dr. Sangeeta Agrawal
• Dr. Reena Wani

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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.

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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