pediatric weight management eliana m. perrin, md, mph department of pediatrics

Pediatric Weight ManagementPediatric Weight Management

Eliana M. Perrin, MD, MPHEliana M. Perrin, MD, MPH

Department of Pediatrics Department of Pediatrics

At least visually we’re not good at At least visually we’re not good at this!this!

1) Recommended by the AAP, AAFP1) Recommended by the AAP, AAFP

2) Flags risk better 2) Flags risk better (Perrin, et al, (Perrin, et al, J Pediatr, April, ’04)J Pediatr, April, ’04)

3) Perhaps earlier intervention?3) Perhaps earlier intervention?

Why should we use BMI?

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>95% Overweight

85-95% At risk for Overweight

5-85% Healthy Weight

<5% Underweight

State Fair FareState Fair FarePizza, funnel cakes, candy Pizza, funnel cakes, candy apples, elephant ears, chili apples, elephant ears, chili dogs, chocolate dipped fries, dogs, chocolate dipped fries, corn dogs, bbq beef corn dogs, bbq beef sandwiches, onion rings, kettle sandwiches, onion rings, kettle corn dogs, caramel corn, corn dogs, caramel corn, sausages, steak sandwiches, sausages, steak sandwiches, rib eye steaks, cotton candy, rib eye steaks, cotton candy, stromboli, buffalo wings, fried stromboli, buffalo wings, fried pickles, country ham biscuits, pickles, country ham biscuits, tempura vegetables, fudge, tempura vegetables, fudge, saltwater taffy, deep fried saltwater taffy, deep fried oreos, and deep fried candy oreos, and deep fried candy bars. If you want to wash these bars. If you want to wash these down, there are any number of down, there are any number of sweetened drink concessions sweetened drink concessions to accommodate you.to accommodate you.

Changes in Relative PricesChanges in Relative Prices

SOURCE: Author calculations based on the Consumer Price Index – All Urban Consumers (U.S. City Averages, 1983-2005)

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All Foods & Beverages Fruits & Veg Fresh Fruit & Veg Fish & Seafood

Dairy Carbonated Drinks Sugar & Sweets Fats & Oils

Key element is preventionKey element is prevention

For prenatal and newborn visits for breast-feeding moms: For prenatal and newborn visits for breast-feeding moms:

Encourage breastfeeding; teach parents infant Encourage breastfeeding; teach parents infant hunger cues & to feed by cue not by the clock; discourage hunger cues & to feed by cue not by the clock; discourage bottle propping bottle propping

For visits with 12-24 month olds: For visits with 12-24 month olds:

Transition to solids- time to focus on the whole Transition to solids- time to focus on the whole family eating together & on healthy foods- fruits and family eating together & on healthy foods- fruits and vegetables, whole grains, lean meats, cooking stylesvegetables, whole grains, lean meats, cooking styles

Don’t forget beverage counseling- milk as meal-Don’t forget beverage counseling- milk as meal-time beverage and water for thirst quenchingtime beverage and water for thirst quenching

Encourage PAEncourage PAEncourage activity for mom and dad while mom Encourage activity for mom and dad while mom

is pregnant- walking is wonderful & good to is pregnant- walking is wonderful & good to get into healthy family habitsget into healthy family habits

Tummy time is great for babies as is exploration Tummy time is great for babies as is exploration playplay

Outside activity/ getting out of the stroller Outside activity/ getting out of the stroller important for toddlers! important for toddlers!

Older childrenOlder children

Starting at age 2: calculate BMI % for age & genderStarting at age 2: calculate BMI % for age & genderAssess: Assess: Diet BehaviorsDiet Behaviors• Sweetened beverage consumption Sweetened beverage consumption • Frequency of dining out and family mealsFrequency of dining out and family meals• Fruit and vegetable consumption Fruit and vegetable consumption • Consumption of excessive portion sizesConsumption of excessive portion sizes• Daily breakfast consumption Daily breakfast consumption Physical Activity BehaviorsPhysical Activity Behaviors• Amount of moderate physical activityAmount of moderate physical activity• Level of screen time and other sedentary activitiesLevel of screen time and other sedentary activitiesAttitudesAttitudes• Self perception or concern about weightSelf perception or concern about weight• Readiness to changeReadiness to change• Experiences with previous attempts to lose weightExperiences with previous attempts to lose weight

If BMI healthy….If BMI healthy….

If BMI healthy (If BMI healthy (≤≤ 85% for age), advise parents to: 85% for age), advise parents to:

Not force kids to clean plates Not force kids to clean plates Replace whole milk w/ lower fat milk (>2yo) Replace whole milk w/ lower fat milk (>2yo) Limit “screen” time & eating in front of the tv! Limit “screen” time & eating in front of the tv! Limit junk food (high fat/sugary, “fast food,” Limit junk food (high fat/sugary, “fast food,”

soda)soda) Tell parents not to provide food as a comfort Tell parents not to provide food as a comfort or or

rewardreward Encourage active playEncourage active play Substitute water and skim milk for juice, Substitute water and skim milk for juice,

lemonade, sweet tea, soda, etc. lemonade, sweet tea, soda, etc.

What next?What next?If BMI is overweight or obese (If BMI is overweight or obese (≥85% for ≥85% for

ageage) or trending upward:) or trending upward:Follow advice from previous slideFollow advice from previous slideAdvise parents and child of weight Advise parents and child of weight

status: show them the BMI chart, talk status: show them the BMI chart, talk about future problems related to about future problems related to overweightoverweight

Protect self-esteem (make your Protect self-esteem (make your discussion @ health as much as discussion @ health as much as possible)possible)

Arrange follow-up visit (schedule a lot of Arrange follow-up visit (schedule a lot of time)time)

What to do at follow up visit? What to do at follow up visit? (continued)(continued)

If BMI If BMI 85% for age or trending upward, 85% for age or trending upward, do thorough evaluation: do thorough evaluation: History of the problemHistory of the problem Review of systemsReview of systems Past Medical HistoryPast Medical History Social HistorySocial History Family Medical HistoryFamily Medical History PEPE LabsLabs Assessment and PlanAssessment and Plan

HistoryHistory

When do parents/child think problems When do parents/child think problems began?began?

What’s the typical intake (include meals, What’s the typical intake (include meals, beverages, snacks)? – 3 day log is bestbeverages, snacks)? – 3 day log is best

Where does that intake occur (school Where does that intake occur (school lunches, babysitter’s, etc)?lunches, babysitter’s, etc)?

How much tv, video, computer time?- 3 How much tv, video, computer time?- 3 day log is bestday log is best

What’s the typical physical activity What’s the typical physical activity pattern?- 3 day log is bestpattern?- 3 day log is best

Review of SystemsReview of Systems

Significant headaches, blurred vision Significant headaches, blurred vision (pseudotumor cerebri?)(pseudotumor cerebri?)

Joint pains (SCFE? Overuse?)Joint pains (SCFE? Overuse?)

Frequent urination, thirst, fatigue Frequent urination, thirst, fatigue (T2DM?)(T2DM?)

Daytime sleepiness, snoring (sleep Daytime sleepiness, snoring (sleep apnea?)apnea?)

Depression (which comes first?)Depression (which comes first?)

Menarchal status (PCO disease?)Menarchal status (PCO disease?)

Past Medical HistoryPast Medical History

Medications (steroids)Medications (steroids)Thyroid diseaseThyroid diseaseGrowth problemsGrowth problemsMental retardationMental retardationHypotoniaHypotonia

Social HistorySocial History

Teasing patterns (motivation?)Teasing patterns (motivation?)Who’s on the child’s “case” at Who’s on the child’s “case” at

home?home?Problems in schoolProblems in schoolDepressionDepressionSuicidalitySuicidalityBingeing/purging Bingeing/purging Safety of the neighborhoodSafety of the neighborhood

Family HistoryFamily History

CAD (early MIs)CAD (early MIs)HypertensionHypertensionType 2 DMType 2 DMThyroid diseaseThyroid diseaseGall bladder diseaseGall bladder diseaseCushing’s Cushing’s DepressionDepressionWeight patternsWeight patterns

PEPE

Height, weight, BMI, BMI% for age and gender, HR, Height, weight, BMI, BMI% for age and gender, HR, BPBP

Hirsuitism?Hirsuitism? FundiFundi Skin, hair qualitySkin, hair quality TonsilsTonsils ThyroidThyroid Acanthosis nigricans?Acanthosis nigricans? Abdominal tendernessAbdominal tenderness Weight distribution patternWeight distribution pattern Tanner Stage of pubertal development/ small Tanner Stage of pubertal development/ small

penis?penis? Joint evaluationJoint evaluation

Acanthosis Nigricans Acanthosis Nigricans

LabsLabs

AAP recommends fasting lipids in patients >95% BMI. AAP recommends fasting lipids in patients >95% BMI. ADA recommends every other year screeningADA recommends every other year screening starting starting at 10 years of age or the onset of puberty, whichever at 10 years of age or the onset of puberty, whichever comes firstcomes first with fasting plasma glucose at least with fasting plasma glucose at least (consider fasting insulin as well) for those with(consider fasting insulin as well) for those with BMI ≥ BMI ≥ 85th percentile for age and sex, who *also* have any 85th percentile for age and sex, who *also* have any two of the following risk factors: a positive family two of the following risk factors: a positive family history of type 2 diabetes in a first or second-degree history of type 2 diabetes in a first or second-degree relative, shows sign of insulin resistance (i.e. relative, shows sign of insulin resistance (i.e. acanthosis nigricans, dyslipidemia, or PCOS), has a acanthosis nigricans, dyslipidemia, or PCOS), has a maternal history of diabetes or GDM, or belongs to maternal history of diabetes or GDM, or belongs to Native American, African American, Latino, Asian Native American, African American, Latino, Asian American, or Pacific Islander racial group. American, or Pacific Islander racial group.

Labs continuedLabs continued

ConsiderConsider::Thyroid studies (T4, TSH)-particularly in Thyroid studies (T4, TSH)-particularly in

child with poor growth or parents child with poor growth or parents insistent about “glandular” problems,insistent about “glandular” problems,

Glucose tolerance test, HgA1C, C-peptide Glucose tolerance test, HgA1C, C-peptide (only if serious concerns about T2DM)(only if serious concerns about T2DM)

Cortisol in the patient with unusual Cortisol in the patient with unusual distribution of weight, growth problemsdistribution of weight, growth problems

Anhyrdous glucose/serum Anhyrdous glucose/serum 17-OHP/testosterone if overweight, 17-OHP/testosterone if overweight, short, hirsuit, and irregular menses….short, hirsuit, and irregular menses….

Labs to worry aboutLabs to worry aboutLDL>130 (and if >190, refer to cardiology) LDL>130 (and if >190, refer to cardiology) Fasting triglyceride>110 (if >500, refer to Fasting triglyceride>110 (if >500, refer to

cardiology for treatment)cardiology for treatment)HDL<40HDL<40Fasting plasma glucose > 110Fasting plasma glucose > 110 (Fasting insulin: glucose ratio that is > 1:4)(Fasting insulin: glucose ratio that is > 1:4)Hemoglobin A1c > 6Hemoglobin A1c > 6Hypoglycemia along with hyperinsulinism Hypoglycemia along with hyperinsulinism

suggests an insulinoma rather than insulin suggests an insulinoma rather than insulin resistance resistance

Intervention ideasIntervention ideasMake it about staying happy/healthy- Make it about staying happy/healthy-

decrease the emphasis on weight.decrease the emphasis on weight.Review the dietary and PA logs (STCs) Review the dietary and PA logs (STCs)

with specific attention to areas of with specific attention to areas of improvement.improvement.

Review stop light guide to foods with the Review stop light guide to foods with the family.family.

Have child pick 1-2 things to change from Have child pick 1-2 things to change from a list. Let it be child’s choice.a list. Let it be child’s choice.

Parents to refrain from nagging.Parents to refrain from nagging.Have family continue to keep a log.Have family continue to keep a log.Nutrition/psychologist referral as needed.Nutrition/psychologist referral as needed.Follow up!Follow up!

How to make the conversation How to make the conversation seamless: Motivational Interviewingseamless: Motivational Interviewing

What is Motivational Interviewing?

Motivational Interviewing (MI):

•Powerful counseling tool

•Motivates & reinforces behavioral change

•Patient - centered

•Directive method for enhancing intrinsic motivation to change

•Helps explore & resolve ambivalence

MI MI (cont.)(cont.)

Basic Principles:Basic Principles:

• Uses open-ended questionsUses open-ended questions

• Applies reflective listeningApplies reflective listening

• Gives feedback in empowering Gives feedback in empowering frameworkframework

• FFeedbackeedback – Give risks and – Give risks and consequences of behaviorconsequences of behavior

““It sounds like your child is watching It sounds like your child is watching quite a bit of TV. Did you know that quite a bit of TV. Did you know that sitting down too much can raise your sitting down too much can raise your child’s chance of getting health child’s chance of getting health problems later on?” problems later on?”

• RResponsibilityesponsibility – Let them know it – Let them know it is up to themis up to them

““Of course it is up to you and her dad to Of course it is up to you and her dad to decide whether or not you want to let decide whether or not you want to let her watch this much TV.” her watch this much TV.”

MI USES THE FRAMES APPROACH

• AAdvicedvice – Offer a professional – Offer a professional recommendation recommendation

““It’s my recommendation as someone who It’s my recommendation as someone who is concerned about Sally’s health to have is concerned about Sally’s health to have her watch less TV, and I can help you help her watch less TV, and I can help you help her cut down on TV watching.”her cut down on TV watching.”

• MMenusenus – Offer a variety of strategies – Offer a variety of strategies

““There’s many options to help Sally cut There’s many options to help Sally cut down on TV. One option is to give her a TV down on TV. One option is to give her a TV budget at the beginning of the week and let budget at the beginning of the week and let her decide how to spend it. Another option her decide how to spend it. Another option is to say that for each hour of TV watched, is to say that for each hour of TV watched, Sally needs to spend an hour getting Sally needs to spend an hour getting activity….”activity….”

FRAMES

• EEmpathympathy – Use a positive and caring – Use a positive and caring mannermanner

““I know that it’s really hard to change a I know that it’s really hard to change a behavior, and that it will be hard for Sally behavior, and that it will be hard for Sally to give up some of her favorite TV to give up some of her favorite TV programs.” programs.”

• SSelf-efficacyelf-efficacy – Communicate a “You – Communicate a “You can do it!” approachcan do it!” approach

““I think from what you told me about your I think from what you told me about your family’s diabetes that you don’t want Sally family’s diabetes that you don’t want Sally to get that disease, and I know that you to get that disease, and I know that you and Sally can work together to do this for and Sally can work together to do this for Sally’s long-term health. And I will help Sally’s long-term health. And I will help every step of the way.”every step of the way.”

FRAMES

Thank you and acknowledgmentsThank you and acknowledgments

• Cynthia BulikCynthia Bulik

• KESMM team (especially Alice KESMM team (especially Alice Ammerman, Suzanne Lazorick)Ammerman, Suzanne Lazorick)

• Clinical colleagues (especially Clinical colleagues (especially Joey Skelton)Joey Skelton)

LDL > 130LDL > 130

LDL 130-190

Weight Management Re-check in 4 months

LDL > 190

Weight Management

Refer to Cardiology to begin treatment

Repeat for two 4 month cycles

LDL elevated for > 1 year

Continue Weight Management

Nutritional Treatment (flax, fish oil)

HDL < 40

Weight Management

Triglycerides > 110Triglycerides > 110

Triglycerides > 700

Weight Management

Refer to Cardiology to begin treatment

Triglycerides 110-700


If < 500, Continue Weight

Management

If > 500

Triglycerides elevated for > 1 year

Nutritional Treatment (flax, fish oil)

Insulin Level Insulin Level ≥≥ 20 20

Glucose < 100


Glucose < 100 Continue Weight

Management

Re-check q4 mos

Glucose 100-125

2 Hour OGTT

If impaired or worse, consider treatment

Glucose 100-125

Baseline 2 Hour OGTT

Glucose > 125

Re-check glucose Obtain UA

If glucose > 125

Refer to Endocrine

Obstructive Sleep Apnea ScreeningObstructive Sleep Apnea Screening

Any one of the following:

•Snores ≥ 50% of time

•Witnessed apnea

•Excessive daytime sleepiness

Two or more of the following:

•Headache in am

•Mouth breathing at night

•Dry mouth/sore throat in am

•Hard to wake in am

•Nocturnal enuresis

•Attention span/behavioral issues

Overnight Polysomnography

F/U with Pulmonologist

LiverLiver

Elevated AST or ALT (>60)

CBC, Complete Metabolic Panel, PT, GGT

Any elevation of ALT or AST

> 6 months

ALT or AST >200 or any laboratory

abnormality

Other

Continue to monitor

Hepatitis Bs Ab, Hepatitis Bs Ag, Hepatitis C Ab, ANA, anti-actin antibody, anti-LKM antibody, ceruloplasmin, PI typing, Liver ultrasound

If abnormal, suspicion of liver disorder- refer

to Hepatology

Liver Biopsy If c/w NASH, begin Metformin

Polycystic Ovaries SyndromePolycystic Ovaries Syndrome

Continue Metformin for 8 more months

DHEA-S17-hydroxyprogesterone

TestosteroneLH, FSH

Sex Hormone Binding Globulin

Pelvic ultrasound

Begin Metformin


If any of the following with insulin resistance:•Oligo- or Amenorrhea•Hirsutism•Acne

2 of the 3 following:•Oligo- or Amenorrhea•Hirsutism- clinical or biochemical

•Severe Acne•Abnormal hair growth•LH/FSH > 2:1•Elevated free testosterone

•Polycystic ovaries on imaging

(no evidence of CAD or other cause of symptoms)

Refer to Gynecology

Yes

ImprovedNot improved

No

HypertensionHypertension

CBC, CMP, Renin assayUrinalysisRenal ultrasound

3 BP’s > 90th% BP’s > 99th% + 5mm

Refer to Cardiology

CBC, CMP, Renin assayUrinalysisRenal ultrasound

Refer emergently to Cardiology

Asthma Assessment

Cough

__daily __per week __per month __None

Timing: Nature: Sputum:

Wheezing


Timing:

Dyspnea


Chest Pain


Symptom Triggers

Weather changes__ Viral illness__ Exercise__ Pollen__ Smoke__

Other_________

Nasal Congestion:___ Hives:____

Sneezing:____ Eczema:____

Pneumonia:__ Bronchitis:__ Sinusitis:__

Exercise Tolerance:__Normal __Limited

GE Reflux Symptoms

__sour taste __heartburn

__spitting up __emesis

OGTT

FPG