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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.