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Re: What Obelix did not know: Non-alcoholic fatty liver disease is a significant co-morbidity of obesity

Dear Editor,

“I never knew anyone could get liver trouble” Obelix in ASTERIX AND THE CHIEFTAIN’S SHIELD

With great interest we read the article by Sabin et al. (2006)[1] that characterises some of the co-morbidities of childhood obesity. The authors convincingly demonstrate significant health risks associated with obesity in a cohort of 204 obese children and adolescents aged 1.7 to 18 years. Atherosclerosis as a result of malfunctioning metabolic pathways such as the insulin MAP Kinase route is in everybody’s mind – but few are concerned about chronic liver disease in obesity. We were disappointed to read another report that did not recognise obesity associated non- alcoholic fatty liver disease (NAFLD) as a significant health risk in obese children.

• In a cohort of 1939 Japanese patients with type 2 diabetes who were followed up over a period of 22 years (mean observation period 9.4 years) the ratio of observed / expected deaths from liver disease was 2.67 and exceeded that of heart disease (1.81), cerebrovascular disease (1.48) and pneumonia (1.22). [2]

• Several groups, including our own, have reported the development of cirrhosis in obese children with NAFLD. [3, 4]

Despite this NAFLD is often overlooked and referrals to paediatric gastroenterologists are made infrequently. [5, 6] We feel morbid obesity and the metabolic syndrome are multi system disorders that need a multidisciplinary approach from a number of paediatric specialists including hepatologists.[7] The sooner we appreciate all aspects of the complex co-morbidities and complications of the obesity epidemic including NAFLD, the better we can care for our patients.

References:

1. Sabin MA, Ford AL, Holly JM, et al.: Characterisation of morbidity in a UK, hospital based, obesity clinic. Arch Dis Child 91:126-130, 2006

2. Sasaki A, Horiuchi N, Hasegawa K, et al.: Mortality and causes of death in type 2 diabetic patients. A long-term follow-up study in Osaka District, Japan. Diabetes Res Clin Pract 7:33-40, 1989

3. Schwimmer JB, Behling C, Newbury R, et al.: Histopathology of pediatric nonalcoholic fatty liver disease. Hepatology 42:641-649, 2005

4. Evans HM, Shaikh MG, McKiernan PJ, et al.: Acute fatty liver disease after suprasellar tumor resection. J Pediatr Gastroenterol Nutr 39:288- 291, 2004

5. Baumann U, McKiernan PJ, Kelly D: The trouble with biopsies... J Pediatric Gastroenterol Nutr in press, 2006

6. Fishbein M, Mogren J, Mogren C, et al.: Undetected hepatomegaly in obese children by primary care physicians: a pitfall in the diagnosis of pediatric nonalcoholic fatty liver disease. Clin Pediatr (Phila) 44:135- 141, 2005

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Re: The demographics and change in BMI-SDS of Asian children attending a weight management clinic

Dear Editor,

Sabin et al in their study on patients in a hospital based weight management clinic inform our understanding regarding the demographics and morbidity of children with obesity(1). However, they only saw a small proportion of children from ethnic minorities. Asian children are more liable to obesity than their white peers(2) so investigating this in different geographical areas is important. Since October 2001 Birmingham Heartlands Hospital has also run a weight management clinic. This clinic is based in an inner city district general hospital serving an ethnically diverse population in the West Midlands where the 2001 census recorded 19.52% of people describing themselves as Asian or Asian British in Birmingham(3). Children referred to the Birmingham Weight Management clinic receive an assessment from a consultant paediatrician with a specialist interest in diabetes and endocrinology and a dedicated dietician; this includes a detailed clinical examination and dietetic history. Advice is given regarding dietary modifications, lifestyle change, and realistic weight loss goals. The majority are screened for metabolic complications like hypertension, impaired glucose tolerance (using a standard OGTT-1.75 g/kg maximum 75 g), hyperlipidemias, fatty liver infiltration etc. Serum Cortisol and sex hormones are estimated if clinically indicated.

From October 2001 to April 2006, 74 patients were referred for assessment. We retrospectively reviewed the notes of 68 patients (92%). Of these, 20 were Asian children (29%), including 11 boys. The mean age at referral was 12.1 (range 6-16), with a mean BMI of 33.03 (range 25-44) with mean BMI-SDS of +3.25 (range 2.01-4.49). This compared with a mean BMI of 36.9/ BMI-SDS of +3.65 for the rest of the children seen in the clinic (including some mixed-race children).

A family history of obesity was documented in 7 children (35%) and Type 2 diabetes in 10 (50%). This is higher than that found in the Caucasian population in Bristol, but similar to the non-Asian children in Birmingham with 43.8% and 41.7% for a family history of obesity and type 2 diabetes respectively. Acanthosis nigricans was found in 13 (65%), greater than those children in Sabin’s paper1. Investigations revealed marginally raised triglycerides in 3 (15%), impaired glucose tolerance in 1 (5%), hypothyroidism in 2, and 1 child was diagnosed with Cushing’s syndrome. Bardot-Biedl Syndrome was recognised in 1 child. Orlistat was prescribed once. Only 1 (2%) of the non-Asian children had a moderately raised triglyceride level, whilst none had impaired glucose tolerance. For the 17 children attending more than one Weight Management Clinic appointment 8 (47%) children achieved a lower BMI-SDS with a mean decrease of 0.22. This was similar to the mean decrease in BMI-SDS of 0.1 for the other children seen in the clinic.

The Asian children in the Birmingham Heartlands clinic have struggled to reduce their weight which has implications for future health. Closer working between hospital based specialist obesity clinics and community programmes like WATCH IT, MEND may tackle this growing problem better(4). Without culturally sensitive management plans we may inadvertently add to the health inequalities of certain populations in the UK.

Acknowledgements: Dr Sarah Ehtisham – conversion of BMI to BMI-SDS

Competing Interests: None

Funding: Nil

References:

1. M A Sabin, A L Ford, J M P Holly, et al Characterisation of morbidity in a UK, hospital based, obesity clinic. Arch Dis Child 2006; 91: 126-130.

2. SA Jebb, KL Rennie, TJ Cole. Prevalence of overweight and obesity among young people in Great Britain. Public Health Nutr 2004; 7(3): 461-5

3. Key Figures for 2001 Census: Census Area Statistics. www.neighbourhood.statistics.gov.uk (last accessed 09/05/07).