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

2. 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

3. 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 and 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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)

10. 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.

11. Laboratory Evaluation for Overweight Children > age2
BMI 85-94%
WITH RISK FACTORS
Fasting Lipids
Repeat Every 2 years if normal

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

13. 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

14. 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

15. 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

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

17. 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

18. 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

19. 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

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

21. 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)

22. 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

23. Staged Treatment Stage 1: Prevention Plus
Stage 2: Structured Weight Management
Stage 3: Comprehensive Multidisciplinary Intervention
Stage 4: Tertiary Care Intervention

24. 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

25. 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

26. 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

27. Stage 2: In Clinic Structured Weight Management
Referral to La Clinica Nutritionist
Enrollment in Weight Management for Children Classes

28. 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

29. Stage 4: Tertiary Care Intervention
Referral to Stanford or UCSF
Medications
Very Low Calorie Diet
Bariatric Surgery

30. 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

31. 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