Post on 01-Apr-2018
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Pediatric Obesity Conference
An Overview of Pediatric Obesity Co-Morbidities for the
Primary Care Provider
Ashley Weedn, MD, MPH, FAAPAssistant Professor
Medical Director, Healthy Futures ClinicDepartment of Pediatrics
University of Oklahoma College of MedicineAshley-Weedn@ouhsc.edu
Disclosure
Under Accreditation Council for Continuing Medical Education guidelines disclosure must be made regarding financial relationships with commercial interests within the last 12
months.
Ashley Weedn, MD, MPH
I have no financial relationships or affiliations to disclose.
Learning Objectives
Upon completion of this presentation, participants should be able to improve physician competence, performance and patient outcomes by being able to:
1. To recognize the various clinical implications of pediatric obesity
2. To identify both emergent and chronic co-morbidities of pediatric obesity
3. To describe the evaluation for common obesity co-morbidities
4. To recognize national guidelines for management of common
comorbidities of pediatric obesity in primary care
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BMI PercentilesValidity in children• Correlates with
adiposity1
• Correlates with adult adiposity2
• Correlates with cardiovascular risk factors3 and long-term mortality4
Overweight
Obese
1 Field AE, Obes Res, 20032 Freedman DS, Pediatrics, 20053 Freedman DS, J Pediatr, 20074 Must A, Int J Obes, 1999
Essential components: medical assessment for pediatric obese children
• Diet• Physical activity• Family history• Review of systems• Physical examinationGoals:
1. Identify targets for behavior change2. Assess risk for co-morbidities
Co-morbidities
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Co-morbidities
Pseudotumor Cerebri• Raised intracranial pressure (ICP) with normal cerebrospinal
fluid and brain parenchyma• Incidence: <1:100,000 among children• Risk factors: females, 12-19 years, NH whites, medications• Symptoms: HA; +/- vomiting, visual changes, pulsatile
tennitus, shoulder/neck pain• Exam findings: +/-papilledema, visual field defects• Dx: CT/MRI; LP (open pressure > 250mmH20)
-dx of exclusion after other causes of ICP are eliminated
• Management: Acetazolamide, neurology and ophthalmology referrals; weight control
• Complication: visual impairment or blindness
Brara SM, J Pediatr, 2012
Pseudotumor Cerebri
Key points: • Always ask about occurrence of
headaches, especially in obese post-pubertal girls
• A fundoscopic exam should be a routine part of the examination of the obese child with a HA and ICP symptoms
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Co-morbidities
Slipped Capital Femoral Epiphysis
• Characterized by displacement of the proximal femoral epiphysis from the metaphysis
• Incidence: ~11:100,000 in all children
• Risk factors: early adolescence, boys, Hispanics & blacks
• Symptoms: limp, complaints of dull, aching groin, thigh, or knee pain (referred by obturator nerve); no preceding trauma
• Exam findings: motion of the hip in abduction and interior rotation is limited on exam
• Dx: AP view of pelvis and frog leg to include both hips (compare hips)
• Management: Orthopedics referral for surgical intervention; weight control
Lehmann, J Pediatr Orthop, 2006
Blounts disease• Pathologic deformity resulting from disruption of normal cartilage
growth at the medial aspect of the proximal tibial physis• Incidence: ~ 11:100,000 children• Risk factors: 2-4 year olds; adolescent, blacks, boys• Mild varus (10 degrees) in obese child can
cause growth retardation of medial tibial physis• Symptoms: knee pain• Exam findings: bowed legs; tibial torsion• Dx: Bilateral lower extremity x-rays• Management: orthopedics referral, weight control, surgery• Complications: deformity, leg length discrepancy
Gettys, Orthop Clin N Am, 2011
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Common musculoskeletal conditions
• Ankle pain and sprains PT referral • Foot pain and pes planus Orthotics referralKey Points:• A thorough hip, knee, ankle, and foot exam should
be a routine part of the evaluation and follow-up of every obese child c/o pain and/or abnormal gait
• For obese children with musculoskeletal complaints, caution recommendation of exercise before thorough exam and/or referral to physical therapy
Co-morbidities
Obstructive sleep apnea• Disordered breathing during sleep characterized by prolonged
partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal sleep patterns
• Prevalence: 37-59% of obese children • Symptoms: snoring, irregular breathing pauses or gasping,
daytime somnolence, enuresis, school and behavioral problems
• Exam findings: +/- tonsillar hypertrophy • Dx: polysomnography (AHI > 1)• Management: Intranasal steroids + referral to ENT (T&A) +/-
referral to sleep medicine specialist (CPAP)• Complications: CVD: Pulmonary HTN RVH
Systemic HTN LVH
Marcus CL, Pediatrics, 2012
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Obstructive sleep apnea
Key points: • Obtain a detailed sleep history on all obese
children: ask specifically about sleep disturbances, snoring, and sleep position
• OSA should be considered in obese children with poor school performance and concentration difficulties
Asthma
• Obesity associated with asthma; unclear temporal relationship
• Obesity as an independent predictor?• Children’s Health Study: 3792 children in California from 1993-1998 Obese children with new-onset asthma Overall Incidence Rate (IR): 31.4
Boys > Girls (IR: 36.6 vs IR: 25.6) Overall Relative Risk (RR) = 1.6 (1.1,2.4)
Boys > Girls (RR: 2.3 vs. 1.1)
Gilliland FD, Am J Epidemiol, 2003
Asthma
• Symptoms: wheeze, cough (notably with activity), chest pain, altered activity patterns, slowing down
• Exam findings: +/- wheeze• Dx: HISTORY, PFTs• Management: Albuterol (prior to activity) +/- inhaled
steroids; goals is to optimize control in every obese, asthmatic child
• Key points: - obese children, if inactive, may not report symptoms unless specifically asked
- as exercise increases, symptoms may emerge
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Co-morbidities
Nonalcoholic fatty liver disease (NAFLD)
• Accumulation of macrovesicular fat in hepatocyes• Prevalence of NAFLD (NHANES 2007-2010)1
Obese females – 27% with NAFLDObese males – 48% with NAFLDPrevalence of NASH: 20-25% of obese children2
• Risk factors: Hispanic and Native Americans; males• Symptoms: typically asymptomatic• Exam findings: +/- hepatomegaly• Screening labs: LFTS• Dx: elevated AST/ALT; fatty liver on ultrasound; liver
bx*Must rule out other potential liver etiology*
1Welsh, J Pediat, 20132Tazawa, Act Paeditr, 1997
Nonalcoholic fatty liver disease (NAFLD)
• Management: weight control (with focus on decreasing sugar, fructose, transfats from diet); referral to GI when ALT > 100
• Complications: - Correlated with T2DM (50% of T2DM with NAFLD)- Progressive: NAFLD NASH Cirrhosis- Independent risk factor for CVD
Estrada, Childhood Obesity, 2014
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NAFLD Algorithm
Source: Children’s Hospital Association Consensus Statements for Comorbidities of Childhood Obesity, Childhood Obesity, 2014
Cholelithiasis
• Prevalence: unknown; 50% of cholecystitis in adolescents associated with obesity1
• Risk factors: females, birth control2
• Symptoms: abdominal pain, +/- nausea, vomiting, fatty food intolerance
• Exam findings: +/- RUQ tenderness; typically none• Dx: abdominal ultrasound• Management: Referral to surgery• Key Point: Gallbladder disease should be considered in
the differential dx of persistent abdominal pain in obese adolescents
1Crichlow, Am J Dig Dis, 19722Koebnick, J Pediatr Gastroenterol Nutr, 2012
Co-morbidities
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Insulin resistance• Prevalence:
- 20% obese children have impaired fasting glucose (IFG1); - 25% of obese children with impaired glucose intolerance (IGT)1; - obese children 12.6 higher odds of higher insulin levels vs. non-obese children2
• Risk factors: minorities, maternal GDM, family history• Symptoms: polyphagia, +/- nocturia, typically asymptomatic • Exam findings: acanthosis nigricans, +/- central adiposity • Dx: Fasting glucose ≥ 100-125 mg/dL
OGTT: Glucose ≥ 140 mg/dLHbA1c ≥ 5.7-6.4
• Management: weight control +/- metformin
1Sinha, N Engl J Med, 20022Juonala, N Engl J Med, 2011
Progression from Euglycemia to T2DM
Insulin resistance• Complications: progression to T2DM
- Insulin level > 30 (35% progress to diabetes)
- Glucose level > 100 (30% progress to diabetes)
- 45% of newly dx diabetic cases in children; correlated
with obesity, particularly rapid weight gain in early
childhood
- Associated with adult cardiovascular disease
• Key point: reversible with weight control – offers an
opportunity to discuss health risk of lifestyle behaviors
with familiesADA, Diabetes Care, 2000
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Polycystic Ovarian Syndrome• Prevalence: 7% among adolescents1
• Risk factors: maternal family history• Symptoms: menstrual irregularity• Exam findings: hirsuitism, +/- acne• Dx: Rotterdam criteria – presence of 2/32
- hyperandrogenism (clinical or biochemical)- ovulatory dysfunction (irregular menses)- polycystic ovaries - dx of exclusion (rule out other causes of hyperandrogenism)
• Management: OCP + weight control +/- metformin; referral to endocrinology and/or adolescent medicine
• Complications: T2DM, Hidradenitis Suppurativa, infertility1Anderson AD, Semin Repro Med, 2014 2Legro RS, Clin Endocrinol Metab, 2013
PCOS Diagnostic Algorithm
Source: Children’s Hospital Association Consensus Statements forComorbidities of Childhood Obesity, Childhood Obesity, 2014
Co-morbidities
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Dyslipidemia
• Prevalence: 39% of obese children1
• Most common lipid abnormality in obese children and adolescents: high TG and low HDL (atherogenic dyslipidemia) -accelerates atherosclerosis
• Symptoms: none• Exam findings: none• Dx2: fasting lipid panel
LDL ≥ 130 HDL < 40
Triglycerides: TG ≥ 100 (<10 years of age) TG ≥ 130 (≥ 10 years of age)
• Management2: Diet, activity; refer to endocrinology or cardiology for LDL > 250 and TG > 500
1Kit BK, JAMA Pediatr, 20152Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents, Pediatrics, 2011
Dyslipidemia Algorithm - TG
• Decrease refined carb intake; replacewith whole grains, vegetables, fruit
• Avoid sugar-sweetened beverages• Avoid trans fats; limit saturated fats• Increase fish consumption
Source: Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents, Pediatrics, 2011
Dyslipidemia Algorithm - LDL
Source: Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents, Pediatrics, 2011
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Risk Factors for Dyslipidemia Management
(+) Family Hx: myocardial infarction, sudden cardiac death in 1st or 2nd-degree relative ≤55 years for males and ≤ 65 years for females
High Level RFsObesity (BMI ≥ 97th percentile)Hypertension requiring drug therapyPresence of high-risk conditionsCigarette smoker
Moderate RFsHypertension – no drug therapyHDL cholesterol ≤ 40 mg/dLPresence of moderate-risk conditionsObesity (BMI percentile ≥ 95th and ≤ 97th)
T1DM and T2DMChronic kidney diseaseKawasaki disease with aneuryms
Chronic inflammatory diseaseHIV infectionNephrotic syndromeKD s/o aneurysms
Dyslipidemia
Key points: • Obtain lipid panel as part of obesity
assessment
• Dietary management in conjunction with RD
• Reversible with weight control – offers an
opportunity to discuss health risk of lifestyle
behaviors with families
Hypertension• Prevalence: 20% of obese children have elevated blood
pressure • Symptoms: +/- HA, fatigue, blurred vision, dizziness; typically
asymptomatic• Exam: auscultation (ensure appropriate size of BP cuff)• Dx: Determined by blood pressure percentiles from pediatric BP
charts based on gender, age, and height percentile≥ 90th BP percentile (Pre-hypertension)≥ 95th BP percentile (Stage 1 HTN) ≥ 99th BP percentile + 5 mmHg (Stage 2 HTN)
- Confirm by manual auscultation- 3 separate BP measurements; average measurements
1Kit BK, JAMA Pediatr, 2015; 2Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents, Pediatrics, 2011
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Hypertension• Management:
- Rule out secondary causes (renal) of HTN: CBC, BMP, and UA
- If elevated BP persists x 3 visits, refer to cardiology or nephrology to assist with pharmacotherapy
- Weight control, with emphasis on diet - Cardiovascular Health Integrated Lifestyle Diet (CHILD diet)
• Key points:- Pediatric hypertension is underdiagnosed- Remember to obtain blood pressure on all obese
patients, beginning at 3! Source: Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents, Pediatrics, 2011
Hypertension Algorithm
Source: Children’s Hospital Association Consensus Statements for Comorbidities of Childhood Obesity, Childhood Obesity, 2014
Simple table to identify children needing further evaluation of blood pressure
Source: Kaelber, Pediatrics, 2009
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Left ventricular hypertrophy
• Thickening of the muscle of the left ventricle of the heart
• LVH prevalence: 30% of obese children with HTN vs. 18% in non-obese children with HTN
• Associated with obesity and HTN• Dx: ECHO• Complications: Independent risk factor for CVD
Daniels SR, Int J Obesity, 2009
Cardiovascular disease
Obesity in childhood consistent predictor of adult heart disease
Bogalusa Heart Study
Muscatine Study
Childhood Determinants of Adult Health Study (CDAH)
Cardiovascular Risk in Young Finns Study (YFS)
Age Risk factors Lesion
5-15 yr ObesityElevated insulin levels
15-24 yr ObesityDyslipidemiaHypertensionInsulin resistance
Risk factors for CVD
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Health consequences of obesity
Childhood obesity is a predictor of increased rate of death, mainly due to an increased risk of cardiovascular disease (CVD)
Must et al., NEJM, 1992
Olshansky, et al, NEJM, 2005
Baker et al., NEJM, 2007
Franks et al, NEJM, 2010
Co-morbidities
Psychological morbidity
• Depression• Anxiety• Low self esteem• Teasing/bullying• Binge eating disorder• Impaired quality of life!• Screen by using validated questionnaires (BASC
or Peds QL) – don’t rely on self or parental report• Refer to psychological services
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Summary: Targeted review of systems
Cardiovascular: chest painPulmonary: exercise intolerance, snoring, daytime
somnolenceEndocrine: polyuria, polydipsia, polyphagia,
hirsuitism, menstrual irregularity, cold intoleranceGI: abdominal painMS: joint pain, limpNeurological: headachesPsychosocial: self esteem, social isolation, anxiety
Summary: Physical Examination
FindingElevated blood pressureAcanthosisIrregular menstrual cycle PapilledemaTonsillar hypertrophyAbdominal PainHepatomegalyLimited hip range of motionLower leg bowingFlat affect
Possible CauseHypertensionInsulin resistance, T2DMPCOSPseudotumor cerebriObstructive sleep apneaGERD, NAFLD, gallbladder dzNAFLD/NASHSCFEBlountsDepression
Summary: Laboratory evaluation
Age BMI Percentile Recommended lab
< 10 years ≥ 85th %tile Fasting lipids
≥ 10 years 85th - 94th & Fasting lipidsno risk factors
≥ 10 years 85th - 94th & Fasting lipids +2 risk factors Fasting glucose +
OR ALT & AST≥ 95th %tile
*other labs/studies as indicated by ROS or physical examBarlow, Pediatrics, 2007
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Resources• Children’s Hospital Association
Consensus Statements- Lipid abnormalities- Abnormal liver enzymes- Hypertension- Polycystic Ovary Syndrome
• NHLBI: Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents
- Available at: http://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/summary
Key Points
• Promptly identify obesity comorbidities requiring immediate attention: - Pseudotumor cerebri - Type 2 Diabetes- Slipped capital femoral epiphysis - Blounts- Obstructive sleep apnea - Cholelithisasis
• Evaluate for chronic obesity co-morbidities on a regular basis, especially for child with continued weight gain:
- Prediabetes - PCOS- NAFLD - GERD- Dyslipidemia - Hypertension- Musculoskeletal pain - Depression, anxiety
Key Points
• All comorbidities require intensive lifestyle changes with focus on weight management; most are reversible; family engagement is key!
• Refer to community resources (dietitian, physical therapist, and psychology) for support
• Refer to specialty clinics for further evaluation and management
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References
Barlow SE, and Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120 Suppl 4:S164-92.
Estrada E, et al. Children’s Hospital Association consensus statements for comorbidities of childhood obesity. Childhood Obesity. 2014; 10:304-317.
August GP, et al. Prevention and treatment of pediatric obesity: an Endocrine Society clinical practice guideline based on expert opinion. J Clin Endocrinol Metab. 2008 Dec;93:4576-4599.
References
Legro RS, et al. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. Clin Endocrinol Metab. 2013;98:4565–4592.
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128 Suppl 5:S213-56.
Marcus CL, et al. Clinical practice guideline: Diagnosis of management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130:1-9.