A BOY with OBESITYDyah Mutia PS*Longitudinal Case

INTRODUCTION*Obesity : abnormal accumulation of fat tissue andcause risk for health.Obesity body mass index > 95th percentilePrevelance of obese children in Indonesia 22% (child between age 6-17 years old)Prevalence of obese children in South Sumatera 20,9%; in Palembang 13,1%.

q

INTRODUCTION*Obesity : abnormal accumulation of fat tissue andcause risk for health.Obesity body mass index > 95th percentilePrevelance of obese children in Indonesia 22% (child between age 6-17 years old)Prevalence of obese children in South Sumatera 20,9%; in Palembang 13,1%.

q

Prevalence, 2007*

INTRODUCTION*Obesity is caused by energy intake larger than it uses abnormality of metabolism metabolic syndrome. Metabolic syndrome risk factor of cardiovascular disease in adulthoodPrevalence of obesity > comorbids > Obesity one of the leading cause of health problems intervention since childhood PreventionMonitoring

CASE

IdentificationAddRAW// 11 years 10 months oldBW 68 Kg(s), Height 148 cm(s)Outside townCome to ED: January 28, 2013

Patient*Age 14th yo

Anamnesis

Present Illness History*

One day before admission, the patient had a headache, no fever, nausea, vomit nor seizure. No history of head The trauma. Patient then taken to a pediatrician. The blood pressure was 140/100mmHg RSMHObesity since 5 years oldPast Illness HistoryNo history of hypertension before

Family Illness HistoryHistory of obesity History of hypertensionHistory of diabetesChief complain: headache

Physical ExaminationAlertBP 140/90mmHgPulse 80x/min (volume & pressure sufficient)Temperature 36,8o C Resp. Rate 30x/minObeseGeneral Findings*

Physical Examination*Spesific FindingsSpesific FindingsA rounded face, chubby cheeks, No dysmorphic features,No tonsil hypertrophyAcanthosis nigricansNormal thorakal examinationAbdominal circumference 100cmStriae abdomenPubertal status A1P1GNormal neurological examination Antropometric:

Weight: 68 kgHeight: 148 cmArm circumference: 32 cmBMI: 31.05 kg/m2Nutritional status: Obesity

Further investigationBlood Examination :

Hb:15,0 gr/dl, WBC:5600/mm3, Plt:150.000/mm3 , DC:0/5/0/30/26/19.Ureum: 12 mg/dl, creatine: 0,5 mg/dl Total cholesterol: 107 mg/dl, Triglyseride 99 mg/dL, HDL 41 mg/dL, LDL 128 mg/dL. SGOT: 29 U/L, SGPT: 13 U/L, BSS 98 mg/dL

Urinalysis :protein (-), glucose (-), ketone (-), blood (-), bilirubin (-), urobilinogen (+), nitrit (-), epithel +, wbc 0-2, eritrocyte 0-1, cast (-), crystal (-)*

Further investigation*Neonatal periode age 4 years oldAdequate qualityand quantity> age 4 years old >> quantityNOW Intake calory >> RDA

Further investigation*Low intensity of daily activity Watching television + 4 hours per dayNo routine exerciseSEDENTARYLIFE

Diagnosis 2nd Grade Hypertension + Obesity*

Genetic/HeredoconstitutionalFathers body height 168 cm Mothers body height 145 cm Genetic Potential Height 157 174 cmMid Parental Height (MPH) 165.5cm. Born spontaneously, aterm G1P0A0, crying instantly, A/S 8/9, BW 3100g, HT: 50 cmThere are another Obese family member. No parents consanguinity Patient is wanted child, his mother checked her pregnant regularly

Pedigree

*

Environmental Factors

MICROMINIMESOMACRO*

Environmental Factor

MICRO: MOTHERMICROMINIMESOMACROAge: 42 years oldReligion: IslamEthnic: JavaLast educationSenior High schoolShe is a house wifeGiving breast milk: 24 monthsAdditional food: 6 monthsImmunization: complete basic imunization.She cares all childrens especially the patientLoves to cookHas no routine physical exerciseMikroMiniMICROMINIMESOMACRO

Environmental Factor

MICRO: Father Sibling - HouseMICROMINIMESOMACROFatherAge: 44 years old/Islam/ JavaLast education: Diploma Work: EnterpreneurMonthly income: + Rp 8.000.000 Rp.10.000.000No smoke or drink, loves his childrenNo routine physical exercise

House Permanent houseGood sanitation and ventilationPAM and PLN

Environmental Factor

MICROMINIMESOMACRO

Environmental Factor

MICROMINIMESOMACROMICROMINIMESOMACROMikroMini

Environmental Factor

MESO: NEIGHBOURHOODMINIMESOMACRO RSMH 5 hours Puskesmas 5 min Available health, religious, market and educational facilities nearby Close contact to neighbour

*

Environmental Factor

*MICROMINIMESOMACRONo health insurance yet

ASUHASIHASAHAdequate stimulation.Parents teach playing, sitting, standing, prayingAdequate nutrition and healthcare,complete basic immunization,

Basic Need FulfillmentLoving & caring family

ProblemThe parents knowledgeCompliance of feeding rulesPatiients compliance for physical exercisePermissive care from parentRisk of health probems related obesityPrognose

Medical ProblemInform , counselling , and educate the parents about risk, management , planning, prognosisEducatefood rulesEducate about physical examinationCounseling about caring pattern in the familyApplying PedsQLEducate family about the prognoseProblemInterventionObesityGrade II Hypertensi onAbdomen circumference.Non completed advance immunisationsEarly pubertyApplying feeding rulesLow salt diet and initiate physical activity, also giving antihypertension drugsAdvanced laboratory examinationsCompleting advance immunizationUnderstanding a teenager need and urgesNon Medical Problem

LONG TERM FOLLOW-UP IN 22 MONTHS with monitoring interval every 3 monthsI - IIIJan 2013May 2015

FOLLOW UP & DISCUSSION

Weight Monitoring*

Height Monitoring*

BMI Monitoring*

Intake Monitoring*RealizationTarget

Case AnalysisCaseFather ObeseMother ObeseSister ObeseUncle Obese, Hypertension, DM

LiteratureObese parents 75-80% obese childrenGene variants :FTO, BDNF, ETV5, FAIM2, KCNJ11, MCR4, MCTH2, NEGR1*

Case AnalysisCaseTotal calories 3075 kcal/day(RDA: 1950-2340 kcal/day)Watching TV > 4 hours/dayNo regular exercises

LiteratureImbalance energy homeostasis in > out adipocytes >> OBESITY Risk of obesity 12,3x higherTo prevent obesity (CDC) regular exercise, >60min (aerobic, muscle and bone strengten*

Case AnalysisCaseFamily lifestyle SedentaryIndicipline to change feeding habbit, reduce stimulus

LiteratureIntervention by family approache effective to reduce obesityReduce duration in watching TVReduce carbohydrate and fat intake*

Syndrome Metabolic Monitoring*HypertensionAbd. circumference 100cmAcanthosis nigricansNormal blood glucoseNormal HDLNormal TriglyserideMonitoringNormotensionAbd.circumference 100cmAcanthosis nigricansFasting blood glucose normalRefuse further investigation Beginning of monitoring End of monitoringEducation

Case AnalysisCaseComorbides:2nd grade hypertension

LiteratureComorbides:Hypertension prevalence in Indonesia 49%, abroad 50%Possibly 3 mechanisms:1. altered autonom function2. insulin resistance3. abnormality of vasculer structure and function*

Case AnalysisCaseComorbides:Hypertension , abdomen circurmference > P80, acanthosis nigricans Metabolic Syndrome ??

LiteratureMetabolic syndrome criteria:Abdomen circumference >P80 with > 2 of these parameters:HypertensionHDL < 40 mg/dlFasting blood glucose > 100mg/dlTriglyseride > 110mg/dl*

Case AnalysisCaseCandidiasis cutisNo sign and symptom of type 2 diabetes melitusNo obstructive sleep apneu/hypoventilation syndrome no tonsil hypertrophyNo abdominal pain no hepatomegaly

LiteraturePrevalence:Skin infection: 50,42%Type 2 DM: 0,4%Obstructive sleep apneu: 38,2% (ind), 79,9% (abroad)Hypoventilation syndrome: 24% (abroad)Fatty acid liver disease: 48,1%*

Case AnalysisCaseNo dislipidemia No blount diseaseNo precox pubertyNo deficiency Fe anemia

LiteraturePrevalence:Dislipidemia: 88,4% (ind), 45,8% (abroad)Blount disease: 2,5%Precox puberty: 0Anemia: 55% (ind), 38,8% (abroad)*

Immunization Monitoring*

Complete basicimmunization

Monitoring Beginning of monitoring End of monitoringRefuse all kind of injections(immunization, blood examination)

Incomplete adolescenceimmunization

Consultation, Education, Information

Case AnalysisCaseNo adolescence immunization refusion

Literature

The importance of adolescence immunization antibody concentration

Monitoring for Developmental Problems*

Weight gainNo reduce BMI

Inconsistency in eating habbitInconsistency in physical activity

EarlypubertyMiddlepubertyDenialCognitive and moral Not capable to predict the long term consequency of present decision Control and independency conflict Defence mechanism To protect him self from theunpleasure reality Permissive Child Care

Case AnalysisCase

PedsQL:87,44% (self report)83,13% (parents report)PSC: no internalization, externalization and attention impaired

Literature*Obesity children depression: 22% (ind), 30% (abroad)discrimination in sosial life obesity ~ lazynessLess satisfaction in dating statusBullying >>

Case AnalysisCaseQuo ad funtionam:dubia ad bonam

LiteratureObesity children 15-30% obesity as adultObesity at age 18 yo risk of3,02-5,35x venous edema1,6-4,2x walking disability1,25-1,48x asthma 1,37-1,42x type 2 DM1,25x sleep apnea1,05x dislipidemia1,02-1,42x hypertension at age 46 yo*

Case AnalysisCaseQuo ad funtionam:dubia ad bonam

Literature

Obesity children in the adulthood period :Girls less educational grade less family income less marriageBoys no difference compared with the normal nutritional status group *

LITERATURE REVIEW*

Etiology123Genetic Parental FatnessLifestyle SedentaryFood Intake >> Imbalance energyhomeostasis

Energy BalanceEnergy balance regulated by factor increasing energy expenditure and energy conserve.

*Energy OutFood intakeAmount & typeEnergy InPhysical activityRoutine metabolismGrowth

Apetite Control*HipotalamusAnorexicanLeptin-MSH - POMCPYYInsulinOrexicanGhrelinCCKNPYAgRP

Diagnose* Acanthosis nigrican, Accelerated height gain, advanced bone age,Burried penis, ginecomastia, Syndrome ?KlinisLaboratorisPsikososialTSH, OGTT , comorbides Depression IMT > 95th percentile, BB/TB >120%, Skin Fold > 20% in boys,> 30% in girlsAntropometrik

ComorbidesEndocrine type 2 DM, insulin resistance, metabolic syndromeRespiratory obstructive sleep apneu, hypoventilation syndromeOrthopedic blount disease, slipped capital femoral epiphysisSkin Infection Hepatology fatty acid liver diseaseDislipidemia.

*

Metabolic SyndromeCriteria: (IDAI)Waist circumference > 80 percentile, with 2 or more of these parameters:- Hypertension- HDL < 40 mg/dl- Triglyseride > 110 mg/dl- Fasting blood glucose > 100mg/dl

*

Management1. Diet modification2. Physical activity no sedentary lifestyle, routine exercise3. Behavioral Changes no sedentary lifestyle, self monitoring4. Environment family participation, school participation

*

AAP Recommendation*

AAP Recommendation*

Prevention* UniversalFor each individu inpopulationLower population's BMIReduction of obesitycomorbides

SecunderComorbides of obesity decrease SelectiveObesity in high risk population decrease Lifestyle changes

Targets

* Thank You

***************