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Pediatric Weight Management

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  1. Pediatric Weight Management Eliana M. Perrin, MD, MPH Department of Pediatrics

  2. At least visually we’re not good at this!

  3. Why should we use BMI? 1) Recommended by the AAP, AAFP 2) Flags risk better (Perrin, et al, J Pediatr, April, ’04) 3) Perhaps earlier intervention?

  4. . . . . . . . . . . . . . . . . . .

  5. >95% Overweight 85-95% At risk for Overweight 5-85% Healthy Weight <5% Underweight

  6. State Fair Fare Pizza, funnel cakes, candy apples, elephant ears, chili dogs, chocolate dipped fries, corn dogs, bbq beef sandwiches, onion rings, kettle corn dogs, caramel corn, sausages, steak sandwiches, rib eye steaks, cotton candy, stromboli, buffalo wings, fried pickles, country ham biscuits, tempura vegetables, fudge, saltwater taffy, deep fried oreos, and deep fried candy bars. If you want to wash these down, there are any number of sweetened drink concessions to accommodate you.

  7. Changes in Relative Prices SOURCE: Author calculations based on the Consumer Price Index – All Urban Consumers (U.S. City Averages, 1983-2005)

  8. Key element is prevention For prenatal and newborn visits for breast-feeding moms: • Encourage breastfeeding; teach parents infant hunger cues & to feed by cue not by the clock; discourage bottle propping For visits with 12-24 month olds: • Transition to solids- time to focus on the whole family eating together & on healthy foods- fruits and vegetables, whole grains, lean meats, cooking styles • Don’t forget beverage counseling- milk as meal-time beverage and water for thirst quenching

  9. Encourage PA Encourage activity for mom and dad while mom is pregnant- walking is wonderful & good to get into healthy family habits Tummy time is great for babies as is exploration play Outside activity/ getting out of the stroller important for toddlers!

  10. Older children Starting at age 2: calculate BMI % for age & gender Assess: Diet Behaviors • Sweetened beverage consumption • Frequency of dining out and family meals • Fruit and vegetable consumption • Consumption of excessive portion sizes • Daily breakfast consumption Physical Activity Behaviors • Amount of moderate physical activity • Level of screen time and other sedentary activities Attitudes • Self perception or concern about weight • Readiness to change • Experiences with previous attempts to lose weight

  11. If BMI healthy…. If BMI healthy (≤ 85% for age), advise parents to: • Not force kids to clean plates • Replace whole milk w/ lower fat milk (>2yo) • Limit “screen” time & eating in front of the tv! • Limit junk food (high fat/sugary, “fast food,” soda) • Tell parents not to provide food as a comfort or reward • Encourage active play • Substitute water and skim milk for juice, lemonade, sweet tea, soda, etc.

  12. What next? If BMI is overweight or obese (≥85% for age) or trending upward: • Follow advice from previous slide • Advise parents and child of weight status: show them the BMI chart, talk about future problems related to overweight • Protect self-esteem (make your discussion @ health as much as possible) • Arrange follow-up visit (schedule a lot of time)

  13. What to do at follow up visit? (continued) If BMI 85% for age or trending upward, do thorough evaluation: • History of the problem • Review of systems • Past Medical History • Social History • Family Medical History • PE • Labs • Assessment and Plan

  14. History When do parents/child think problems began? What’s the typical intake (include meals, beverages, snacks)? – 3 day log is best Where does that intake occur (school lunches, babysitter’s, etc)? How much tv, video, computer time?- 3 day log is best What’s the typical physical activity pattern?- 3 day log is best

  15. Review of Systems Significant headaches, blurred vision (pseudotumor cerebri?) Joint pains (SCFE? Overuse?) Frequent urination, thirst, fatigue (T2DM?) Daytime sleepiness, snoring (sleep apnea?) Depression (which comes first?) Menarchal status (PCO disease?)

  16. Past Medical History • Medications (steroids) • Thyroid disease • Growth problems • Mental retardation • Hypotonia

  17. Social History • Teasing patterns (motivation?) • Who’s on the child’s “case” at home? • Problems in school • Depression • Suicidality • Bingeing/purging • Safety of the neighborhood

  18. Family History • CAD (early MIs) • Hypertension • Type 2 DM • Thyroid disease • Gall bladder disease • Cushing’s • Depression • Weight patterns

  19. PE • Height, weight, BMI, BMI% for age and gender, HR, BP • Hirsuitism? • Fundi • Skin, hair quality • Tonsils • Thyroid • Acanthosis nigricans? • Abdominal tenderness • Weight distribution pattern • Tanner Stage of pubertal development/ small penis? • Joint evaluation

  20. Acanthosis Nigricans

  21. Labs AAP recommends fasting lipids in patients >95% BMI. ADA recommends every other year screening starting at 10 years of age or the onset of puberty, whichever comes first with fasting plasma glucose at least (consider fasting insulin as well) for those with BMI ≥ 85th percentile for age and sex, who *also* have any two of the following risk factors: a positive family history of type 2 diabetes in a first or second-degree relative, shows sign of insulin resistance (i.e. acanthosis nigricans, dyslipidemia, or PCOS), has a maternal history of diabetes or GDM, or belongs to Native American, African American, Latino, Asian American, or Pacific Islander racial group.

  22. Labs continued Consider: Thyroid studies (T4, TSH)-particularly in child with poor growth or parents insistent about “glandular” problems, Glucose tolerance test, HgA1C, C-peptide (only if serious concerns about T2DM) Cortisol in the patient with unusual distribution of weight, growth problems Anhyrdous glucose/serum 17-OHP/testosterone if overweight, short, hirsuit, and irregular menses….

  23. Labs to worry about • LDL>130 (and if >190, refer to cardiology) • Fasting triglyceride>110 (if >500, refer to cardiology for treatment) • HDL<40 • Fasting plasma glucose > 110 • (Fasting insulin: glucose ratio that is > 1:4) • Hemoglobin A1c > 6 • Hypoglycemia along with hyperinsulinism suggests an insulinoma rather than insulin resistance

  24. Intervention ideas • Make it about staying happy/healthy- decrease the emphasis on weight. • Review the dietary and PA logs (STCs) with specific attention to areas of improvement. • Review stop light guide to foods with the family. • Have child pick 1-2 things to change from a list. Let it be child’s choice. • Parents to refrain from nagging. • Have family continue to keep a log. • Nutrition/psychologist referral as needed. • Follow up!

  25. How to make the conversation seamless: Motivational Interviewing

  26. What is Motivational Interviewing? • Motivational Interviewing (MI): • Powerful counseling tool • Motivates & reinforces behavioral change • Patient - centered • Directive method for enhancing intrinsic motivation to change • Helps explore & resolve ambivalence

  27. MI (cont.) Basic Principles: • Uses open-ended questions • Applies reflective listening • Gives feedback in empowering framework

  28. MI USES THE FRAMES APPROACH • Feedback– Give risks and consequences of behavior “It sounds like your child is watching quite a bit of TV. Did you know that sitting down too much can raise your child’s chance of getting health problems later on?” • Responsibility– Let them know it is up to them “Of course it is up to you and her dad to decide whether or not you want to let her watch this much TV.”

  29. FRAMES • Advice – Offer a professional recommendation “It’s my recommendation as someone who is concerned about Sally’s health to have her watch less TV, and I can help you help her cut down on TV watching.” • Menus – Offer a variety of strategies “There’s many options to help Sally cut down on TV. One option is to give her a TV budget at the beginning of the week and let her decide how to spend it. Another option is to say that for each hour of TV watched, Sally needs to spend an hour getting activity….”

  30. FRAMES • Empathy– Use a positive and caring manner “I know that it’s really hard to change a behavior, and that it will be hard for Sally to give up some of her favorite TV programs.” • Self-efficacy – Communicate a “You can do it!” approach “I think from what you told me about your family’s diabetes that you don’t want Sally to get that disease, and I know that you and Sally can work together to do this for Sally’s long-term health. And I will help every step of the way.”

  31. Thank you and acknowledgments • Cynthia Bulik • KESMM team (especially Alice Ammerman, Suzanne Lazorick) • Clinical colleagues (especially Joey Skelton)

  32. LDL > 130 LDL 130-190 LDL > 190 Weight Management Re-check in 4 months Repeat for two 4 month cycles Weight Management Refer to Cardiology to begin treatment LDL elevated for > 1 year Continue Weight Management Nutritional Treatment (flax, fish oil)

  33. HDL < 40 Weight Management

  34. Triglycerides > 110 Triglycerides > 700 Triglycerides 110-700 Weight Management Re-check in 4 months Weight Management Refer to Cardiology to begin treatment If > 500 If < 500, Continue Weight Management Triglycerides elevated for > 1 year Nutritional Treatment (flax, fish oil)

  35. Insulin Level ≥ 20 Glucose > 125 Glucose < 100 Glucose 100-125 Re-check glucose Obtain UA Baseline 2 Hour OGTT Weight Management Re-check in 4 months If glucose > 125 Glucose 100-125 Glucose < 100 Continue Weight Management Re-check q4 mos Refer to Endocrine 2 Hour OGTT If impaired or worse, consider treatment

  36. Obstructive Sleep Apnea Screening • Any one of the following: • Snores ≥ 50% of time • Witnessed apnea • Excessive daytime sleepiness • Two or more of the following: • Headache in am • Mouth breathing at night • Dry mouth/sore throat in am • Hard to wake in am • Nocturnal enuresis • Attention span/behavioral issues Overnight Polysomnography F/U with Pulmonologist

  37. Liver Elevated AST or ALT (>60) CBC, Complete Metabolic Panel, PT, GGT Any elevation of ALT or AST > 6 months ALT or AST >200 or any laboratory abnormality Other Continue to monitor Hepatitis Bs Ab, Hepatitis Bs Ag, Hepatitis C Ab, ANA, anti-actin antibody, anti-LKM antibody, ceruloplasmin, PI typing, Liver ultrasound If c/w NASH, begin Metformin If abnormal, suspicion of liver disorder- refer to Hepatology Liver Biopsy

  38. Polycystic Ovaries Syndrome DHEA-S 17-hydroxyprogesterone Testosterone LH, FSH Sex Hormone Binding Globulin Pelvic ultrasound • If any of the following with insulin resistance: • Oligo- or Amenorrhea • Hirsutism • Acne • 2 of the 3 following: • Oligo- or Amenorrhea • Hirsutism- clinical or biochemical • Severe Acne • Abnormal hair growth • LH/FSH > 2:1 • Elevated free testosterone • Polycystic ovaries on imaging • (no evidence of CAD or other cause of symptoms) Begin Metformin Weight Management Re-check in 4 months Yes Not improved Improved No Continue Metformin for 8 more months Refer to Gynecology

  39. Hypertension 3 BP’s > 90th% BP’s > 99th% + 5mm CBC, CMP, Renin assay Urinalysis Renal ultrasound CBC, CMP, Renin assay Urinalysis Renal ultrasound Refer emergently to Cardiology Refer to Cardiology

  40. Asthma Assessment Cough __daily __per week __per month __None Timing: Nature: Sputum: Wheezing __daily __per week __per month __None Timing: Dyspnea __daily __per week __per month __None Chest Pain __daily __per week __per month __None Symptom Triggers Weather changes__ Viral illness__ Exercise__ Pollen__ Smoke__ Other_________ Exercise Tolerance:__Normal __Limited Nasal Congestion:___ Hives:____ Sneezing:____ Eczema:____ GE Reflux Symptoms __sour taste __heartburn __spitting up __emesis Pneumonia:__ Bronchitis:__ Sinusitis:__

  41. OGTT FPG