Evaluation of Obese Child

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 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

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

• lt5 Underweight
• 5-84 Healthy Weight
• 85-94 Overweight
• 95-98 Obese
• gt99 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 lt55)

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 gt
age2

• BMI 85-94
• WITH RISK FACTORS
• Fasting Lipids
• Repeat Every 2 years if normal

12
Laboratory Evaluation for Overweight Children gt
age10

• BMI 85-94
• WITHOUT RISK FACTORS
• Fasting Lipid Profile

13
Laboratory Evaluation for Overweight Children gt
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 gt age 10

• BMI gt95
• 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
• lt 30 minutes of activity per day or consistently
  unbalanced diet
• Source CHDP Provider Information Notice No.
  05-16

16
CHDP Lab Recommendations Overweight Children gt
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
• 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
• 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 gt126 mg/ml
• Casual glucose gt200 mg/ml
• Impaired glucose tolerance
• Fasting glucose gt100 mg/ml
• Casual glucose gt140 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 ChildBrief Focused
Advise

• Step 1 Engage the Patient/Parent
• How do you feel about your childs wt?
• Step 2 Share Information
• Your childs 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 ChildBrief Focused
Advise

• Step 3 Determine if Parent RECEPTIVE to
  discussion about childs 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 lt2 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
• Lets 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 1230-130pm at TV
• Obesity Progress Notes
• Two versions
• Soon to roll out Obesity Registry
• Fundraiser at Yoshis 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