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Complications of obesity in children and adolescents during covid-19 pandemic: A narrative review

Authors:
  • Clínica Stella Maris
  • Hospital Nacional Guillermo Almenara Irigoyen

Abstract and Figures

Obesity in children and adolescents has increased exponentially around the world. Furthermore, the COVID-19 pandemic has led to a higher pediatric obesity rate. The excess adipose tissue generates a dysregulation of adiponectin, ghrelin, and leptin, among others. Metabolic alterations can develop cardiovascular disease, dyslipidemias, arterial hypertension, type 2 diabetes mellitus, nonalcoholic fatty liver disease, sleep disorders, and higher risk of COVID-19 severity. Obesity has different therapeutic approaches such as behavioral weight loss programs, pharmacologic treatments, and surgical procedures. Therefore, timely diagnosis and treatment are important to decrease the mortality in obesity among pediatric population.
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DOI
Complications of obesity in children and adolescents during covid-19 pandemic: A
narrative review
Review Article
1,a 2,b 3,b
Marcio Concepción-Zavaleta , Anthony Ramos-Yataco , Carlos Alcalde-Loyola , Diego
3,b 4,c 5,a 5,a
Moreno-Marreros , Julia Coronado-Arroyo ,Sofia Ildefonso-Najarro , María Quispe-Flores ,
5,a 6,d 7,e
Esteban Plasencia-Dueñas , Luis Concepción-Urteaga , Francisca Zavaleta-Gutiérrez ,
5,a
Freddy Valdivia Fernández-Dávila
Complicaciones de la obesidad en niños y adolescentes durante la
pandemia de COVID-19: Una revisión narrativa
Vol. 14 Supl. Nº 1 ( 2021 ) | SARS-CoV-2, COVID-19 y Pandemia
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hnaaa
Cross Ref. DOI: 10.35434/rcmhnaaa | OJS https://cmhnaaa.org.pe/ojs
ISSN | impresa: 2225-5109; Electrónica: 2227-4731
REVISTA DEL CUERPO MÉDICO HOSPITAL NACIONAL
ALMANZOR AGUINAGA ASENJO, chiclayo, perú
Vol. 14 Supl. Nº 1 ( 2021 )
SARS-CoV-2, COVID-19 y Pandemia
FILIATION
1. Division of Endocrinology. Clínica Stella Maris.
2. Division of Internal Medicine. Hospital Ricardo Cruzado Rivarola, Nasca, Peru.
3. School of Medicine. Universidad Nacional de Trujillo, Trujillo, Peru.
4. Division of Obstetrics and Gynecology. Clínica Vesalio.
5. Division of Endocrinology. Hospital Nacional Guillermo Almenara Irigoyen.
6. Hospital Regional Docente de Trujillo, Trujillo, Peru.
7. Division of Neonatology. Hospital Belén de Trujillo, Trujillo, Peru.
a. Endocrinologist.
b. General Physician.
c. Gynecologist.
d. PhD in Medicine.
e. Pediatrician and Neonatologist.
ORCID
1. Marcio José Concepción Zavaleta / 0000-0001-9719-1875
2. Diego Martín Moreno Marreros / 0000-0001-5396-7360
3. Sofia Pilar Ildefonso Najarro / 0000-0003-1952-2338
4. Carlos Alcalde Loyola / 0000-0001-8572-0549
5. Anthony Ramos- Yataco / 0000-0001-6224-3372
6. Luis Alberto Concepción Urteaga / 0000-0003-0462-3101
7. Francisca Elena Zavaleta Gutiérrez / 0000-0002-5497-3735
8. Freddy Roynall Valdivia Fernández Dávila / 0000-0002-6468-2106
9. Esteban Alberto Plasencia Dueñas / 0000-0001-8766-7083
10. María Alejandra Quispe Flores / 0000-0002-7390-3150
11. Julia Cristina Coronado Arroyo / 0000-0002-4916-8205
CORRESPONDENCE
Diego Martin Moreno Marreros.
Adress: Fco. Adrianzen 312 Sta Maria V etapa.
Phone: +51-950291202
EMAIL
diegomorenosud@hotmail.com
CONFLICTS OF INTEREST
The authors declare that there is no conflict of interest that could be perceived as prejudicing
the impartiality of the research reported.
FINANCING
Self-financing.
PEER REVIEW
Received: 30/05/2021
Accepted: 24/08/2021
HOW TO CITE
Concepción-Zava leta, M., Ramos- Yataco, A., Alcalde-Loyola, C., Moreno-Ma rreros, D.,
Coronado- Arroyo, J., I ldefonso- Najarro, S., Quispe -Flores, M., Plasenc ia-Dueña s, E.,
Concepción-Urteaga, L., Zavaleta-Gutiérrez, F., & Fernández-Dávila, F. Complicaciones de la
obesidad en niños y adolescentes durante la pandemia de COVID-19: Una revisión narrativa.
Revista Del Cuerpo Médico Hospital Nacional Almanzor Aguinaga Asenjo, 2021, 14(Sup1), 55 -
61. https://doi.org/10.35434/rcmhnaaa.2021.14Sup1.1175
This work is under a Licencia Creative Commons Atribución 4.0 Internacional.
Printer Version: ISSN: 2225-5109
Electronic Version: ISSN: 2227-4731
Cross Ref. DOI: 10.35434/rcmhnaaa
OJS: https://cmhnaaa.org.pe/ojs
ABSTRACT
Background: Obesity in children and adolescents has
increased exponentially around the world. Furthermore,
the COVID-19 pandemic has led to a higher pediatric
obesity rate. The excess adipose tissue generates a
dysregulation of adiponectin, ghrelin, and leptin, among
others. Metabolic alterations can develop cardiovascular
disease, dyslipidemias, arterial hypertension, type 2
diabetes mellitus, nonalcoholic fatty liver disease, sleep
disorders, and higher risk of COVID-19 severity. Obesity
has different therapeutic approaches such as behavioral
weight loss programs, pharmacologic treatments, and
surgical procedures. Therefore, timely diagnosis and
treatment are important to decrease the mortality in
obesity among pediatric population.
Keywords: Adolescents ; Children; Complications;
Obesity; COVID-19 (Source: DeCS-BIREME).
RESUMEN
Introducción: La obesidad en niños y adolescentes ha
aum entado exponenci almente en todo el mund o.
Asimismo, la pandemia del coronavirus (COVID-19) ha
conducido a una mayor tasa de obesidad pediátrica. El
exceso de tejido adiposo genera una desregulación de
hormonas como adiponectina, ghrelina y leptina, entre
otras. Las alteraciones metabólicas pueden ocasionar
enfermedad cardiovascular, dislipidemias, hipertensión
arterial, diabetes mellitus tipo 2, enfermedad del hígado
graso no alcohólico, trastornos del sueño y mayor riesgo
de COVID-19 severo. La obesidad tiene diferentes
enfoques terapéuticos, como programas conductuales de
rd ida de peso , trata mient os f arm ac o gi cos y
proc edi mient os qui rgico s. De e sta man era , el
diagnóstico y el tratamiento oportuno es importante para
disminuir la mortalidad asociada a la obesidad en la
población pediátrica.
Palabras Clave: Adolescentes, niños, complicaciones,
obesidad, COVID-19. (Fuente: DeCS-BIREME).
https://doi.org/10.35434/rcmhnaaa.2021.14Sup1.1175
55
Marcio Concepción-Zavaleta, Anthony Ramos-Yataco, Carlos Alcalde-Loyola, Diego Moreno-Marreros, Julia Coronado-Arroyo, Sofia Ildefonso-Najarro, María Quispe-Flores,
Esteban Plasencia-Dueñas, Luis Concepción-Urteaga, Francisca Zavaleta-Gutiérrez, Freddy Valdivia Fernández-Dávila
Revista del Cuerpo Médico del HNAAA, Vol. 14 Supl. Nº 1 ( 2021 ) | SARS-CoV-2, COVID-19 y Pandemia
INTRODUCTION
Obesity is a public health problem. Over the years, its
prevalence and incidence have been progressively increasing
(1,2)
worldwide . The global prevalence of obesity has increased
at an alarming rate in children and adolescents from 0.7% to
5.6% in boys and from 0.9% to 7.8% in girls between 1975 and
(2)
2016 .
The nutritional status classifications in children and
adolescents can be classified according to body mass index
(BMI) (Table 1). Although BMI provides a good measure of body
fat in adults, children body fat varies according to age and
gender. As such, fixed levels of BMI provide inaccurate
(3)
comparisons .
Table 1. Weight categories for youth (2-18 years)
according to body mass index (BMI).
Additionally, according to the WHO, in children under 5 years
of age, overweight can be diagnosed when the weight/height
ratio is greater than 2 standard deviation and obesity when
the weight/height ratio is greater than 3 standard deviations.
In Peru, during the last decade, the prevalence of overweight
and obesity in children under 5 years of age, after having
reached their minimum values in 2016 (6.1% and 1.5%
respectively), have been increasing progressively to 6.7%
overweight and 2.1% obesity for the second quarter of 2021,
according to the Sistema de Información Del Estado
(1)
Nutricional (SIEN) of the Instituto Nacional de Salud (INS) .
(2)
Obesity is associated with multiple comorbidities , including
cardiovascular, dermatologic, endocrine, gastrointestinal,
neurologic, orthopedic, psychosocial, and pulmonary
comorbidities (Table 2).
Table 2. Comorbidities of obesity in children and
adolescents
PATHOPHYSIOLOGY
Obesity in children has a complex etiology that originates
from environmental factors (sedentary lifestyle, high-calorie
(2)
diets) in modern societies . Nonetheless, genetic factors
may play an important role in its pathogenesis. However, the
role of genes in obesity may be modest, and obesity
predisposition may result from a combination of specific
genes. More studies need to be conducted to fully understand
th e g ene–e n viron ment intera c tion and epige n etic s
(4)
mechanism related to obesity .
Obesity substantially increases the risk of metabolic and
cardiovascular diseases such as type 2 diabetes mellitus,
fatty liver disease, hypertension, myocardial infarction and
(2)
stroke . The increase in adipose tissue influences the
pathogenesis of atherosclerosis. Adipose tissue includes two
types, namely, white adipose tissue (WAT) and brown adipose
tissue.
WAT secretes peptides and proteins that play an important
role in obesity, insulin resistance, immune functions,
atherosclerosis, and CVD. Among them, adiponectin stands
out, that is expressed at high levels in lean and healthy
(5)
people and is deregulated in obesity . Molecular studies
have reported that adiponectin could modulate atherogenic
mechanisms involved in endothelial cells (nitric oxide
production, mitigation of pro-atherogenic mediators,
st abil i zati on of the coron ary pla q ue, and arte rial
vasodilation). Likewise, it is known that perivascular adipose
tissue, particularly in obese people, promotes local
inflammation and deterioration of endothelial function,
providing a link between adipose tissue and vascular
(6)
disease .
On the other hand, obesity is considered an inflammatory
state, in which an increase in adipose tissue and a reduction
in adiponectin levels occurs. Its unbalance perpetuates
inflammation, leading to cardiometabolic alterations.
Furthermore, obesity leads to insulin resistance and
endothelial dysfunction due to the formation of pro-
(6)
inflammatory cytokine and lipid metabolism products .
En d o thelia l dysfun c t ion has been assoc i a t ed w ith
ca rdio vas cula r c ondi tion s, suc h a s athe rosc lero sis,
(5)
hypertension (HT), hyperlipidemia, and insulin resistance .
Obesity is associated with elevated levels of leptin and
greater release of reactive oxygen species from the
endoplasmic reticulum, generating less insulin secretion and
sensitivity. Leptin influences the production of nitric oxide
and activates the sympathetic system, causing sodium
retention, systemic vasoconstriction, and blood pressure
(7)
elevation .
OBESITY AND COVID-19
The COVID-19 pandemic led to different policies to contain
the virus, such as lock-downs around the world, resulting in
physical activity and changes in dietary behavior among
children and adolescents. In addition, the reduction in social
interaction causes isolation and a feeling of loneliness among
(8)
children, leading to changes in emotional eating .
NUTRITIONAL STATUS BMI
Underweight BMI <5th percentile for age
Normal weight BMI ≥ 5th to < 85th percentile for age
Overweight BMI ≥ 85th to <95th percentile for age
Obesity BMI ≥ 95th
Severe obesity BMI ≥ 120 % of the 95 th percentile or a BMI ≥ 35 Kg/m2
Cardiovascular Hypertension, dyslipidemia, abnormal cardiac structure and function
and adult cardiovascular disease
Dermatology Acanthosis nigricans, striae, intertrigo, furunculosis, hydradenitis
suppurativa
Endocrine
Prediabetes, diabetes mellitus, metabolic syndrome,
hyperandrogenism and polycystic ovary syndrome, growth and
puberty
Gastrointestinal Nonalcoholic fatty liver disease, cholelitiasis
Neurologic Idiopathic intracranial hypertension
Orthopedic Slipped capital femoral epiphysis, fractures, genu varus or valgus
Psychosocial Social isolation, anxiety, depression, distorted peer relationships,
disorder eating patterns
Pulmonary Asthma, obstructive sleep apnea, obesity hypoventilation syndrome
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Complications of obesity in children and adolescents during covid-19 pandemic: A narrative review
Revista del Cuerpo Médico del HNAAA, Vol. 14 Supl. Nº 1 ( 2021 ) | SARS-CoV-2, COVID-19 y Pandemia
As a result of this, children gained weight, and the
prevalence of childhood obesity increased in different
(8)
countries . In the Unites States, the prevalence increased
(9)
more than 15% . In China, the BMI increased significantly in
adolescents and young adults (15–17 years), while the
prevalence of obesity increased from 10.5% to 12.9% (I <
(10)
0.001) in these age groups . A new term, “covibesity,” was
introduced to describe the worsening of obesity rates due to
(11)
confinements .
The three main risk factors that link obesity with COVID-19
demonstrated in adults that are also present in children and
adolescents are chronic subclinical inflammation, impaired
immu ne response, a nd underlyin g car dio respiratory
(12)
diseases . Obesity is linked to a pro-inflammatory state
induced by the production of cytokines such as interleukin-6
(IL-6) and C-reactive protein. These cytokines have been
positively correlated with COVID-19 severity, and their higher
levels in obese pediatric population may be related to
(13)
increased susceptibility to severe infection .
OBESITY AND CARDIOVASCULAR RISK
Both obesity and atherosclerosis are considered chronic
inflammatory conditions, in which the activation of
nonspecific and immune-adaptive proce sses pl ays a
(1 4)
signifi cant role . The pat hogenesis of obesi ty and
atherosclerosis has several common factors. In both cases,
the oxidized LDL particles and free fatty acids activate the
inflammatory process and trigger the disease. Inflammation
is responsible for all steps toward atherosclerosis, from the
onset of endothelial dysfunction to atherosclerotic plaques,
causing complications, and is related to obesity, insulin
(15)
resistance, and type 2 diabetes (T2DM) .
Fat tissue releases adipocytokines, which induce insulin
resistance, endothelial dysfunction, hypercoagulability, and
systemic inflammation, facilitating the atherosclerotic
process. In visceral obesity, inflammatory adipocytokines
(e.g., TNF-α, IL-6, MCP-1, leptin, and resistin) rise to higher
levels. Furthermore, increased C-reactive protein level is
associated with an increased risk of myocardial infarction,
(16)
peripheral vascular disease, and diabetes mellitus .
Likewise, obesity leads to heart failure through several
indirect mechanisms. Excess weight leads to hemodynamic
changes: an increase in cardiac output and blood pressure has
2
been observed, and an increase in BMI of 5 kg/m generates a
5 mmHg increase in systolic blood pressure. On the one hand,
it is related to the activation of the renin–angiotensin
–aldosterone system and the increased activity of the
(7)
sympathetic nervous system .
Obesity increases the aldosterone level and expression of the
mineralocorticoid receptor, promoting interstitial fibrosis,
platelet aggregation, and endothelial dysfunction in the
heart. Increased blood volume facilitates venous return flow,
which improves preload, causing increased ventricular wall
tension and ultimately leading to ventricular dilation. The
inflammatory cytokines (TNF-α, IL-1, IL-6, IL-8), which are
increased in obese people, also play an important role in
heart failure development. The effect of leptin and
adiponectin on the metabolism and extracellular matrix can
contribute directly to the myocardial transformation. The
accumulation of triglycerides in the heart muscle can be
observed regularly in obese patients and facilitates the
ge n e ra t i on of t o xi c me ta b ol i t es ( ce r a mi d e a n d
(16)
diacylglycerol), causing apoptosis of cardiomyocytes .
Besides, obesity has been shown to increase the probability
of heart failure, not only by itself but also through associated
medical comorbidities (Figure 1).
Figure 1.
Impact of obesity on the development and worsening of heart failure.
Several studies have shown the relationship between obesity
and atrial fibrillation (Figure 2). Obese patients have a 1.52
times higher risk of developing atrial fibrillation compared to
the normal weight population. Likewise, an increased risk of
su d de n c a rd i a c d e a t h , str o ke , t h ro m bo e m b o l i c
complications, and heart failure exists in patients with atrial
fibrillation. Moreover, atrial fibrillation lengthens the
hospitalization time and worsens quality of life and physical
(17)
capacity .
Figure 2.
Association of obesity and the development of cardiac arrhythmias.
2
Morbid obesity (defined as BMI > 35 kg/m ) potentially causes
a wide range of alterations in heart performance, including
changes in cardiac hemodynamics, left ventricular function,
(18)
and morphology (Table 3).
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Revista del Cuerpo Médico del HNAAA, Vol. 14 Supl. Nº 1 ( 2021 ) | SARS-CoV-2, COVID-19 y Pandemia
Screening for cardiometabolic risk factors (HT, dyslipidemia,
T2DM) should be undertaken in all children with obesity.
Specific coronary risk scores, such as the Framingham risk
score, are well established for clinical risk stratification in
adults; however, no similar risk stratification tools are
(19)
available in children .
A risk score developed from the PDAY (Prediction of coronary
artery calcium in young adults using the pathobiological
Determinants of Atherosclerosis in Youth) study has been
used in pediatric, using the autopsy findings in subjects 15–34
years of age and coronary heart disease risk factors (gender,
age, serum lipoprotein concentrations, smoking, HT, obesity,
and hyperglycemia) to estimate the probability of advanced
atherosclerotic lesions in the coronary arteries. However,
more studies are needed to assess the utility of this risk
(20)
score .
SLEEP DISORDERS AND OBESITY
Sleep restriction seems to be related to our modern way of
life. People who sleep little can have difficulties in
maintaining a healthy lifestyle in the current environment
since it promotes excessive consumption of food and
sedentary behaviors. Moreover, there is strong evidence to
support that sleep reduction is a contributor to obesity in all
(21)
age groups of the pediatric population . Increased food
intake seems to be the main explanation for why a lack of
(22)
sleep can lead to weight gain .
Chaput JP et al. hypothesized an interesting theory to explain
the relationship between short sleep duration and obesity.
For weight gain to occur, there must be an imbalance
between energy intake and expenditure. The energy intake is
determined by eating food, and the energy expenditure is
determined by physical activity. Both factors would be
altered by a decrease in sleep, the consequence of which
(22)
would be weight gain . (Figure 3). However, this author does
not define exactly the number of hours that would be the
threshold to define short sleep, which would have this effect
(weight gain). Subsequent studies clearly show that sleeping
for less than 6 h is considered a cutoff point for this particular
(23)
effect and other harmful effects on health .
HEMODYNAMICS
blood volume, stroke volume/work
arterial pressure, LV wall stress
Pulmonary artery hypertension
CARDIAC STRUCTURE
LV concentric remodeling, hypertrophy
Left atrial enlargement
RV hypertrophy
CARDIAC FUNCTION LV diastolic or systolic dysfunction
RV failure
RV: Right ventricle, LV: Left ventricle.
Table 3. Impact of obesity on hemodynamics and heart
morphology.
Figure 3.
Relation between short sleep and obesity.
Marcio Concepción-Zavaleta, Anthony Ramos-Yataco, Carlos Alcalde-Loyola, Diego Moreno-Marreros, Julia Coronado-Arroyo, Sofia Ildefonso-Najarro, María Quispe-Flores,
Esteban Plasencia-Dueñas, Luis Concepción-Urteaga, Francisca Zavaleta-Gutiérrez, Freddy Valdivia Fernández-Dávila
58
Revista del Cuerpo Médico del HNAAA, Vol. 14 Supl. Nº 1 ( 2021 ) | SARS-CoV-2, COVID-19 y Pandemia
Obstructive sleep apnea (OSA) is an obesity-related
complication that has recently gained attention. It is defined
as a breathing disorder during sleep in which partial or
complete airway obstruction disrupts ventilation. The
prevalence of OSA varies between 1% and 5% in general
pediatric population; however, among obese children and
adolescent, the prevalence of OSA is estimated to range
between 20% and 61%. OSA in obese children is associated
with cardiovascular complications such as right and left
ventricular dysfunction, besides increased systolic blood
(24)
pressure . All this information suggests that OSA may have a
negative impact on long-term cardiovascular health.
NAFLD AND OBESITY
Nonalcoholic fatty liver disease (NAFLD) is directly linked to
obesity and has become a major cause of chronic liver disease
among children and adolescent with obesity. Two hypotheses
have been put forward to explain the pathophysiology of
NAFLD. First, obesity-related hyperinsulinemia and insulin
(25)
resistance lead to liver steatosis . Second, the oxidative
stress by reactive oxygen sp ecies (ROS) may cause
hepatocellular damage inhibiting mitochondrial respiratory
chain enzymes. Furthermore, ROS may cause lipid membrane
peroxidation, apoptosis of hepatocytes induced by Fas
li g a n d, and cy t ok i n e pr o du c t i o n , p e r p e t u at i n g
(26)
hepatocellular injury and fibrosis .
NAFLD has been recognized as an independent risk factor for
CVD; however, the association is still debated in pediatric
population. This association has not been fully understood
yet, but increased visceral fat tissue and insulin resistance
(27)
may be important contributing factors . NAFLD is part of the
metabolic syndrome, which is an atherogenic state.
(28)
Atherosclerosis has been shown to begin in pediatric age .
To the best of our knowledge, the mechanism by which NAFLD
may lead to atherogenesis is not elucidated, but increased
visceral adipose tissue expressed by particularly periaortic
fat thickness, altered lipoprotein metabolism, insulin
resistance, and inflammatory cytokines released by NAFLD
may play a significant role. (Figure 4)
TREATMENT OF OBESITY IN CHILDREN AND ADOLESCENTS
The three main treatment approaches for pediatric obesity
are diet and lifestyle mo di fic ation, pharmacological
interventions, and surgical management.
A. BEHAVIORAL INTERVENTIONS FOR WEIGHT LOSS
Successful weight loss can be improved by incorporating
(29)
behavioral strategies .
Examples of well-proven behavioral weight loss programs
designed to reduce body weight include the Diabetes
Prevention Project, the Look AHEAD Study for Adults, and
family-based behavioral weight loss programs (FBT) for
(29)
children . Systematic reviews in this area show that
adults who participate in behavioral weight loss (BWL)
programs of 12–26 sessions lose approximately 6% of their
(30)
body weight , while children who participate in at
(26) (31)
least BWL sessions lose 0.2 ZBMI , both clinically
significant weight losses associated with multiple
improvements in health.
The trials used different intervention methods, such as
group, individual, and mixed. Group interventions
consisted of classroom-style sessions that lasted from 1 to
2 h and ranged from eight group sessions over 2.5 months
to weekly group sessions over 1 year. Most individual-
based interventions provided individual counseling
sessions, with or without ongoing telephone support, with
(32)
a median number of sessions in the first year of 12 .
Mixed-based interventions included the same number of
group and individual counseling sessions. Most of these
interventions were carried out for more than 1 year and
involved more than 12 sessions (median, 23 sessions in
total in therst year). In the technology-based
interventions, web-based intervention modules, web-
based self-monitoring, mobile pho ne- bas ed text
messages, smartphone apps, social media platforms, or
DVD learning were included. In addition, in most of these
behavioral interventions, self-control was promoted by
(33)
recording daily dietary intake . Using websites that
provided real-time feedback on the total calories
consumed for the day based on the foods and portion sizes
recorded, the remaining calories can help achieve the
(34)
participant's personal daily goal .
Most of these behavioral interventions were designed to
help participants achieve or maintain a weight loss of
5%–10% or more through a combination of dietary changes
(29)
and increased physical activity .
B. PHARMACOLOGICAL INTERVENTION
The 2017 Endocrine Society Clinical Practice Guidelines
recommend pharmacotherapy for children or adolescents
after a formal program of intensive lifestyle modification
(35)
has failed .
Or l i s t a t i s t h e o nl y F D A ( U S Foo d a n d D r ug
Administration)-approved weight loss medication for use
in children 12 years who are overweight/obese. This
lipase inhibitor is associated with 1-2 kg weight loss in
adolescents. It has been associated with modest
improvement in diastolic blood pressure and a marker of
endothelial function (flow-mediated dilation), but its
cumulative effect on reducing cardiometabolic disease
(35)
remains unknown .
Figure 4.
Relationship between obesity and non-alcoholic fatty liver disease.
Complications of obesity in children and adolescents during covid-19 pandemic: A narrative review
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Revista del Cuerpo Médico del HNAAA, Vol. 14 Supl. Nº 1 ( 2021 ) | SARS-CoV-2, COVID-19 y Pandemia
Metformin is the most common agent evaluated for the
treatment of obesity in children. Randomized trials of
metformin have demonstrated modest weight loss (2–4
kg) in youth with marked improvement in markers of
insulin resistance. However, similar to studies conducted
for orlistat, most metformin trials are ≤ 1 year in
d u r a ti o n , a n d th e d u r a b l e e e c t o f t h e s e
p h a r m ac ol og ic al ag e n t s o n w e i g h t l o s s or
ca rdio meta boli c r isk redu c tion r equi res furth er
(36)
investigation .
C. SURGICAL MANAGEMENT
Bariatric surgery is a treatment option for obese
adolescents. Three procedures are primarily used for
adolescent bariatric surgery, namely, laparoscopic sleeve
gastrectomy (LSG), laparoscopic adjustable gastric
banding (LAGB), and Roux-en-Y gastric bypass (RYGB).
Weight loss occurs due to a restrictive and malabsorptive
(37)
component .
Th e Internation a l Ped i a t r i c E n d o s urgery Group
recommends surgery in adolescents who have attained or
(37)
almost attained adult stature with specific guidance .
(Table 4).
Due to the complex nature intervention, particularly at
the vulnerable age of these patients, the use of
multidisciplinary team has become well established as
the gold standard of care necessary to provide a safe and
efficient service.
The team members recommended by the American
Society of Metabolic and Obesity Surgeon (ASMBS)
includes an experienced bariatric surgeon; a pediatrician
with a speciality in endocrinology and nutrition; a
dietician with experience in pediatric obesity; and a
psychiastrist or psychologist with specialty training in
(38)
treating eating disorders and obesity in adolescents .
Regarding the outcomes of the surgical management of
obesity in this population, there are several studies
carried out. In the Swedish Adolescent Morbid Obesity
Surgery study, a prospective nationwide study, they
performed laparoscopic RYGB in adolescents aged 13–18
years old. A signicant lower B MI w as o bserv ed
postoperatively compared with age-matched medically
managed controls. Moreover, cardiovascular risk factors
substantially improved after surgery, including glucose
to l e ra n c e, bl oo d pre s s ur e , a n d p l as m a l i pi d
concentra t i o n . All pati e n t s e x p e ri en ce d T 2 D M
(39)
remission . The Follow-up of Adolescent Bariatric
Surgery at 5 Plus Years (FABS 5+) investigated the
outcomes of adolescent bariatric surgery 5–12 years after
RYGB. In that study, mean baseline BMI was reduced
postoperatively by 29%. Furthermore, there were
(40)
remission of T2DM and resolution rate of hypertension .
CONCLUSIONS
- Obesity by itself, and its associated comorbidities,
generates structural and functional alterations, increasing
cardiovascular risk.
- The pathophysiological processes that link obesity with
atherosclerosis and CVD imply a chronic inflammatory
state.
- People with obesity without metabolic abnormalities have
a higher risk of coronary artery disease and heart failure
than metabolically healthy people of normal weight.
- Severe obesity in children and adolescents is associated
with a higher incidence of HT, dyslipidemia, and impaired
fasting glucose.
- Timely diagnosis and treatment of obesity is important to
decrease the mortality among pediatric population.
REQUIREMENTS
• Severe obesity (BMI ≥ 40) with serious obesity related comorbidities.
• Have attained or depending on the severity of comorbidity, nearly attained adult stature.
• Have failed at least 6 months of organized conventional attempts at weight management.
• Demonstrated commitment to comprehensive pediatric psychological evaluation both before and after surgery and agree to avoid pregnancy
for at least 1 year post-operatively.
• Be capable of and willing to adhere to nutritional guidelines post-operatively.
• Have decisional capacity and provide informed assent for surgical management.
arterial pressure, LV wall stress
Pulmonary artery hypertension
SERIOUS COMORBID
CONDITIONS
Type 2 diabetes mellitus
Moderate to severe obstructive sleep apnea
Pseudotumor cerebri
Severe and progressive steatohepatitis
LESS SERIOUS
COMORBIDITIES
• Weigh related arthropathy
• Hypertension
• Dyslipidemia
• Venous stasis disease
• Urinary incontinence
• Non-alcoholic fatty liver disease
• Gastroesophageal reflux
• Severe psychosocial distress and significant impairment in activity of daily living
Table 4. Criteria for bariatric surgery in adolescents.
Marcio Concepción-Zavaleta, Anthony Ramos-Yataco, Carlos Alcalde-Loyola, Diego Moreno-Marreros, Julia Coronado-Arroyo, Sofia Ildefonso-Najarro, María Quispe-Flores,
Esteban Plasencia-Dueñas, Luis Concepción-Urteaga, Francisca Zavaleta-Gutiérrez, Freddy Valdivia Fernández-Dávila
60
Revista del Cuerpo Médico del HNAAA, Vol. 14 Supl. Nº 1 ( 2021 ) | SARS-CoV-2, COVID-19 y Pandemia
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