Traveling CME Daniel Preud’Homme, MD, FACN, FAAP Professor of Pediatrics. Director , Adolescent Medicine Diplomate, American Board of Clinical Lipidology

( the patient is usually asymptomatic) Prevention or treatment BMI Classification Assessment ( the patient is usually asymptomatic) Medical Risk Evaluation Prevention or treatment <85th percentile H&P, Growth Family History (obesity and disease) Low No P 85th-94th percentile Family History obesity Diabetes Early heart disease HTN High Risk group Moderate yes or no Depending upon clinical judgment Stage 1 >95th percentile >30kg/M2 for adolescent (T4-5) same High Yes Stage 2 Stage 3 Stage 4 >99th >30-34 Kg/m2 Very High

Readiness to change: Modifiers of Cognitive changes Weight category Parents of overweight children, compared with parents of at-risk-for-overweight children, had an odds ratio (OR) of 4.54 (95% confidence interval [CI]: 2.07–9.93)for being in the preparation/action stage of change versus the precontemplation stage Age of the child Parents of older children (8 –12 years), compared with parents of younger children, also had significantly higher odds (OR: 3.73; 95% CI: 1.77–7.86) of being in the preparation/action stage of change rather than the precontemplation stage. Presence of a health problem Parents who thought their child’s weight was a health problem had 16.0 times the odds of being in the preparation/action stage (95% CI: 6.33– 40.33). Parental obesity Parents who perceived themselves to be overweight had higher odds of being in the contemplation stage (OR: 7.39; 95% CI: 2.66 –20.51) than being in the preparation/ action stage of change (OR: 3.86; 95% CI: 1.82– 8.18). Doctor defining the health risk The child’s doctor had commented that the child’s weight was a health problem, the odds that the parent would be ready to make a change increased to 10.80 (95% CI: 3.78 –30.86)

Classification Medical Risk Testing <85th percentile H&P, Growth Family History (obesity and disease) Lipid Panel Universal screening 9-11 and 17-21 year old If indicated: 2-8 and 11-16 years old 85th-94th percentile Family History obesity Diabetes Early heart disease HTN High Risk group   Laboratory …PRN Insulin resistance ( HgA1c, FBG, Fasting Insulin) Lipid panel CBC CMP TFT >95th percentile Or >99th percentile >30kg/m2 (preteen) >34kg/m2 (teen) High risk group Laboratory…definitely ( HgA1c, FBG, Fasting Insulin, OGTT)

Atherosclerosis: The lipid story Who Guidelines Tests/ frequency 2-8 and 11-16 year old ►FMHx of Cardiovascular event in first and second degree relatives under the age of 55(males)and 65(females) ►Parent with a TC ≥ 240 mg/dl ►child has Diabetes,BMI≥ 95th, smokes cig. ►One Moderate to high risk condition Expert Panel on Integrated Guidelines for cardiovascular health and risk reduction in children and adolescent. 2012. Fasting Lipid profile 9-11 and 17-21 years old ► universal screening Fasting or Non fasting Lipid profile High level Risk factors for early CV event Moderate level Risk factors for early CV event Stage 2 HTN: ≥ 99th percentile + 5mmh/hg BMI≥ 97TH High risk condition: renal failure, DM(1-2), heart transplant, Kawasaki with aneurysm Stage 1 HTN BMI≥ 95th HDL-C≤ 40mg/dl(males) or 50mg/dl ( females) Moderate –risk condition (nephrotic syndrome, chronic inflammatory conditions, HIV, Kawasaki with regressed aneurism)

+ for diabetes, Gestational Diabetes, Insulin resistance such as PCOS Acanthosis Nigricans = evidence of hyperinsulinemia hence insulin resistance (my suggestions based on American Diabetes Association guidelines for diabetes screening of asymptomatic patients) BMI Family history Tests > 85th % or >25 + for diabetes, Gestational Diabetes, Insulin resistance such as PCOS A1c, Fasting Insulin, Fasting Glucose Suggest strongly a 2 hours Oral Glucose tolerance test. (With or without insulin level.) No family history Fasting Non fasting A1c, Glucose, insulin A1c, Glucose, Also perform a Lipid profile Fasting or non Fasting, to complete evaluation of the Metabolic Syndrome

Subclinical hypothyroidism Elevated TSH, normal free T4 and the presence of… Dyslipidemia Insulin resistance Subclinical inflammation Increased CHD Overlap with obesity itself/IR Reversible with weight loss Normalizes after weight loss.

To treat or not to treat Unnecessary to treat TSH Normalization is about 73.6% after repeat X1. Nl free T4 in the context of TSH(5-10mIU/ml) does not cause the symptoms attributed to thyroid dysfunction. In patient with TSH above 10mIU/l 40% normalized 33% Decreased to mild elevation in 25% Remained high

Decreased Folic acid intake? 85% From Children’s hospital of Buffalo

NAFLD Progressive but requires many “hit” to arrive at cirrhosis Can be painful ( dull) Treatment: weight loss Vitamin E controversial.

Phenotypes 4 major clinical phenotypes of of PCOS  Frank PCOS Classic Ovulatory PCOS Mild Biochemical/Clinical Hyperandrogenism  ChronicAnovulation Polycystic Ovaries Prevalence 48 – 71% 7-40% 7-18% 7-16%

Other diagnosis National Institutes of Health, 1990 National Institute of Child Health and Human Development (NICHD) Guidelines Patient demonstrates: 1. Clinical and/or biochemical signs of hyperandrogenism 2. Oligo-anovulation or chronic anovulation 3. Exclusion of other causes of androgen excess and anovulatory infertility is necessary.

Diagnosis (cont’d) Cushing Syndrome Hyperprolactinemia Pregnancy Requires exclusion of other disorders that may result in menstrual irregularity and hyperandrogenism including: Adrenal/Ovarian tumors Imaging studies May have rapidly progressive hirsutism Serum testosterone > 5nmol/l Late onset congenital adrenal hyperplasia 17-hydroxyprogesterone level 1 hr after cosyntropin stimulation < 1000 ng/dL rules out Cushing Syndrome 24 hr urine sample for free cortisol > 4x upper limit of normal diagnostic Hyperprolactinemia Fasting serum prolactin Pregnancy Turner Syndrome

Criteria of the Metabolic syndrome 1 Requirement (BMI, or a measure of obesity) + 2 parameters = 3 metabolic abnormalities

Definition criteria for metabolic syndrome in children and adolescents AHA criteria IDF criteria Ages (years) 12 to19 6 to 9 10 to 15 >15 >15 (adult criteria) Waist circumference ≥90th percentile for age, sex, and race/ethnicity ≥90th percentile for age (MS as entity is not diagnosed) ≥90th percentile or adult cut-off if lower ≥94 cm for Europid males, ≥80 cm for females Blood pressure age, sex, and height ≥Systolic 130 or ≥diastolic 85 mmHg ≥Systolic 130 or diastolic ≥85 mm Hg or treatment of previously diagnosed hypertension Triglycerides ≥110 mg/dL ≥ 150 mg/dL ≥ 150 mg/dl specific treatment for high triglycerides HDL-C HDL-C 10th percentile for race and sex <40 mg/dL <40 mg/dL in males <50 mg/dL in females specific treatment for low HDL-C Fasting glucose 100 mg/dL Fasting glucose 100 mg/dL or known T2DM

Read and treat slides

How to read and treat the Blood Pressure (JNC7) In the Obese Patient. Pre Hypertension Stage 1 Hypertension (5% to 47% in obese pt) Stage 2 (prevalence: 0.025% to 44% in obese Patients)) Blood pressure (3 repeated measures) 90th -95th percentile 95th – (99th percentile +5 mm/hg) >99th + 5 mm/hg   Age >12 (mm/Hg) Or >120/80 Or > 140/90 160/100 Evaluation Not needed Not needed if NL heart or kidney Renal Panel, UA, angiotensin, renal vascular imaging(CT), echocardiogram Treatment Health Lifestyle= 5-2-1-0 Plan DASH DASH, NA restriction ACEI Thiazide ( 12.5-25 mg) Refer to Pediatric Health Life if evaluation is negative or Cardiology/renal for evaluation.

Read and Treat: Lipid profile Normal Mild-moderate Severe LDL cholesterol <130 mg/dl 130-190 mg/dl >190 mg/dl HDL cholesterol >40 mg/dl male >50 mg/dl female   Less than 20 mg/dl Triglycerides <150 mg/dl 150 – 400mg/dl >400 mg/dl Treatment Health Lifestyle = 5-2-1-0 Plan Focus on the starches and 5-2-1-0 Plan. CHILD 1-2 diets CHILD 1or 2 diets Drugs If no better after 6 month to 1 year consider: Simvastatin: 10-40 mg to decrease LDL-C by 30 to 40% Atorvastatin:10-20 mg to decrease LDL-C by 35 to 45% Referral to PHLC

How to read and treat the results of Glucose metabolism testing (fasting)   Normal Impaired fasting Glucose (pre-diabetes) Diabetes Fasting Glucose <100 mg/dl 100-125mg/dl >125mg/dl if all blood sugars are elevated Fasting Insulin <17 units/L >17 units/L = hyperinsulinemia FGIR >7 <7= insulin resistance Hg A1c <5.7 % 5.8-6.4% at risk to develop Diabetes 6.5% if the blood sugars are also high. Valid for adult only Treatment Health Lifestyle= 5-2-1-0 Plan Focus on the starches and Refer to Pediatric Health Life Center or Endocrine

How to read and treat the results of Oral Glucose challenge (OGTT) (fasting)   Normal Pre-diabetes (790.21;790.22 Diabetes (250.00) Fasting Glucose <100 mg/dl 100-125 >125 if all blood sugars are elevated 2 hours glucose <140 mg/dl 140-199 >200 if all blood sugars are elevated Hg A1c <5.7 % 5.8-6.4% at risk to develop Diabetes 6.5% if the blood sugars are also high. (Valid for adult only) Treatment Health Lifestyle= 5-2-1-0 Plan Focus on the starches and Refer to Pediatric Health Life Center or Endocrine

How to read and treat Thyroid function tests In the Obese Patient. TSH 4-10 mIU/ml Positive Antibodies TSH >10 mIu/ml Test Repeat x 1 Repeat testing after 3 months Repeat testing in 1-2 months   Evaluation Repeat third time with antibodies. If negative If still positive or T4 is low: send to Endocrinology Send to endocrinology Treatment Health Lifestyle= 5-2-1-0 Plan Possible levothyroxine supplementation Levothyroxine

Note: any elevation of direct bilirubin should prompt a GI evaluation How to read and treat Liver enzymes elevation. Note: any elevation of direct bilirubin should prompt a GI evaluation In the Obese Patient. ALT <40 IU/ml or < 2 X ULN ALT > 2 X ULN ALT elevation >>> 2 X ULN Test Repeat x 1 in 6-12 month if weight /BMI increases Repeat testing 1 to 3 months Repeat testing 1-2 weeks   Evaluation None ALT > 2 X ULN on 2 tests Abdominal Ultrasound Consider exclusion tests Consider exclusion tests or GI evaluation Treatment Health Lifestyle= 5-2-1-0 Plan NAFLD: BMI or weigh Loss Vitamin E