PEDIATRIC OBESITY I have had no financial relationships to disclose. - - PDF document

5/10/2013 1 PEDIATRIC OBESITY

VANESSA CURTIS, MD May 17, 2013

Relevant Financial Relationships

I have had no financial relationships to disclose.

Acute Care Visit

12 year old female with “asthma” Family reports that child has been having chest pain and SOB for the past 2 weeks Patient is generally healthy but has a history of asthma and has presented multiple times for similar symptoms. She denies wheezing and says “rest makes my pain better, moving makes it worse”. There is a family history of asthma, newly diagnosed type 2 diabetes in her mother, and her father died at age 47 years of a heart attack.

Acute Care Continued

Vitals: HR 85 BP 134/67 Weight 65kg (144lb) Height 155cm (61”)

BMI 27 kg/m2

Physical exam: No distress or increased work of breathing Normal lung sounds with no wheezing No tenderness to palpation on chest wall Normal S1 and S2 without murmur; pulses 2+ without edema Abdomen soft, nontender, nondistended Darkened skin along posterior neck and in axillae with skin

tags

Workup shows normal CXR and EKG Labs remarkable for glucose of 156 mg/dL, otherwise BMP

and CBC are normal

Alarming Statistics

Nationally, 66% of adults and 33% of children and

adolescents are overweight or obese

Since 1980, number of obese adults has doubled Since 1970, number of obese adolescents has tripled Since 1970, number of obese children has quadrupled Current generation of children may not outlive their parents Health-related quality of life scores of obese children and

adolescents lower than scores from children with cancer receiving chemotherapy

Childhood obesity tracks into adulthood

F as in Fat: How Obesity Threatens America’s Future 2010. Trust for America’s Health - www.healthyamericans.org DeMattia L and Denny SL. Ann Amer Acad Polit Soc Sci. 2008;615:83-99. Clarke WR and Lauer RM. Crit Rev Food Sci Nutr. 1993;33:423-430. Schwimmer JB et al. JAMA. 2003;289:1813-1819.

Audience Response

What percent of Iowa children are overweight or obese?

1.

Less than 5%

2.

5-10%

3.

10-20%

4.

20-30%

5.

30-40%

6.

Over 40%

10

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Audience Response

What percent of Iowa children are overweight or obese?

1.

Less than 5%

2.

5-10%

3.

10-20%

4.

20-30%

5.

30-40%

6.

Over 40%

0% 0% 0% 0% 0% 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Obesity Among US Children

2003 2005 2007 National Survey of Children’s Health

Audience Response

A child with a BMI at the 90%ile for age and sex is considered:

1.

At risk for overweight

2.

Big Boned

3.

Overweight

4.

Obese

5.

Healthy

6.

Unlikely to make the cross country team

10

Audience Response

A child with a BMI at the 90%ile for age and sex is considered:

1.

At risk for overweight

2.

Big Boned

3.

Overweight

4.

Obese

5.

Healthy

6.

Unlikely to make the cross country team

0% 0% 0% 0% 0% 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

How is Pediatric Obesity Different?

Use BMI percentiles to define weight status BMI is plotted on the CDC BMI-for-age growth charts (separate

for girls and boys) to obtain a percentile ranking

Children don’t always control their environment Food sources Activity opportunities Behavior is modeled Focus needs to be on family, not child Weight loss is not always the goal

Weight Status Category Percentile Underweight Less than the 5th percentile Healthy Weight 5th percentile to less than the 85th percentile Overweight 85th to less than the 95th percentile Obese Equal to or greater than the 95th percentile

BMI (kg/m2)

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Example BMI Growth Chart

Example Patient 12 year old female Weight 65kg (144lb) Height 155cm (61”) BMI 27 kg/m2

Why Worry About Pediatric Obesity?

Risks of adult obesity Obese as an…. Infant 14% chance Preschooler 17% chance 7 years old 41% chance 12 years old 75% chance Adolescence 90% chance

Audience Response

All of the following are components of the metabolic syndrome EXCEPT?

1.

Elevated Blood Pressure

2.

High triglycerides

3.

Obese BMI

4.

High LDL cholesterol

5.

Fasting glucose over 100 mg/dl

10

Audience Response

All of the following are components of the metabolic syndrome EXCEPT?

1.

Elevated Blood Pressure

2.

High triglycerides

3.

Obese BMI

4.

High LDL cholesterol

5.

Fasting glucose over 100 mg/dl

0% 0% 0% 0% 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Metabolic Syndrome

Adults Central Obesity WC > 102 cm (88 cm) BMI >30 kg/m2 Hypertriglyceridemia >150 mg/dL Depressed HDL <40 mg/dL (50) Hypertension Varies, >135/85 Impaired glycemic control IR or T2DM IFG (>100 mg/dL) IGT on OGTT Pediatrics No clear consensus Need to use

height/age/sex/racial norms

5th-84th percentile “HEALTHY WEIGHT” 85th-94th percentile “OVERWEIGHT” ≥95th percentile “OBESE” Provide education on healthy diet and physical activity to maintain weight velocity Diabetes screening† – fasting glucose

† Screen if 2 or more risk factors present: family history of diabetes, signs of insulin resistance, race (Native American, African American, Hispanic, Asian/South Pacific Islander), Glucose <100 (normal) Encourage healthy diet and physical activity Rescreen in 2 years Glucose≥126 (diabetes) Refer to Pediatric Endocrinology Glucose between 100-125 (pre-diabetes) Encourage dietary and physical activity changes Rescreen in 1 year Liver disease screening – ALT/AST Cholesterol screening – fasting lipid panel Blood pressure screening - Average of 3 blood pressure measurements (use tables to identify blood pressure percentiles ALT, AST <2X upper limit Rescreen in 2 years ALT, AST >2X upper limit Refer to Pediatric Gastroenterology Blood Pressure <90th percentile (normal) Encourage healthy diet and physical activity Recheck at next visit Blood Pressure between 90th-94th percentile (pre-hypertension) Encourage dietary and physical activity changes Recheck in 6 months Blood Pressure ≥95th percentile (hypertension) Refer to Pediatric Nephrology Total Cholesterol<170, LDL<110, Triglycerides<130 Rescreen in 3-5 years Total Cholesterol≥170, LDL≥110, Triglycerides ≥130 Refer to Pediatric Cardiology

Pediatric Overweight and Obesity Comorbidity Screening Algorithm

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Hypertension

Prevalence has been increasing with a 10-year lag behind

• besity trend

Causes of elevated blood pressure White coat hypertension Primary hypertension (essential) Secondary hypertension Coarctation of the aorta Kidney disease Obesity Need 3 separate measurements – now what? 24 hour ambulatory blood pressure monitor School nurse and/or other health provider Search medical records Caveats – inappropriate cuff size, anxious at visit, health at visit

Din-Dzetham al. Circulation. 2007;116:1488-1496.

Dyslipidemia

Process of atherosclerosis begins in childhood and is

progressive throughout life

Prevalence of lipid abnormalities is increasing Lab findings: Elevated TG levels Elevated LDL levels Low HDL levels

Lipid Research Clinics Program. The Lipid Research Clinics Population Studies Data Book. 1980;DHHS publication no. (NIH) 80-1527. National Cholesterol Education Program. Pediatrics. 1992;89(3):509-511. Daniels SR et al. Pediatrics. 2008;122:198-208. NHLBI Expert Panel. Pediatrics. 2011;128:S213-S256.

TC = total cholesterol; TG = triglycerides † Not established by NCEP, these values are taken from NHANES study values ‡ Values are for children <10 years and children ≥10 years PERCENTILE TC LDL TG † ‡ HDL † NON-HDL Acceptable < 75th <170 <110 <75 (<90) ≥45 <120 Borderline 75th-95th 170-199 110-129 75-99 (129) 40-44 120-144 Elevated > 95th ≥200 ≥130 ≥100 (≥130) <40 ≥145

Diabetes

Insulin resistance is common Type 2 vs Type 1 diabetes can be difficult to discern at

presentation

45% of new pediatric diagnoses are T2DM Racial and ethnic disparities Normal IGT IFG T2DM

Audience Response

Of the following, which patient has the highest likelihood of having T2DM?

1.

8 yo NHW male

2.

12 yo NHW female

3.

5 yo Hispanic female

4.

15 yo American Indian male

5.

7 yo Black female

10

Audience Response

Of the following, which patient has the highest likelihood of having T2DM?

1.

8 yo NHW male

2.

12 yo NHW female

3.

5 yo Hispanic female

4.

15 yo American Indian male

5.

7 yo Black female

0% 0% 0% 0% 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Age and Racial/Ethnic Disparities in T2DM Incidence

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Non-Alcoholic Fatty Liver Disease

No treatment for fatty liver disease Projections from UNOS indicate NAFLD will overtake HCV

as the most common primary diagnosis of liver failure in liver transplant recipients by 2020

Genetic Factors Energy Excess Insulin resistance

Other Comorbidities Barriers to Counseling

Child’s weight gain is “just a phase” and “will grow out of it” Discomfort about weight-related issues Time constraints Lack of resources Receptiveness of family to discussion

Back to the Acute Care Patient

Your patient may have had chest pain secondary to deconditioning. She also had elevated blood pressure, impaired glucose tolerance, signs of insulin resistance. She has a high likelihood of developing cardiovascular disease and diabetic disease giver her family history. Ideally, You counsel this family regarding her weight, current status of obesity-related disease, and assist in referrals for additional support and/or counseling.

Role of Primary Care Providers

Provide assessment of growth Measurement of BMI Evaluate for complications related to obesity Blood pressure evaluations Laboratory screening Guidance regarding healthy eating, physical activity, and

consequences of obesity

Assist in referrals for additional obesity-related disease

guidance

5th-84th percentile “HEALTHY WEIGHT” 85th-94th percentile “OVERWEIGHT” ≥95th percentile “OBESE” Provide education on healthy diet and physical activity to maintain weight velocity Diabetes screening† – fasting glucose

† Screen if 2 or more risk factors present: family history of diabetes, signs of insulin resistance, race (Native American, African American, Hispanic, Asian/South Pacific Islander), Glucose <100 (normal) Encourage healthy diet and physical activity Rescreen in 2 years Glucose≥126 (diabetes) Refer to Pediatric Endocrinology Glucose between 100-125 (pre-diabetes) Encourage dietary and physical activity changes Rescreen in 1 year Liver disease screening – ALT/AST Cholesterol screening – fasting lipid panel Blood pressure screening - Average of 3 blood pressure measurements (use tables to identify blood pressure percentiles ALT, AST <2X upper limit Rescreen in 2 years ALT, AST >2X upper limit Refer to Pediatric Gastroenterology Blood Pressure <90th percentile (normal) Encourage healthy diet and physical activity Recheck at next visit Blood Pressure between 90th-94th percentile (pre-hypertension) Encourage dietary and physical activity changes Recheck in 6 months Blood Pressure ≥95th percentile (hypertension) Refer to Pediatric Nephrology Total Cholesterol<170, LDL<110, Triglycerides<130 Rescreen in 3-5 years Total Cholesterol≥170, LDL≥110, Triglycerides ≥130 Refer to Pediatric Cardiology

Pediatric Overweight and Obesity Comorbidity Screening Algorithm

5/10/2013 6

University of Iowa Cardio-Metabolic Clinic

Multidisciplinary clinic targeting comorbidities of childhood

• besity

Cardiology Endocrinology Psychology Nutrition Exercise Physiology Other services provided based on presence of additional

conditions

• Gastroenterology
• Nephrology
• Sleep Specialists
• Surgery

Questions, Comments, Ideas