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 SensitivityAvoid: 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 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 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 ChildBrief 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 ChildBrief 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.: 05-16Office 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