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Proteins Biochem > Pediatric Obesity: Health Implications > Flashcards

Pediatric Obesity: Health Implications Flashcards

1
Q

Definitions of

Overweight and Obesity by BMI

A

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

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2
Q

BMI =
Weight Status

*Know this slide

A

We use percentile ranges comparing with other Pediatric population

Percentile Ranges:
1. <5th underweight

  1. 5-85th healthy weight
  2. 85-95th overweight *
  3. > 95th obese
    i. excess adiposity
  4. > 99th severely obese
    i. Comorbidities!!!**
    ii. ~4% US population
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3
Q

BMI vs. weight and height

A

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.

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4
Q

CDC BMI Chart

A

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.

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5
Q

Severe Child Obesity Definition

A

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

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6
Q

“Severe Obesity” BMI Chart

A

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.
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7
Q

Assessment – Weight Status

A

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

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8
Q

Communicating with families

A

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

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9
Q

Obj 2. Epidemiology: Prevalence

A

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

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10
Q

Childhood Obesity Prevalence Summary

A

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

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11
Q

Complication of Childhood Obesity

A

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.

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12
Q

Cardiovascular Risk Factors in Childhood

A

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

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13
Q

CVD Risk Factors and

Atherosclerosis in the Young

A

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

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14
Q

Pediatric Obesity and Pulmonary

A
  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
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15
Q

Obesity Hypoventilation

Syndrome Treatment

A

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)
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16
Q

Endocrine and Impaired blood glucose in Pediatrics

A
  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
17
Q

Polycystic Ovarian Syndrome (PCOS)

A

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

18
Q

Hypothyroid

Pediatric Endocrinology

A

a. Clinical Note–> Associated with poor linear growth

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

19
Q

Neurologic/Ophthalmologic Pathology in pediatric obesity

A

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

20
Q

Many different GI pathologies in pediatric obesity

A
  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
21
Q

Body Mass Index for the younglings

A

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

22
Q

Health impact of obesity in childhood

A

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

23
Q

Medical Assessment critical points

A

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

24
Q

Targeted history (goal is to identify behaviors for change)

A

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%)

25
Q

Should you do labs for any kid?

A

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%)

26
Q

WHAT TO DO?!!!

A

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)
27
Q

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

A

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

28
Q

Acanthosis nigricans

A

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.

29
Q

Medical Assessment – Obese Child

A
  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
30
Q

Assessment of the Overweight/Obese Child- Lifestyle

A

Key Diet Factors Associated with Obesity:
1. Sweetened Beverages and Juice

  1. Fruit and Vegetable intake
    i. fiber, low energy density
  2. Energy Dense foods
    i. processed
  3. Restaurant Meals
    i. (not limited to fast food) vs. family meals at home
  4. Large Portion Sizes
    i. Especially poorly-satiating starches
  5. Frequency of eating:
    i. Schedule for meals/snacks ~q3hrs, breakfast qAM
31
Q

Assessment of the Overweight/Obese Child - Lifestyle

A

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

32
Q

Assessment –

Family History

A

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
33
Q

Treatment - Overview

A

Staged Model – 2007 Expert Committee Recs
1. Prevention Plus (Primary Care)

  1. Structured Wt Management (MD + RD)
  2. Multidisciplinary Wt Management
    • MD, RD, Psych, PT
  3. Tertiary Care
    highly structured diets, surgery, meds
34
Q

Evidence Supporting Motivational Interviewing (MI)

A

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

35
Q

Treatment – Interviewing styles

A

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

36
Q

Motivational Interviewing for Childhood Obesity

A

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.”

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