Transcript Presentation 1 - North Carolina Foundation for Advanced Health

Systematic Assessment and
Treatment of Childhood Obesity
Annette Frain, RD, LDN
Ben Hooker, MS, MD, MPH, FAAP
Disclosures
Annette Frain
This speaker is employed by Triad Adult and
Pediatric Medicine, Inc and has no other
financial sources to disclose.
Ben Hooker
This speaker is employed by Triad Adult and
Pediatric Medicine, Inc and has no other
financial sources to disclose.
How bad is the problem? (1)
Since 1980, obesity among children and
adolescents has almost tripled.
9.5% of children 0 to 2 years are OBESE
(≥95% Weight : Length ratio)
14.8% of 2 to 19 year olds are
OVERWEIGHT
16.9% of 2 to 19 year olds are OBESE
(2)
Public Health (3)
Number of the heaviest (BMI > 97%) children is
increasing, even if overall percentage has
stabilized.
North Carolina will spend over $11 billion dollars
annually by 2018 on health care costs
attributable to obesity.
Allowing this problem to continue to grow at its
current pace will have dire economic, social, and
public health consequences, including lower life
expectancy in the 21st century.
Health Disparity
1 of 7 low-income, preschool-aged children is
obese.
The rate of obese and overweight HISPANIC and
AFRICAN-AMERICAN children ages 2-19 is
38.2% and 35.9%, respectively, while their
CAUCASIAN counterparts are at 29.3%.
Childhood obesity rates of AFRICAN AMERICANS
and HISPANICS increased by 120% between
1986-1998, but among non-Hispanic whites it
grew by only 50%.
Health Risks: NOW (4)
Obese children are more likely to have:
1.
High blood pressure and high cholesterol
(risk factors for cardiovascular disease).
In one study, 70% of obese children had
at least one CVD risk factor, and 39%
had two or more.
2.
Increased risk of impaired glucose
tolerance, insulin resistance and type 2
diabetes.
Health Risks: NOW
3.
Breathing problems, such as sleep
apnea, and asthma.
4.
Joint problems and musculoskeletal
discomfort.
5.
Fatty liver disease, gallstones, and
gastro-esophageal reflux.
6.
Greater risk of social and psychological
problems.
Health Risks: LATER (4)
1.
Obese children are more likely to
become obese adults.
2.
If children are overweight, obesity in
adulthood is likely to be more severe.
3.
Adult obesity is associated with a
number of serious health conditions
including heart disease, diabetes, and
some cancers.
Obesity Management Strategy
Obesity management is like management of any
other CHRONIC DISEASE:
Requires patient-centered and well-coordinated
care (MD/PNP, RD, Behavioral Health, Nursing,
Exercise), preferably within the context of a
Patient Centered Medical Home.
Obese children seen by general pediatricians can
be effectively managed using standardized
practices:
a. Evidence-based messages
b. Motivational interviewing techniques
Obesity Management System (5)
SORT:
Identify all practice methods currently used
to manage obesity in the practice. Evaluate
practices for effectiveness and discontinue
duplicate practices.
SET IN ORDER:
Order practices into a logical practice
protocol for assessing, risk stratifying, and
step-wise management of obesity.
Obesity Management System
SHINE:
Improve each step already in place to
achieve the desired goal.
STANDARDIZING:
Make execution of each step consistent
across the practice. Make standard the
evidence-based messages used, intervals
between visits, documentation, referrals,
etc.
Obesity Management System
SUSTAIN:
Ongoing system assessment in the form of
continuous PDSA cycles. Patient input is
critical to ensure the program is and
remains patient-centered.
Obesity Management (6)
At every PE appointment for children ≥2 years:
1.
HEIGHT, WEIGHT, and BMI:
a. Accurately MEASURE height and weight,
manual BP
b. CALCULATE BMI and plot according to
percentile by age and gender
(7)
c. CDC child and teen BMI calculator
2.
HISTORY and PHYSICAL EXAM
3.
LABS
Risk Stratification
Once appropriate data is in hand, it is
possible to assign a risk category to the
patient.
This RISK CATEGORY determines
treatment.
Determining Risk Category
Start with BMI definition (by age and gender):
<5th%
Underweight
5th% to <85th%
Healthy weight
85th% to 94th%
Overweight
95th% to 98th%
Obese
≥99th%
Obese (increased risk)
(7)
(8)
(9)
Truth? Or, just an excuse?
“I’m not fat! My mom says I’m big-boned!”
“I'm not fat, I just haven't grown into my body yet!”
“I'm not fat, I'm buff!”
(9)
Personal Risk Factors
Elevated BP for age and gender
Ethnicity (AA, NA, Hispanic, PI)
Puberty
Medications (steroids, anti-psychotics,
AED)
Acanthosis nigricans
LGA or SGA at birth
Disabilities
Family Risk Factors
Type 2 DM
Hypertension
High cholesterol
Gestational diabetes in mother
First degree relative with early death from
cardiac disease or stroke
Lab Screening (11)
1.
FH of dyslipidemia or premature
CVD or dyslipidemia (male first
degree relative ≤55 yrs, female first
degree relative ≤65 yrs).
2.
Patients for whom FH is not known
or those with other CVD risks:
overweight, obese, HTN, cigarette
smoking, or diabetes.
3.
Screen with FASTING lipid profile.
Lab Screening (10)
Per the provided algorithm:
<10 yrs BMI ≥ 85th%, no risk factors
OR
≥10 yrs
BMI 85th to 94th%, no risk factors
Consider fasting lipids.
≥10 yrs
BMI 85th to 94th%, ≥2 risk factors
OR
≥10 yrs
BMI ≥ 95th%,
Do fasting lipids every 6 months, plus fasting
glucose, LFT.
However… (12)
Recent research:
FH is not sensitive or specific in
identifying those children who may
need medication.
Proposing UNIVERSAL screening:
First at 9 to 11 years old, then
Repeat at 16 to 19 years old
However… (13)
FASTING is currently still recommended, but:
Study from UNC (fasting v. NON-FASTING):
Total Cholesterol and HDL were same,
LDL varied slightly,
TG varied the most.
It may be as effective to draw lipids at the same
visit that prompts the decision to do so.
Risk Stratification
1.
Defined by BMI as overweight, obese, or
obese (increased risk),
2.
Identified risk factors by PE and history,
3.
Collected blood for appropriate labs.
We are ready to get started on treatment,
BUT…
(14)
Are they ready? (15)
TRANSTHEORETICAL MODEL (TTM) OF
CHANGE identifies 5 stages of change:
1.
PRE-CONTEMPLATION:
No intent to change in the next 6 months.
“Unmotivated”
2.
CONTEMPLATION:
Intend to change in the next 6 months.
“Ambivalent”
Stages of Change
3.
PREPARATION:
Intends to take steps within 1 month.
“Active”, but in EARLY change.
4.
ACTION:
Has made obvious lifestyle changes.
More tempted to relapse.
5.
MAINTENANCE:
Working to prevent relapse, consolidate gains.
Less tempted to relapse.
(16)
Readiness to Change
Information alone does not motivate
change.
A unilateral agenda is unlikely to
work.
When you find a “ready patient”…
TOGETHER you work to find what motivates
them to make lifestyle changes.
MOTIVATIONAL INTERVIEWING:
To move a family that is not ready to change
closer to making changes.
To create a shared agenda to change lifestyle
for the family that is ready to change.
Motivational Interviewing
Child is the focus, but family is also
engaged.
Foster a co-operative relationship.
Incremental changes add up over time
to produce a healthier lifestyle.
(17)
(10)
Prevention (10)
HEALTHY WEIGHT (BMI < 85th%)
OVERWEIGHT (BMI 85-94th%), no risk
factors
Reinforce healthy behaviors,
Address questions and concerns,
Correct any misconceptions,
Follow on a yearly basis to reassess BMI and
risk factors.
Step 1 Treatment
OVERWEIGHT (BMI 85-94th%) WITH risk
factors
OBESE (BMI ≥ 95th%)
Treatment starts with the coordinated efforts of the
PCP and RD.
Meet with PCP or RD once every 1 to 3 months.
Review previous visit and identify ways to make
progress.
Step 1 Treatment
Evidence-based messages about healthier
eating and physical activity are the content
of patient-provider dialogue.
Information is important to advance the
patients understanding of the problem of
obesity, but is not sufficient to motivate
the patient to change.
Eat Smart, Move More NC's Seven
Target Behaviors (18)
1. Promote breastfeeding
2. Increased physical activity
3. More fruits and vegetables
4. No sugar-sweetened beverages
5. Reduce screen time
6. More meals at home
7. Smaller portions of food and drinks
Step 1 Treatment
Managed by PCP +/- RD
Visits every 1-3 months
If RD involved, the two clinicians must
communicate regularly.
BEHAVIORAL HEALTH CLINICIAN may also
become involved, if appropriate.
GOAL: Slow velocity of weight gain, then BMI
decreases as patient grows in height.
“Warm Hand-Off’
PCP assesses the family’s “readiness to change,”
finds they are ready to make lifestyle changes.
PCP calls the RD in to give more detailed nutrition
counsel. Calling the RD in on the spot increases
the impact of counseling and improves the
chances that the family will follow-up.
Continued contact between PCP and RD ensures
consistent messages and helps the patient and
family continues to perceive this as an important
issue.
IF,
Patient does not stabilize or improve after 3 to 6
months of Step 1 treatment
OR
Patient > 6 years old with BMI >99th percentile at
initial assessment
THEN
STEP 2 treatment
Step 2 Treatment
OVERWEIGHT WITH RISK FACTORS (no
improvement after 3-6 months)
OBESE (no improvement after 3-6 months)
EXTREMELY OBESE (BMI >99th%) and >6
YEARS OLD
Designated Provider (DP) with an interest
in obesity
DP coordinates care with RD.
DP or RD sees these patients once per month.
Step 2 Treatment
DP starts with a comprehensive history and physical
exam to collect data to RISK STRATIFY the
patient.
Also, perform detailed screening for Psychosocial
factors that may make change difficult.
May be appropriate to involve the BEHAVIORAL
HEALTH CLINICIAN.
Entire family is still the target.
Step 2 Treatment
GOAL: Weight maintenance, allowing BMI
to decrease as the patient grows.
IF
Patient fails to improve or stabilize over 3
to 6 months
THEN
STEP 3 treatment
Step 3 Treatment
OVERWEIGHT WITH RISK FACTORS
(no improvement after 3-6 months of
Step 1 or 3-6 months of Step 2 treatment)
OBESE (no improvement after 3-6 months
of Step 1 or 3-6 months of Step 2
treatment)
EXTREMELY OBESE and >6 YEARS
OLD (with no improvement after 3-6
months of Step 2 treatment)
Step 3 Treatment
Most intense phase
Often carried out at a tertiary care center.
Weekly visits for 8 to 12 weeks,
Seen by the DP, RD, and BEHAVIORAL
HEALTH CLINICIAN at every visit.
GOAL: Weight maintenance or gradual
weight loss.
“Given what we know
about the health benefits
of physical activity,
it should be mandatory
to get a doctor’s permission
NOT to exercise.”
—Author Unknown
Exercise
Physical activity is FUN!!!
Each family defines fun differently
Be aware of parents limitations
Have a sensitivity to the environment
Safety of the neighborhood
Access to exercise resources
Generally, we encourage limited screen
time (<2 hours per day), but “active
videogames” can be a compromise
Medications
(18)
1. Hypertension
2. Dyslipidemia
3. Metabolic syndrome
(20)
Table 8-5. Anti-hypertensive Medications with Pediatric Dosing
Angiotensin-converting enzyme (ACE) inhibitors
Drug
Initial Dose
Maximum Dose
Interval Evidence FDA
Benazepril
0.2 mg/kg/day up to 10 mg/day Daily
0.6 mg/kg/day up to 40 mg/day
RCT
Captopril
0.3-0.5 mg/kg/dose (>12 mos)
6 mg/kg/day
TID
RCT
NO
Case series
Fosinopril
(Children >50 kg)
5-10 mg/day
40 mg/day
Daily
RCT
YES
Lisinopril
0.07 mg/kg/day up to 5 mg/day Daily
0.6 mg/kg/day up to 40 mg/day
RCT
YES
Quinapril
5-10 mg/day
80 mg/day
RCT
Daily
YES
(20)
(20)
(21)