Laura Kinlin, MD, Hospital for Sick Children
Laura Kinlin is a staff physician in the Division of Paediatric Medicine and a post-doctoral research fellow in the SickKids Research Institute. A graduate of Dalhousie Medical School, she completed residency training in Paediatrics at the University of Toronto and an Academic General Paediatrics Fellowship at The Hospital for Sick Children. Her clinical and research interests include growth and nutrition in autism spectrum disorder (ASD). Her research is supported by a Fellowship Award from the Canadian Institutes of Health Research (CIHR).
Dr. Laura Kinlin answers the outstanding questions….
Would you start metformin in a non-obese patient?
As far as I’m aware, there is no evidence relevant to role of metformin in preventing weight gain with initiation of an atypical antipsychotic. The studies included in my presentation were focused on children and youth with ASD who had already experienced weight gain with psychotropic medication. More broadly, the role of metformin in paediatric obesity (not specific to children and youth with ASD) has also focused on treatment rather than prevention.
Although metformin is generally a safe medication it can have side effects (most commonly GI – diarrhea and cramping for example). Given the paucity of evidence regarding a preventive role for metformin and the potential for side effects, I would not start metformin in the situation you describe. I’d recommend close follow-up and consideration of metformin if weight gain is a concern.
At what age is bariatric surgery an option?
Guidelines for bariatric surgery used to include puberty maturity as an eligibility criterion. However, current guidelines do not recommend limiting access to surgery based on pubertal status or physical maturity. Bariatric surgery is typically considered an option in “adolescence,” although there are no widely accepted cutoffs for defining adolescence. In their guidelines, the AAP defines adolescence from age 13 years to age 18 years (Armstrong, S., Bolling, C., Michalsky, M., & Reichard, K. (2019). Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices. Pediatrics (Evanston), 144(6), e20193223–. https://doi.org/10.1542/peds.2019-3223). The American Society for Metabolic and Bariatric Surgery defines adolescence similarly to the World Health Organization – between the ages of 10 and 19 years of age ((Pratt JSA, Browne A, Browne NT, et al. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surg Obes Relat Dis. 07 2018;14(7):882-901.). It is widely accepted that the individual should be developmentally able to understand the risks and benefits of surgery, and be able to adhere to the lifestyle modifications required.
Is there an age at which the weight problem becomes recognized?
Great question. The relationship between age and risk of obesity in children and youth with ASD isn’t entirely clear. In at least one study, risk of obesity started as early as 2 to 5 years of age (Hill AP, Zuckerman KE, Fombonne E. Obesity and Autism. Pediatrics. 2015;136(6):1051-1061. doi:10.1542/peds.2015-1437). Other studies suggested that with increasing age there is higher risk of obesity (Must A, Eliasziw M, Phillips SM, et al. The Effect of Age on the Prevalence of Obesity among US Youth with Autism Spectrum Disorder. Child Obes. 2017;13(1):25-35. doi:10.1089/chi.2016.0079). I’m working with the Ontario data I presented to explore this question further. At what age risk of obesity is highest, relative to typically developing children and youth? Are growth trajectories (i.e., growth patterns over time) different in children and youth with ASD relative to typically developing children and youth?
Resources Mentioned in Session
- Diagnostic and Statistical Manual of Mental Disorders. 5th edn
- Autism Spectrum Disorder Among Children and Youth in Canada 2018: A Report of the National Autism Spectrum Disorder Surveillance System
- Association among obesity, overweight and autism spectrum disorder: a systematic review and meta-analysis
- The risk of overweight and obesity in children with autism spectrum disorders: A systematic review and meta-analysis
- 58 Overweight and obesity in children with autism spectrum disorder: Findings from primary care electronic medical records
- Food selectivity in children with autism spectrum disorders and typically developing children
- A comparison of eating behaviors between children with and without autism
- Comparison of sedentary behaviors between children with autism spectrum disorders and typically developing children
- Comparison of physical activity between children with autism spectrum disorders and typically developing children
- Television, video game and social media use among children with ASD and typically developing siblings
- Weight gain and metabolic risks associated with antipsychotic medications in children and adolescents
- Weight Gain and Metabolic Consequences of Risperidone in Young Children With Autism Spectrum Disorder
- Autism and Obesity: Prevalence, Molecular Basis and Potential Therapies
- Sleep in Autism
- Food as a reward and weight status in children with autism
- “Girls don’t have big tummies”: The experiences of weight-related discussions for children with autism spectrum disorders
- Autism Spectrum Disorder and the Child’s Weight-Related Behaviors: A Parents’ Perspective
- Post-diagnostic management and follow-up care for autism spectrum disorder
- Weight Management in Primary Care for Children With Autism: Expert Recommendations
- Recommendations for treatment of child and adolescent overweight and obesity
- Modification of motivational interviewing for use with people with mild intellectual disability and challenging behaviour
- Metformin for Treatment of Overweight Induced by Atypical Antipsychotic Medication in Young People With Autism Spectrum Disorder: A Randomized Clinical Trial
- A Randomized, Placebo-Controlled Trial of Metformin for the Treatment of Overweight Induced by Antipsychotic Medication in Young People With Autism Spectrum Disorder: Open-Label Extension
- ASMBS pediatric metabolic and bariatric surgery guidelines, 2018
- ATN/AIR-P Video Tol Kit: Medication Decisions and Pill Swallowing
- Is this Stomach, Mouth or Heart Hunger?- Craving Change