sophie lanciers, md, faap, diplomate abom assistant
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PEDIATRIC WEIGHT MANAGEMENT:SCREENING & WORK UP
SOPHIE LANCIERS, MD, FAAP, DIPLOMATE ABOM
ASSISTANT PROFESSOR OF PEDIATRIC GASTROENTEROLOGY
PEDIATRIC OBESITY
• CRITICAL PUBLIC HEALTH ISSUE
• MAJOR CAUSE OF MORBIDITY AMONG AMERICAN CHILDREN
• PRE-DIABETES, DIABETES, NON-ALCOHOLIC FATTY LIVER DISEASE,
BLOUNT’S DISEASE, SLIPPED CAPITAL FEMORAL EPIPHYSIS,
OBSTRUCTIVE SLEEP APNEA, MENTAL HEALTH ISSUES...
• CONDITIONS PREVIOUSLY THOUGHT TO BE ONLY FOUND IN ADULTS
PREVALENCE• OBESITY HAS BECOME ONE OF THE MOST IMPORTANT PUBLIC HEALTH
PROBLEMS IN THE US
• INCREASE PREVALENCE OBESITY MEANS INCREASE IN COMORBIDITIES
• 32% CHILDREN AND ADOLESCENTS ARE OVERWEIGHT (22% 15
YEARS AGO)
• 17% OBESE (11% 15 YEARS AGO)
• JACKSON: UP TO 70% REPORTED OVERWEIGHT BY SCHOOLS
• CHILDHOOD OBESITY => ADULTHOOD OBESITY IN 80%
MONTANA STATISTICS
• ADULT OBESITY 28.3%, UP FROM 15.6% IN 2000 AND 8.4% IN 1990
• ADULT OBESITY NOW ABOVE 35% IN 7 STATES, TRENDS CONSISTENTLY
GOING UP
• OBESITY IN 2 TO 4 YRS: 12.1% (WIC), HIGH SCHOOL STUDENTS 11.5%
(NEW DATA, STATE OF OBESITY)
• DIAGNOSED DIABETES INCREASED FROM 2.8% IN 1990 TO 9.3% IN 2018
• HEART DISEASE CASES IN 2010: 64,244, PROJECTED FOR 2030: 304,870
PRE-DIABETES AND DIABETES TYPE 2
• IN THE US 33.9% OLDER THAN 18 HAVE DIAGNOSED PRE-DIABETES
• 7.4% ADULTS IN MONTANA REPORT HAVING PRE-DIABETES
• CHILDREN DIAGNOSED WITH TYPE 2 DIABETES MORE THAN DOUBLED IN
RECENT YEARS, APPEARS TO COINCIDE WITH INCREASE IN OBESITY BASED
ON PRIVATE INSURANCE DATA
• IN 2018 17.2% AMERICAN INDIAN/ALASKA NATIVES DIAGNOSED WITH
DIABETES, 8.7% WHITE NON HISPANICS IN MONTANA
• DATA FROM CDC AND MONTANA BEHAVIORAL RISK FACTOR
SURVEILLANCE SYSTEM, 2018
OBESITY: DEFINITION / DIAGNOSIS
• BMI CLINICALLY PRACTICAL TOOL FOR ASSESSMENT
• BODY WEIGHT IN KG / HEIGHT IN METER SQUARED
• CORRELATES WITH ADIPOSITY AND COMPLICATIONS OF CHILDHOOD
OVERWEIGHT
• LIMITATIONS: OVERESTIMATES ADIPOSITY IN INCREASED MUSCLE
MASS AND VICE VERSA
DEFINITION/ DIAGNOSIS
• BMI >85TH PERCENTILE = OVERWEIGHT
• BMI >95TH PERCENTILE = OBESE
• BMI CAN ALSO BE DETERMINED USING CALCULATOR FOR BOYS AND
GIRLS
• TO BE MEASURED YEARLY IN CHILDREN OLDER THAN 2 YEARS.
DEFINITION/ DIAGNOSIS
• BMI < 85TH PERCENTILE BUT INCREASING MORE THAN 3 OR 4 UNITS/
YEAR AFTER 4 YRS OF AGE: SIMPLE TIPS NUTRITION AND EXERCISE.
• BMI > 85TH PERCENTILE: SCREEN FOR CO-MORBIDITIES, COUNSEL FOR
LIFESTYLE CHANGES, DIETICIAN
• BMI > 95TH PERCENTILE: SIGNIFICANT RISK FOR OBESITY AS ADULT,
SCREEN FOR CO-MORBIDITIES, DIRECT COUNSELING CLINICIAN,
REGULAR FOLLOW UP FOR PROGRESS (2 MONTHS)
GENETIC SYNDROMES
• SINGLE GENE DISORDERS ARE RARE:
• PRADER-WILLI: 1/15.000 BIRTHS, 15Q PARTIAL DELETION
• SMALL AT BIRTH, FTT UNTIL +/- 18 MONTHS
• DIAGNOSIS: DNA METHYLATION STUDY
• RARE DISORDERS: BARDET-BIEDL, COHEN SYNDROME, ALSTROM
SYNDROME, LEPTIN DEFICIENCY
EVALUATION
• GOAL: TO IDENTIFY TREATABLE CAUSES AND CO-MORBIDITIES
• COMPLETE HISTORY AND PHYSICAL
• LABORATORY AND RADIOLOGICAL STUDIES
EVALUATION
• HISTORY:
• AGE OF ONSET, GRADUAL OR SUDDEN
• DIETARY HISTORY:
• IDENTIFICATION CARETAKERS
• INTAKE HIGH CALORIE FOODS
• SKIPPING MEALS
• INABILITY TO CONTROL APPETITE
EVALUATION
• EXERCISE HISTORY:
• WALKING OR RIDING BIKE TO SCHOOL
• TIME SPENT IN PLAY
• SCHOOL RECESS AND PE
• WEEKEND ACTIVITIES
• ASSESSMENT SCREEN TIME (TV, GAMES)
EVALUATION
• REVIEW OF ALL MEDICATIONS, ALSO IN THE PAST:
• STEROID USE FOR ASTHMA AT YOUNG AGE
TRIGGER FOR WEIGHT GAIN
• PSYCHOACTIVE DRUGS (RISPERIDONE)
• ANTIEPILEPTIC DRUGS
EVALUATION
• REVIEW OF SYSTEMS:
• ABRUPT ONSET WEIGHT GAIN:
• MEDICATION INDUCED
• MAJOR PSYCHOSOCIAL TRIGGER
• ENDOCRINE CAUSES (CUSHING DISEASE,
HYPOTHALAMIC TUMOR)
• OBESITY SYNDROMES
EVALUATION
• REVIEW OF SYSTEMS: SYMPTOMS OF
COMPLICATIONS:
• HEADACHES/VOMITING > PSEUDOTUMOR
CEREBRI
• SNORING/ SOMNOLENCE > SLEEP APNEA
• ABDOMINAL PAIN > GALLSTONES
• POLYDIPSIA, POLYURIA > DIABETES
• HIP PAIN, KNEE PAIN > SLIPPED EPIPHYSIS
• AMENORRHEA, HIRSUTISM > PCOS
EVALUATION
• FAMILY HISTORY:
• OBESITY IN 1 OR BOTH PARENTS IMPORTANT PREDICTOR FOR ADULT
OBESITY
• RISK OF COMORBIDITIES INFLUENCED BY FAMILY HISTORY:
• CARDIOVASCULAR DISEASE, HYPERTENSION, DIABETES, LIVER OR
GALLBLADDER DISEASE AND RESPIRATORY INSUFFICIENCY IN FIRST
AND SECOND DEGREE RELATIVES.
EVALUATION
• PSYCHOSOCIAL HISTORY:
• DEPRESSION
• SCHOOL AND SOCIAL ISSUES, FRIENDS?,
BULLYING?
• NEGATIVE PEER PERCEPTION, BEING TEASED
• TOBACCO USE, INCREASES LONG TERM
CARDIOVASCULAR RISK
EVALUATION
• PHYSICAL EXAM:
• DYSMORPHIC FEATURES > GENETIC SYNDROME?
• ASSESSMENT OF AFFECT
• FAT DISTRIBUTION:
• BUFFALO TYPE: CUSHING SYNDROME
• ABDOMINAL OBESITY: ASSOCIATED WITH
METABOLIC SYNDROME, PCOS AND INSULIN
RESISTANCE
EVALUATION
• PE: BLOOD PRESSURE:
• PROPER SIZED CUFF
• HYPERTENSION: BP > 95TH PERCENTILE FOR
AGE, GENDER AND HEIGHT ON 3 SEPARATE
OCCASIONS
EVALUATION
• PE: STATURE:
• EXOGENOUS OBESITY: INCREASED LINEAR HEIGHT, TALL
FOR AGE, BONE AGE NORMAL OR ADVANCED
• ENDOGENOUS OBESITY: SHORT STATURE IN MOST CASES,
GROWTH VELOCITY SLOWED.
• PRADER-WILLI SHORT FOR GENETIC POTENTIAL, NO
PUBERTAL GROWTH SPURT
• MC4R MUTATION: BIG SINCE BIRTH, 1 TO 2.5% OF OBESE
INDIVIDUALS, MOST COMMON KNOWN GENETIC CAUSE
EVALUATION
• PE: HEAD, EYES, THROAT:
• MICROCEPHALY: COHEN SYNDROME
• BLURRED DISC MARGINS: PSEUDOTUMOR CEREBRI
• NYSTAGMUS, VISUAL COMPLAINTS: HYPOTHALAMIC-
PITUITARY LESION
• RETINITIS PIGMENTOSA: BARDET- BIEDL SYNDROME
• LARGE TONSILS: OBSTRUCTIVE SLEEP APNEA
• EROSIONS TOOTH ENAMEL: SELF INDUCED VOMITING,
GERD
EVALUATION
• PE: SKIN AND HAIR
• DRY, COARSE HAIR: HYPOTHYROIDISM
• STRIAE: IF DARK, DEEP > CUSHINGS
• ACANTHOSIS NIGRICANS: INSULIN
RESISTANCE, DIABETES, PREDIABETES
• HIRSUTISM: PCOS, CUSHINGS
EVALUATION
• PE: MUSCULOSKELETAL
• NON PITTING EDEMA: HYPOTHYROIDISM
• POSTAXIAL POLYDACTYLY: BARDET- BIEDL SYNDROME
• SMALL HANDS AND FEET: PRADER- WILLI
• SCFE: LIMITED RANGE OF MOTION AT HIP, GAIT
ABNORMALITY
• BLOUNT DISEASE, GENU VARA: BOWING OF LEGS, TIBIAL
TORSION
• PES PLANUS AND PRONATION OF FEET> PAIN DURING
EXERCISE
EVALUATION
• PE: GENITOURINARY
• GENETIC OR ENDOCRINE CAUSES:
• UNDESCENDED TESTICLES, SMALL PENIS, SCROTAL
HYPOPLASIA> PRADER-WILLI
• SMALL TESTES: PRADER-WILLI, BARDET-BIEDL
• DELAYED OR ABSENT PUBERTY: HYPOTHALAMIC
PITUITARY TUMORS, PRADER-WILLI, BARDET-BIEDL
• PRECOCIOUS PUBERTY: HYPOTHALAMIC PITUITARY
LESION
EVALUATION
• PE: DEVELOPMENT
• MOST SYNDROMIC CAUSES ASSOCIATED
WITH COGNITIVE OR DEVELOPMENTAL DELAY
• PRADER-WILLI ASSOCIATED WITH HYPOTONIA
IN INFANCY AND DELAYED MOTOR
DEVELOPMENT
EVALUATION AT INITIAL VISIT
• LABORATORY STUDIES:
• NOT FULLY STANDARDIZED
• MOST SUGGEST ROUTINE SCREENING FOR DIABETES 2,
DYSLIPIDEMIA, HYPERTENSION AND FATTY LIVER DISEASE IN
OVERWEIGHT OR OBESE CHILDREN
• LIPID SCREENING BETWEEN 2 AND 8 YRS IF OBESE, OLDER IF
OVERWEIGHT.
• SCREENING FOR DIABETES RECOMMENDED IN CHILDREN 10
YEARS OLD, BMI> 85TH PERCENTILE AND 2 OTHER RISK
FACTORS( FAMILY HISTORY, ACANTHOSIS, ETHNICITY)
EVALUATION AT INITIAL VISIT
• LABORATORY TESTS:
• LIVER FUNCTION TESTS SHOULD BE OBTAINED,
NAFLD TYPICALLY ASYMPTOMATIC
• ADDITIONAL TESTING IF FINDINGS OF
HYPOTHYROIDISM, PCOS, CUSHING
SYNDROME, AND SLEEP APNEA
EVALUATION
• RADIOGRAPHIC :
• PLAIN X-RAY LOWER EXTREMITIES IF SYMPTOMS
SCFE OR BLOUNT DISEASE
• ABDOMINAL ULTRASOUND IF SUSPICION
GALLSTONES
• ABDOMINAL ULTRASOUND TO CONFIRM FATTY
LIVER, SEVERITY OF LIVER INVOLVEMENT DOES
NOT CORRELATE WITH RADIOGRAPHIC FINDINGS
• BRAIN IMAGING IF NEUROLOGIC SYMPTOMS
TREATMENT
• WHY TREAT:
• COMORBID CONDITIONS BIGGEST KILLERS IN THE
US
• EVEN SMALL WEIGHT LOSS CAN HAVE A MAJOR
BENEFICIAL EFFECT ON HEALTH RISKS
• COSTS TO SOCIETY COULD BE GREATLY REDUCED
WITH ADEQUATE TREATMENT AND PREVENTION
TREATMENT
• GOALS:
• REGULATION OF BODY WEIGHT AND FAT WITH
ADEQUATE NUTRITION FOR GROWTH AND
DEVELOPMENT
• LONG TERM BEHAVIOR/ LIFESTYLE CHANGES
• EATING BEHAVIOR
• EXERCISE BEHAVIOR
TREATMENT
• BEST TREATMENT IS PREVENTION
• TREATMENT ASAP, EARLIEST INTERVENTION BEST
OUTCOME
• FAMILY INTERVENTION
• LONG TERM TREATMENT
• SHORT TERM GOALS
TREATMENT OF OBESITY
• LEVELS OF TREATMENT:
1. PRIMARY CARE IS THE FRONTLINE, PROVIDING BASIC
EDUCATION, VISITS EVERY 6 TO 8 WEEKS.
2. MORE STRUCTURED, DIETICIAN, MONTHLY VISITS WITH
CLINICIAN WHEN FAIL 6 MONTHS
3. MULTIDISCIPLINARY APPROACH
4. TERTIARY FINAL STAGE, UNSUCCESSFUL IN STAGE 3
• INVOLVES BARIATRIC SURGERY, VERY LOW CALORIE
DIETS AND MEDICATIONS.
WELLNESS AND WEIGHT PROGRAM
• MULTIDISCIPLINARY APPROACH:
• BEHAVIOR MODIFICATION, PSYCHOLOGICAL SUPPORT,
FAMILY INTERVENTION
• DIET/ NUTRITION EDUCATION
• EXERCISE/ EXERCISE EDUCATION
• MEDICAL SUPERVISION
TREATMENT
• NUTRITION EDUCATION:
• IDENTIFY MAJOR FOOD GROUPS, LEARN CARB
COUNTING
• LABEL READING
• LOW FAT, HEALTHY FATS
• FAST FOOD EDUCATION
• DINING OUT TIPS
• PORTIONS!
TREATMENT
• EXERCISE/ EXERCISE EDUCATION:
• BASED ON LEVEL OF OBESITY, INDIVIDUALIZED
• EXERCISE PHYSIOLOGIST
• LIFESTYLE CHANGES, FAMILY INTERACTION
• MAINTAIN LEAN BODY MASS WHILE DIETING
ANY FORM OF EXERCISE IS BETTER THAN NOTHING!
TREATMENT
• BEHAVIOR MODIFICATION:
• PSYCHOLOGIST SCREENS FOR
UNDERLYING DISORDERS
• FAMILY INTERVENTION
• GOAL SETTING
• POSITIVE ROLE MODELING
• LEARN LIMITS
• CHOOSING ALTERNATIVES
• RELAPSE PREVENTION
CONCLUSION
• BEST TREATMENT IS PREVENTION…
• THE EARLIER THE INTERVENTION THE BETTER:
• EDUCATION
• SCHOOL BASED: .
• SCHOOL LUNCHES
• PHYSICAL EDUCATION
• NUTRITION EDUCATION
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