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FALL15 N833 Adv Pedi Probs > Obesity > Flashcards

Obesity Flashcards

1
Q

Normal or healthy weight in a pediatric population

percentiles

A

> 5th and < 85th

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2
Q

Overweight in pediatric population

percentiles

A

> 85th and < 95th

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3
Q

Obese in pediatric population

percentiles

A

_>_95th

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4
Q

Components of Dietary and Physical Activity Assessment

A
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5
Q

ROS findings in setting of pediatric obesity + possible causes

A
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6
Q

Components of a physical exam in setting of pediatric overweight/obesity

A

•Blood Pressure

•Height and weight

•BMI

•Ideal body weight

•Skin

•Skinfold thickness*

  • •Midarm circumference**
  • •Waist circumference measurements**
  • *not recommended by expert committee*
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7
Q

Diagnostic evaluation

85th-94th % for weight (overweight) with and w/o risk factors

A
  • 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*
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8
Q

Diagnostic evaluation: > 95th percentile

A

Fasting lipids, AST & ALT, fasting glc

*other tests may be ordered based on RFs - e.g., nocturnal polysomnography, OGTT, TFTs, etc

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9
Q

Major health risks of obesity for pediatric patients

A
  • 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.
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10
Q

Causes of pediatric dyslipidemia

A
    1. Genetic defects, including familial hypercholesterolemia, familial defective apolipoprotein B, and familial hypertriglyceridemia.
    1. Secondary dyslipidemia related to obesity, type 2 diabetes or drug exposures.
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11
Q

How do kids differ/change in terms of lipid levels?

A
  • 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.
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12
Q

Reasons we may be missing kids w/risk factors

A

Not asking

Widespread statin use in parents mask CVD risk

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13
Q

Universal screening for dyslipidemia?

A

NHLBI recommends! D/t lack of accurate clinical markers to ID at risk

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14
Q

When to screen lipid levels in kids?

A
  • 9-11yo
  • 17 to 21 yo (after HDL and LDL changes that occur during puberty)
  • Nothing under 2yo, selectively at other times
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15
Q

Fasting vs non-fasting lipids in kids w/no known risk factors

A

TC and HDL: preferred

can be measured accurately in non-fasting individuals making it more practical in pediatrics.

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16
Q

What to do if fasting lipids are abnormal?

A

measure at least twice

Intervals between measurements should be two weeks to three months

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17
Q

Non-pharm tx of hyperlipidemia in pediatric population

A

Dietary interventions

Elimination of smoke exposure

Increased activity

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18
Q

Pharm tx of HLD in pediatric population

A
  • Statins
  • Fibric acids
  • Bile acid sequestrants
  • Omega-3 fish oils

*Most statins approved in kids _>_10yo

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19
Q

Relationship between childhood BP and adult BP

A

Childhood BP is a predictor

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20
Q

CV risks associated w/HTN in kids

A

contributes to early dvpt of CVD

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21
Q

T/F

Childhood HTN is defined by normative distribution rather than clinical outcomes.

A

True

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22
Q

Most important determinant of BP in kids

A

BMI

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23
Q

Symptoms of HTN in kids

A
  • Headache
  • Seizures
  • Changes in mental status
  • Focal neurologic complaints
  • Visual disturbances
  • CV complaints indicative of HF such as CP, palpitations, cough, or SOB
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24
Q

BP screening Recs

AAP

A

Begin at 3yo for routine office and emergency visits

Before 3yo if hx of neonatal complications

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25
Q

Percentiles for normal BP in kids

A

SBP and DBP <90th%

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26
Q

Percentiles for prehypertension in kids

A

Prehypertension:

SBP or DBP ≥90th% but <95th% or

>120/80 mmHg
(even if <90th% for age, gender, and height)

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27
Q

Stages 1 and 2 HTN in kids

percentiles

A
  • Must be measured on 3+ separate occasions
  • Stage 1: SBP/DBP between 95th% and 99th% + 4mmHg
  • Stage 2 HTN: SBP/DBP _>_99th% + 5mmHg
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28
Q

Follow up if pre-HTN

A

recheck in 6 months

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29
Q

F/U if stage 1 HTN

A

recheck in 2 weeks or sooner if patient is symptomatic

30
Q

F/U if stage 2 HTN

A

If symptomatic: evaluate immediately

If not: evaluate w/in the week

31
Q

Non-pharm Tx for HTN in kids

A
  • Weight reduction
    • systolic and diastolic BP falls 1 mmHg for each 1 kg lost
  • Regular exercise
  • Diet modifications, including salt restrictions
32
Q

Pharm Tx for HTN: Who is a candidate?

A

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
33
Q

Pharm Tx for HTN: what are your choices?

A

ACE/ARB

Thiazide

BB

CCB

34
Q

most common cause of liver disease in children

A

obesity - non-alcoholic fatty liver disease

35
Q

Steatosis vs NASH

A
  • 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
36
Q

Pathogenesis of fatty liver disease in kids

A

Not fully understood but is linked to insulin resistance

Common comorbidities: insulin resistance, dyslipidemia and hypertension.

37
Q

Diagnosis of fatty liver disease: signs, labs, imaging, diagnostic tests

A
  • 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.
38
Q

Tx for fatty liver in kids

A
  • Weight loss
  • Emphasis on physical activity, improves insulin sensitivity
  • Counsel against alcohol use
39
Q

Orthopedic issues r/t obesity in kids

A
  • Joint pains
  • Excess sprains/strains
  • Forceful falls
  • Lengthier recovery time
  • Back pain due to excess abdominal weight
  • SCFE & Blount’s (bow-legs)
40
Q

What is SCFE?

A

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)

41
Q

Polycystic Ovary Syndrome (PCOS): S/S

A
  • Obesity
  • Hirsutism
  • Scalp hair loss
  • Treatment-resistant acne
  • Menstrual irregularity
  • Excessive menstrual bleeding
  • Acanthosis nigricans
  • Hyperhidrosis
42
Q

H&P findings of PCOS

A
  • 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)
43
Q

Causes of PCOS

A
  • Unknown!
  • Contributions heritable and nonheritbale intrauterine and extrauterine factors
    • Insulin resistance
    • Obesity*
44
Q

Lab / Diagnostic testing for PCOS

A
  • 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

45
Q

Tx of PCOS

A
  • 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
46
Q

Duration of PCOS tx

A

not clear

Recommendation: until gynecologically mature (5 years post menarche) or substantial wt loss

47
Q

Longterm risks of PCOS

A

Increased risk for metabolic syndrome, T2D, CVD, endometrial carcinoma

48
Q

S/S of prediabetes

A
  • 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
49
Q

Who should be screened for T2D?

A
  • 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
50
Q

Diagnostic criteria for prediabetes

A
51
Q

Diagnostic criteria for diabetes

A
52
Q

Tx for prediabetes

A
  • Intensive lifestyle interventions
    • Weight reduction
    • Dietary Interventions
    • Physical Exercise
  • Screened and rescreened for T2DM at least annually
  • Metformin: controversial
53
Q

OSA: S/S in kids

A
  • 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
54
Q

OSA: PE in kids

A
  • Most children with OSA have normal PE except:
  • Adenotonsillar hypertrophy*
  • Obesity*
  • Poor growth
  • High arched palate
55
Q

Sequelae of untreated OSA in kids

A
  • -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.
56
Q

OSA: grading of tonsil size in kids

A
57
Q

Causes of OSA in kids

A
  • Abnormal upper airway anatomy
  • Adenoid hypertrophy
  • Chronic nasal congestion
  • Abnormal maxillomandibular development
  • Neuromotor disease
58
Q

Screening and diagnostics for OSA in kids

A
  • 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
59
Q

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
  • 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
60
Q

Tx of OSA in kids

A
  • 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

61
Q

Major culprits in pediatric obesity?

A
  • 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
62
Q

Expert AAP Committee Guidelines: pediatric obesity

A
  • 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:
    1. A diet high in fiber, rich in calcium & balanced macronutrients
    1. Restrict highly processed, calorie-dense, nutrient-poor foods
63
Q

Weight maintenance vs weight loss in pediatric population?

A
  • •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.
64
Q

AAPs 4 Stage approach for Weight Mgt

A
  • 1.Prevention Plus
  • 2.Structured Weight Management;
  • 3.Comprehensive Multidisciplinary Intervention; and
  • 4.Tertiary Care Intervention.
65
Q

AAP prevention plus: describe this step

A

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
66
Q

AAP: structured weight management

describe this goal

A
  • 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
67
Q

AAP: Comprehensive Multidisciplinary Intervention

describe this goal

A
  • 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
68
Q

AAP: 4. Tertiary Care Interventions

describe this goal

A
  • 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.
69
Q

Modalities for tertiary interventions

pediatric obesity

A

Various

  • highly structured diet
  • medications: orlistat
  • bariatric surgery.
70
Q

When to dose statins

A

HS: LDL synthesis occurs at night

FALL15 N833 Adv Pedi Probs (10 decks)

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