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Various studies have found that approximately 10% of prepubertal and 15% of adolescent age groups are obese.1
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Obesity in children is a BMI for age >95th percentile while overweight is >85th percentile. There is a risk of obesity-associated diseases and carrying the problem into adulthood, with a greater risk of obesity, premature death and disability.
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Childhood obesity is rising at an alarming rate worldwide—the figure is reportedly ten times higher than it was in 1970. The WHO reported that over 340 million children and adolescents aged 5–19 years were overweight or obese in 2016, with almost half of them living in Asia (WHO MONICA project).
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Raising the issue with parents and child requires sensitivity and discretion. Parents often blame obesity in children on their ‘glands’, but endocrine or metabolic causes are rare and can be readily differentiated from exogenous obesity by a simple physical examination and an assessment of linear growth. Children with exogenous obesity tend to have an accelerated linear growth whereas children with secondary causes are usually short.
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Congenital or inherited disorders associated with obesity
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Prader–Willi syndrome
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The characteristic features are bizarre eating habits (e.g. binge eating), obesity, hypotonia, hypogonadism, intellectual disability, small hands and feet and a characteristic facial appearance (narrow bifrontal diameter, ‘almond-shaped’ eyes and a ‘tented’ upper lip). Progressive obesity results from excessive intake in addition to decreased caloric requirements (see CHAPTER 18).
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Laurence–Moon–Biedl syndrome
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The characteristic features are obesity, intellectual disability, polydactyly and syndactyly, retinitis pigmentosa and hypogonadism.
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Beckwith–Wiedemann syndrome
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Characteristics include excessive growth, macrosomia, macroglossia, umbilical hernia and neonatal hypoglycaemia. Children appear obese as they are above the 95th percentile by 18 months of age. Intelligence is usually in the normal range.
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Endocrine disorders in children that can rarely cause obesity include hypothyroidism (often blamed as the cause but seldom is), Cushing syndrome, insulinomas, hypothalamic lesions, Fröhlich syndrome (adiposogenital dystrophy) and Stein–Leventhal syndrome (PCOS) in girls.
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Managing obesity in children
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Childhood obesity usually reflects an underlying problem in the family system. It can be a very difficult emotional problem in adolescents, who develop a poor body image. An important strategy is to meet with family members, determine whether they perceive the child’s obesity as a problem and whether they are prepared to solve the problem. The family dynamics will have to be assessed and strategies outlined. This may involve referral for expert counselling. It is worth pointing out that children eat between one-third and two-thirds of their meals at school so schools should be approached to promote special programs for children who need weight reduction.
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Conventional therapy by dietary modification, increasing energy expenditure by increasing activity, reducing sedentary behaviour, behaviour modification and family involvement is recommended. The best outcomes are achieved with a specialist team working with the whole family.5 Some authorities emphasise that weight maintenance rather than weight loss is appropriate since many children will ‘grow into their weight’.7
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Cushing syndrome is the term used to describe the chemical features of increased free circulating glucocorticoid. The most common cause is iatrogenic with the prescribing of synthetic corticosteroids. The spontaneous primary forms such as Cushing disease (pituitary dependent hyperadrenalism) are rare. As the disorder progresses the body contour tends to assume the often quoted configuration of a lemon with matchsticks (see CHAPTER 23).
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Change in appearance
Central weight gain (truncal obesity)
Hair growth and acne in females
Muscle weakness
Amenorrhoea/oligomenorrhoea (females)
Thin skin/spontaneous bruising
Polymyalgia/polydipsia (diabetes mellitus)
Insomnia
Depression
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The patient should be referred for diagnostic evaluation, including plasma cortisol and overnight dexamethasone suppression tests.
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Untreated Cushing syndrome has a very poor prognosis, with premature death from myocardial infarction, cardiac failure and infection; hence early diagnosis and referral is essential.
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Obesity and overweight are the most common pathological conditions in our society, creating on increasing public health problem. Worldwide in 2016, 39% of adults aged 18 years and over were overweight (39% of men and 40% of women) and 13% were obese (11% of men and 15% of women). Caused by an accumulation of adipose tissue, the problem is described as a ‘global health epidemic’ and also as a chronic disease (see TABLE 78.3). Each year, more than a million adults die due to conditions associated with obesity. It is not the extra weight per se that causes problems, but the excess fat. Calculating the BMI gives a better estimate of adiposity, and it is convenient and preferable to use this index when assessing the overweight and obese. However, recent data suggest that the distribution of body fat is as important a risk factor as its total amount. Abdominal fat (upper body segment obesity, or ‘apple’ obesity) is considered a greater health hazard than fat in the thighs and buttocks (lower body segment obesity, or ‘pear’ obesity) (see FIG. 78.1).
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Obese patients with high waist–hip ratios (>1.0 in men and >0.9 in women) have a significantly greater risk of diabetes mellitus, stroke, coronary artery disease and early death than equally obese people with lower waist–hip ratios.2
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In regard to the BMI reference scale it is worth noting that the risks follow a J-shaped curve (see FIG. 78.2) and are only slightly increased in the overweight range but increase with obesity so that a BMI of >40 carries a threefold increase in mortality.
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The consequences of obesity include:
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cardiovascular:
metabolic:
– dyslipidaemia*
– type 2 diabetes*
– insulin resistance
– hyperuricaemia/gout
– infertility
– PCOS
mechanical:
other:
– hiatus hernia/GORD
– gall bladder disease*
– fatty liver
– cancer (various)
– kidney disease (check microalbuminuria)
– excessive daytime sleepiness
– erectile dysfunction/subfertility
– psychological problems/depression/anxiety
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Obesity is responsible for 80% of type 2 diabetes, 35% of ischaemic heart disease and 55% of hypertension in European adults.
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An imperative of treatment is to address the serious comorbidities of type 2 diabetes and insulin resistance. Lifestyle changes are fundamental to outcomes.
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Treatment is based on four major interventions, the choice of which depends on the degree of obesity, the associated health problems and the health risk posed. Both the WHO and the NHMRC recommend the approach to obesity and overweight being based on these lifestyle changes, but with an emphasis on realistic goals.
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reduction in energy (calorie) intake
change in diet composition including reduced fat intake
increased physical activity
behavioural therapy
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Pharmacological agents are not used for first-line therapy although they may have a place in management, especially at grade III level of obesity. Surgery is an option for the treatment of morbid obesity.
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There is no single effective method for the treatment of obesity, which is a difficult and frustrating problem. A continuing close therapist/patient contact has a better chance of success than any single treatment regimen.
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no further weight gain
loss of 5–10% initial body weight
improve activity
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Most successful programs involve a multidisciplinary approach to weight loss, embracing the four major interventions. The first goal should be no further weight gain. Emphasis must be on maintenance of weight loss. Behaviour modification is important and the most valuable strategy is to emphasise planning and record keeping with a continuous weekly diary of menus, exercise and actual behaviour.
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Social support is essential for a successful weight loss program. A better result is likely if close family members, especially the chief cook, are involved in the program, preferably striving for the same goals.2
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A doctor–patient strategy
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A close therapeutic supportive relationship with a patient can be effective using the following methods:8
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Promote realistic goals. Lose weight at the same rate that it was gained (i.e. slowly)—for example, 5–10 kg a year. A graph can be used for this purpose with an ‘exaggerated’ scale on the vertical axis so that small variations appear highly significant and encouraging (see FIG. 78.3).
Dietary advice. It is important to be realistic and allow patients to eat their normal foods but advise them about quantity and frequency. Give advice on simple substitutions (e.g. fortified skim milk in place of whole milk, high-fibre wholemeal bread instead of white bread, and fruit and vegetables instead of biscuits and cakes as in-between snacks).8 Reduce fat intake to <30% of total calorie intake.7 A strategy that seems to work effectively is to advise patients, especially those who are overweight (and grade I obesity), to eat one-third less than they usually do and discipline themselves not to ‘pick’ and to avoid second helpings.
Counselling is simple and commonsense. It involves being supportive, interested and encouraging. A list of tips on coping is provided (see below ‘A practical plan’ for grade II and III obesity) and the patient advised to keep a food, exercise and behaviour diary.
Review. ‘Review is the most vital part of the weight loss programme as it stimulates and revitalises motivation and enables assessment of progress.’8 It should be frequent initially (e.g. fortnightly), then monthly until the goal weight has been achieved and then 3-monthly. It is important never to be judgmental or critical if progress is unsatisfactory.
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The following patient education sheet to be handed to patients represents useful advice to offer the obese patient.8 The emphasis is on a healthy lifestyle program.
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A brisk walk for at least 20–30 minutes each day is the most practical exercise.
Other activities such as tennis, swimming, golf and cycling are a bonus.
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Provide patients with a glycaemic index guide (see CHAPTER 10).
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oatmeal (soaked overnight in water); after cooking, add fresh or dried fruit; serve with fat-reduced milk or yoghurt
or
muesli (homemade or from a health food store)—medium serve with fat-reduced milk, perhaps add extra fruit (fresh or dried)
slice of wholemeal toast with a thin scraping of margarine, spread with Vegemite, Marmite or sugar-free marmalade
fresh orange juice or herbal tea or black tea/coffee
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Morning and afternoon tea:
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Summer (cold)—lean meat cuts (grilled, hot or cold), poultry (skin removed) or fish; fresh garden salad; slices of fresh fruit
Winter (hot)—lean meat cuts (grilled), poultry (skin removed) or fish; plenty of green, red and yellow vegetables and small potato; fruit for sweets
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Have sensible goals; do not ‘crash’ diet but have a 6–12 month plan to achieve your ideal weight.
Go for natural foods; avoid junk foods.
Select fish, poultry and lean meats.
Trim excess fat from meat and skin from poultry.
Eat more breads (wholemeal), cereals, fruit and vegetables.
Increase intake of complex carbohydrates that contain starch and fibre.
Plant food is good for you; have it as part of breakfast.
Eat less sugar; avoid lollies and syrups.
Avoid alcohol, sugary soft drinks and high-calorie fruit juices.
Strict dieting without exercise fails.
If you are mildly overweight, eat one-third less than you usually do.
Do not eat biscuits, cakes, buns, etc. between meals (preferably at no time).
Limit the intake of full-cream products, fried foods and fatty take-away meals.
Limit the amount of butter or margarine on vegetables and bread.
Reduce calorie intake; reduce fat intake to <30% of total calorie intake.
What you usually eat matters most, not what you eat occasionally.
Use high-fibre foods to munch on.
Drink copious water—at least 2 L a day.
A small treat once a week may add variety.
Avoid seconds and do not eat leftovers.
Avoid non-hungry eating.
Eat slowly—spin out your meal.
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Pharmacological agents
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A variety of these adjuvant agents are available or imminent but they have limitations and need to be used with caution, if at all. Adverse effects can be problematic. Consider for those with a BMI >30 kg/m2 and failed well-supervised lifestyle measures.
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Local, acting on GIT:
Centrally acting agents:
— amphetamine derivatives (reduce hunger): phentermine 15–40 mg (o) daily (limited use and not recommended)
— serotonin analogues (enhance satiety): fluoxetine 20–40 mg (o) daily in depressed patients but only temporary weight reduction7
— other SSRIs, e.g. sertraline
— sibutramine 10–15 mg (o) daily (monitor BP)
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A summary of systemic reviews to date indicates that the effectiveness of serotonin analogues is unknown or, with sibutramine and phentermine, of some benefit, which has to be weighed against adverse effects, including the potentially fatal serotonin syndrome. The same applies to orlistat, which, together with a low-fat eating program, does produce extra weight loss over placebo.11 Drugs should not be expected to have a continuing effect after therapy ceases.
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Inappropriate drug treatment includes bulk-forming laxatives, thyroxine, diuretics, complementary and alternative medicines (which may cause adverse cardiovascular effects).7
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Food replacement agents such as Optifast have been promoted but there is insufficient evidence so far to evaluate their effectiveness and the reduced intake of key vitamins. Long-term results are disappointing.
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Surgery (bariatric surgery)5,7
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Surgery is the most effective treatment for obesity, but is associated with risks such as malabsorption4 and nutritional deficiency.12 In those with morbid obesity (about 2% of the population) unresponsive to behaviour modification therapy and a course of pharmacological agents for 3 months or so, gastric banding has a place. It is recommended in those with a BMI >40 or >35 with at least one severe comorbidity such as poorly controlled diabetes or severe OSA.13,14 One example is Lap-Band, which is inserted laparoscopically and can be adjusted and eventually removed with minimal significant residual adverse defect left in the stomach. It appears to be effective for 10 years.5,14 Sleeve gastrectomy gastric bypass such as Roux-en-Y bypass and other techniques can be considered.