Care of the Pediatric Obese Patient: A Practical

ApproachLisa L Watson, CPNP

Clinical Operations LeadDuke Healthy Lifestyles

I have no financial disclosures (unfortunately)…

Financial Disclosures

See obesity for what it is – a sign of what’s really going on

Treat obesity as a chronic illness that requires follow-up and ongoing changes in treatment

Realize that confrontational measures often backfire

Have an increased appreciation for how hard it is to lose weight

Come away with at least one concrete way you can help these kids

By the end of this talk, I hope you…

Why Should We Care

Retrieved from http://www.mozartinshape.org/misvsobesity/whymis.php?id=ch02 on October 17, 2013

Obese kids have similar quality of life scores as kids with cancer…

JAMA. 2003 Apr 9;289(14):1813-9.Health-related quality of life of severely obese children and adolescents.

Results: Compared with healthy children and adolescents, obese children and adolescents reported significantly (P<.001) lower health-related QOL in all domains (mean [SD] total score, 67 [16.3] for obese children and adolescents; 83 [14.8] for healthy children and adolescents). Obese children and adolescents were more likely to have impaired health-related QOL than healthy children and adolescents (odds ratio [OR], 5.5; 95% confidence interval [CI], 3.4-8.7) and were similar to children and adolescents diagnosed as having cancer (OR, 1.3; 95% CI, 0.8-2.3). Children and adolescents with obstructive sleep apnea reported a significantly lower health-related QOL total score (mean [SD], 53.8 [13.3]) than obese children and adolescents without obstructive sleep apnea (mean [SD], 67.9 [16.2]). For parent proxy report, the child or adolescent's BMI z score was significantly inversely correlated with total score (r = -0.246; P =.01), physical functioning (r = -0.263; P<.01), social functioning (r = -0.347; P<.001), and psychosocial functioning (r = -0.209; P =.03).

Epidemic within an epidemic

Childhood obesity has more than doubled in the past 30 years.

By comparison, the proportion of children classified as “severely obese” has tripled. Currently 4% of all children fall in this category. By 2030, overall obesity in the US is expected to

increase by 31% while severe obesity is expected to increase by 130%.

Ogden CL et al. Journal of the American Medical Association 2014;311(8):806-814. National Center for Health Statistics. Health, United States, 2011: U.S. Department of HHS; 2012. National Institutes of NHLBI, 2010.IOM, Dietz W et al, Roundtable on Childhood Obesity, 2014.Skelton et al, Archives, 2009. Finkelstein E, American Journal of Preventative Medicine, 2012.

This isn’t rocket science…..

……it’s harder

Why is this SO Hard?

Why is this SOOOO Hard?

Retrieved from: https://www.google.com/search?q=metabolic+pathways&espv=2&biw=1204&bih=631&source=lnms&tbm=isch&sa=X&ved=0CAYQ_AUoAWoVChMIzOHo-c-cyAIVg5qACh34SQsh&dpr=1#imgrc=wNHhoHn8yZWQGM%3A, September 29, 2015.

A Calorie is NOT a Calorie

Continued misconception: Food intake – Energy expenditure = Net weight

gain

Example

Multiple systems regulate weight

Berthoud et al, Physiology, 2008, 23 75-83

Hormonal Controla) Adipokinesb) Gastrointestinal peptides

Neural Controla) Homeostatic system

(metabolic brain)b) Hedonic system (emotional

brain)c) Cognitive brain

Environmental Controla) Stressb) Circadian rhythmc) Thermoregulation and BATd) Microbiotae) Infection

Old Definition: An inert tissue

“Adipose tissue, or fat, is an anatomical term for loose connective tissue composed of adipocytes. Its main role is to store energy in the form of fat, although it also cushions and insulates the body.”

-Google

Adipose Tissue IS an Organ

New Definition: A dynamic metabolic organ

Adipose tissue, or fat, is a dynamic and varied endocrine organ comprised of several cell types. Its physiology and functions are, in part, distribution-dependent. A complex interplay of neurohormonal factors determines its synthesis, breakdown, and storage.

Adipose Tissue IS an Organ

Ahmed, N. (2015). Pathophysiology of Obesity, Blackburn Course in Obesity Medicine

Over 600 adipokines have been identified!

The Adipocyte: An Endocrine Factory

Retrieved from https://www.google.com/search?q=adipose+tissue&es_sm=93&source=lnms&tbm=isch&sa=X&ved=0CAcQ_AUoAWoVChMI3MuqlZGgyAIVBp-ACh26Iwvh&biw=1204&bih=631#imgdii=fLywxRLs6Eo33M%3A%3BfLywxRLs6Eo33M%3A%3Bup7D8Hkg30_eAM%3A&imgrc=fLywxRLs6Eo33M%3A, September 30, 2015.

Step 1: Broach the topic of obesity with the family Step 2: Find out what’s important to the patient

(it’s usually NOT their health) Step 3: Take a lifestyle history Step 4: Check for Comorbidities Step 5: Treat Comorbididities and use motiviational

interviewing to encourage lifestyle/behavioral change

Step 6: Manage expectations, keep engaged, reevaluate, refer

So Now We’re Here…Now What?

STEP 1How to Breach the Topic of Obesity with the

Patient and Family

BMI: weight (kg) / [height (m)]2 Talk about it as a way of predicting future

health, not weight. (ie “The BMI is your health number.”)

Predicts risk of future heart disease, diabetes, etc. Think of it like a stop light Refer to the child’s BMI as a zone (green zone, yellow zone, red zone) AVOID language like healthy weight, overweight, obese Don’t necessarily want to lose weight. May just need to stabilize rate of weight gain. Remind them it’s not all about the

numbers

Talking About BMI

Retrieved from http://prowellness.vmhost.psu.edu/prevention/understanding_risk/bmi on November 2, 2013

What would be better or easier if you lost weight? If you can make one thing in your life better, what would it be? Sports Clothes Friends Feeling better Less teasing

Step 2: Find out what’s important to your patient

5 vegetables and fruits 3 meals a day 2 no more than 2 hours of screen time 1 hour of daily activity Almost none of the sugary stuff Sleep Eating behaviors (eating quickly, second

helpings, what does it feel like when they’re full, food sneaking/seeking behaviors)

Step 3:Take a lifestyle history

Insulin Resistance (prediabetes)/Diabetes

Heart Disease Nonalcoholic Fatty Liver Disease

(NAFLD) Kidney Disease Musculoskeletal Abnormalities Endocrine Abnormalities Reproductive issues Psychological Disorders Genetic Causes

STEP 4:Rule Out Comorbidities

Blood Pressure Screen: Check 2 BPs with each visit (use average of the two) If high, double check manually

Diabetes Screen: Fasting glucose, insulin, HgbA1c

Cholesterol Screen: Fasting lipid panel with calculated LDL HS CRP

NAFLD Screen: ALT, AST

Thyroid Screen: TSH

Other Screens: Uric Acid 25-OH Vit D Urine Microalbumin

Tests to Consider

Fasting Labs:Glucose: >100 orInsulin >17A1c: 5.7-6.4 insulin resistanceA1c 6.5 or > is T2DMLook for acanthosis in nuchal folds, axilla, groin

Insulin Resistance / Type 2 Diabetes

For all levels of insulin resistance: Decrease CHO Increase protein (EVERYTIME they eat they need a protein) Increase exercise Consider low carbohydrate diet

A1c >6% - treat with metformin to prevent progression to T2DM

* Start metformin 500mg PO with dinner x 1 week. If tolerating well, increase to 1000mg daily. May go as high as 2 grams daily

* Refer to Healthy Lifestyles

A1c > 6.5% - still start metformin, add BID glucose checks and endocrine referral (page them), and refer to Healthy Lifestyles

Start metformin 500mg PO with dinner x 1 week. If tolerating well, increase to 1000mg daily. May go as high as 2 grams daily

How to treat IRS

Fasting lipid panel with calculated LDL: Total Cholesterol < 170 LDL < 130 HDL > 40 (ideally > 60) Triglycerides < 110

High Sensitivity C-Reactive Protein (predicts risk of athelerosclerosis)

< 0.3 Low risk 0.3-0.5: Moderate risk >0.5: High risk

Heart Disease

DO NOT RECOMMEND LOW FAT! When you take fat out of food, sugar content rises. Leads to worsening lipid profiles. Instead: Hyperlipidemia:

LDL >160mg/dL refer to lipid clinic for consideration of statins

Low HDL (HDL < 40mg/dL): Increase exercise, avoid partially hydrogenated oils

Hypertriglyceridemia (Triglycerides > 110mg/dL): Decrease CHO intake

Mixed Dyslipidemia (any combo of the above, but usually Triglycerides > 100mg/dL, HDL < 40mg/dL): Total Cholesterol > 170mg/dL and/or LDL > 130mg/dL <

160mg/dL:

How to Treat High Cholesterol

HS CRP > 0.3 mg/dL (at any risk level) Encourage anti-inflammatory diet by

decreasing CHO Increase exercise Repeat in 6 to 12 months

How to Treat Elevated HS CRP

You’ve already had 2 great talks about this.

How to Treat Elevated BP/Hypertension

Caused by excessive central adiposity ALT > 40U/L Need to rule out other causes (ie infectious,

autoimmune) Hispanic males most susceptible

Nonalcoholic Fatty Liver Disease

Retrieved from https://www.google.com/search?q=fatty+liver&biw=1600&bih=759&source=lnms&tbm=isch&sa=X&sqi=2&ved=0CAYQ_AUoAWoVChMIupDynuahyAIVAY0NCh2K2wH1#imgrc=FIjlp6jITXsVnM%3A October 1, 2015

Decrease central adiposity Low carbohydrate diet Increase exercise Refer to GI if ALT elevated longer than 12

months or if ALT > 90U/L.

How to Treat NAFLD

There is NO agreed upon guideline for norms and supplementation

Vitamin D Deficiency: < 20ng/mL Supplement vitamin D3 2000 IU daily; take with

adequate calcium source Recheck in 8 weeks

Vitamin D Insufficiency: 20-30ng/mL Daily MVI

Vitamin D

S/Sx of endocrine dysfunction i.e. signs of hypothyroidism, dorsocervical fat

pad, moon facies, hypogonadism Consider TSH, 8AM cortisol, testosterone,

endocrine referral Dysmorphic features

Consider FISH and genetic referral Early onset obesity before the age of 5 years

old Leptin Deficiency MC4R Mutation Prader Willi Consider genetic referral

When to suspect an intrinsic/genetic cause?

Acanthosis Striae “Buffalo hump”, “moon facies” Tonisillar hypertrophy, swollen turbinates Liver hypertrophy Genu Varus/Genu Valgum Pes planus Panniculosis/Panniculitis

Physical Exam

Acanthosis

Retrieved from http://escholarship.org/uc/item/6fj340w2 on November 2, 2013.

Striae

Retrieved from http://pictures.doccheck.com/com/photo/15948-striae-distensae-stretch-marks on October 1, 2015

Buffalo Hump & Moon Facies

Retrieved from http://www.plasticsurgeryportal.com//articles/buffalo-hump-removal-surgery/318 onNovember 2, 2013.

Retrieved from http://jofem.org/index.php/jofem/article/view/5/16 onNovember 2, 2013.

Tonsilar HypertrophySwollen Turbinates

Retrieved from http://emedicine.medscape.com/article/868925-overview on November 2, 2013.

Retrieved from http://chandrajayasuriya.com/?q=node/43 on November 2, 2013.

Retrieved from http://bowlegs.com.ua/deforming_arthrosis.htm on November 2, 2013.

Genu ValgumGenu Varus

Retrieved from http://www.eurolab.ua/skin-beauty/915/ on November 2, 2013.

Pes Planus

Retrieved from http://www.dermis.net/dermisroot/en/39760/image.htm on November 2, 2013.

Panniculosis

Don’t forget to assess for social stressors, trauma, bullying, depression, anxiety (both in the child and in the parent) PHQ, PSC, SCARED screens

If you do not get a hold of the psychological component, you will not get a hold of the obesity…

OBESITY IS JUST A SIGN OF WHAT’S REALLY GOING ON

Parents working 2 jobs Homelessness Risk of deportation Violence Unsafe neighborhoods Depression/Anxiety Chronic Illness Food Insecurity Poverty….poverty…poverty

Remember – you don’t know the whole story

PT – consider exercise fitness testing, aquatic therapy. (Remember, these kids are deconditioned. Your first job is to keep them safe and injury free).

RD – partner with a dietician to help guide the families in lifestyle changes

Mental Health – help the family overcome underlying issues and stress

Build Your Team – this takes a multidisciplinary approach

Referral based clinic Child must have BMI > 95th%

Multidisciplinary team Medical providers, dieticians, PT, LPC

Access to Bull City Fit Assess and manage comorbidities related to

pediatric obesity Use MI to guide patients and families toward

healthy change

Duke Healthy Lifestyles

Contact me anytime Lisa.watson@duke.edu (919) 684-1297 (office)

(919) 620-5394 (appointment)

Questions?