1. Glucose and Cholesterol Screening for Pediatric Obesity A Training for CHDP Providers Prepared by: The CHDP Nutrition Subcommittee

2. Goal  To ensure that children and adolescents with BMI ≥ 85 th percentile, as well as those who are at risk but not overweight, are screened for the most common medical conditions associated with childhood overweight

3. Agenda  Review the medical conditions associated with pediatric overweight/obesity  Summarize the risk factors for complications of pediatric overweight/obesity that need to be identified as part of a health assessment  Clarify the guidelines as described in CHDP Provider Information Notices 05-16 and 05-22

4. Overweight & Obese Children California children ages 2 to <5 2009 CDC Pediatric Nutrition Surveillance System growth statistics from CHDP PM160 report

5. Overweight & Obese Children California children ages 5 to <20 years 2009 CDC Pediatric Nutrition Surveillance System growth statistics from CHDP PM160 report

6. Accurate Weight & Stature

7. BMI Percentile  Select the appropriate growth chart  Record the data  Calculate BMI  Plot measurements  Interpret plotted measurements Boys: 2 to 20 years BMI > 99th % Severely obese > 95th % Obese 85th to < 95 th % Overweight < 5th % Underweight

8. BMI % Growth Chart Obese Overweight Normal* Underweight Lab Tests (cholesterol & glucose) In-depth Medical Assessment Note in chart: “Counsel & Follow-up” Measurements Weight Height Age Plot Assessment Algorithm + - *Further tests may be warranted depending on family history

9. Conditions Associated with Childhood Overweight  Cardiovascular Conditions High Blood Cholesterol Lipid Disorders Hypertension (HTN)  Endocrine Conditions Type 2 Diabetes Insulin Resistance Impaired Glucose Tolerance Menstrual Irregularities Polycystic Ovarian Syndrome  Gastrointestinal Conditions Non-Alcoholic Fatty Liver Disease (NAFLD) Gallstones  Orthopedic Conditions Accelerated Growth Hip Disorders  Psychological Conditions Depression/Self-Esteem Substance Abuse Disordered Eating Discrimination  Pulmonary Conditions Asthma Sleep Apnea

10. Recommended Screening for Children ≥ 5 Years of Age Screen for both cholesterol & glucose* if BMI ≥ 85 th % AND two of the following risk factors (may be repeated as medically necessary):  BMI ≥ 95 th %  Family history of diabetes  Black, Hispanic, American Indian, Asian, Pacific Islander, Native Alaskan  One of the following: acanthosis nigricans, HTN, dyslipidemia or polycystic ovarian syndrome  Less than 30 minutes activity/day or consistently unbalanced diet *This training is not intended to cover all aspects of type 1 or type 2 diabetes

11. Recommended Screening for Children ≥ 5 Years of Age Screen for cholesterol if one of the following risk factors is present (may be repeated as medically necessary):  One parent or grandparent had heart/vascular disease, heart attack, heart death, heart surgery or stroke at ≤ 55 years of age*  One parent has a cholesterol level ≥ 240 mg/dl* * Family history may not be available for all children

12. Referral & Care Management for Abnormal Test Results  Fasting glucose ≥ 126 mg/dl (elevated): counsel & repeat test, endocrinology referral and/or CCS referral*  Cholesterol > 170 - < 200 mg/dl (borderline): counsel & repeat test in one year*  Cholesterol ≥ 200 mg/dl (elevated): cardiac referral and/or CCS referral* *Clinical judgment should be used

13. Screening Guide

14. Billing Instructions DescriptionCodeAgeReimbursement Blood glucose – collection & analysis, or collection & handling 255 years through 20 years 11 months $4.34 Blood/serum cholesterol – collection & analysis or collection & handling 265 years through 20 years 11 months $4.03

15. Completing the PM160 25 26 Blood glucose Use Code 25 and/or 26 ONLY if collecting the sample. Otherwise, denote: “Sent for glucose and/or cholesterol lab.” Laboratories Blood Glucose – Code 25 Cholesterol – Code 26 Blood/Serum Cholesterol

16. Resources  For the AMA 2007 Expert Committee Recommendations, go to: www.ama-assn.org/ama/pub/category/11759.html  For the AAP policy on lipid screening and heart health in children, go to: www.aap.org/advocacy/releases/july08lipidscreening.htm  American Diabetes Association: Type 2 Diabetes in Children and Adolescents. Pediatrics 105:671-680, 2000

17. Summary  Lab screening is necessary to provide quality care for children who are overweight/obese  Glucose and cholesterol screening facilitates early identification of children who are at risk for diabetes and cardiovascular disease  Abnormal lab results can help guide providers to initiate early intervention and/or referral to treatment