PEDIATRIC WEIGHT MANAGEMENT:SCREENING & WORK UP

SOPHIE LANCIERS, MD, FAAP, DIPLOMATE ABOM

ASSISTANT PROFESSOR OF PEDIATRIC GASTROENTEROLOGY

PEDIATRIC OBESITY

• CRITICAL PUBLIC HEALTH ISSUE

• MAJOR CAUSE OF MORBIDITY AMONG AMERICAN CHILDREN

• PRE-DIABETES, DIABETES, NON-ALCOHOLIC FATTY LIVER DISEASE,

BLOUNT’S DISEASE, SLIPPED CAPITAL FEMORAL EPIPHYSIS,

OBSTRUCTIVE SLEEP APNEA, MENTAL HEALTH ISSUES...

• CONDITIONS PREVIOUSLY THOUGHT TO BE ONLY FOUND IN ADULTS

PREVALENCE• OBESITY HAS BECOME ONE OF THE MOST IMPORTANT PUBLIC HEALTH

PROBLEMS IN THE US

• INCREASE PREVALENCE OBESITY MEANS INCREASE IN COMORBIDITIES

• 32% CHILDREN AND ADOLESCENTS ARE OVERWEIGHT (22% 15

YEARS AGO)

• 17% OBESE (11% 15 YEARS AGO)

• JACKSON: UP TO 70% REPORTED OVERWEIGHT BY SCHOOLS

• CHILDHOOD OBESITY => ADULTHOOD OBESITY IN 80%

MONTANA STATISTICS

• ADULT OBESITY 28.3%, UP FROM 15.6% IN 2000 AND 8.4% IN 1990

• ADULT OBESITY NOW ABOVE 35% IN 7 STATES, TRENDS CONSISTENTLY

GOING UP

• OBESITY IN 2 TO 4 YRS: 12.1% (WIC), HIGH SCHOOL STUDENTS 11.5%

(NEW DATA, STATE OF OBESITY)

• DIAGNOSED DIABETES INCREASED FROM 2.8% IN 1990 TO 9.3% IN 2018

• HEART DISEASE CASES IN 2010: 64,244, PROJECTED FOR 2030: 304,870

PRE-DIABETES AND DIABETES TYPE 2

• IN THE US 33.9% OLDER THAN 18 HAVE DIAGNOSED PRE-DIABETES

• 7.4% ADULTS IN MONTANA REPORT HAVING PRE-DIABETES

• CHILDREN DIAGNOSED WITH TYPE 2 DIABETES MORE THAN DOUBLED IN

RECENT YEARS, APPEARS TO COINCIDE WITH INCREASE IN OBESITY BASED

ON PRIVATE INSURANCE DATA

• IN 2018 17.2% AMERICAN INDIAN/ALASKA NATIVES DIAGNOSED WITH

DIABETES, 8.7% WHITE NON HISPANICS IN MONTANA

• DATA FROM CDC AND MONTANA BEHAVIORAL RISK FACTOR

SURVEILLANCE SYSTEM, 2018

OBESITY: DEFINITION / DIAGNOSIS

• BMI CLINICALLY PRACTICAL TOOL FOR ASSESSMENT

• BODY WEIGHT IN KG / HEIGHT IN METER SQUARED

• CORRELATES WITH ADIPOSITY AND COMPLICATIONS OF CHILDHOOD

OVERWEIGHT

• LIMITATIONS: OVERESTIMATES ADIPOSITY IN INCREASED MUSCLE

MASS AND VICE VERSA

DEFINITION/ DIAGNOSIS

• BMI >85TH PERCENTILE = OVERWEIGHT

• BMI >95TH PERCENTILE = OBESE

• BMI CAN ALSO BE DETERMINED USING CALCULATOR FOR BOYS AND

GIRLS

• TO BE MEASURED YEARLY IN CHILDREN OLDER THAN 2 YEARS.

DEFINITION/ DIAGNOSIS

• BMI < 85TH PERCENTILE BUT INCREASING MORE THAN 3 OR 4 UNITS/

YEAR AFTER 4 YRS OF AGE: SIMPLE TIPS NUTRITION AND EXERCISE.

• BMI > 85TH PERCENTILE: SCREEN FOR CO-MORBIDITIES, COUNSEL FOR

LIFESTYLE CHANGES, DIETICIAN

• BMI > 95TH PERCENTILE: SIGNIFICANT RISK FOR OBESITY AS ADULT,

SCREEN FOR CO-MORBIDITIES, DIRECT COUNSELING CLINICIAN,

REGULAR FOLLOW UP FOR PROGRESS (2 MONTHS)

GENETIC SYNDROMES

• SINGLE GENE DISORDERS ARE RARE:

• PRADER-WILLI: 1/15.000 BIRTHS, 15Q PARTIAL DELETION

• SMALL AT BIRTH, FTT UNTIL +/- 18 MONTHS

• DIAGNOSIS: DNA METHYLATION STUDY

• RARE DISORDERS: BARDET-BIEDL, COHEN SYNDROME, ALSTROM

SYNDROME, LEPTIN DEFICIENCY

EVALUATION

• GOAL: TO IDENTIFY TREATABLE CAUSES AND CO-MORBIDITIES

• COMPLETE HISTORY AND PHYSICAL

• LABORATORY AND RADIOLOGICAL STUDIES

EVALUATION

• HISTORY:

• AGE OF ONSET, GRADUAL OR SUDDEN

• DIETARY HISTORY:

• IDENTIFICATION CARETAKERS

• INTAKE HIGH CALORIE FOODS

• SKIPPING MEALS

• INABILITY TO CONTROL APPETITE

EVALUATION

• EXERCISE HISTORY:

• WALKING OR RIDING BIKE TO SCHOOL

• TIME SPENT IN PLAY

• SCHOOL RECESS AND PE

• WEEKEND ACTIVITIES

• ASSESSMENT SCREEN TIME (TV, GAMES)

EVALUATION

• REVIEW OF ALL MEDICATIONS, ALSO IN THE PAST:

• STEROID USE FOR ASTHMA AT YOUNG AGE

TRIGGER FOR WEIGHT GAIN

• PSYCHOACTIVE DRUGS (RISPERIDONE)

• ANTIEPILEPTIC DRUGS

EVALUATION

• REVIEW OF SYSTEMS:

• ABRUPT ONSET WEIGHT GAIN:

• MEDICATION INDUCED

• MAJOR PSYCHOSOCIAL TRIGGER

• ENDOCRINE CAUSES (CUSHING DISEASE,

HYPOTHALAMIC TUMOR)

• OBESITY SYNDROMES

EVALUATION

• REVIEW OF SYSTEMS: SYMPTOMS OF

COMPLICATIONS:

• HEADACHES/VOMITING > PSEUDOTUMOR

CEREBRI

• SNORING/ SOMNOLENCE > SLEEP APNEA

• ABDOMINAL PAIN > GALLSTONES

• POLYDIPSIA, POLYURIA > DIABETES

• HIP PAIN, KNEE PAIN > SLIPPED EPIPHYSIS

• AMENORRHEA, HIRSUTISM > PCOS

EVALUATION

• FAMILY HISTORY:

• OBESITY IN 1 OR BOTH PARENTS IMPORTANT PREDICTOR FOR ADULT

OBESITY

• RISK OF COMORBIDITIES INFLUENCED BY FAMILY HISTORY:

• CARDIOVASCULAR DISEASE, HYPERTENSION, DIABETES, LIVER OR

GALLBLADDER DISEASE AND RESPIRATORY INSUFFICIENCY IN FIRST

AND SECOND DEGREE RELATIVES.

EVALUATION

• PSYCHOSOCIAL HISTORY:

• DEPRESSION

• SCHOOL AND SOCIAL ISSUES, FRIENDS?,

BULLYING?

• NEGATIVE PEER PERCEPTION, BEING TEASED

• TOBACCO USE, INCREASES LONG TERM

CARDIOVASCULAR RISK

EVALUATION

• PHYSICAL EXAM:

• DYSMORPHIC FEATURES > GENETIC SYNDROME?

• ASSESSMENT OF AFFECT

• FAT DISTRIBUTION:

• BUFFALO TYPE: CUSHING SYNDROME

• ABDOMINAL OBESITY: ASSOCIATED WITH

METABOLIC SYNDROME, PCOS AND INSULIN

RESISTANCE

EVALUATION

• PE: BLOOD PRESSURE:

• PROPER SIZED CUFF

• HYPERTENSION: BP > 95TH PERCENTILE FOR

AGE, GENDER AND HEIGHT ON 3 SEPARATE

OCCASIONS

EVALUATION

• PE: STATURE:

• EXOGENOUS OBESITY: INCREASED LINEAR HEIGHT, TALL

FOR AGE, BONE AGE NORMAL OR ADVANCED

• ENDOGENOUS OBESITY: SHORT STATURE IN MOST CASES,

GROWTH VELOCITY SLOWED.

• PRADER-WILLI SHORT FOR GENETIC POTENTIAL, NO

PUBERTAL GROWTH SPURT

• MC4R MUTATION: BIG SINCE BIRTH, 1 TO 2.5% OF OBESE

INDIVIDUALS, MOST COMMON KNOWN GENETIC CAUSE

EVALUATION

• PE: HEAD, EYES, THROAT:

• MICROCEPHALY: COHEN SYNDROME

• BLURRED DISC MARGINS: PSEUDOTUMOR CEREBRI

• NYSTAGMUS, VISUAL COMPLAINTS: HYPOTHALAMIC-

PITUITARY LESION

• RETINITIS PIGMENTOSA: BARDET- BIEDL SYNDROME

• LARGE TONSILS: OBSTRUCTIVE SLEEP APNEA

• EROSIONS TOOTH ENAMEL: SELF INDUCED VOMITING,

GERD

EVALUATION

• PE: SKIN AND HAIR

• DRY, COARSE HAIR: HYPOTHYROIDISM

• STRIAE: IF DARK, DEEP > CUSHINGS

• ACANTHOSIS NIGRICANS: INSULIN

RESISTANCE, DIABETES, PREDIABETES

• HIRSUTISM: PCOS, CUSHINGS

EVALUATION

• PE: ABDOMEN

• ABDOMINAL TENDERNESS: GALLBLADDER

DISEASE

• HEPATOMEGALY: NAFLD

EVALUATION

• PE: MUSCULOSKELETAL

• NON PITTING EDEMA: HYPOTHYROIDISM

• POSTAXIAL POLYDACTYLY: BARDET- BIEDL SYNDROME

• SMALL HANDS AND FEET: PRADER- WILLI

• SCFE: LIMITED RANGE OF MOTION AT HIP, GAIT

ABNORMALITY

• BLOUNT DISEASE, GENU VARA: BOWING OF LEGS, TIBIAL

TORSION

• PES PLANUS AND PRONATION OF FEET> PAIN DURING

EXERCISE

EVALUATION

• PE: GENITOURINARY

• GENETIC OR ENDOCRINE CAUSES:

• UNDESCENDED TESTICLES, SMALL PENIS, SCROTAL

HYPOPLASIA> PRADER-WILLI

• SMALL TESTES: PRADER-WILLI, BARDET-BIEDL

• DELAYED OR ABSENT PUBERTY: HYPOTHALAMIC

PITUITARY TUMORS, PRADER-WILLI, BARDET-BIEDL

• PRECOCIOUS PUBERTY: HYPOTHALAMIC PITUITARY

LESION

EVALUATION

• PE: DEVELOPMENT

• MOST SYNDROMIC CAUSES ASSOCIATED

WITH COGNITIVE OR DEVELOPMENTAL DELAY

• PRADER-WILLI ASSOCIATED WITH HYPOTONIA

IN INFANCY AND DELAYED MOTOR

DEVELOPMENT

EVALUATION AT INITIAL VISIT

• LABORATORY STUDIES:

• NOT FULLY STANDARDIZED

• MOST SUGGEST ROUTINE SCREENING FOR DIABETES 2,

DYSLIPIDEMIA, HYPERTENSION AND FATTY LIVER DISEASE IN

OVERWEIGHT OR OBESE CHILDREN

• LIPID SCREENING BETWEEN 2 AND 8 YRS IF OBESE, OLDER IF

OVERWEIGHT.

• SCREENING FOR DIABETES RECOMMENDED IN CHILDREN 10

YEARS OLD, BMI> 85TH PERCENTILE AND 2 OTHER RISK

FACTORS( FAMILY HISTORY, ACANTHOSIS, ETHNICITY)

EVALUATION AT INITIAL VISIT

• LABORATORY TESTS:

• LIVER FUNCTION TESTS SHOULD BE OBTAINED,

NAFLD TYPICALLY ASYMPTOMATIC

• ADDITIONAL TESTING IF FINDINGS OF

HYPOTHYROIDISM, PCOS, CUSHING

SYNDROME, AND SLEEP APNEA

EVALUATION

• RADIOGRAPHIC :

• PLAIN X-RAY LOWER EXTREMITIES IF SYMPTOMS

SCFE OR BLOUNT DISEASE

• ABDOMINAL ULTRASOUND IF SUSPICION

GALLSTONES

• ABDOMINAL ULTRASOUND TO CONFIRM FATTY

LIVER, SEVERITY OF LIVER INVOLVEMENT DOES

NOT CORRELATE WITH RADIOGRAPHIC FINDINGS

• BRAIN IMAGING IF NEUROLOGIC SYMPTOMS

TREATMENT

• WHY TREAT:

• COMORBID CONDITIONS BIGGEST KILLERS IN THE

US

• EVEN SMALL WEIGHT LOSS CAN HAVE A MAJOR

BENEFICIAL EFFECT ON HEALTH RISKS

• COSTS TO SOCIETY COULD BE GREATLY REDUCED

WITH ADEQUATE TREATMENT AND PREVENTION

TREATMENT

• GOALS:

• REGULATION OF BODY WEIGHT AND FAT WITH

ADEQUATE NUTRITION FOR GROWTH AND

DEVELOPMENT

• LONG TERM BEHAVIOR/ LIFESTYLE CHANGES

• EATING BEHAVIOR

• EXERCISE BEHAVIOR

TREATMENT

• BEST TREATMENT IS PREVENTION

• TREATMENT ASAP, EARLIEST INTERVENTION BEST

OUTCOME

• FAMILY INTERVENTION

• LONG TERM TREATMENT

• SHORT TERM GOALS

TREATMENT OF OBESITY

• LEVELS OF TREATMENT:

1. PRIMARY CARE IS THE FRONTLINE, PROVIDING BASIC

EDUCATION, VISITS EVERY 6 TO 8 WEEKS.

2. MORE STRUCTURED, DIETICIAN, MONTHLY VISITS WITH

CLINICIAN WHEN FAIL 6 MONTHS

3. MULTIDISCIPLINARY APPROACH

4. TERTIARY FINAL STAGE, UNSUCCESSFUL IN STAGE 3

• INVOLVES BARIATRIC SURGERY, VERY LOW CALORIE

DIETS AND MEDICATIONS.

WELLNESS AND WEIGHT PROGRAM

• MULTIDISCIPLINARY APPROACH:

• BEHAVIOR MODIFICATION, PSYCHOLOGICAL SUPPORT,

FAMILY INTERVENTION

• DIET/ NUTRITION EDUCATION

• EXERCISE/ EXERCISE EDUCATION

• MEDICAL SUPERVISION

TREATMENT

• NUTRITION EDUCATION:

• IDENTIFY MAJOR FOOD GROUPS, LEARN CARB

COUNTING

• LABEL READING

• LOW FAT, HEALTHY FATS

• FAST FOOD EDUCATION

• DINING OUT TIPS

• PORTIONS!

TREATMENT

• EXERCISE/ EXERCISE EDUCATION:

• BASED ON LEVEL OF OBESITY, INDIVIDUALIZED

• EXERCISE PHYSIOLOGIST

• LIFESTYLE CHANGES, FAMILY INTERACTION

• MAINTAIN LEAN BODY MASS WHILE DIETING

ANY FORM OF EXERCISE IS BETTER THAN NOTHING!

TREATMENT

• BEHAVIOR MODIFICATION:

• PSYCHOLOGIST SCREENS FOR

UNDERLYING DISORDERS

• FAMILY INTERVENTION

• GOAL SETTING

• POSITIVE ROLE MODELING

• LEARN LIMITS

• CHOOSING ALTERNATIVES

• RELAPSE PREVENTION

CONCLUSION

• BEST TREATMENT IS PREVENTION…

• THE EARLIER THE INTERVENTION THE BETTER:

• EDUCATION

• SCHOOL BASED: .

• SCHOOL LUNCHES

• PHYSICAL EDUCATION

• NUTRITION EDUCATION

THANK YOU !

QUESTIONS ?