Update on Adolescent Health Care

Kerri Meyer, MDKAPA October 2010

Disclosures Statement

I have no relevant financial relationships with the manufacture(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.

I do not intend to discuss any unapproved/investigative use of a commercial product/device in my presentation.

Objectives

At the conclusion of this talk, the practitioner should be able to

1) Demonstrate effective screening of high risk behaviors and mental health problems in adolescents

2) Apply current guidelines and techniques for STD testing and Pap smears in the clinical setting

3) Provide recommended screening and intervention for overweight and obese teens in the clinical setting

Why is the adolescent psychosocial assessment important?

The major causes of morbidity and mortality in adolescence are not identified by a medical review of systems

If you don’t ask– they won’t tell!

Causes of Death in Teens

1) Unintentional Injury (50%)2) Homicide3) Suicide

** Over half of teen deaths involve substances!** One quarter of all teen sexual encounters

involve substances

High Risk Behaviors in Teens: Subs

According to the CDC Youth Risk Behavior Survey (YRBS) of 9th through 12th graders across the country, in the 30 days prior:

• 28% of teens have ridden with a drunk driver• 10% have driven drunk• 20% smoked cigarettes• 42% drank alcohol (25% binged)• 21% smoked marijuana (37% have tried)

High Risk Behaviors in Teens: Violence

According to YRBS 2009• 18% of teens have carried a weapon

– 6% a gun!• 32% of teens have been in at least one

physical fight • 10% intimate partner violence

High Risk Behaviors in Teens: SexAccording to YRBS 2009• 46% of high school students have had sexual intercourse

• 14% with >4 partners • 70% are SA by 19yrs• 23% report using contraception with last encounter• 60% condom use with last encounter

• SA teens who don’t use contraceptives have a 85-90% chance of becoming pregnant within 1 year (AGI)

• Every year nearly 1/4 of new STIs occur among adolescents (including HIV infections)

Teen Pregnancy• Unintended in <18 yrs is 65% (30% at 20-24 y/o)• 2004 data: 415,000 births 15-19 y/o (41.2/1000)

– KS is now 53/1,000 – Hispanics teens have higher rate

• Reasons for no use of contraception • “I didn’t think I could get pregnant” (46%)• “I did not expect to have sex” (31%)

– CDC 2002 National Survey of Family Growth• Outcomes:

• National Vital Statistics Reports, 2003, Vol. 52, No. 10.

Teen Pregnancy Rates Worldwide

0 10 20 30 40 50 60 70 80 90

Bulgaria

Romania

Georgia

Estonia

Hungary

Latvia

New Zealand

England and Wales

Canada

Australia

Slovak Republic

Scotland

Czech Republic

Norway

Israel

Switzerland

Denmark

Finland

France

Slovenia

Ireland

Germany

Belgium

Spain

Netherlands

Italy

Japan

Per 1000

USA

Family Planning Perspectives/ 2000

“The Bad News”

Depression

According to YRBS 2009, in the previous year:

• 28% reported symptoms of depression• 14% had seriously considered suicide• 10% had made a plan for suicide• 6% had made a suicide attempt

ConfidentialityMinors can consent to care and treatment

related to:– Pregnancy– Contraception (It is unconstitutional to

require consent for contraceptive services).

– STDs (physician can notify parents without teen permission)

– Rape/Abuse – Drug or alcohol abuse/ addiction (not

required to inform parents)

WAYS TO PROTECT PATIENT CONFIDENTIALITY• Do not discuss patient information is

elevators, hallways, and waiting rooms.• Interview your patient in a private place.

Make sure the door is closed.• Give patients privacy when asking them to fill

out forms. Give them a clip board.• Discuss confidentiality at the beginning of

the appointment.• Discuss the possibility of disclosure of

specific tests performed or meds given through health insurance billing statements sent home to the parents.

• If a teen gives you a contact phone number, make sure that you can leave messages.

• Ask before you send snail mail to a teen’s home regarding lab results or appointment reminders.

• Make sure any handouts are small enough to fit in a purse or wallet. Offer them to the teen in private.

What is the HEADDS interview?

• A tool for assessing a teen’s psychosocial well-being

• Widely used by adolescent health care providers across the country

HEADDS Interview

• Home• Education • Activities• Drugs• Depression• Sex

Home

• Who lives at home?• Where are BOTH

parents and what are the nature of those relationships?

• Any changes at home?• Do you feel safe at

home?

Education

• School and grade• Any special classes?• Grades• Truancy• Fighting/bullying• Future Plans

Activities• “What do you like to do when you’re not in school?”• Sports, hobbies, groups or clubs?• Friendships!!• Physical Activity• Computer/TV time

Drugs• Tobacco• Alcohol• Other drugs

• “Even though you aren’t using drugs, are your friends doing that stuff?”

CRAFFT questions

• Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?

• Do you ever use alcohol or drugs to RELAX, feel better about yourself or fit in?

• Do you ever use alcohol or drugs while you are by yourself, ALONE?

• Do you ever FORGET things you did while using alcohol or drugs?

• Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?

• Have you ever gotten into TROUBLE while you were using alcohol or drugs?

Depression• “Do you ever feel down,

sad or depressed?”• “Have you ever been so

upset, angry or depressed that you thought about hurting yourself or someone else?”

SIGECAPS Depression Screen

• Sleep• Interests• Guilt / worthlessness• Energy• Concentration• Appetite• Pleasure• Suicide

What We Know: STI’s• 26% Females with first SA <15 PID

– More than 100,000 women become infertile each year as a result of PID

• HPV prevalence: 5.5 million new US cases/yr– In the US, 20 million people are currently infected (half are

teens).– Up to 90% may clear infection– High risk types less likely to clear

• Chlamydia 2007: 1.1 million new cases – US: 370/100,000– This is the largest number of cases ever reported to CDC for

any condition. It represents an increase of 7.5% is one year’s time!

US Chlamydia Prevalence By Age

www.cdc.gov/std/Chlamydia2004/default.htm

HIV in Adolescents• In 2003, an estimated 3,807 youth aged 13-24 received a diagnosis of

HIV/AIDS, representing 12% of people diagnosed that year.• Individuals who are infected with STDs are at least two to five times more

likely than uninfected individuals to acquire HIV infection if they are exposed to the virus through sexual contact.

• Clearly documented decrease in risk behaviors with known positive disease

• Among youth age 13 to 19:– 66% of HIV infections occurred among non-Hispanic, black youth.– 24% among non-Hispanic white teens.– 8% among Latino teens.

CDC, 2004

STI Screening in AdolescentsUSPSTF (US Preventive Service Task Force)

Females: Annually screen all SA women <25 years• Chlamydia

– If positive, repeat testing in 3 months • GC• Trich and BV• HIV: new guidelines push to increase screening (next slide)• Syphillis: high risk• Herpes: no routine screening• Hepatitis C: If known exposure or IVDA

Males: Bottom line– screen them too (except for BV and trich)

Testing Methods• Females:

– Chlamydia and GC PCR testing• Vaginal swab (practitioner vs self swab)• Endocervical• Urine (not a great option)

• Males:– Chlamydia and GC PCR testing

• Urine• Urethral swab• Could also consider urine dip for WBC as a screen

HIV Screening: CDC Recommendations

• Routine, voluntary screening for adolescents 13 + • Repeat annually for high risk• Opt out screening (routine, may be declined)• No written consent for testing • No pre-testing risk reduction counseling• Communicate test results in same way as any

other screening test

STI Treatment in Adolescents

• No test of cure recommended– NAAT may remain positive for 3-6 wks p tx

• Repeat Chlamydia testing in 3 months– Re-infection rates up to 5-10%

• If treating PID- treat for GC and Chlamydia (consider BV/Trich)

• Patient delivered partner therapy

HPV• Prevalence among adolescent populations from 20-80%

depending on population studied.• ACOG new recommendations:

– First pap smear at 21yrs• Gardasil:

– Routine immunization now recommended for females and males starting at age 11yrs.

– Works by preventing four HPV types: • HPV 16 and 18, which cause 70% of cervical cancers• HPV 6 and 11, which cause 90% of genital warts • The vaccine has no therapeutic effect on HPV-related

disease, so it will not treat existing diseases or conditions caused by HPV.

Obesity in Adolescence

• According to the CDC YRBS:– 28% of teens are overweight or obese– Only 22% are eating 5 fruits/veggies a day– 29% are drinking at least one soda daily– 23% are completely sedentary– 25% are on the computer >3hours daily– 33% watch TV >3hours daily

How many children are obese?

45

4

67

5

11 11

16 16

18.817.4

0

2

4

6

8

10

12

14

16

18

20

% O

be

se

1963-1970

1971-1974

1976-1980

1988-1994

1999-2002

2003-2004

6-11 Years12-19 Years

JAMA, April 5, 2006, Vol 295, No. 13, 1549-1555

Since 1963, the number of obese children in the U.S.

has tripled!

11.513

19.217.7

2222.5

17.3

21.8

16.3

0

5

10

15

20

25

% O

bes

e

2-5 Yrs 6-11 Yrs 12-18 Yrs

White Black Mexican American

JAMA, April 5, 2006, Vol 295, No. 13, 1549-1555

• Black• Hispanic• American

Indian• Alaska

Native

What children are at greater risk?

How many children have type 2 diabetes?

• Non-Type 1 Diabetes in children is now 32% of cases (10 fold increase from 1982-1994).(1)

• The lifetime risk of developing diabetes for a hispanic female born in the United States in the year 2000 until their death is 1 in 2.(2)

• This may be the first generation of children who may live less long than their parents as a result of the consequences of overweight and type 2 diabetes.(3)

1. Pediatrics May 2005 Vol. 115 No. 5: pp. e553-e5602. JAMA 2003 October 8;290(14):1884-18903. New Engl J Med Vol. 352(11) March 2005, pp. 1138-1145

What are the modifiable obesity risk factors?

METABOLISMGENES

POVERTYCULTURE

BEHAVIOR ENVIRONMENT

What are the evidence-based behavioral strategies?

• Breastfeed• Limit sugar-sweetened beverages• Consume the recommended fruits and vegetables• Eat daily breakfast• Limit fast food• Use appropriate portion size• Eat meals together as a family• Limit television and screen time and keep televisions out

of children’s bedrooms• Encourage moderately vigorous physical activity of 60

minutes a day or more

What are the evidence-based environmental strategies?

• Prompts to increase stair use• Access to places and opportunities for physical activity• School based physical activity with better trained PE

teachers and increased length of time students are physically active

• Comprehensive work-site approaches including education, employee and peer support for physical activity, incentives, and access to exercise facilities.

• Availability of nutritious foods, point of purchase strategies, train health care providers to provide nutritional counselingAm J Health Promotion 2005;19(3):167-193www.thecommunityguide.org

Assessment Overview

• Medical Risks– Height, Weight, BMI, Blood Pressure, Pulse– Family History– Review of Systems– Physical Examination– Laboratory Tests

• Behaviors and Attitudes– Diet Behaviors– Physical Activity Behaviors– Attitudes

Measure BMI Annually

• Measure BMI at Well Child Care Visits– Calculation Tools: www.cdc.gov/, www.nhlbisupport.com/bmi/

– Download apps to your phone

• Make a weight diagnosis using BMI % for age– < 5%ile Underweight– 5-84%ile Healthy Weight– 85-94%ile Overweight– 95-98%ile Obesity– >=99%ile

For Patient Communication...

• Weight or Excess Weight• Body Mass Index (BMI)• Risk for Diabetes & Heart

Disease

Measure Blood Pressure Annually

• Use a cuff large enough to cover 80% of the arm

• Diagnose hypertension using NHLBI tables http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

131/85129/84139/88136/8717 Yr

129/84126/82132/84128/8214 Yr

123/81121/79124/82121/8011 Yr

118/78115/76119/79116/788 Yr

112/73110/72115/74112/725 Yr

108/65105/63109/63106/612 Yr

90%50%90%50%

131/85129/84139/88136/8717 Yr

129/84126/82132/84128/8214 Yr

123/81121/79124/82121/8011 Yr

118/78115/76119/79116/788 Yr

112/73110/72115/74112/725 Yr

108/65105/63109/63106/612 Yr

90%50%90%50%

BOYS HEIGHT % GIRLS HEIGHT %

Blood Pressure 95% by Age, Sex and Height %

AGE

Pediatrics Vol. 114 No. 2 August 2004 pp. 555-576

Take a Family History and Review of Systems

• Family History– Parental Obesity– Cardiovascular disease, Hypertension, Dyslipidemia– NIDDM, Insulin Resistance

• Review of Systems– Anxiety, school avoidance, social isolation (Depression)

– Polyuria, polydipsia, weight loss (Type 2 diabetes mellitus)– Headaches (Pseudotumor cerebri)– Night breathing difficulties (Sleep apnea, hypoventilation syndrome, asthma)– Daytime sleepiness (Sleep apnea, hypoventilation syndrome, depression)– Abdominal pain (Gastroesophageal reflux, Gall bladder disease, Constipation)– Hip or knee pain (Slipped capital femoral epiphysis)

– Oligomenorrhea or amenorrhea (Polycystic ovary syndrome)

Assess Behaviors and Attitudes• Diet Behaviors

– Sweetened-beverage consumption– Fruit and vegetable consumption– Frequency of eating out and family meals– 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– Successes, barriers and challenges

Things To Look For On The Physical Exam

• Poor linear growth (Hypothyroidism, Cushing’s, Prader-Willi syndrome)

• Dysmorphic features (Genetic disorders, including Prader–Willi syndrome)

• Acanthosis nigricans (NIDDM, insulin resistance)

• Hirsutism and Excessive Acne (Polycystic ovary syndrome)

• Violaceous striae (Cushing’s syndrome)

• Papilledema, cranial nerve VI paralysis (Pseudotumor cerebri)

• Tonsillar hypertrophy (Sleep apnea)

• Abdominal tenderness (Gall bladder disease, GERD, NAFLD)

• Hepatomegaly (Nonalcoholic fatty liver disease (NAFLD))

• Undescended testicle (Prader-Willi syndrome)

• Limited hip range of motion (Slipped capital femoral epiphysis)

• Lower leg bowing (Blount’s disease)

Things To Look For On The Physical Exam

• Acanthosis nigricans (NIDDM, insulin resistance)

• Violaceous striae (Cushing’s syndrome)

Laboratory Tests to Consider

• BMI 85-94%ile Without Risk Factors– Fasting Lipid Profile

• BMI 85-94%ile Age 10 Years & Older With Risk Factors – Fasting Lipid Profile– ALT and AST– Fasting Glucose

• BMI >= 95%ile Age 10 Years & Older – Fasting Lipid Profile– ALT and AST– Fasting Glucose– Other Tests as Indicated by Health Risks

Every 2 Years

Every 2 Years

Prevention Overview

• Obesity Prevention at Medical Office Visits– BMI Screening for All Children 2 Years and Older– Universal Consistent Evidence-Based Health

Messages– Patient-Centered Communication– Early Intervention and Referral if Indicated

• Health Professional Support and Advocacy– Tools and Resources– Advocacy in Schools and Communities

Give Consistent Evidence-Based Prevention Messages to All Families• Dietary Intake

– Breastfeeding for the first 12 months or longer– Limit or eliminate consumption of sugar-sweetened beverages– Eat the the recommended quantities of fruits and vegetables

• Physical Activity– Limit television and other screen time to no more than 2 hours/day– Remove television and other screens from children’s bedrooms– Moderate to vigorous physical activity for at least 60 minutes a day

• Eating Behaviors– Eat breakfast every day– Limit eating out, especially at fast food restaurants– Have regular family meals– Limit portion sizes

Motivational Interviewing -Change Talk and Self-Perception

• People are more powerfully influenced by what they hear themselves say than by what someone else says to them.

– Encourage your patients to say the things that you usually tell them.

– Help your patients to talk themselves into making a change!

• Self-motivating statements made by the patient:

– Recognition of an issue – Reasons for making a change – Hazards of not making a change

• Free Online CME - www.kphealtheducation.org

Office-Based Motivational Interviewing to Prevent Childhood Obesity

• Nonrandomized clinical trial involving 91 children ages 3-7 years with a BMI 5-94%ile and a parent BMI > 30

• 15 pediatricians and 5 RD’s assigned to…

– Control – standard care– Minimal Intervention – 10-15 minute MI session

with MD, 1 month after well child care visit– Intensive Intervention – Minimal + 45-50 minute MI

session with RD, 6 months after well child care visit• BMI%ile decreased 0.6% (control), 1.9% (minimal), 2.6%

(intensive)Arch Pediatr Adolesc Med. 2007;161:495-501

Treatment Overview

• Treatment Goals– Behavioral Goals and Parenting Skills– Self Esteem and Self Efficacy– BMI Velocity, Weight Loss Targets and BMI %ile

• A Staged Approach– Prevention Plus– Structured Weight Management– Comprehensive, Multidisciplinary Intervention– Tertiary Care Intervention

Treatment Goals - Health Behaviors• Lifelong healthy behaviors such as physical activity will improve

health outcomes regardless of weight change• Improving self esteem and self efficacy can also improve health

outcomes• Small consistent changes over time can make a big difference!

– Consistent behavioral changes averaging 110 to 165 kcal/day may be sufficient to counterbalance the energy gap which leads to excess weight gain in some children.

– Changes in excess dietary intake (eg, eliminating one sugar-sweetened beverage at 150 kcal/can) may be easier to attain than increases in physical activity levels (1.9 hours walking for an extra 150 kcal).

Pediatrics Vol. 118 No. 6 December 2006 pp. e1721-1733

Treatment Goals - BMI• The long term BMI goal will need to be individualized based on

risk factors and genetics– BMI < 85%ile - Ideal long term goal– BMI 85-94%ile - Some children can be healthy in this range

• Short term BMI goals will need to be individualized based on genetics, risk factors and the intensity of the intervention– Decrease in BMI velocity– Weight maintenance– Weight loss

• Younger and more mildly obese children should change weight more gradually than older, more severely obese youth

Treatment Goals - Weight Loss Targets

* Excessive weight loss should be evaluated for high risk behaviors

BMI 85-94%ile No Risks

BMI 85-94%ile With Risks

BMI 95-98%ile BMI >= 99%ile

Age 2-5 Years

Maintain weight velocity

Decrease weight velocity or weight maintenance

Weight maintenance

Gradual weight loss of up to 1 pound a month if BMI is very high (>21 or 22 kg/m2)

Age 6-11 Years

Maintain weight velocity

Decrease weight velocity or weight maintenance

Weight maintenance or gradual loss (1 lb per month)

Weight loss (average is 2 pounds per week)*

Age 12-18 Years

Maintain weight velocity. After linear growth is complete, maintain weight

Decrease weight velocity or weight maintenance

Weight loss (average is 2 pounds per week)*

Weight loss (average is 2 pounds per week)*

A Staged Approach - Overview• Stage 1 - Prevention Plus

– Family visits with physician or health professional– Frequency individualized to family needs and risk

factors

• Stage 2 - Structured Weight Management– Family visits with physician or health professional

with training in childhood weight management. Visits can be individual or group.

– May include visits with a dietitian, exercise therapist or counselor

– May include self-monitoring, goal setting and rewards

– Frequency monthly or individualized to family needs and risk factors

• Stage 1 and 2 Behavioral Recommendations– Decrease screen time to 2 or fewer hours a day.– Minimize sugar-sweetened beverages. Ideally,

these beverages would be eliminated from a child’s diet.

– Consume at least 5 servings of fruits and vegetables daily.

– Be physically active 1 hour or more daily. – Prepare more meals at home as a family. The

goal is 5-6 times a week.– Consume a healthy breakfast daily.– Involve the whole family in lifestyle changes

• Stage 3 - Comprehensive, Multidisciplinary Intervention

– Multidisciplinary team with experience in childhood obesity

– Frequency often weekly group sessions for 8-12 weeks with follow up

• Stage 4 - Tertiary Care Intervention (for select children only when provided by experienced programs with established clinical or research protocols)

– Medications - sibutramine, orlistat– Very-low-calorie diets– Weight control surgery - gastric bypass or

banding (not FDA approved for children but in clinical trials)

ObesityAlgorithm

1) Health risks include medical or behavioral risk

2) Lab every 2 years

3) Progress to next stage if no improvement in BMI/weight after 3-6 months and family willing

4) Weight loss goal = 2 lbs/week average

Healthy Weight

BMI 5-84%ile

Overweight

BMI 85-94%ile

Obese

BMI 95-98%ileBMI >=99%ile

Assess Behaviors & Attitudes - Eating, Physical Activity, Sedentary Time, Motivation

Assess Medical Risks - Family History, Review of Systems, Physical Examination (BMI, BP)

Assess Fasting Lipid Profile

YesNo

Assess ALT, AST, Fasting Glucose(2)

Other Tests as Indicated by Health Risks

Prevention Counseling - Empathize/Elicit - Provide - Elicit

Stage 1 Prevention Plus(3)

Stage 2 Structured Weight Management(3)

Stage 3 Comprehensive Multidisciplinary Intervention(3)

Stage 4 Tertiary Care InterventionTreatment

Prevention

Assessment

Health Risks?(1)

Maintain Weight Velocity & Reassess Annually

Maintain Weight or Gradual Loss(4) &

Reassess Every 3-6 Months

Maintain Weight or Decrease Velocity & Reassess Every

3-6 Months

Gradual to Moderate Weight

Loss(5) & Reassess Every 3-6 Months

Overcoming Challenges

Lack of Patient Motivation & Provider Skills

Not Enough Time

No Reimbursement

Motivational Interviewing

Office Systems and Tools

Team Based Care

Coding Strategies

Advocacy

Pediatrics Vol. 116 No. 1 July 2005 pp. 238-239

Step 1 - Prevention at Well Care Visits

• Assess all children for obesity at all well care visits 2-18 years– Measure BMI and make a weight diagnosis– Measure blood pressure and use the NHLBI tables to diagnose

hypertension– Take a family history and review of systems to identify obesity risk factors– Assess behaviors and attitudes– Looks for signs of co-morbid conditions on the physical exam– Order the appropriate laboratory tests

• Give consistent evidence-based messages for all children regardless of weight.

• Use Empathize/Elicit - Provide - Elicit to improve the effectiveness of your counseling

Step 2 - Prevention Plus Visits

• Develop an office based approach (www.NICHQ.org) for follow up of overweight and obese children which may include:– Health education materials– Behavioral risk assessment and self-monitoring tools– Action planning and goal setting tools– Other health professionals such as dietitians and psychologists

• Use motivational interviewing at Prevention Plus Visits for ambivalent families and to improve the success of action planning (www.kphealtheducation.org)

• Develop a reimbursement strategy for Prevention Plus Visits (www.aap.org/healthtopics/overweight.cfm or contact aapcodinghotline@aap.org)

Step 3 - Beyond Your Practice

• Advocate for improved access to fresh fruits and vegetables and safe physical activity in your community and schools

• Identify and promote community services which encourage healthy eating and physical activity

• Identify or develop more intensive weight management interventions for your families who do not respond to Prevention Plus

• Join the Childhood Obesity Action Network (www.NICHQ.org) to learn from your colleagues and accelerate progress

Assessment, Prevention and Treatment of Childhood Obesity: Recommendations from the Expert Committee on Childhood

Obesity

• National Sponsors– CDC– HRSA– AMA

• Endorsed By– AAP– ADA– NAASO– Others...

Writing Group LeadsNancy Krebs MD, MSKen Resnicow, PhDBonnie Spear, PhD, RD

Implementation Guide LeadsVictoria Rogers, MDScott Gee, MDLenna Liu, MD, MPH Jane McGrath, MD

Presentation Resources

• Amy Lacroix, MD in Omaha, NB• Laurie Hornberger, MD in Kansas City, MO• Society for Adolescent Medicine• PRCH (Physicians for Reproductive Health and Choice)• National Program To Prevent Teen Pregnancy• CDC website• AAP and Bright Futures• NICHQ's Childhood Obesity Action Network• Assessment, Prevention and Treatment of Childhood Obesity:

Recommendations from the Expert Committee on Childhood Obesity