C H A P T E R 7 suggesting a defect both in secretion and clearance15, 17. Alterations in GH receptors and circulating GH-‐binding proteins support these changes18, 19. Bocca et al showed that insulin resistance and cardiovascular risk factors are al-‐ ready evident in overweight and obese children with a mean age of 4.7 years. An association exists between insulin resistance and BMI, waist circumference and percentage body fat20. The question arises if obesity will improve by rhGH treat-‐ ment. It is dubious to give rhGH treatment to obese children. However, if a child suffers from obesity due to an insulin resistance, rhGH therapy is theoretically indi-‐ cated but, as in all cases of insulin resistance known as diabetic type II, the first step is lowering weight by means of dietary measures. One can discuss if rhGH treatment is indicated in very obese children. Like bariatric surgery, these treatment options are controversial in pediatric patients. Bariatric surgery in children results in clinically significant weight loss, but also has the po-‐ tential for serious complications21. Therefore, this is not a usual treatment option. But in the case of severe obesity, where other treatment options failed, it is ques-‐ tionable if more risky therapies, under strict monitoring, are indicated if we take the severe comorbidities of obesity into account. Costs Not only the health consequences of overweight in childhood are a serious problem, but also the financial aspect. Consequences and comorbidities of obesity like cardi-‐ ovascular diseases, DM type II, orthopedic problems, skin abnormalities and psy-‐ chosocial problems such as underachievement in school and lower self-‐esteem, will lead to rising health care costs if the incidence of obesity is increasing in the future. Treating obesity and obesity-‐related conditions costs billions of dollars a year. By one estimate, the United States spent $190 billion on obesity-‐related health care expenses in 2005, double previous estimates22. The medical costs of obesity-‐related illnesses in the United States have been estimated at $209.7 billion annually (in 2008)23. Not only these direct costs have to be taken into consideration, but also indirect costs like absence from work due to ilness. Obese employees miss more days from work due to short-‐term absences, long-‐term disability, and premature death than non-‐obese employees24. Some studies show that obese employees have also lower wages25. One can imagine that obese persons with possible psychosocial problems and lower self-‐esteem due to their weight are less likely to ask for increment in salary or improvement of career options. One can imagine that these problems also apply for children at school. Obese children suffer from bullying, are less self-‐ assured and therefore probably less motivated to go to school. 110
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