Pediatric Obesity: Health Implications

Question 1

Definitions of

Overweight and Obesity by BMI

Answer 1

a. CDC BMI (kg/m2) charts for age-gender 2-20 yrs
i. Reflects weight relative to linear growth
ii. Correlation with excess adiposity in children

b. “Obese”: >95th percentile correlates well
75% sensitive, 95% specific for excess adiposity

c. “Overweight”: 85th-95th percentile correlation fair
~50% specific for excess adiposity

Question 2

BMI =
Weight Status

*Know this slide

Answer 2

We use percentile ranges comparing with other Pediatric population

Percentile Ranges:
1. <5th underweight

2. 5-85th healthy weight
3. 85-95th overweight *
4. > 95th obese
   i. excess adiposity
5. > 99th severely obese
   i. Comorbidities!!!**
   ii. ~4% US population

Question 3

BMI vs. weight and height

Answer 3

a. Normal physiology: BMI increases from birth and peaks around 7mo (the “infant BMI peak”).
b. BMI then decreases, reaches a minimum, “the adiposity rebound” around 6years of age, then begins to increase again.
c. This child’s nadir for BMI occurs early at 3yo (hence “early rebound”), which has been associated with obesity both later in childhood and in adulthood.

Question 4

CDC BMI Chart

Answer 4

This slide shows how the BMI trend of an adolescent with severe obesity might appear, or ‘not appear’ on the standard CDC growth chart once it hits the ceiling.

Question 5

Severe Child Obesity Definition

Answer 5

a. Alternate Definition of Severe Obesity:
“Percent of 95th percentile”

Recommended by American Heart Association

b. BMI >120% of 95th percentile BMI for age
i. Or > 35kg/m2
ii. Consistent with “Class 2 Obesity” in adults
iii. Closely approximates 99th percentile

c. A “Severe Obesity” Growth Chart created by Children’s Hospital Colorado
i. Allows tracking of progress in severely obese

Question 6

“Severe Obesity” BMI Chart

Answer 6

On the “Severe Obesity” BMI chart:

• The vertical axis extends to 64 kg/m^2.
• The standard 95th percentile is depicted in black.
• Each smoothed line above represents a BMI that is 15%, 25%, 35% etc above the 95th percentile obesity cutoff.
• The Severe Obesity cutoff at 120% of the 95th percentile BMI is shown in brick red color.

Question 7

Assessment – Weight Status

Answer 7

a. Communicating with families
i. Avoid using the word ‘obese’ with families
ii. Obese-stigmatizing as “fat” and non-motivating

b. Motivating and Non-Stigmatizing Terms
i. In English: ‘unhealthy weight’ or ‘unhealthy BMI’

c. For Spanish Speakers:
“demasiado peso por su salud”
= too much weight for his/her health

Question 8

Communicating with families

Answer 8

a. Discuss AVOIDABLE Health Risks with parents:
Study of Obese 11yr olds Obese at ~35yrs
Thinks to avoid:
i. RR Type II DM 5.4 [3.4-8.5]
ii. RR Hypertension 2.7 [2.2-3.3]
iii. RR Carotid Atherosclerosis 1.7 [1.4-2.2]
arthritis, colon and breast cancer

b. Discuss with Child Quality of Life issues:
i. Sports, energy, confidence, clothing

Question 9

Obj 2. Epidemiology: Prevalence

Answer 9

Between 1972-2000, the prevalence among adults doubled and among kids tripled.
Among youth, the prevalence of obesity has not changed from 2003-2004 through the latest released NHANES data 2013-2014

Question 10

Childhood Obesity Prevalence Summary

Answer 10

a. Prevalence Tripled 1980-2005—>Plateau since 2003

b. Higher Prevalence Groups
i. Older children—> adolescents
ii. Native American, Black, Latino
iii. Low socioeconomic status
- SES explains much of variation by race/ethnicity
- Maternal Education most important SES predictor of childhood obesity worldwide1

Question 11

Complication of Childhood Obesity

Answer 11

So we know childhood obesity is prevalent, but why do we treat it?

a. One reason is the high prevalence of heart disease risk factors present in obese children and a high rate of persistence of obesity into adulthood as seen in this large cohort study in Bogalusa LA.
b. Another reason is that many obese children suffer from co-morbid conditions such as sleep apnea or depression that markedly effect their quality of life.
c. Most significantly, severe obesity in childhood is associated with early mortality in adulthood.

Question 12

Cardiovascular Risk Factors in Childhood

Answer 12

Bogalusa Heart Study n=6731 5-17 yrs

a. 70% of Obese children had two or more:
- High LDL Cholesterol
- Low HDL Cholesterol
- High Blood Pressure
- Insulin resistance

b. Obesity persists: 84% remained obese at age 27yrs

c. Severely Obese Children (BMI >99th percentile)
i. high rates of CVD risk factors RR = ~10
ii. Increased mortality in adulthood

Question 13

CVD Risk Factors and

Atherosclerosis in the Young

Answer 13

a. Autopsied 2-39 year olds

b. Fatty Streaks and Plaques in Coronary Arteries
i. Increased with increasing number of risk factors at baseline
ii. Obesity, high BP, cholesterol, Triglycerides, LDL, low HDL

Question 14

Pediatric Obesity and Pulmonary

Answer 14

1. Obstructive Sleep Apnea
   i. 13-33% of obese youth, Diagnosed by Polysomnogram
   ii. Snoring most nights, apnea, poor sleep, nocturnal enuresis, AM headaches, fatigue, poor school performance
2. Obesity Hypoventilation Syndrome
   i. Severe obesity + restrictive lung disease = hypoventilation; may lead to right heart failure; hypoxemic respiratory drive
   ii. Dyspnea, edema, somnolence

Question 15

Obesity Hypoventilation

Syndrome Treatment

Answer 15

Obesity hypoventilation Syndrome Treatment:

• Positive Pressure
• JUDICIOUS supplemental O2 (they have a high CNS CO2 setpoint, so you do NOT want to take away the only thing driving their breathing)

Question 16

Endocrine and Impaired blood glucose in Pediatrics

Answer 16

1. Impaired glucose metabolism
   i. Elevated fasting glucose = 100-125
   ii. Impaired glucose tolerance = 2 hr OGGT 140-199
   iii. Prediabetes = HgbA1C 5.7-6.4
   ROS: Acanthosis nigricans

2. Type 2 Diabetes (T2DM)---> Prevalence
~1:10,000
   i. Fasting glucose >126,
   ii. 2 hr OGGT/postprandial >200; 
  iii. HgA1c >6.5
 ROS:  Polyuria and polydipsia, nocturnal enuresis, unintentional weight loss

Question 17

Polycystic Ovarian Syndrome (PCOS)

Answer 17

a. Clinical Note:
For likely dx:
1) Abnormal Bleeding Pattern +
2) Hyperandrogenism

• Most common cause of infertility in women
• Increased risk of:
• Metabolic syndrome
• DM2
• Possibly CVD and endometrial ca

b. Review of Systems:
- Oligomenorrhea (<9 menses/year)
- Hyperandrogenism= hirsutism, severe acne

Note: Ovarian cysts on ultrasound not required for diagnosis in teenage females

Question 18

Hypothyroid

Pediatric Endocrinology

Answer 18

a. Clinical Note–> Associated with poor linear growth

b. Review of Systems:
cold intolerance, decline in school performance, coarse features, thin hair, constipation

Question 19

Neurologic/Ophthalmologic Pathology in pediatric obesity

Answer 19

Psuedotumor Cerebri:

a. Clinical findings:
- Papilledema, peripheral vision loss possible
- Consult neuro/ophthalmology
- Rare: ~1/100,000 children

b. Review of Systems:
Headaches (severe, recurrent)
often worse in AM or supine

Question 20

Many different GI pathologies in pediatric obesity

Answer 20

1. Non Alcoholic Fatty Liver Disease (NAFLD)
   i. 10-25%+ of obese youth;
   ii. Elevated ALT;
   iii. Rule out other etiologies of liver disease with persistent elevation > 2 x normal
   iv. Steatohepatitis fibrosis cirrhosis
   ROS: commonly asymptomatic
2. GER
   i. Increased intra-abdominal pressure
   ROS: epigastric/chest discomfort after meals, nausea in AM
3. Gallstones
   i. Can happen with rapid weight loss
4. Constipation /
   Encopresis
   i. Very Common
   ii. low fiber diet

Question 21

Body Mass Index for the younglings

Answer 21

Body Mass Index for age charts
BMI charts allow tracking 2-20 years – U-shaped curve ~6 with nader at age ~6 years;
Correlates with body fatness modestly 85-95th percentile, strongly above 95th percentile;
Allows identification of excessive rate of weight gain relative to linear growth
Progressive or rapid crossing of BMI percentiles upward indicates intervention

1. Overweight
   BMI of age & sex between 85th – 94th %
2. Obese: BMI for age & sex > 95th %
3. Severe obesity: two numerically similar definitions:
   1) BMI ≥ 99th percentile
   2) BMI ≥120% of the 95th percentile corresponds to Class II adult

Expressing % above the 95th percentile allows tracking of severe obesity
The term “morbid obesity” is reserved for adults

BMI > 95th % associated with co-morbidities; BMI > 99th% greatly increases co-morbidities

Question 22

Health impact of obesity in childhood

Answer 22

a. Effects observed in every physiologic system:

• Most common: Obstructive sleep apnea, metabolic syndrome (insulin resistance, hyper/dys-lipidemia, hypertension), hepatic(NAFLD/NASH), decreased quality of life – mood and anxiety disorders
• Less common, not rare: Endocrine (T2DM, PCOS), orthopedic (Blount’s disease, SCFE)

b. Persistence of overweight into adulthood:
i. related to parent’s weight, age of onset, severity; Risk of heart disease and type 2 DM is reversible if obesity resolves by young adulthood

Question 23

Medical Assessment critical points

Answer 23

CALCULATE & PLOT BMI AT LEAST ONCE/YR FOR ALL CHILDREN > 2 YR

Visual diagnosis performs very poorly vs BMI, especially for young children

Use CDC-W.H.O. Wt-for-Length charts below age 2 yrs; >95th % = ‘Overweight’

Early infant weight gain (highest quartile) correlates strongly with later obesity

Question 24

Targeted history (goal is to identify behaviors for change)

Answer 24

a. Dietary factors – many evidence-based candidate behaviors: sugar sweetened beverages (SSB); juice; fruits & veg intake (start in infancy); restaurant food; portion sizes; meal patterns (skipping/ grazing); snacks, fiber, breakfast, family meals, eating in front of TV

b. Physical activity/sedentary behavior: goal 1+hrs active play/day
i. Amount of sedentary time, especially screen time, TV in bedroom
ii. Organized sports/activities, Outdoor time/free play
iii. Adequate Sleep (2-5 yrs 11hrs, 6-12 yrs 10hrs, 13-18 yrs 9 hrs)

c. Family history: Obesity, cardiovascular disease, type 2 diabetes
i. Family hx important to assess risk for individual child

d. Review of systems: look for symptoms of co-morbidities

e. Physical exam: looking for signs of co-morbidities (e.g. hypertension, acanthosis
nigricans, acne/hirsutism, striae, organomegaly, joint pain, stigmata of genetic
syndromes, neurologic function)

f. Labs: screening labs in obese: fasting lipids, ALT, fasting glucose and/or HgA1c q1-2yrs
i. starting by age 10 or Tanner 2, earlier (2-9 years if severely obese BMI>99%)

Question 25

Should you do labs for any kid?

Answer 25

a. No, focus on patients who fall in the obese category (above the 95th percentile) b. Labs: screening labs in obese: fasting lipids, ALT, fasting glucose and/or HgA1c q1-2yrs i. starting by age 10 or Tanner 2, earlier (2-9 years if severely obese BMI>99%)

Question 26

WHAT TO DO?!!!

Answer 26

Start Early! Tailor treatment to severity – ie, be realistic. AAP Stages of Treatment: 1. “Prevention Plus” (most feasible for primary care setting) a. 5210+: 5 fruits/vegetables, 2 hours TV or less, 1 hour activity, 0 SSB, +others 2. Structured Weight Management (PCP plus dietitian and/or psych) 3. Comprehensive, multidisciplinary weight management (diet, exercise, behavior program) 4. Tertiary care intervention (e.g. controlled/supervised diets, meds, surgery)

Question 27

Principles of basic treatment for child overweight (aka Prevention Plus):

Answer 27

a. Learn and Use Motivational Interviewing Skills: i. Identify the family’s motivating values, which may differ from provider’s and vary culturally. b. Use OARrrrS: Open-ended questions, Affirmations, Reflections, Rolling with Resistance, Reframing, and Summaries. • Involve the family – the younger the child, the more important the parent • Clean up the environment: e.g. get problem foods out of home – soda, chips, etc i. Collaborative Management:“Negotiate” w/ family on a few behaviors to target for change for both diet & PA: e.g. eat out less frequently, ↑ f/v, ↓ soda/SSB; limit TV time; TV out of bedroom; encourage outside time c. Joint prioritizing & decision making(ie, MD does not dictate but may give menu of changes) d. Cognitive Behavioral Techniques: • Self monitoring – “If you can’t count it, you can’t change it.” e.g. daily steps, F/V servings, water • Accountability, +Reinforcement/Rewards for behavior change – child & parent work together

Question 28

Acanthosis nigricans

Answer 28

a. Acanthosis nigricans is a brown to black, poorly defined, velvety hyperpigmentation of the skin. It is usually found in body folds, such as the posterior and lateral folds of the neck, the armpits, groin, navel, forehead, and other areas. b. It typically occurs in individuals younger than age 40, may be genetically inherited, and is associated with obesity or endocrinopathies, such as hypothyroidism, acromegaly, polycystic ovary disease, insulin-resistant diabetes, or Cushing's disease.

Question 29

Medical Assessment – Obese Child

Answer 29

1. Plot BMI at least yearly > 2 years of age 2. Assess i. Targeted diet and activity history ii. Family history: CVD risk factors & obesity 3. Review of Systems for comorbidities 4. Vitals/Physical Exam for comorbidities 5. Labs: Lipids, Glucose/HgA1c, ALT, Vit D i. Lipids - 2-8yrs if severely obese or +Fam Hx early CAD - Lipid screening for all kids (once between 9-11y and again between 17-21y)* ii. HgA1C: start after age 10 yrs or Tanner 2

Question 30

Assessment of the Overweight/Obese Child- Lifestyle

Answer 30

Key Diet Factors Associated with Obesity: 1. Sweetened Beverages and Juice 2. Fruit and Vegetable intake i. fiber, low energy density 3. Energy Dense foods i. processed 4. Restaurant Meals i. (not limited to fast food) vs. family meals at home 5. Large Portion Sizes i. Especially poorly-satiating starches 6. Frequency of eating: i. Schedule for meals/snacks ~q3hrs, breakfast qAM

Question 31

Assessment of the Overweight/Obese Child - Lifestyle

Answer 31

Key Activity Factors a. Physical Activity – 60 minutes moderate per day Everyone = Prevention i. Infants: parents promote movement, discourage screen media other than very limited video chatting ii. Preschool: outdoor time iii. School Age – PE and recess, afterschool free-play - Organized activities/sports, Chores, ‘exercise’ in adolescents b. Sedentary Time – Max 1 h for 2-5y; < 2hours for older kids i. TV ii. Video Games iii. Computer iv. Phone/Texting c. Inadequate sleep---> excess weight gain

Question 32

Assessment – | Family History

Answer 32

1st Degree relatives: 1. Severe Obesity i. Single gene disorders are rare ii. >100 genetic variants in population studies associated with obesity (no widespread clinical application yet) 2. Cardiovascular Disease Risk Factors i. Early CAD/MI ii. Type II DM iii. Hypertension iv. Hyperlipidemia 3. Hypothyroidism 4. Psychiatric issues - Eating Disorders

Question 33

Treatment - Overview

Answer 33

Staged Model – 2007 Expert Committee Recs 1. Prevention Plus (Primary Care) 2. Structured Wt Management (MD + RD) 3. Multidisciplinary Wt Management - MD, RD, Psych, PT 4. Tertiary Care highly structured diets, surgery, meds

Question 34

Evidence Supporting Motivational Interviewing (MI)

Answer 34

For Childhood Obesity i. “BMI2 Study” Brief Motivational Interviewing for Body Mass Index, PROS AAP sponsored 4 visits MD + RD -3.7 BMI percentile at 24 months ii. Harvard Pilgrim Network study MI training plus electronic decision support BMI -.51 kg/m^2 at 12 months

Question 35

Treatment – Interviewing styles

Answer 35

a. Motivational Interviewing – A directive, patient-centered counseling style for eliciting behavior change by exploring and resolving ambivalence.” b. Goal: Elicit Change Talk “I can…” “Because…” Perceived Empathy predicts behavior change

Question 36

Motivational Interviewing for Childhood Obesity

Answer 36

OARrrrS a. Open-ended questions “tell me about what makes eating healthier hard for your family…” b. Affirmations “you feel preventing diabetes is important…” c. Reflections: make them think again “so… you eat fast food because you are too busy to cook 5 nights a week…” OR “there is nothing harmful about your son’s current BMI…” d. Roll with Resistance – Resist the urge to tell them what to do Don’t attempt to solve the problem for them e. Reframing “You are able to cook 2 nights a week, what allows you to succeed in that?” f. Summaries “Preventing diabetes is important to you, so you plan to start cooking 4 days a week instead of fast food.”