Update on Pediatric Obesity

Lessons LearnedDiane Dooley MD

Pediatric OverweightQuality Improvement Project – 2005-7

Phase 1 Measure and

Graph BMI for Age

Counseling rates of overweight children

Phase 2 Phase 3

M e a s u re m e n t a n d F e e d b a c k

1 2 %

6 7 %

4 7 %

7 5 %6 8 %

8 8 %

0 %

1 0 %

2 0 %

3 0 %

4 0 %

5 0 %

6 0 %

7 0 %

8 0 %

9 0 %

1 0 0 %

%

H C # 1 H C # 2 H C # 3

2 0 0 4

2 0 0 5

2 0 0 6

C lin ic a l s ta f f d e m o n s tra te d s u b s ta n t ia l im p ro v e m e n t in th e ra te s o f c a lc u la t io n fo r B M I fo r a g e

Measurement and Feedback

0

10

20

30

40

50

60

70

Counseled

2004

2005

2006

2007

Chart reviews demonstrated 88% increase in rate of diagnosis and counseling

Pediatric OverweightQuality Improvement Project

Phase 1 Measure and

Graph BMI for Age

Counseling rates of overweight children

Counseling rates, diagnosis and follow-up of overweight children

Phase 2 Phase 3

CCRMC QIP Pediatric obesity

Assess all children for obesity•BMI Calculated, graphed – Percentile on well child form

•Diagnosis made by provider

•85-94% Overweight, > 95% Obese

Clinical Evaluation•Assess for hypertension, acanthosis nigricans, hepatomegaly, slipped capital femoral epiphysis, asthma

•Family history of diabetes, early MI, hypertension, obesity

Program Tools

CDC growth charts/ BMI wheels

Treatment algorithm Negotiation Sheet Order sheet Educational

materials Community, health

system referrals

BMI-for-age

For children, BMI changes with age

Percentile correlates with body fat, secondary complications

BMI-for-age definitions:85-95% At risk for

overweight>95% Overweight

Pediatric Hypertension

•Use appropriate cuff size

•Risks: Obesity, family history of hypertension, History of prematurity, low birth weight, congenital heart disease, renal disease

•Evaluate blood pressure results based upon age, gender and height

•BP above 90% - prehypertensive

•BP above 95% - hypertensive

NAFLD Non-alcoholic fatty liver disease

Vague recurrent abdominal pain Prevalence 10-20% of overweight childrenDue to hyperinsulinemia, hepatic insulin

resistanceMore common in Hispanics,

Asians, American IndiansSmall percent progress to

steatohepatitis, cirrhosis, hepatocarcinoma

CCRMC QIP Pediatric obesity

Assess health behaviors and attitudes•Consider screening questionaire

Negotiate a behavioral change

Order any appropriate lab tests•Fasting lipids, Fasting glucose, AST, ALT

Screening recommendations for childhood diabetes

10 years old or onset of pubertyOverweight (>85% BMI)+ 2 risk factors

Family history of T2DM in first or second degree relativeAmerican Indian, Black, Hispanic or Asian/Pacific IslanderSigns of insulin resistance (acanthosis, hypertension, dyslipidemia, PCOS)

Pediatric Dyslipidemia

Differential includes:Monogenic dyslipidemiaSecondary lipid disorders: nephrotic

syndrome, hypothyroidism, etc Idiopathic dyslipidemia

Screening recommended:Family history CAD < 55 years or elevated

cholesterolRisk of CAD: smoking, OW, sedentary

Follow up and referrals

Schedule a return visit

Offer appropriate educational materials

Consider referrals: Health educator, Registered dietician WIC, Food stamps School lunch program Headstart, preschool Obesity intervention program – e.g. WeCan, NEW Kids Pediatric specialty referral