PEDIATRIC OBESITY I have had no financial relationships to disclose. - PDF document

5/10/2013 Relevant Financial Relationships PEDIATRIC OBESITY I have had no financial relationships to disclose. VANESSA CURTIS, MD May 17, 2013 Acute Care Visit Acute Care Continued 12 year old female with “asthma” � Vitals: � HR 85 BP 134/67 Weight 65kg (144lb) Height 155cm (61”) BMI 27 kg/m 2 Family reports that child has been having chest pain and � Physical exam: SOB for the past 2 weeks � No distress or increased work of breathing � Normal lung sounds with no wheezing Patient is generally healthy but has a history of asthma and � No tenderness to palpation on chest wall has presented multiple times for similar symptoms. She � Normal S1 and S2 without murmur; pulses 2+ without edema denies wheezing and says “rest makes my pain better, moving makes it worse”. � Abdomen soft, nontender, nondistended � Darkened skin along posterior neck and in axillae with skin tags There is a family history of asthma, newly diagnosed type 2 � Workup shows normal CXR and EKG diabetes in her mother, and her father died at age 47 years of a heart attack. � Labs remarkable for glucose of 156 mg/dL, otherwise BMP and CBC are normal Alarming Statistics Audience Response � Nationally, 66% of adults and 33% of children and What percent of Iowa children are overweight or obese? adolescents are overweight or obese � Since 1980, number of obese adults has doubled Less than 5% 1. � Since 1970, number of obese adolescents has tripled 5-10% 2. � Since 1970, number of obese children has quadrupled 10-20% 3. � Current generation of children may not outlive their parents 20-30% 4. � Health-related quality of life scores of obese children and 30-40% 5. adolescents lower than scores from children with cancer Over 40% 6. receiving chemotherapy � Childhood obesity tracks into adulthood 10 F as in Fat: How Obesity Threatens America’s Future 2010. Trust for America’s Health - www.healthyamericans.org DeMattia L and Denny SL. Ann Amer Acad Polit Soc Sci. 2008;615:83-99. Clarke WR and Lauer RM. Crit Rev Food Sci Nutr. 1993;33:423-430. Schwimmer JB et al. JAMA. 2003;289:1813-1819. 1

5/10/2013 Audience Response Obesity Among US Children What percent of Iowa children are overweight or obese? 2003 2005 Less than 5% 100% 1. 90% 2. 5-10% 80% 70% 10-20% 3. 60% 50% 20-30% 4. 40% 30% 30-40% 5. 20% 10% 0% 0% 0% 0% 0% 0% Over 40% 6. 0% 2007 National Survey of Children’s Health Audience Response Audience Response A child with a BMI at the 90%ile for age and sex is A child with a BMI at the 90%ile for age and sex is considered: considered: At risk for overweight At risk for overweight 100% 1. 1. 90% Big Boned Big Boned 2. 2. 80% 70% Overweight Overweight 3. 3. 60% 50% Obese Obese 4. 4. 40% 30% Healthy Healthy 5. 5. 20% Unlikely to make the cross country team Unlikely to make the cross 10% 6. 6. 0% 0% 0% 0% 0% 0% 0% country team 10 How is Pediatric Obesity Different? BMI (kg/m 2 ) � Use BMI percentiles to define weight status � BMI is plotted on the CDC BMI-for-age growth charts (separate for girls and boys) to obtain a percentile ranking Weight Status Category Percentile Underweight Less than the 5th percentile Healthy Weight 5th percentile to less than the 85th percentile Overweight 85th to less than the 95th percentile Obese Equal to or greater than the 95th percentile � Children don’t always control their environment � Food sources � Activity opportunities � Behavior is modeled � Focus needs to be on family, not child � Weight loss is not always the goal 2

5/10/2013 Why Worry About Pediatric Example BMI Growth Chart Obesity? � Example Patient � Risks of adult obesity � 12 year old female � Obese as an…. � Weight 65kg (144lb) � Infant � 14% chance � Preschooler � 17% chance � Height 155cm (61”) � 7 years old � 41% chance � BMI 27 kg/m 2 � 12 years old � 75% chance � Adolescence � 90% chance Audience Response Audience Response All of the following are components of the metabolic All of the following are components of the metabolic syndrome syndrome EXCEPT? EXCEPT? Elevated Blood Pressure 100% 1. 90% Elevated Blood Pressure 1. 80% High triglycerides 2. 70% High triglycerides 2. 60% Obese BMI 3. 50% Obese BMI 3. 40% High LDL cholesterol 4. 30% 20% High LDL cholesterol 4. 0% 0% 0% 0% 0% Fasting glucose over 100 10% 5. 0% Fasting glucose over 100 mg/dl 5. mg/dl 10 Pediatric Overweight and Obesity Metabolic Syndrome Comorbidity Screening Algorithm � Adults � Pediatrics 5 th -84 th percentile 85 th -94 th percentile ≥ 95 th percentile “HEALTHY WEIGHT” “OVERWEIGHT” “OBESE” � Central Obesity � No clear consensus Blood pressure screening - Average of 3 blood pressure measurements (use tables to identify blood pressure percentiles � WC > 102 cm (88 cm) � Need to use � BMI >30 kg/m 2 height/age/sex/racial Blood Pressure between 90 th -94 th percentile Blood Pressure <90 th percentile (normal) Blood Pressure ≥ 95 th percentile (pre-hypertension) Encourage healthy diet and physical activity (hypertension) Encourage dietary and physical activity changes norms Recheck at next visit Refer to Pediatric Nephrology � Hypertriglyceridemia Recheck in 6 months � >150 mg/dL Cholesterol screening – fasting lipid panel � Depressed HDL Provide education on healthy diet and physical Total Cholesterol<170, LDL<110, Triglycerides<130 Total Cholesterol ≥ 170, LDL ≥ 110, Triglycerides ≥ 130 Rescreen in 3-5 years Refer to Pediatric Cardiology activity to maintain � <40 mg/dL (50) weight velocity Diabetes screening † – fasting glucose � Hypertension † Screen if 2 or more risk factors present: family history of diabetes, signs of insulin resistance, � Varies, >135/85 race (Native American, African American, Hispanic, Asian/South Pacific Islander), � Impaired glycemic control Glucose <100 (normal) Glucose between 100-125 (pre-diabetes) Glucose ≥ 126 (diabetes) � IR or T2DM Encourage healthy diet and physical activity Encourage dietary and physical activity changes Refer to Pediatric Endocrinology Rescreen in 2 years Rescreen in 1 year � IFG (>100 mg/dL) Liver disease screening – ALT/AST � IGT on OGTT ALT, AST <2X upper limit ALT, AST >2X upper limit Rescreen in 2 years Refer to Pediatric Gastroenterology 3

5/10/2013 Hypertension Dyslipidemia � Prevalence has been increasing with a 10-year lag behind � Process of atherosclerosis begins in childhood and is obesity trend progressive throughout life � Causes of elevated blood pressure � Prevalence of lipid abnormalities is increasing � White coat hypertension � Lab findings: � Primary hypertension (essential) � Elevated TG levels � Secondary hypertension � Elevated LDL levels � Coarctation of the aorta � Low HDL levels � Kidney disease PERCENTILE TC LDL TG † ‡ HDL † NON-HDL � Obesity < 75 th Acceptable <170 <110 <75 (<90) ≥ 45 <120 � Need 3 separate measurements – now what? Borderline 75 th -95 th 170-199 110-129 75-99 (129) 40-44 120-144 Elevated > 95 th ≥ 200 ≥ 130 ≥ 100 ( ≥ 130) <40 ≥ 145 � 24 hour ambulatory blood pressure monitor TC = total cholesterol; TG = triglycerides � School nurse and/or other health provider † Not established by NCEP, these values are taken from NHANES study values ‡ Values are for children <10 years and children ≥ 10 years � Search medical records Lipid Research Clinics Program. The Lipid Research Clinics Population Studies Data Book. 1980;DHHS publication no. (NIH) 80-1527. � Caveats – inappropriate cuff size, anxious at visit, health at visit National Cholesterol Education Program. Pediatrics. 1992;89(3):509-511. Daniels SR et al. Pediatrics. 2008;122:198-208. Din-Dzetham al. Circulation. 2007;116:1488-1496. NHLBI Expert Panel. Pediatrics. 2011;128:S213-S256. Diabetes Audience Response � Insulin resistance is common Of the following, which patient has the highest likelihood of � Type 2 vs Type 1 diabetes can be difficult to discern at having T2DM? presentation 8 yo NHW male � 45% of new pediatric diagnoses are T2DM 1. 12 yo NHW female � Racial and ethnic disparities 2. 5 yo Hispanic female 3. 15 yo American Indian male 4. 7 yo Black female 5. Normal IGT IFG T2DM 10 Age and Racial/Ethnic Disparities in T2DM Audience Response Incidence Of the following, which patient has the highest likelihood of having T2DM? 8 yo NHW male 100% 1. 90% 80% 12 yo NHW female 2. 70% 60% 5 yo Hispanic female 3. 50% 40% 30% 15 yo American Indian 4. 20% 0% 0% 0% 0% 0% male 10% 0% 7 yo Black female 5. 4