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Preventive Pediatric Cardio-Metabolic Risk Clinic; The Certified Nurse Practitioner Role and Collaborative Educational

Preventive Pediatric Cardio-Metabolic Risk Clinic; The Certified Nurse Practitioner Role and Collaborative Educational Models: What’s in it for me?. Kennesaw State Graduate Nursing Program July 24 th , 2010 Eduardo Monta ña, M.D.,M.P.H. Children’s Cardiovascular Medicine Marietta, Georgia.

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Preventive Pediatric Cardio-Metabolic Risk Clinic; The Certified Nurse Practitioner Role and Collaborative Educational

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  1. Preventive Pediatric Cardio-Metabolic Risk Clinic; The Certified Nurse Practitioner Role and CollaborativeEducational Models:What’s in it for me? Kennesaw State Graduate Nursing Program July 24th, 2010 Eduardo Montaña, M.D.,M.P.H. Children’s Cardiovascular Medicine Marietta, Georgia

  2. Global Prevalence:Metabolic Syndrome(global invasion of McDonald’s) • 14% USA (NHANES) • 9.5% Europe (WHO) • 7.4% Egypt, 9%Iran (Mod. NCEP) • 4.5% Mexico, 6.5% Colombia (IDF) • 9-12% India, ?? China/Russia • Male predilection, race/gender det. • 33% adolescents • Obese 28.7%-49.7% (mod. & Sev.)

  3. Metabolic Syndrome Criteria • Waist Men 40” Women 35” • Children (waist to hip ratio) • HDL men <40 women < 50 mg/dl • TG > 110 mg/dl • Fasting Serum Glucose: impaired 100-125 mg/dl diabetes > 125 mg/dl • SBP/DBP 135/85 mmHg (> 95th % age and gender CDC) • Variable Criteria: age, BMI, physical characteristics (insulin mU/ml x fasting glucose mmmol/L)/22.5; HOMA-IR (>2.5%)

  4. Framingham 10 year Cardiac Risk Score • http://www.framinghamheartstudy.org/risk/hrdcoronary.html • (based on The Adult Treatment Panel III, JAMA. 2001) • OutcomeHard coronary heart disease (HCHD) (myocardial infarction or coronary death) • Duration of follow-upMaximum of 12 years with risk calculated at 10 years • Population of interestIndividuals free of CHD, intermittent claudication and diabetes, 30-79 years of age • Predictors • Age • Total cholesterol • HDL • SBP • Treatment for hypertension • Smoking status

  5. WHY WORRY ABOUT PEDIATRIC OBESITY? • Pediatric obesity is of epidemic proportion. • Pediatric obesity is the most common chronic disease of childhood. • Chronic Non-communicable diseases are a global challenge • “obesogenesis” and “New World Syndrome”

  6. Evidence for Atherosclerosis Beginning in Childhood • Fatty streak formation occurs in human fetal aortas and is enhanced by maternal hypercholesterolemia (JCI 1997;100:2680-2690) • Bogalusa Heart Study: Fatty streaks at age 3. More frequent in adolescence (NEJM 1986;314:138-144) • Pathobiological Determinants of Atherosclerosis in Youth (PDAY) (N=2876, ages 15-34) Found that the extent of fatty streaks and fibrous plaques in the Ao and Cor arteries is strongly correlated with elevated cholesterol (ATVB 1997;17(1):95-106)

  7. Evidence for Atherosclerosis Beginning in Childhood • Bogalusa Heart Study: Fatty Streaks were present in about 50% of individuals during childhood and in 85% of young adults. • By young adulthood, fibrous plaques were present in 69% • atherosclerotic lesions correlated positively with total cholesterol, LDL cholesterol, triglycerides, blood pressure and with BMI. • atherosclerotic lesions in childhood rose exponentially with increasing #RF. (NEJM 1998;338:1650-1656)

  8. Evidence for Atherosclerosis Beginning in Childhood • Bogalusa Heart Study (N=486): Childhood measurement of LDL-C and BMI predict carotid IMT in young adults (JAMA.2003;290:2271-2276) • The Cardiovascular Risk in Young Finns Study (N = 2229): Risk factor profile assessed in 12-18 year olds predicts adult common carotid IMT independently of contemporaneous risk factors. Suggesting that exposure to CVD RF early in life may induce changes in arteries that contribute to the development of atherosclerosis. (JAMA.2003;290:2277-2283)

  9. Pediatric and Adolescent obesity: Comorbidities • IR/CMR vs. Type II DM • Fatty streaks vs. CAD • Hypertension • Future Risk Cancer • Sports Injuries vs. Joint disease • Gallbladder disease • EIB vs. Pulmonary disease

  10. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY • Psychosocial • Most common complication of pediatric obesity • Increased rates of depression • Poor self esteem • Obese adolescents negative self image may carry over into adulthood

  11. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY • Endocrine • Increased linear growth (“hyperalimentation Synd.) • Advanced bone age • Earlier onset of puberty • Acanthosis nigricans

  12. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY • Societal discrimination • Obese females have lower acceptance rate at colleges than non-obese females • National Longitudinal Survey of Youth: obese adolescent females as young adults had less education, less income, higher poverty rate, decreased rate of marriage vs nonose females

  13. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY • Hypertension • Myth: Primary hypertension uncommon in childhood • 60% of children diagnosed with hypertension are obese, 24-30 % are obese. • Use pediatric standards • Rule out secondary causes (renal, hormonal, endocrine)

  14. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY • Hyperlipidemia • “Gaussian Distribution” theory- 5% RULE • FACT: The atherosclerotic process begins in childhood. • Genetic Basis of Dyslipidemias 1:500 most common FH, autosomal Co-Dominant • Most Dietary/cultural/lifestyle etiology Prevalence ?? 1:50, 1:100; population studies needed

  15. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY: GI • New GI epidemic: Fatty Liver • Hepatic steatosis present in 25-83% of obese children • 10-15% of obese children have elevated liver enzymes: steatohepatitis or non-alcoholic fatty liver disease • Rashid: 83% of children with steatohepatitis were obese. 75% had fibrosis-cirrhosis (NASH); liver transplantation?

  16. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY: GI Part II • Gastrointestinal: Hi Fat Dilemma • Cholelithiasis • 50% of cases of cholecystitis in adolescents are obese • Gastritis, Pancreatitis, Colitis? • GI malignancies? • Hiatal Hernias, diverticulitis

  17. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY: :Orthopeadic • Orthopedic/sports related injury • Stress/Strain and Breaks • Slipped capital femoral epiphysis • 30-50% are obese • Blount’s disease (Tibia vara) • 70% are obese • Neurologic • Pseudotumor cerebri

  18. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY: Pulmonary • Respiratory • Sleep disorder in 1/3 • Sleep apnea: 7% of obese, 1/3 if >150% & breathing difficulties • Hypoventilation syndrome/PAH/cor pulmonale • Exercise Induced Bronchospasm • Increased infections? Malignancies?

  19. BARRIERS TO THERAPY OF PEDIATRICOBESITY • Lack of Time, commitment, education of primary care providers • many providers/clinics do not address obesity, measure BMI much less HEP • Healthy Doc = Healthy Patient Study Emory; E. Frank MD, MPH • Reverse incentives for primary care, not value based (EBM)

  20. Health Care Reform? Or Wall Street Reform:Disease Mgt. vs. Disease Prevention • “Big Three” Pharma, Unmanaged Care and Biotech • Economic impact: est. cost of obesity 2002 $117 billion • HC exp 2015 est. 10 Trillion!! • #1 non communicable obesity related illness. • U.S. Bankruptcy!?

  21. BARRIERS TO THERAPY OF PEDIATRIC OBESITY • Volume based not value based • Lack of reimbursement for obesity related conditions • Median reimbursement rate 11% for obesity code (ICD 278.01) • Lack of standard treatment protocols, based on EBM, no professional consensus • Social / environmental barriers: food in security, physical insecurity, socio-cultural insecurity – “Harrah’s Casino” anecdote

  22. “Communities putting prevention to work”Fighting against school nutrition and activity policies • Requiring daily physical activity as academic stimulus • Prioritizing Health Education and wellness though nutrition policy • Eliminate vending machines • Creating a culture of Wellness • Staff commitment to prevention

  23. PREVENTION: Collaborative COMMUNITY partnerships • Private-Public entrepreneurial relationshiops; • RWJ model “Active Living By Design:5 P’s” • Place: green-space-safe parks, events, social networking • Products: Learning Platforms/curricula for families and professionals • Promotion: Social/Experiencial marketing • Price: Whats in it for me? Value based medicine • Policy: Commitment and funding prevention for the future

  24. Government’s Role in Prevention of childhood obesity?: managing WALL STREET! • Fight marketing with marketing: Coke: “Fructose Corn Syrup “Live positively with natural sugars” • Un-Managed Care? provide reimbursement for anticipatory guidance for nutrition and physical activity • Food Industry: The 30 second heart attack!

  25. Model for PREVENTION for the CPFNP: Health Literacy of the Primary Care Provider • Become a Health Partner • Commit to further education and training of office staff • Implement a PPCMR model • Peer to Peer Support through advocacy • Avoid the “slow death” vortex of primary care

  26. Global Wellness Partners Welcome ترحيب Willkommen Bienvenidos Приветствовать 欢迎커뮤니티환영 Boas-vindas स्वागतAccueil Καλωσόρισμα歓迎 “COR ALEGRO SANO ANIMA”………………….“Happy Heart Healthy Mind”…..”Corazón Alegre Mente Sana”…… “My Home Your Home”…”집이 네 집”……“Ma Maison Votre Maison”…..”Mi Casa Su Casa…

  27. Thank You BeWell WELLNESS……WELLNESS…..…WELLNESS…………..WELLNESS ….CASA CHILDREN CASA FAMILY CASA COMMUNITY CASA WORLD……. GLOBAL WELLNESS PARTERS…GLOBAL WELLNESS PARTNERS

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