A Case of Childhood Obesity CHRIS CLEMENTE, MD ELIZABETH MCNANY, MD MARCH 9, 2019

Transcription

1 A Case of Childhood Obesity CHRIS CLEMENTE, MD ELIZABETH MCNANY, MD MARCH 9, 2019

2 Overview I. Introduction I. Epidemiology, diagnosis, etiology II. III. IV. Case Report Patient Co-Morbidities I. Fatty Liver II. Hypothyroidism Treatment and Prevention I. Resources in our communities V. Conclusions

3 Childhood Obesity Obesity serious public health problem in the United States, putting children/adolescents at risk for poor health About 1 in 5 children and adolescents (13.7 mil) in the US are obese Prevalence of obesity decreased with increasing level of education of the household head Prevalence of obesity has been increasing over the past 15 years

4 Health risks Obesity can lead to many poor health outcomes, obesity children are more likely to develop the following conditions: Hypertension Hyperlipidemia Impaired glucose tolerance/diabetes Breathing problems (asthma and sleep apnea) Joint problems/musculoskeletal pain Fatty liver disease GERD Anxiety and depression Low self-esteem Possible social issues like bullying Obese children are more likely to become obese adults

5 Contributing factors Behaviors Eating high calorie, low-nutrient foods and beverages Note getting enough physical activity Sedentary activities (TVs/other screen devices) Poor sleep routines Environment Can be difficult to get healthy food and physical activity when in places that do no support these habits Being limited to the foods and activities provided at child care, schools Affordability of healthy foods Peer and social supports Marketing Policies in the community

6 Etiology Environmental factors sedentary lifestyle (video games, TV), caloric input > caloric output, sugar-sweetened drinks, lack of sleep Medications (eg olanzapine, glucocorticoids) Genetic factors or specific syndromes Endocrine disorders For example growth hormone deficiency, cortisol excess Hypothalamic lesions

7 Definitions BMI = weight (kg) / [height (m)] 2 Adults BMI < 18.5 = underweight BMI = normal weight BMI = overweight BMI > 30 = obese For children between age 2-20, based on percentile for age and sex: BMI <5 th percentile = underweight BMI 5 th - 85 th percentile = normal weight BMI >85 th -95 th percentile = overweight BMI > 95 th percentile = obese

8 Case Report

9 Patient History 14 yo male with pmhx of ADHD, hypothyroidism, and elevated liver enzymes presents for routine well child exam. He has been dealing with childhood obesity above the 95 th percentile for weight and BMI since 9 years old. He has been noncompliant with thyroid medication. At age 6, he was diagnosed with ADHD and put on stimulant medication By age 12, he was able to come off medications and control his symptoms with behavioral modifications His first documented abnormal thyroid (low T4, elevated TSH) and liver enzymes were from intake labs performed at age 12. Family history: mother hypothyroidism, diabetes, hyperlipidemia

10 Physical Exam T 98F, RR 14, HR 78, BP 132/77 HT 5 9, WT 228lb, BMI (99 th percentile) General alert, cooperative, overweight HEENT pupils equal and reactive, ears normal bilaterally, oropharynx unremarkable, no palpable neck masses Lungs clear to auscultation bilaterally Heart regular rate and rhythm, no murmurs Abdomen soft, non-tender, no organomegaly Extremities atraumatic, no edema Neuro normal without focal findings

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12 How do you screen for obesity? How do you address obesity or what tools do you use?

13 American Academy of Pediatrics Institute for Healthy Childhood Weight Professional Education Clinical Support tools Parent/patient resources

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15 Another example from European Society of Endocrinology and the Pediatric Endocrine Society

16 Lab evaluation Fasting lipids Fasting glucose, or consider A1c ALT/AST

17 Labs 4/23/2015 7/14/ /7/2016 8/31/ /18/ /13/2017 8/10/2018 TSH T AST ALT Alkaline Phosphatase Hemoglobin A1c Cholesterol 120 Triglycerides 71 HDL 45 LDL Calculated 61

18 Fatty Liver and Obesity Due to the elevated liver enzymes a RUQ ultrasound was performed FINDINGS: The liver is significantly echogenic with decreased through transmission suggesting fatty infiltration. The gallbladder and biliary ducts are normal. The common duct measures 3 mm. There are no gallstones. Visualized portions of the pancreas are unremarkable. IMPRESSION: Hepatic steatosis. No evidence of gallstones or biliary ductal dilation.

19 Fatty Liver and Obesity Obesity is associated with increased risk of fatty liver disease In one study non alcoholic fatty liver disease was found in 1/3 of obese boys and ¼ of obese girls NASPGHAN (North American Society for Pediatric Gastroenterology, Hepatology and Nutrition) reported prevalence ranges from 0.7% in ages 2-4 to 9-38% in obese children

20 NASPGHAN screening recommendations Screening is recommended between age 9-11 for all obese children Screening is recommended in overweight children with other risk factors (central adiposity, insulin resistance, pre-diabetes or diabetes, dyslipidemia, family history). Can consider screening in earlier children. Consider repeat screening every 2-3 years unless risks improve or sooner if child develops additional risks. Treatment is weight management

21 Hypothyroidism and obesity 4/23/2015 7/14/ /7/2016 8/31/ /18/ /13/2017 8/10/2018 TSH ( ) T4 ( )

22 Hypothyroidism and Obesity: Multiple studies link thyroid hormone abnormalities with body composition and weight. Some reports suggest that weight loss leads to improved thyroid lab values. This raises the question; Does hypothyroidism cause obesity, or vice versa? Mild elevations in TSH is common in obese children Studies have shown that correcting hypothyroid results in minimal weight loss, and hypothyroidism itself may not cause significant weight gain.

23 Case Report Management Elevated AST and ALT: Due to abnormal lab values U/S was performed that revealed hepatic steatosis. Pediatric gastroenterologist did further work up and ruled out viral hepatitis, autoimmune hepatitis, Wilson s disease, alpha-1 antitrypsin deficiency, and celiac disease. Recommended diet and exercise Elevated TSH and low T4: started on synthroid. However, getting TSH to target levels has been difficult due to medication noncompliance and trouble with close follow up

24 Management of Obesity What steps do you do to manage obesity? What has been successful for you?

25 Management of Obesity

26 Prevention-Plus Protocol for the Treatment of Childhood Obesity (Stage 1) Eat five or more servings of fruits and vegetables daily Use television and computer for no more than two hours per day Do not keep a television in child's bedroom Participate in at least 60 minutes of moderate to vigorous physical activity per day Do not consume sugar-sweetened beverages Eat breakfast daily Limit meals outside the home Have family meals at least five to six times per week Allow child to self-regulate food intake and avoid food restriction (e.g., a child should be permitted to eat portions of food until satiated, no more, or less)

27 Structured Weight-Management Protocol for the Treatment of Childhood Obesity (Stage 2) Develop a low energy-dense, balanced-macronutrient diet plan Increase structured daily meals and snacks Schedule supervised physical activity for at least 60 minutes per day Limit television and computer use to less than one hour per day Increase monitoring of screen time, physical activity, dietary intake, and dining habits by physician, patient, and/or family; use logs if necessary

28 STAGE 3 (COMPREHENSIVE, MULTIDISCIPLINARY INTERVENTION) AND STAGE 4 (TERTIARY- CARE INTERVENTION) Consider referral to trained teams that deal with obesity, these patients may need interventions that require time and training beyond the scope of family practice doctor. Children's Healthy Weigh of Buffalo, Women and Children s Hospital of Buffalo, Buffalo, NY Weight Management Programs, Morgan Stanley Children s Hospital New York, NY METABOLISM/WEIGHT-MANAGEMENT

29 Treatment and Management of childhood obesity Points to consider when creating a successful treatment plan Self monitoring of target behaviors (food logs) Stimulus control (access, removing TV from bedroom) Goal-setting (specific, measurable, attainable, realistic, timely) Family involvement (positive reinforcement of target behaviors, parental participation) Motivational interviewing clinician helps family focus on achieving behavioral goals, not the goal of weight loss itself

30 Prevention Prevention is the best way to decrease the prevalence of obesity in the country Identify children at risk of developing obesity in the first 2 years of age by using growth charts. Identifying risk factors Prenatal parental obesity, gestational diabetes, maternal smoking during pregnancy Child never breast feeding, rapid infant weight gain, short sleep duration, depression, having a disability in addition to behavioral risks Monitor BMI changes at each health care visit so earlier identification of children who start to cross BMI percentiles upward can be accomplished

31 Steps to maintain healthy weight Parents and families should be encouraged to model healthy behaviors for children Changes to the foods parents bring into the home and how they sore and serve it can help children make healthier choices Buy fewer sugar sweetened beverages/high calorie snack and sweats If these are bough for an occasion, buy just before and remove after Healthy foods should be in planes site and readily available (water fruits vegetables) High calorie foods made less visible (wrapped in foil, placed in the back Encourage 5 or more servings of fruits and vegetables a day Reduce sedentary behavior Fewer TVs in house, no TV in bedroom or kitchen Sleep, children sleeping less than 9 hours more likely to be overweight Identify opportunities for families to get physical activity together to meet 60 minutes a day and give families a prescription for physical activity as a reminder. (walking, sports, park, playground, bicycle )

32 Any other tips that have worked in your practice?

33 Resources in our Community The North Area YMCA (Liverpool, NY) has recently received funding to start a new weight loss program geared specifically for obese children. Pilot program looking to start the end of this month for about 8-10 families. Big commitment for the family, 2 times a week, 2 hour sessions for 15 weeks. >95 th percentile for weight, ages 7-13 May have full program in the future. Referrals to peds endocrine, Joslin Center, should be considered in patients that have obesity with a complication such as dyslipidemia, PCOS, pre-diabetes, diabetes.

34 Case Report - Discussion It is unclear if this patient s thyroid levels have been difficult to control due to poor compliance alone, or if continued weight changes and obesity contributes to his persistent abnormal values Therefore, it is imperative to treat not just his hypothyroidism, but also his obesity at the same time. Discussions with patient and his mother have begun to include formulating a plan to work on weight goals. Patient plans to start getting involved with school sports and family has been receptive to meet with a nutritionist about further discussions about diet Consistent follow up will be a barrier to helping patient and his family help work on weight loss and continued evaluation of obesity related comorbidities.

35 Conclusions Childhood obesity is a serious problem with increasing incidence Patient s should have BMI evaluated at least yearly Primary care physicians need to address patients BMI Obese patients should be evaluated for co-morbid conditions Primary care physicians can assist patients in developing strategies to treat obesity Prevention is the best way to decrease prevalence of obesity, counseling should begin early on at each well child visit

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37 References 1. Overweight & Obesity. Centers for Disease Control and Prevention. Reviewed September 17, Accessed January 21, Sanyal D, Raychaudhuri M. Hypothyroidism and obesity: An intriguing link. Indian J Endocrinol Metab. 2016;20(4): Grandone A, Santoro N, Coppola F, Calabrò P, Perrone L, Del Giudice EM. Thyroid function derangement and childhood obesity: an Italian experience. BMC Endocr Disord. 2010;10:8. Published 2010 May 4. doi: / Crocker MK, Kaplowitz P. Treatment of paediatric hyperthyroidism but not hypothyroidism has a significant effect on weight. Clin Endocrinol (Oxf). 2010;73(6): Anderson EL, Howe LD, Jones HE, Higgins JP, Lawlor DA, Fraser A. The Prevalence of Non-Alcoholic Fatty Liver Disease in Children and Adolescents: A Systematic Review and Meta-Analysis. PLoS One. 2015;10(10):e Published 2015 Oct 29. doi: /journal.pone Vos MB, Abrams SH, Barlow SE, et al. NASPGHAN Clinical Practice Guideline for the Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease in Children: Recommendations from the Expert Committee on NAFLD (ECON) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). J Pediatr Gastroenterol Nutr. 2017;64(2): Moran R. Evaluation and Treatment of Childhood Obesity. Am Fam Physician Feb 15;59(4): Styne DM, Arslanian SA, Connor EL, et al. Pediatric Obesity-Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(3): American Academy of Pediatrics Institute for Healthy Childhood Weight. Accessed February Daniels SR, Hassink SG, committee on nutrition. The Role of the Pediatrician in Primary Prevention of Obesity. Pediatrics Jul; 136 (1):e275-e Barlow S, Expert Committee. Expert committee recommendations regarding prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics. 2007;120(4):S164-S192.

38 Thank you! QUESTIONS/COMMENTS?