Evaluation of Obese Child Marlene Rodriguez, MD FAAP La Clinica de la Raza Peer Review July 29, 2006

Role of Provider in Obesity Prevention 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 CA 5th highest prevalence of pediatric overweight for 2-5 year old Prevalence of overweight preschool children and adolescents has doubled between 1976-1980 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 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 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 <5% Underweight 5-84% Healthy Weight 85-94% Overweight 95-98% Obese >99% Proposed Category of “Extreme Obesity” not yet on BMI charts

BMI 99% Cut-Points (kg/m2) 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. Measure blood pressure using age and size appropriate cuff Obesity Risk Factors based on Hx and Exam Take Focused Family Hx Obesity DMT2 CVD such as HTN, cholesterol Early death from stroke or cardiovascular disease (age <55)

Assess for Other Causes of Obesity 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 BMI 85-94% WITH RISK FACTORS Fasting Lipids Repeat Every 2 years if normal

Laboratory Evaluation for Overweight Children > age10 BMI 85-94% WITHOUT RISK FACTORS Fasting Lipid Profile

Laboratory Evaluation for Overweight Children > age10 BMI 85-94% 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.) Repeat Every 2 years if normal

Laboratory Evaluation for Obese Children > age 10 BMI >95% 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.) Urine microalbumin or microalbumin/creatine ratio (Stanford Recommendation) Repeat Every 2 years if normal

CHDP Risk Factors FHx of Diabetes Race/ethnicity: Black, Hispanic, American Indian, Asian, Pacific Islander, Native Alaskan Signs of Insulin Resistance 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 BMI 85-94% WITH AT LEAST 2 CHDP RISK FACTORS Fasting Glucose and Cholesterol Source: CHDP Provider Information Notice No.: 05-16

Abnormal Labs Elevated Transaminase Levels Elevated Lipid Panel 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 Dietary Counseling, Lifestyle Modification AHA recommendation to start statins in some children still controversial

Abnormal Labs Elevated Transaminase Levels 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. Abnormal Fasting Glucose Criteria for DMT2 GTT (3 hour) with fasting glucose and insulin levels If the above are abnormal refer to Endo at CHO Criteria for DMT2 Criteria for DMT2 Fasting glucose >126 mg/ml Casual glucose >200 mg/ml Impaired glucose tolerance: Fasting glucose >100 mg/ml Casual glucose >140 mg/ml

Obesity Co-Morbities NAFLD/NASH Sleep Apnea SCFE Asthma PCOS Self-image/self-esteem Depression

Other Targeted Lab Tests 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 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 Step 1: Engage the Patient/Parent How do you feel about your child’s wt? Step 2: Share Information 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. Step 4: Make a Key Advise Statement I would strong encourage you to… 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 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 Referral to La Clinica Nutritionist Enrollment in Weight Management for Children Classes

Stage 3: Comprehensive Multidisciplinary Intervention Referral to Healthy Hearts 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 Pediatric Obesity Taskforce 2nd Thursday every month 12:30-1:30pm at TV Obesity Progress Notes 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