Obesity Flashcards
Normal or healthy weight in a pediatric population
percentiles
> 5th and < 85th
Overweight in pediatric population
percentiles
> 85th and < 95th
Obese in pediatric population
percentiles
_>_95th
Components of Dietary and Physical Activity Assessment
ROS findings in setting of pediatric obesity + possible causes
Components of a physical exam in setting of pediatric overweight/obesity
•Blood Pressure
•Height and weight
•BMI
•Ideal body weight
•Skin
•Skinfold thickness*
- •Midarm circumference**
- •Waist circumference measurements**
- *not recommended by expert committee*
Diagnostic evaluation
85th-94th % for weight (overweight) with and w/o risk factors
- No Risk factors: fasting lipids
- Risk factors: lipids, AST and ALT, fasting BG
- Risk factors: family hx obesity related dzes, elevated BP, elevated lipids, tobacco use)*
- *other tests may be ordered based on RFs - e.g., nocturnal polysomnography, OGTT, TFTs, etc*
Diagnostic evaluation: > 95th percentile
Fasting lipids, AST & ALT, fasting glc
*other tests may be ordered based on RFs - e.g., nocturnal polysomnography, OGTT, TFTs, etc
Major health risks of obesity for pediatric patients
- High BP and high cholesterol (RFs for CVD).
- Fatty liver disease, gallstones, GERD
- impaired glucose tolerance, insulin resistance, T2D
- Breathing problems, such as sleep apnea, and asthma.
- Joint problems and musculoskeletal discomfort.
- depression, behavioral problems, and issues in school.
- Low self-esteem, low self-reported QoL
- Impaired social, physical, and emotional functioning.
- more likely to become obese adults.
Causes of pediatric dyslipidemia
- Genetic defects, including familial hypercholesterolemia, familial defective apolipoprotein B, and familial hypertriglyceridemia.
- Secondary dyslipidemia related to obesity, type 2 diabetes or drug exposures.
How do kids differ/change in terms of lipid levels?
- Change through growth.
- Very low at birth and rise slowly to 2yo.
- Levels remain relatively constant: 2 years until adolescence.
- Puberty TC and LDL decrease
- then rise in the late teen years.
- Males: decrease in HDL during puberty.
- Female: HDL levels remain stable until menopause.
Reasons we may be missing kids w/risk factors
Not asking
Widespread statin use in parents mask CVD risk
Universal screening for dyslipidemia?
NHLBI recommends! D/t lack of accurate clinical markers to ID at risk
When to screen lipid levels in kids?
- 9-11yo
- 17 to 21 yo (after HDL and LDL changes that occur during puberty)
- Nothing under 2yo, selectively at other times
Fasting vs non-fasting lipids in kids w/no known risk factors
TC and HDL: preferred
can be measured accurately in non-fasting individuals making it more practical in pediatrics.
What to do if fasting lipids are abnormal?
measure at least twice
Intervals between measurements should be two weeks to three months
Non-pharm tx of hyperlipidemia in pediatric population
Dietary interventions
Elimination of smoke exposure
Increased activity
Pharm tx of HLD in pediatric population
- Statins
- Fibric acids
- Bile acid sequestrants
- Omega-3 fish oils
*Most statins approved in kids _>_10yo
Relationship between childhood BP and adult BP
Childhood BP is a predictor
CV risks associated w/HTN in kids
contributes to early dvpt of CVD
T/F
Childhood HTN is defined by normative distribution rather than clinical outcomes.
True
Most important determinant of BP in kids
BMI
Symptoms of HTN in kids
- Headache
- Seizures
- Changes in mental status
- Focal neurologic complaints
- Visual disturbances
- CV complaints indicative of HF such as CP, palpitations, cough, or SOB
BP screening Recs
AAP
Begin at 3yo for routine office and emergency visits
Before 3yo if hx of neonatal complications
Percentiles for normal BP in kids
SBP and DBP <90th%
Percentiles for prehypertension in kids
Prehypertension:
SBP or DBP ≥90th% but <95th% or
>120/80 mmHg
(even if <90th% for age, gender, and height)
Stages 1 and 2 HTN in kids
percentiles
- Must be measured on 3+ separate occasions
- Stage 1: SBP/DBP between 95th% and 99th% + 4mmHg
- Stage 2 HTN: SBP/DBP _>_99th% + 5mmHg
Follow up if pre-HTN
recheck in 6 months
F/U if stage 1 HTN
recheck in 2 weeks or sooner if patient is symptomatic
F/U if stage 2 HTN
If symptomatic: evaluate immediately
If not: evaluate w/in the week
Non-pharm Tx for HTN in kids
- Weight reduction
- systolic and diastolic BP falls 1 mmHg for each 1 kg lost
- Regular exercise
- Diet modifications, including salt restrictions
Pharm Tx for HTN: Who is a candidate?
Limited to those who are most likely to benefit
- Symptomatic HTN
- Stage 2 HTN
- Stage 1 HTN that persists despite 4-6 months of nonpharmacolgic therapy
- Patients with diabetes or dyslipidemia
Pharm Tx for HTN: what are your choices?
ACE/ARB
Thiazide
BB
CCB
most common cause of liver disease in children
obesity - non-alcoholic fatty liver disease
Steatosis vs NASH
- Steatosis - increased liver fat without inflammation
-
Non-alcoholic steatohepatitis (NASH) - increased liver fat with inflammation
- not well described in kids. May –> fibrosis, cirrhosis, and ultimately liver failure
Pathogenesis of fatty liver disease in kids
Not fully understood but is linked to insulin resistance
Common comorbidities: insulin resistance, dyslipidemia and hypertension.
Diagnosis of fatty liver disease: signs, labs, imaging, diagnostic tests
- Signs: RUQ pain, hepatomegaly, abdominal discomfort, weakness, fatigue or malaise.
- Lab: Elevation in ALT, AST, alkaline phosphate and gamma glutamyl transpeptidase.
- Imaging: US, MRI more accurate
- Liver biopsy indications have not been established.
Tx for fatty liver in kids
- Weight loss
- Emphasis on physical activity, improves insulin sensitivity
- Counsel against alcohol use
Orthopedic issues r/t obesity in kids
- Joint pains
- Excess sprains/strains
- Forceful falls
- Lengthier recovery time
- Back pain due to excess abdominal weight
- SCFE & Blount’s (bow-legs)
What is SCFE?
SCFE – Slipped capital femoral epiphysis
actually the proximal femur that slips, misnomer
UpToDate: AVN is a rare unlikely complication of SCFE - more associated with Legg Calve Perthes (typically ages 4-10yo)
Polycystic Ovary Syndrome (PCOS): S/S
- Obesity
- Hirsutism
- Scalp hair loss
- Treatment-resistant acne
- Menstrual irregularity
- Excessive menstrual bleeding
- Acanthosis nigricans
- Hyperhidrosis
H&P findings of PCOS
- Medication hx
- that mask (OCPs or systemic acne meds) or cause (androgenic steroids or antiepileptic drugs) symptoms
- Degree and distribution of sexual hair growth (Ferriman-Gallwey Score)
Causes of PCOS
- Unknown!
- Contributions heritable and nonheritbale intrauterine and extrauterine factors
- Insulin resistance
- Obesity*
Lab / Diagnostic testing for PCOS
- Serum testosterone: total is cheaper, free is better
- DHEAS
Other possible tests: cortisol to r/o Cushing’s, TSH to r/o thyroid, U/S to r/o tumor
Tx of PCOS
- First line: combination OCPs!
- Hair reduction methods and anti-androgen tx– for uncontrolled hirsutism
- Lifestyle modification is first line treatment for overweight and obesity
- Metformin: possible but role still controversial in adolescents
- abnl glc tolerance, lipid abnormalities not normalized by wt loss
- titrate to max of 2000 mg/day
Duration of PCOS tx
not clear
Recommendation: until gynecologically mature (5 years post menarche) or substantial wt loss
Longterm risks of PCOS
Increased risk for metabolic syndrome, T2D, CVD, endometrial carcinoma
S/S of prediabetes
- Overweight or obese (BMI _>_85th percentile)
- Weight change, polydipsia, polyuria, blurred vision
- Clinical features associated with insulin resistance:
- Acanthosis nigricans, hypertension, dyslipidemia, s/s of PCOS
- +FHx
Who should be screened for T2D?
- Overweight or obese and have 2+ following:
- T2DM in a 1st or 2nd -degree relative
- High-risk racial/ethnic group: Native American, African American, Latino, Asian American, or Pacific Islander
- Signs of insulin resistance or conditions associated with insulin
- Maternal history of DM or GDM during the child’s gestation
Diagnostic criteria for prediabetes
Diagnostic criteria for diabetes
Tx for prediabetes
- Intensive lifestyle interventions
- Weight reduction
- Dietary Interventions
- Physical Exercise
- Screened and rescreened for T2DM at least annually
- Metformin: controversial
OSA: S/S in kids
- Disrupted sleep
- Frequent awakening, gasping, agitated sleep, apnea, restless sleep, or sleeping in unusual position
- Parasomnias
- Nocturnal enuresis
- Snoring
- Daytime symptoms
- Mouth breathing & hyponasal speech, HA, excessive daytime sleepiness
OSA: PE in kids
- Most children with OSA have normal PE except:
- Adenotonsillar hypertrophy*
- Obesity*
- Poor growth
- High arched palate
Sequelae of untreated OSA in kids
- -cardiovascular complications
- -impaired growth (including failure to thrive)
- -learning problems
- -behavioral problems
- -Early diagnosis and treatment of OSA may decrease morbidity. However, diagnosis is frequently delayed.
OSA: grading of tonsil size in kids
Causes of OSA in kids
- Abnormal upper airway anatomy
- Adenoid hypertrophy
- Chronic nasal congestion
- Abnormal maxillomandibular development
- Neuromotor disease
Screening and diagnostics for OSA in kids
- Nocturnal Polysomnography (PSG)
- If PSG not available, referral to otolaryngologist for home sleep apnea test
- Pediatric Sleep Questionnaire
- Sleep Related Disorder Scale (SRBD)
- I’M SLEEPY screening tool
According to the American Academy of Sleep Medicine (AASM) A and B criteria should be present for a child to be diagnosed with OSA.
- A criteria – one or more:
- Snoring
- Labored, paradoxical, or obstructed breathing during the child’s sleep
- Sleepiness, hyperactivity, behavioral problems, or learning problems
B criteria – (PSG) demonstrates one or both:
- One or more obstructive apneas, mixed apneas, or hypopneas, per hour of sleep.
- A pattern of obstructive hypoventilation, defined as at least 25% of total sleep time with hypercapnia (PaCO2 >50 mmHg) associated with one or more of the following:
- Snoring
- Flattening of the nasal pressure waveform
- Paradoxical thoracoabdominal motion
Tx of OSA in kids
- Adenotonsillectomy: 1st line if healthy
- CPAP/BiPAP: if adenotonsillectomy C/Ied or insufficient
- Watchful waiting: if mild/moderate - can re-eval in 6mo
- Adjunctive Therapies
- Weight loss
- Environmental controls
follow closely for recurrence. OSA may recur after treatment and may worsen with age or weight gain
Major culprits in pediatric obesity?
- Strongest evidence: decreased physical activity, increased sedentary screen time, increased intake sugared beverages
- Less rigorous evidence: skipping breakfast, reduced intake of fruit, veggies, inadequate dietary fiber, fever family meals, more fast food dining
Expert AAP Committee Guidelines: pediatric obesity
- 1.Eliminate consumption of sugar-sweetened beverages
- 2.Limit television & other screen time (
- 3.Encourage >1 hr moderate to vigorous activity daily
- 4.Eat breakfast daily
- 5.Encouraging > 5 servings fruits & vegetables/d
- 6.Limit eating out, particularly fast foods
- 7.Encourage family meals in which parents & children eat together
- 8.Limit portion size- visualized with the new USDA plate model
- Also recommended:
- A diet high in fiber, rich in calcium & balanced macronutrients
- Restrict highly processed, calorie-dense, nutrient-poor foods
Weight maintenance vs weight loss in pediatric population?
- •Weight maintenance may be appropriate in younger children, as BMI will improve with increase in height.
- •Older children and severely obese children can lose up to 2 lbs a week.
AAPs 4 Stage approach for Weight Mgt
- 1.Prevention Plus
- 2.Structured Weight Management;
- 3.Comprehensive Multidisciplinary Intervention; and
- 4.Tertiary Care Intervention.
AAP prevention plus: describe this step
Introduced for children 2 -18 years with BMI of >85th percentile.
- Nutrition Goals:
- Eat ≥5 servings of fruits and vegetables per day
- Elimination of sugar-sweetened beverages
- Eat breakfast every day
- Eat most meals at home as a family
- Activity Goals:
- <2 hours of TV/screen time per day (if child is <2, NO screen time)
- More than 1 hour of physical activity per day
- Behavioral Goals
- Reinforce goals at each health care visit
- Allow child to self regulate, avoid overly strict eating regimens
- Weight goals:
- Weight maintenance with growth that results in decreasing BMI as age increases.
- Follow up monthly!
- If no improvement in BMI/weight status after 3-6 months, then advancement to stage 2 is indicated
AAP: structured weight management
describe this goal
- Nutrition Goals: Stage 1 plus:
- Daily eating plan, with scheduled meals and snacks (breakfast, lunch, dinner and 1-2 snacks per day)
- Emphasize foods with low energy density
- Reduce frequency and quantity of foods with high energy density (e.g., fried food, baked goods, fats, etc.)
- Limit portion size
- Set explicit behavior goals
- Activity Goals:
- Less than 1 hour of TV/other screen time daily
- More than 1 hour of supervised active play per day, to ensure activity
- Behavioral Goals
- Monitor eating and physical activities through logs
- Use positive reinforcement techniques (reward system)
- Strong parental involvement for school-aged children
- Weight goals:
- Wt. maintenance w/ growth that results in ↓BMI as age increases.
- Follow up monthly!
- If no improvement in BMI/weight status after 3-6 months, then advancement to stage 3 is indicated
AAP: Comprehensive Multidisciplinary Intervention
describe this goal
- Characterized by increased intensity of behavioral change strategies, greater frequency of patient-provider contact, and specialist involvement.
- Nutrition Goals: Stage 2 plus:
- Structured diet and physical activity designed for negative energy balance
- Activity Goals:
- Stage 2 supported by behavioral interventions
- Behavioral Goals
- Similar, but with increased structure and accountability
- Parent training in behavioral techniques to improve home eating and activity environment
- Weight goals:
- Wt. maintenance or gradual weight loss until BMI is in 85th percentile.
- Weight loss should not exceed 1 lb/month for children 2 to 5 years of age or 2 lb/week for older obese children and adolescents.
- Follow up weekly!
- If no improvement in BMI/weight status after 3-6 months, then advancement to stage 4 is indicated
AAP: 4. Tertiary Care Interventions
describe this goal
- For severely obese youths who have been unable to improve their degree of adiposity and morbidity risks through lifestyle interventions.
- Candidates should have
- attempted weight loss at the level of stage 3 (comprehensive multidisciplinary intervention),
- should have the maturity to understand possible risks associated with stage 4 interventions,
- and should be willing to maintain physical activity, to follow a prescribed diet, and to participate in behavior monitoring.
Modalities for tertiary interventions
pediatric obesity
Various
- highly structured diet
- medications: orlistat
- bariatric surgery.
When to dose statins
HS: LDL synthesis occurs at night
