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

2. ( 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

3. 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 (95% CI: 3.78 –30.86)

4. Classification Medical Risk Testing <85th percentile H&P, Growth
Family History (obesity and disease)
Lipid Panel
Universal screening and year old
If indicated: 2-8 and 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)

5. Atherosclerosis: The lipid story
Who
Guidelines
Tests/ frequency
2-8 and 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
Fasting
Lipid profile
9-11 and 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)

6. + 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

7. 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.

8. 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

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

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

11. 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%

12. 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.

13. 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

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

15. 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

16. Read and treat slides

17. 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=
Plan
DASH
DASH, NA restriction
ACEI
Thiazide ( mg)
Refer to Pediatric Health Life if evaluation is negative or
Cardiology/renal for evaluation.

18. Read and Treat: Lipid profile
Normal
Mild-moderate
Severe
LDL cholesterol
<130 mg/dl
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 =
Plan
Focus on the starches and
Plan.
CHILD 1-2 diets
CHILD 1or 2 diets
Drugs
If no better after 6 month to 1 year consider:
Simvastatin: mg to decrease LDL-C by 30 to 40%
Atorvastatin:10-20 mg to decrease LDL-C by 35 to 45%
Referral to PHLC

19. How to read and treat the results of Glucose metabolism testing (fasting)
Normal
Impaired fasting Glucose (pre-diabetes)
Diabetes
Fasting Glucose
<100 mg/dl
mg/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 %
% at risk to develop Diabetes
6.5% if the blood sugars are also high. Valid for adult only
Treatment
Health Lifestyle=
Plan
Focus on the starches and
Refer to Pediatric Health Life Center or Endocrine

20. 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
>125 if all blood sugars are elevated
2 hours glucose
<140 mg/dl
>200 if all blood sugars are elevated
Hg A1c
<5.7 %
% at risk to develop Diabetes
6.5% if the blood sugars are also high. (Valid for adult only)
Treatment
Health Lifestyle=
Plan
Focus on the starches and
Refer to Pediatric Health Life Center or Endocrine

21. 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=
Plan
Possible levothyroxine supplementation
Levothyroxine

22. 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=
Plan
NAFLD:
BMI or weigh Loss
Vitamin E