Update on Childhood Obesity Barbara Thompson, MD Pediatric Endocrinology Mary Bridge Children’s Hospital

MHS/MMA Pediatric Well Child Checks 4/1/12-3/31/13

Assessment of Obesity BMI kg/m2 Index of adiposity Correlates with markers of secondary complications of obesity: blood pressure, lipids, and lipoproteins

BMI >95%ile for age and sex: These children should undergo an evaluation Also have a significant likelihood of persistence of obesity into adulthood 85-95%ile: at risk for obesity

BMI Curves

The Medical History Identifies modifiable lifestyle behaviors Assessment of current and future risks for medical co morbidities Assessment of patient and family’s readiness to change A history of poor growth despite weight gain more likely to suggest hormone disorders or genetic syndromes

Singe gene disorders Prader-Willi, Bardet-Biedl, Alstorm and Cohen syndromes Relatively rare Genetic testing may be indicated when specific findings are present

Hypothyroidism Frequently a concern of parents but does not usually cause severe obesity Usually has cessation of linear growth Extremely unlikely in the tall obese child

Complications of Obesity Orthopedic: SCFE, Blount’s disease Neurologic: pseudotumor cerebri Respiratory: Obstructive sleep apnea, obesity hypoventilation syndrome Endocrine: PCOS, Diabetes Cardiovascular: Hypertension, dyslipidemia GI: NAFLD

Who to evaluate? BMI <85%ile: not at risk for overweight –Diet and exercise counseling especially if parents are obese BMI 85-95%ile: At risk for overweight Evaluate family history, blood pressure, cholesterol, degree of change in BMI and family’s concern about weight

Evaluation of Co-Morbidities Sleep and Respiratory Gastrointestinal Endocrine Disorders Blood pressure Lipids Orthopedic Disorders Depression

Sleep/Respiratory Prevalence may be >50% among adolescents with severe obesity Ask about snoring and daytime somnolence Obstructive sleep apnea may occur in the absence of enlarged tonsils May lead to RVH and pulmonary hypertension Diagnosis made by polysomnography

NAFLD Most common cause of liver disease in children Includes simple steatosis, steatohepatits, fibrosis, and cirrhosis resulting from fatty liver Generally asymptomatic but may have vague, recurrent abdominal pain Screen with routine abdominal exams and AST/ALT Initial treatment is weight loss and improving insulin resistance GERD, gallstones and constipation also common in obesity

Type 2 Diabetes The rise in type 2 is occurring world wide in parallel with an increase in childhood obesity NHANES- 29% of self-reporting adolescents with diabetes (12-19y) had type 2 In a group without diabetes 11% had impaired fasting glucose

Risk Factors Overweight Family History Ethnicity Conditions with insulin resistance

Who should we screen? Screening recommendations for type 2 diabetes mellitus (T2DM) in children and adolescents Overweight status Body mass index 85th percentile for age and gender, Weight for height 85th percentile, Weight 120 percent of ideal for height Plus any two of the following risk factors: 1.Family history of T2DM in a 1st or 2nd degree relative 2.High-risk race/ethnicity African American, Hispanic, Asian Pacific Islander,Native American 3.Signs of insulin resistance on physical examination or conditions associated with insulin resistance : Acanthosis Nigricans, Hypertension, Dyslipidemia, Polycystic ovary syndrome Begin screening at age 10 years or at onset of puberty if this occurs less than 10 years old. Repeat screening every 2 years Diabetes Care Feb;29(2):212-7.

How should we screen? FPG or OGTT? The ADA recommends measuring a fasting plasma glucose (FPG) as the preferred method of screening because it is more convenient, less expensive, and less invasive than the oral glucose tolerance test (OGTT). An FPG 126 mg per dL is consistent with the diagnosis of diabetes An FPG 100 mg/dL to 125 mg/dL demonstrates impaired fasting glucose (IFG) and is consistent with the diagnosis of pre-diabetes. Patients with IFG should undergo an OGTT.

Criteria for diagnosis Normoglycemia IFG/IGTDiabetes FPG <100mg/dlFPG>100 and <126 FPG>126 2 hour PG <1402 hour PG hour PG >200 Symptoms of diabetes and random glucose >200

Metabolic Syndrome Constellation of metabolic derangements that include obesity, insulin resistance, dyslipidemia, and hypertension NHANES defined metabolic syndrome as waist circumference >90 th %ile, BP>90 th %ile, FPG>110mg/dL, HDL and triglycerides >90 th %ile Predicts both type 2 diabetes mellitus and premature coronary artery disease

Hypertension Evaluation based on gender, age and height Hypertension systolic and/or diastolic >95 th percentile Prehypertension th percentile Start with lifestyle changes May need ambulatory blood pressure monitoring

Dyslipidemia Fasting lipid profile should be obtained when BMI>85 th percentile Total cholesterol levels of 200 mg/dL is high LDL 130 mg/dL is high Start with dietary changes Consider treatment after 6 months of therapy: Age>10y, LDL >160mg/dl

Psychiatric Disorders Depression may precede or result from an obesity Look for anxiety, body dissatisfaction, eating disorders Sexual and physical abuse increase the risk of severe obesity

Orthopedic Disorders Blount disease: painless bowing of the lower extremity, dx with anteroposterior radiographic views of the affected knee obtained while standing SCFE: hip or knee pain and pain with walking, impaired range of motion, b/l frog-leg radiographic views

Summary of Medical Screening History: BMI change Meds: medications that may affect weight ROS: snoring/sleep problems, abd pain, menstrual irreg, hip, knee, or leg pain, polyuria, thirst, depression Family Hx: obesity, T2DM, HTN, lipid abnormalities, heart disease

Primary Care Laboratory Assessment BMI>95%ileTests >85%ile with no risk factorsFasting lipid levels >85-95%ile with risk factorsFasting lipid levels, AST and ALT, fasting glucose >95%ileFasting lipid levels, AST and ALT, fasting glucose Pediatrics, December 2007

Weight….Let’s talk Peggy Norman, MS,RD,CDE Pediatric Weight and Wellness Program Coordinator Mary Bridge Children’s Hospital

Weight…. Let’s LISTEN 20 years of adult obesity care –5000 hrs listening to overweight adults –3000 adult group hours –Reviewed 1000s for food diaries 15 years with pediatrics –1000 hrs listening to parents of overweight children –1000 hrs listening to overweight teens and children –2000 family group hours

Stages of Intervention Stage 1: Primary care Stage 2: Structured weight management Stage 3: Multidisciplinary Intervention Stage 4: Tertiary Care Intervention – VLCD, bariatric surgery, medications AAP – Expert Committee Recommendations Regarding the Prevention, Assessment and Treatment of child and Adolescent Overweight and Obesity (Barlow 2007)

MHS/MMA Pediatric Well Child Checks 4/1/12-3/31/13

Pediatric Weight and Wellness Program Participation (4/1/12-3/31/13)

WHAT is 5210?  Ready, Set, Go! 5210 program interventions center on the use of the common message of “5‐2‐1‐0”. These behaviors are supported by science and endorsed as recommendations by medical professionals:

READY, SET, GO! 5210 Continuing the Call to Action for Obesity Prevention READY, SET, GO! MISSION Ready, Set, Go! 5210 mission is to increase physical activity and healthy eating among each of the six sectors that influence youth and families; 1.Schools 2.After School 3.Early Childhood 4.Health Care 5.Workplace 6.Community 7.And….Faith Communities

Consistent Message for Every Child Every family hears the health message at well child checks ( all 14,103 plus other opportunities?) Discuss healthy growth for age – using BMI Connect 5210 message to future health

Consistent Messaging from Providers Provider is committed to 5210 message Practice is committed to 5210 message Reflected in the office environment Involved in community leadership

5210 SmartPhrase: type.5210 to drop into Patient Instructions

Child with weight concern Ask permission to talk about weight Avoid shame, blame Acknowledge that there are no simplistic solutions Use the 5210 goals to agree on at least one behavior change Refer to stage 2 or 3 There is NO ONE “RIGHT WAY” to TALK about WEIGHT

Referral to Family Wellness Program Family receives packet that frames complexity of weight by addressing beliefs, parenting skills and environment message reinforced Family contacted by letter to encourage them return packet at 3 month point. Family knows a resource exists

Stage 3: Family Wellness Program Pre Assessment Questionnaire and lab work required In-depth Medical Assessment –Medical evaluation –Nutrition and Activity evaluation –Psychosocial evaluation –Goal setting Invitation to year long intervention

Year Long Intervention Quarterly rolling starts 3 week intensive “ Basic Core" Monthly for 1 year Opportunities to connect with each other between groups on own communities Weekly swim group Gift Card incentive for participation 85% qualify for max financial assistance

Case Profiles - Teens Kayla ’ 11.5” 269 # BMI % Hypertriglyceridemia High life stressors Program: over 18 months 23 visits 32 mental health visits Fitness/habit measures stable 6’ 0.5” 297# BMI % Brandon -15 5’5.75” 300# BMI % Intermittent Asthma Low life stressors Program: 18 months 18 visits Fitness/habit measures improved 5’7” 267# BMI % + 30 lbs- 30 lbs

Thank-you

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