Transcript Evaluation of Obese Child

Evaluation of Obese Child
Marlene Rodriguez, MD FAAP
La Clinica de la Raza
Peer Review
July 29, 2006
Role of Provider in Obesity
Prevention
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Screen weight status using BMI
Routinely deliver obesity prevention
messages (regardless of wt) during well
child exams
Order appropriate lab tests
Follow-up and/or refer
Prevalence of Childhood Obesity
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CA 5th highest prevalence of pediatric
overweight for 2-5 year old
Prevalence of overweight preschool children
and adolescents has doubled between 19761980 and 1999-2002 and more than tripled for
school aged children.
1/2 overweight school age children and 1/3
overweight pre-schoolers become overweight
adults
Increasing incidence DMT2 4.1 per 1000 in
children
Source: CHDP Provider Information Notice No.: 05-16
AMA Recommended Behaviors for
Obesity Prevention and Treatment
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Breastfeed
Increase Physical Activity
Limit TV and Screen time
Eat more fruits and veggies
Eat Breakfast Daily
Eat out less often, avoid fast food
Limit Portion Sizes
Limit sugar-sweetened beverages
Overweight Sensitivity
Avoid:
Replace with:
Obese, heavy, overweight, fat Unhealthy weight
Ideal Weight
Healthy weight
Fix the child
Family Behavior Change
Focus on weight
Focus on Lifestyle
Diets or “bad foods”
Healthier food choices
Exercise
Activity or play
Obesity Prevention at WCC
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Assess all children for obesity at all well
child checks starting at age 2
Use Body Mass Index (BMI) to screen
for obesity
Plot BMI on BMI growth chart
Diagnostic Categories
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<5%
5-84%
85-94%
95-98%
>99%
Underweight
Healthy Weight
Overweight
Obese
Proposed Category of
“Extreme Obesity” not yet
on BMI charts
BMI 99% Cut-Points
2
(kg/m )
Age Years
Boys
Girls
5
20.1
21.5
6
21.6
23.0
7
23.6
24.6
8
25.6
26.4
9
27.6
28.2
10
29.3
29.9
11
30.7
31.5
12
31.8
33.1
13
32.6
34.6
14
33.2
36.0
15
33.6
37.5
16
33.9
39.1
17
34.4
40.8
Obesity Prevent at WCC cont.
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Measure blood pressure using age and size
appropriate cuff
Obesity Risk Factors based on Hx and Exam
Take Focused Family Hx
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Obesity
DMT2
CVD such as HTN, cholesterol
Early death from stroke or cardiovascular disease
(age <55)
Assess for Other Causes of
Obesity
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Is there Developmental delay?
Is the child short for his weight?
Are there physical findings such as
hypogondadism?
Was there early hypotonia or poor
feeding?
If yes, then consider referral for genetic
counseling or endo evaluation.
Laboratory Evaluation for
Overweight Children > age2
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BMI 85-94%
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WITH RISK FACTORS
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Fasting Lipids
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Repeat Every 2 years if normal
Laboratory Evaluation for
Overweight Children > age10
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BMI 85-94%
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WITHOUT RISK FACTORS
Fasting Lipid Profile
Laboratory Evaluation for
Overweight Children > age10
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BMI 85-94%
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WITH RISK FACTORS
Fasting Lipid Profile
ALT & AST
Fasting Glucose
Fasting Insulin* may support dx of insulin resistance
(*La Clinica recommendation not part of official guidelines.)
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Repeat Every 2 years if normal
Laboratory Evaluation for
Obese Children > age 10
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BMI >95%
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REGARDLESS OF RISK FACTORS
Fasting Lipid Profile
ALT & AST
Fasting Glucose
Fasting Insulin* may support dx of insulin resistance
(*La Clinica recommendation not part of official guidelines.)
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Urine microalbumin or microalbumin/creatine
ratio (Stanford Recommendation)
Repeat Every 2 years if normal
CHDP Risk Factors
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FHx of Diabetes
Race/ethnicity:
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Signs of Insulin Resistance
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Black, Hispanic, American Indian, Asian, Pacific
Islander, Native Alaskan
Acanthosis Nigrans
PCOS
HTN
Dyslipidemia
< 30 minutes of activity per day or
consistently unbalanced diet
Source: CHDP Provider Information Notice No.: 05-16
CHDP Lab Recommendations
Overweight Children > age 5
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BMI 85-94%
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WITH AT LEAST 2 CHDP RISK FACTORS
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Fasting Glucose and Cholesterol
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Source: CHDP Provider Information Notice No.: 05-16
Abnormal Labs
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Elevated Transaminase Levels
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Check alpha-1 antitrypsin, ceruloplasm, ANA and
hepatitis antibodies
Liver U/S detects NAFLD but does not predict
fibrosis
Liver Bx to r/o fibrosis
Elevated Lipid Panel
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Dietary Counseling, Lifestyle Modification
AHA recommendation to start statins in some
children still controversial
Abnormal Labs
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Elevated Transaminase Levels
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Check alpha-1 antitrypsin, ceruloplasm, ANA and
hepatitis antibodies
Liver U/S detects NAFLD but does not predict
fibrosis
Liver Bx to r/o fibrosis
Abnormal Labs Cont.
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Abnormal Fasting Glucose
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Criteria for DMT2
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GTT (3 hour) with fasting glucose and insulin levels
If the above are abnormal refer to Endo at CHO
Criteria for DMT2
Fasting glucose
Casual glucose
>126 mg/ml
>200 mg/ml
Impaired glucose tolerance:
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Fasting glucose
Casual glucose
>100 mg/ml
>140 mg/ml
Obesity Co-Morbities
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NAFLD/NASH
Sleep Apnea
SCFE
Asthma
PCOS
Self-image/self-esteem
Depression
Other Targeted Lab Tests
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ECG, echocardiography in severe obesity
Liver U/S or bx if abnl LFTs
Urine Microalbumin/creatine ratio
Polysomnography
Skeletal radiographs (knee,hip,spine)
Plasma 17-OH progesterone, plasma
DHEAS, androstenedione, testosterone (free
and total), LH and FSH measurements
Genetic testings (FISH, fragile X)
NAFLD/NASH
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Similar to alcoholic liver disease but in people
who do not drink
Silent elevation of AST/ALT
Most common cause of Hepatitis in US
pediatric population
Male gender, Hispanic ethnicity, increasing
obesity are risk factors
Require bx for DX, but changes seen with US
Can go on to cirrhosis and transplant
No way to determine which NAFLD pt will go
onto fibrosis
Staged Treatment
Stage 1: Prevention Plus
Stage 2: Structured Weight Management
Stage 3: Comprehensive Multidisciplinary
Intervention
Stage 4: Tertiary Care Intervention
Counseling the Overweight Child
Brief Focused Advise
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Step 1: Engage the Patient/Parent
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How do you feel about your child’s wt?
Step 2: Share Information
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Your child’s current weight puts him/her at
risk for diabetes, heart dz, etc..
Use BMI graphic from HEAC
Effective Communications with Families Kaiser Permanente 2004
Counseling the Overweight Child
Brief Focused Advise
Step 3: Determine if Parent RECEPTIVE to discussion
about child’s weight:
If YES then move onto Step 4
If NO, determine if labs need to be ordered,
and set up follow-up to discuss results.
This is one way to initiate a conversation about
weight and health.
Effective Communications with Families Kaiser Permanente 2004
Counseling Obese Child Cont.
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Step 4: Make a Key Advise Statement
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I would strong encourage you to…
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Get up and play hard at least one hour/day
Cut back on screen time to <2 hours/day
Eat at least 5 helpings of fruits & veggies/day
Cut back on sweetened drinks such as soda, juice,
sports drinks
Step 5: Arrange for Follow-up
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Let’s set up future appt to talk about how things
are going
Effective Communications with Families Kaiser Permanente 2004
Stage 2: In Clinic Structured
Weight Management
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Referral to La Clinica Nutritionist
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Enrollment in Weight Management for
Children Classes
Stage 3: Comprehensive
Multidisciplinary Intervention
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Referral to Healthy Hearts
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Part of Cardiology Dept at CHO
Formerly Heathly Eating Active Living
(HEAL) clinic
Requires Fasting glucose, insulin, ALT,
AST, lipid panel, Hgb AIC
Go through referral specialist
There is now a waitlist
Stage 4: Tertiary Care
Intervention
Referral to Stanford or UCSF
Medications
Very Low Calorie Diet
Bariatric Surgery
La Clinica Resources
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Pediatric Obesity Taskforce
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Obesity Progress Notes
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2nd Thursday every month 12:30-1:30pm at TV
Two versions
Soon to roll out Obesity Registry
Fundraiser at Yoshi’s to benefit Childhood
Obesity Prevention
Health-e-resource.com
Sources
CHDP Provider Information Notice No.: 05-16
Office Evaluation of the Obese Child: New Expert Committee
Recommendations. L.D. Hammer, MD. Practical Strategies
for Managing and Preventing Childhood Obesity Conference.
Expert Committee Recommendations on Assessment,
Prevention and Treatment of Child and Adolescent
Overweight and Obesity 2007 NICHQ
Counseling the Overweight Child: A training for CHDP
providers. CHDP Statewide Nutrition Subcommitee
December 2008
Pre-Diabetes in Kids and Adolescents. Sue Haverkamp, MD
MSPH, La Clinica de la Raza, Peer Review 31 May 2006