Longitudinal Case

A BOY with
OBESITY
Dyah Mutia PS

INTRODUCTION
Obesity : abnormal accumulation of fat
tissue and
cause risk for health.

Obesity body mass index > 95th

percentile

Prevelance 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%.

INTRODUCTION
Obesity : abnormal accumulation of fat
tissue and
cause risk for health.

Obesity body mass index > 95th

percentile

Prevelance 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%.

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 adulthood
Monitoring
Prevalence of obesity > comorbids >

Prevention
Obesity one of the leading cause of health problems
intervention since childhood

CASE

Identification
Add

Patien
t

RAW// 11 years 10 months old

BW 68 Kg(s), Height 148 cm(s)
Outside town
Come to ED: January 28, 2013
Age 14th yo
7

Anamnesis
Chief complain: headache

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
RSMH

Past Illness
History

No history of
hypertension
before
Family Illness
History

History of obesity

History of
hypertension

Physical Examination
General Findings
Alert
BP 140/90mmHg
Pulse 80x/min (volume &
pressure sufficient)
Temperature 36,8o C
Resp. Rate 30x/min
Obese

Physical Examination
Spesific Findings

A rounded face, chubby cheeks,

No dysmorphic features,
No tonsil hypertrophy
Acanthosis nigricans
Normal thorakal examination
Abdominal circumference 100cm
Striae abdomen
Pubertal status A1P1G
Normal neurological examination

10

Spesific Findings

Antropometric:
Weight: 68 kg
Height: 148 cm
Arm circumference: 32 cm
BMI:
31.05 kg/m2
Nutritional status: Obesity

Further investigation
Laboratory findings

Blood 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 (-)

11

Further investigation
DIET Analysis
Neonatal periode age 4 years old

Adequate quality
and quantity

> age 4 years old

>> quantity

NOW

Intake calory >> RDA

3075 kkal

12

Further investigation
ACTIVITY Analysis

Low intensity of daily activity

Watching television + 4 hours per day

No routine exercise

13

SEDENTARY
LIFE

Diagnosis

2nd Grade Hypertension + Obesity

14

Genetic/Heredoconstitutional
Patient is wanted child, his mother
checked her pregnant regularly

Born spontaneously, aterm

G1P0A0, crying instantly, A/S 8/9,
BW 3100g, HT: 50 cm
There are another Obese family
member. No parents consanguinity

Fathers body height 168 cm

Mothers body height 145 cm
Genetic Potential Height 157 174 cm
Mid Parental Height (MPH) 165.5cm
.

Pedigree

= Penderita

= Laki-aki

= obesitas
= obesitas,
DM,
hipertensi

16

= Perempuan

Environmental Factors
MACRO
MESO

MINI

MICRO

17

MACRO

Environmental Factor

MESO

Mini
MINI

MICRO: MOTHER

MICRO

Mikro

Age: 42 years old

Religion: Islam

Ethnic: Java

Last educationSenior High school

She is a house wife

Giving breast milk: 24 months

Additional food: 6 months

Immunization: complete basic

imunization.

She cares all childrens especially the

patient

Loves to cook

Has no routine physical exercise

MACRO
MESO
MINI
MICRO

Environmental Factor
MICRO: Father Sibling - House
Father

Age: 44 years old/Islam/ Java

Last education: Diploma

Work: Enterpreneur

Monthly income: + Rp 8.000.000

Rp.10.000.000

No smoke or drink, loves his children

No routine physical exercise

House

Permanent house

Good sanitation and ventilation

PAM and PLN

MACRO
MESO
MINI
MICRO

Environmental Factor

MACRO
MESO

Mini
MINI
MICRO

MICRO
Mikro

Environmental Factor

MACRO
MESO
MINI

Environmental Factor
MESO: NEIGHBOURHOOD

RSMH 5 hours

Puskesmas 5 min

Available health, religious,

market and educational
facilities nearby

Close contact to
neighbour

22

MACRO
MESO
MINI
MICRO

Environmental Factor

No health insurance yet

23

Basic Need Fulfillment

Adequate
stimulation.
Parents teach
playing, sitting,
standing, praying

ASUH
Adequate
nutrition and
healthcare,
complete basic
immunization,

ASAH

ASIH
Loving & caring
family

Problem
Intervention

Problem
1.
2.
3.

Medical Problem

4.

5.

1.

Non Medical
Problem

2.
3.

4.
5.

6.

Obesity
Grade II Hypertensi on
Abdomen circumference.
Non completed advance
immunisations
Early puberty

The parents knowledge

Compliance of feeding rules
Patiients compliance for
physical exercise
Permissive care from parent
Risk of health probems
related obesity
Prognose

1.
2.

3.
4.
5.

1.

2.
3.
4.

5.
6.

Applying feeding rules

Low salt diet and initiate physical
activity, also giving antihypertension
drugs
Advanced laboratory examinations
Completing advance immunization
Understanding a teenager need and
urges
Inform , counselling , and educate
the parents about risk,
management , planning, prognosis
Educatefood rules
Educate about physical examination
Counseling about caring pattern in
the family
Applying PedsQL
Educate family about the prognose

LONG TERM FOLLOW-UP IN 22 MONTHS

with monitoring interval every 3 months

May 2015

VIIIX

Jan 2013

IV-VI
I - III

X-XI

FOLLOW UP
&
DISCUSSION

Weight Monitoring
100
90
80

kg

70
60
50
40
30
20
10
1

5
Trimester

28

10

Height Monitoring

29

BMI Monitoring
32.8
32.6
32.4
32.2
32.0
31.8
31.6

kg/m2

31.4
31.2
31.0
30.8
30.6
30.4
30.2
30.0
29.8
1

5
Trimester

30

10

Intake Monitoring
3600

Realizatio
n
Target

3400
3200

kkal

3000
2800
2600
2400
2200

Column
D

2000
1

Trimester

31

10

Case Analysis

Case

Father Obese

Mother Obese

Sister Obese
Uncle Obese, Hypertension,
DM

32

Literature

Obese parents 75-80%

obese children

Gene variants :

FTO, BDNF, ETV5, FAIM2,

KCNJ11, MCR4, MCTH2,
NEGR1

Case Analysis

Case

Total calories 3075

kcal/day(RDA: 1950-2340
kcal/day)
Watching TV > 4 hours/day
No regular exercises

33

Literature

Imbalance energy
homeostasis in > out
adipocytes >> OBESITY

Risk of obesity 12,3x higher

To prevent obesity (CDC)

regular exercise, >60min
(aerobic, muscle and bone
strengten

Case Analysis

Case

Family lifestyle

Literature

Intervention by family approache

Sedentary

effective to reduce obesity

Indicipline to change feeding

habbit, reduce stimulus

Reduce duration in
watching TV
Reduce carbohydrate and
fat intake

34

Syndrome Metabolic
Monitoring
Hypertension
Abd. circumference
100cm
Acanthosis nigricans
Normal blood glucose
Normal HDL
Normal Triglyseride

Beginning of
monitoring

35

Monitoring

Education

Normotension
Abd.circumference 100cm
Acanthosis nigricans
Fasting blood glucose normal
Refuse further investigation

End of
monitoring

Case Analysis

Case

Comorbides:
2nd grade hypertension

Literature

Comorbides:
Hypertension prevalence in
Indonesia 49%, abroad 50%
Possibly 3 mechanisms:
1. altered autonom function
2. insulin resistance
3. abnormality of vasculer structure
and function

36

Case Analysis

Case

Literature

Metabolic syndrome criteria:

Comorbides:

Hypertension , abdomen
circurmference > P80, acanthosis
nigricans

Abdomen circumference >P80 with

> 2 of these parameters:

Hypertension

HDL < 40 mg/dl

Fasting blood glucose > 100mg/dl

Triglyseride > 110mg/dl

Metabolic Syndrome ??

37

Case Analysis

Case

Literature

Prevalence:

Candidiasis cutis
No sign and symptom of type 2
diabetes melitus

Skin infection: 50,42%

Type 2 DM: 0,4%

Obstructive sleep apneu: 38,2%

(ind), 79,9% (abroad)

No obstructive sleep
apneu/hypoventilation syndrome
Hypoventilation syndrome: 24%
no tonsil hypertrophy
No abdominal pain
hepatomegaly
38

no

(abroad)

Fatty acid liver disease: 48,1%

Case Analysis

Case

Literature

Prevalence:

No dislipidemia

Dislipidemia: 88,4% (ind), 45,8%

(abroad)

No precox puberty

Blount disease: 2,5%

No deficiency Fe anemia

Precox puberty: 0

Anemia: 55% (ind), 38,8% (abroad)

No blount disease

39

Immunization Monitoring

Beginning of
monitoring

Complete basic
immunization

Monitoring

Refuse all kind of injections

(immunization, blood examination)

Consultation, Education, Information

40

End of
monitoring

Incomplete
adolescence
immunization

Case Analysis

Case

Literature

No adolescence immunization The importance of adolescence

immunization
refusion
antibody concentration <<
low immunization compliance in
childhood
risks of adulthood disease

41

Monitoring for Developmental

Problems
Early
puberty

Cognitive and moral

Not capable to predict the
long term consequency of
present decision

Middle
puberty

Control and
independency
conflict

Denial

Defence mechanism
To protect him self from
the
unpleasure reality

42

Permissive
Child Care

Inconsistency in eating habbit

Inconsistency in physical
activity

Weight gain
No reduce BMI

Case Analysis

Case

PedsQL:
87,44% (self report)
83,13% (parents report)

PSC: no internalization,
externalization and attention
impaired

43

Literature

Obesity children
depression: 22% (ind), 30% (abroad)
discrimination in sosial life obesity ~
lazyness
Less satisfaction in dating status
Bullying >>

Case Analysis

Case

Obesity children 15-30% obesity as

adult

Obesity at age 18 yo risk of

Quo ad funtionam:
dubia ad bonam

Literature

3,02-5,35x venous edema

1,6-4,2x walking disability
1,25-1,48x asthma
1,37-1,42x type 2 DM
1,25x sleep apnea
1,05x dislipidemia
1,02-1,42x hypertension
at age 46 yo
44

Case Analysis

Case

Quo ad funtionam:

dubia ad bonam

45

Literature

Obesity children in the adulthood period :

Girls less educational grade
less family income
less marriage
Boys no difference compared with
the normal nutritional status group

LITERATURE
REVIEW

46

Etiology
1

Genetic Parental Fatness

2

Lifestyle Sedentary
3
Food Intake >> Imbalance energy
homeostasis

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

Food intake
Amount & type

Energy In

Physical activity
Routine metabolism
Growth

Energy Out

48

Apetite Control
Hipotalamus

Orexican

Anorexican

Ghrelin

Leptin

CCK

-MSH - POMC

NPY

PYY

AgRP

Insulin

49

Diagnose
Antropometrik

Klinis

Laboratoris

Psikososial

IMT > 95th percentile,

BB/TB >120%,
Skin Fold > 20% in boys,> 30% in girls
Acanthosis nigrican, Accelerated
height gain, advanced bone age,
Burried penis, ginecomastia,
Syndrome ?
TSH, OGTT , comorbides

Depression

50

Comorbides
Endocrine type 2 DM, insulin resistance,
metabolic syndrome

Respiratory obstructive sleep apneu,

hypoventilation syndrome

Orthopedic blount disease, slipped capital femoral

epiphysis

Skin Infection

Hepatology fatty acid liver disease

Dislipidemia.

51

Metabolic Syndrome
Criteria: (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

52

Management
1. Diet modification
2. Physical activity no sedentary lifestyle,
routine exercise
3. Behavioral Changes no sedentary lifestyle,
self monitoring
4. Environment family participation,
school participation

53

AAP Recommendation

54

AAP Recommendation

55

Prevention
Selective

Universal
For each individu in
population

Lower population's BMI

Reduction of obesity
comorbides

Targets

Obesity in high risk

population decrease
Lifestyle changes

Secunder

Comorbides of obesity
decrease

56

Thank You

57