Preventive Pediatric Cardio-Metabolic Risk Clinic; The Certified Nurse Practitioner Role and Collaborative Educational Models: What

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Preventive Pediatric Cardio-Metabolic Risk
Clinic The Certified Nurse Practitioner Role and
Collaborative Educational Models
Whats in it for
me?

• Kennesaw State
• Graduate Nursing Program
• July 24th, 2010
• Eduardo Montaña, M.D.,M.P.H.
• Childrens Cardiovascular Medicine
• Marietta, Georgia

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Global Prevalence Metabolic Syndrome
(global invasion of McDonalds)

• 14 USA (NHANES)
• 9.5 Europe (WHO)
• 7.4 Egypt, 9Iran (Mod. NCEP)
• 4.5 Mexico, 6.5 Colombia (IDF)
• 9-12 India, ?? China/Russia
• Male predilection, race/gender det.
• 33 adolescents
• Obese 28.7-49.7 (mod. Sev.)

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Metabolic Syndrome Criteria

• Waist Men 40 Women 35
• Children (waist to hip ratio)
• HDL men lt40 women lt 50 mg/dl
• TG gt 110 mg/dl
• Fasting Serum Glucose impaired 100-125 mg/dl
  
• 
  diabetes gt 125 mg/dl
• SBP/DBP 135/85 mmHg (gt 95th age and
  gender CDC)
• Variable Criteria age, BMI, physical
  characteristics
• (insulin mU/ml x fasting glucose mmmol/L)/22.5
  HOMA-IR (gt2.5)

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Framingham 10 year Cardiac Risk Score

• http//www.framinghamheartstudy.org/risk/hrdcorona
  ry.html
• (based on The Adult Treatment Panel III, JAMA.
  2001)
• OutcomeHard coronary heart disease (HCHD)
  (myocardial infarction or coronary death)
• Duration of follow-upMaximum of 12 years with
  risk calculated at 10 years
• Population of interestIndividuals free of CHD,
  intermittent claudication and diabetes, 30-79
  years of age
• Predictors
• Age
• Total cholesterol
• HDL
• SBP
• Treatment for hypertension
• Smoking status

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WHY WORRY ABOUT PEDIATRIC OBESITY?

• Pediatric obesity is of epidemic proportion.
• Pediatric obesity is the most common chronic
  disease of childhood.
• Chronic Non-communicable diseases are a global
  challenge
• obesogenesis and New World Syndrome

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Evidence for Atherosclerosis Beginning in
Childhood

• Fatty streak formation occurs in human fetal
  aortas and is enhanced by maternal
  hypercholesterolemia
• (JCI 19971002680-2690)
• Bogalusa Heart Study Fatty streaks at age 3.
  More frequent in adolescence (NEJM
  1986314138-144)
• Pathobiological Determinants of Atherosclerosis
  in Youth (PDAY) (N2876, ages 15-34) Found that
  the extent of fatty streaks and fibrous plaques
  in the Ao and Cor arteries is strongly correlated
  with elevated cholesterol
• (ATVB 199717(1)95-106)

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Evidence for Atherosclerosis Beginning in
Childhood

• Bogalusa Heart Study Fatty Streaks were present
  in about 50 of individuals during childhood and
  in 85 of young adults.
• By young adulthood, fibrous plaques were present
  in 69
• atherosclerotic lesions correlated positively
  with total cholesterol, LDL cholesterol,
  triglycerides, blood pressure and with BMI.
• atherosclerotic lesions in childhood rose
  exponentially with increasing RF. (NEJM
  19983381650-1656)

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Evidence for Atherosclerosis Beginning in
Childhood

• Bogalusa Heart Study (N486) Childhood
  measurement of LDL-C and BMI predict carotid IMT
  in young adults (JAMA.20032902271-2276)
• The Cardiovascular Risk in Young Finns Study (N
  2229) Risk factor profile assessed in 12-18 year
  olds predicts adult common carotid IMT
  independently of contemporaneous risk factors.
  Suggesting that exposure to CVD RF early in life
  may induce changes in arteries that contribute to
  the development of atherosclerosis.
  (JAMA.20032902277-2283)

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Pediatric and Adolescent obesity
Comorbidities

• IR/CMR vs. Type II DM
• Fatty streaks vs. CAD
• Hypertension
• Future Risk Cancer
• Sports Injuries vs. Joint disease
• Gallbladder disease
• EIB vs. Pulmonary disease

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CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY

• Psychosocial
• Most common complication of pediatric obesity
• Increased rates of depression
• Poor self esteem
• Obese adolescents negative self image may carry
  over into adulthood

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CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY

• Endocrine
• Increased linear growth (hyperalimentation
  Synd.)
• Advanced bone age
• Earlier onset of puberty
• Acanthosis nigricans

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CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY

• Societal discrimination
• Obese females have lower acceptance rate at
  colleges than non-obese females
• National Longitudinal Survey of Youth obese
  adolescent females as young adults had less
  education, less income, higher poverty rate,
  decreased rate of marriage vs nonose females

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CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY

• Hypertension
• Myth Primary hypertension uncommon in childhood
• 60 of children diagnosed with hypertension are
  obese, 24-30 are obese.
• Use pediatric standards
• Rule out secondary causes (renal, hormonal,
  endocrine)

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CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY

• Hyperlipidemia
• Gaussian Distribution theory- 5 RULE
• FACT The atherosclerotic process begins in
  childhood.
• Genetic Basis of Dyslipidemias 1500 most common
  FH, autosomal Co-Dominant
• Most Dietary/cultural/lifestyle etiology
• Prevalence ?? 150, 1100 population studies
  needed

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CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY GI

• New GI epidemic Fatty Liver
• Hepatic steatosis present in 25-83 of obese
  children
• 10-15 of obese children have elevated liver
  enzymes steatohepatitis or non-alcoholic fatty
  liver disease
• Rashid 83 of children with steatohepatitis were
  obese. 75 had fibrosis-cirrhosis (NASH) liver
  transplantation?

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CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY GI
Part II

• Gastrointestinal Hi Fat Dilemma
• Cholelithiasis
• 50 of cases of cholecystitis in adolescents are
  obese
• Gastritis, Pancreatitis, Colitis?
• GI malignancies?
• Hiatal Hernias, diverticulitis

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CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY
Orthopeadic

• Orthopedic/sports related injury
• Stress/Strain and Breaks
• Slipped capital femoral epiphysis
• 30-50 are obese
• Blounts disease (Tibia vara)
• 70 are obese
• Neurologic
• Pseudotumor cerebri

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CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY
Pulmonary

• Respiratory
• Sleep disorder in 1/3
• Sleep apnea 7 of obese, 1/3 if gt150
  breathing difficulties
• Hypoventilation syndrome/PAH/cor pulmonale
• Exercise Induced Bronchospasm
• Increased infections? Malignancies?

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BARRIERS TO THERAPY OF PEDIATRIC OBESITY

• Lack of Time, commitment, education of primary
  care providers
• many providers/clinics do not address obesity,
  measure BMI much less HEP
• Healthy Doc Healthy Patient Study Emory E.
  Frank MD, MPH
• Reverse incentives for primary care, not value
  based (EBM)

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Health Care Reform? Or Wall Street
ReformDisease Mgt. vs. Disease Prevention

• Big Three Pharma, Unmanaged Care and Biotech
• Economic impact est. cost of obesity 2002 117
  billion
• HC exp 2015 est. 10 Trillion!!
• 1 non communicable obesity related illness.
• U.S. Bankruptcy!?

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BARRIERS TO THERAPY OF PEDIATRIC OBESITY

• Volume based not value based
• Lack of reimbursement for obesity related
  conditions
• Median reimbursement rate 11 for obesity code
  (ICD 278.01)
• Lack of standard treatment protocols, based on
  EBM, no professional consensus
• Social / environmental barriers food in
  security, physical insecurity, socio-cultural
  insecurity Harrahs Casino anecdote

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Communities putting prevention to
workFighting against school nutrition and
activity policies

• Requiring daily physical activity as academic
  stimulus
• Prioritizing Health Education and wellness though
  nutrition policy
• Eliminate vending machines
• Creating a culture of Wellness
• Staff commitment to prevention

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PREVENTION Collaborative COMMUNITY partnerships

• Private-Public entrepreneurial relationshiops
• RWJ model Active Living By Design5 Ps
• Place green-space-safe parks, events, social
  networking
• Products Learning Platforms/curricula for
  families and professionals
• Promotion Social/Experiencial marketing
• Price Whats in it for me? Value based medicine
• Policy Commitment and funding prevention for the
  future

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Governments Role in Prevention of childhood
obesity? managing WALL STREET!

• Fight marketing with marketing Coke Fructose
  Corn Syrup Live positively with natural sugars
• Un-Managed Care? provide reimbursement for
  anticipatory guidance for nutrition and physical
  activity
• Food Industry The 30 second heart attack!

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Model for PREVENTION for the CPFNP Health
Literacy of the Primary Care Provider

• Become a Health Partner
• Commit to further education and training of
  office staff
• Implement a PPCMR model
• Peer to Peer Support through advocacy
• Avoid the slow death vortex of primary care

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COR ALEGRO SANO ANIMA.Happy Heart
Healthy Mind..Corazón Alegre Mente Sana
My Home Your Home?? ? ?Ma Maison Votre
Maison..Mi Casa Su Casa

• Global Wellness Partners
• Welcome ????? Willkommen Bienvenidos
  ?????????????? ???????? Boas-vindas ??????
  Accueil ?a??s???sµa??

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Thank You BeWell
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