DISCLOSURES: 8/27/18 USE OF A SHARED MEDICAL APPOINTMENT FOR PEDIATRIC OBESITY

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1 DISCLOSURES: Nothing to disclose USE OF A SHARED MEDICAL APPOINTMENT FOR PEDIATRIC OBESITY Catherine Lux, DNP,RN,CPNP-PC ENVIRONMENTAL CAUSES OBJECTIVES: Discuss socioeconomic and demographic factors relating to the pediatric obesity epidemic. Discuss the complications and comorbidities of obesity in the pediatric population what makes childhood obesity different? Discuss clinical workup of the overweight or obese child. Discuss treatment options for the pediatric population. Discuss the implementation of a Shared Medical Appointment for primary treatment of obesity in children. Availability of High Glycemic Index Foods Portion Distortion Decreased sleep time Screen Time Media Influence Sedentary Lifestyles Built Environment-food and exercise deserts Obesogenic chemical exposure Epigenetics Children are especially vulnerable to poor nutrition and intake of empty calories. The NHANES revealed that the top dietary energy sources for children aged 2-18 years were, in order, grain deserts, pizza, and soda. According to the USDA, the consumption of sugar sweetened beverages is the single largest contributors of calories and added sugar in the American diet (IOM, 2012, p. 167). (Reedy & Krebs-Smith, 2010, p. 1) 1

2 METABOLIC PROGRAMMING PERIODS OF BIOLOGIC VULNERABILITY: The concept that environmental and nutritional influences during critical periods in development, particularly during gestation, can have permanent effects on an individual s predisposition to obesity and metabolic disease Gestation Adiposity Rebound- 3 to 7 years Puberty Kish, W. et al. (March 13, 2015) Definition; epidemiology; and etiology of obesity in children and adolescents. UpToDate. ADIPOSITY REBOUND PUBERTY-THE PERFECT STORM Hormonal changes--obese children tend to gain abnormally more weight during the 9-12 year range, when puberty is activating hormonal changes that cause increased adipose tissue development Social behaviors--increasingly sedentary pursuits, peer pressure, self-esteem issues, and more independence re dietary choices, risk taking behaviors. ADOLESCENT HORMONES: LEPTIN A key trigger for puberty and weight gain First discovered in 1994 Adipocytokine a substance that is secreted by adipose tissue Signals to the hypothalamus that sufficient energy is present Leptin deficiency signals a starvation state and hunger. Insulin seems to inhibit leptin from signaling satiety, promoting increased fat stores. This process may be developmentally necessary in order to trigger menses in girls, as leptin deficiency precludes pubertal onset 2

3 MEDICAL CONDITIONS ASSOCIATED WITH OBESITY 1. genetic disorders (Rare ): short stature, developmental delay 2. Sleep apnea: consistent snoring, daytime somnolence., hypertrophic tonsils, behavior issues 3. Hypertension: elevated blood pressure on 3 separate occasions, (appropriate cuff size/technique ) 4. Silent conditions: lipids, diabetes, NAFLD 5. PCOS: fewer than 9 menses per year 6. Orthopedic issues: Blount s, tibial bowing, Slipped capital femoral epiphysis (hip or knee pain, limp) CLINICAL EVALUATION BMI-current status and trend ROS pattern of weight gain, comorbidities History-family, psychosocial, diet, eating patterns (questionnaire) Physical Exam Labs Patient education and counseling ACANTHOSIS NIGRICANS DIABETES Overweight (BMI 85th percentile) Plus any two of the following risk factors Family history of type 2 diabetes in 1st or 2nd degree relatives Race/ethnicity (African-American, Hispanic, Native American, Pacific Islander) Insulin resistance signs (acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovary syndrome) Maternal diabetes during gestation Start at age 10 or onset of puberty (whichever is earlier) Fasting glucose OR hemoglobin A1c Screen every 3 years HYPERTENSION DYSLIPIDEMIA Measure annually starting age 3 years 3 elevated measures are needed for diagnosis New data tables (data from children with healthy weight) Elevated blood pressure (formerly prehypertension) 90 th %ile 13 years: 120/80 Hypertension stage 1 à 95 th %ile Hypertension stage 2 à 95 th %ile + 12 mmhg Fasting lipids Age 2-8 years if BMI >=95% or CV risk factors 9-11 years EVERYONE AT LEAST ONCE years BMI5-85% +CV risk BMI >= 85% 17-21years EVERYONE AT LEAST ONCE 3

4 OTHER LABS NAFLD SCREEN Screen with ALT Age 2-8 years if BMI >/= 95% Age 9-21 years if BMI 85-95% + risk factors If BMI >/=95% Vitamin D Serum 25(OH) Vit D Levels < deficient Vitamin D trapped in adipose tissue Thyroid Rarely causative factor Short stature, disrupted growth velocity Mildly elevated TSH more common in obese children Goiter TREATMENT Staged approach based on level of obesity and comorbidity Lifestyle modification-diet, exercise dose effect Assessment of food and exercise patterns goal setting Nutritional education Medications not recommended currently for pediatric populations Investigative therapies BARLOW SE. EXPERT COMMITTEE RECOMMENDATIONS REGARDING THE PREVENTION, ASSESSMENT AND TREATMENT OF CHILD AND ADOLESCENT OVERWEIGHT AND OBESITY: SUMMARY REPORT. PEDIATRICS. 2007;120(SUPPL 4):S164-S192. TIME CONSTRAINTS SHARED MEDICAL APPOINTMENT (SMA) Time spent on health supervision topics in children 2 10 y Diet counseling 42 seconds (interquartile [IQ] 21-85) Growth 15 seconds (IQ 7-31) Physical activity 12 seconds (IQ 5-22) Martin. J Pediatr 2008;153:706 A way to deliver enhanced patient education while providing individual disease management in a cost-effective way (Schmucker, 2006). AKA Group Medical Appointment (GMA) Made up of three components: Group setting Patient interactions and opportunity for peer support One-on-one clinical encounter with provider 4

5 STAFFING BENEFITS Multidisciplinary team including: Facilitator (nurse, nutritionist, pharmacist, patient educator, etc.) Provider Nurse Support/clerical staff Lab* Scribe* Pharmacist* *optional Increase face time with provider Increase access for patients Provide accesss to multidisciplinary team Provide increased patient education Enlist patient peer support for disease management Improve outcomes Maximize provider efficiency and productivity Decrease provider burnout (Schmucker, 2006) ORIGINS OF SMA REQUIREMENTS FOR PARTICIPATION Credited to Dr. Edward Noffsinger of Kaiser in California Nurse practitioners were using this model previously cluster visits 1970 s Well baby visits (Morse, 2009) Current clinic patient Had physical within past year Recommended labs and work up for obesity School aged Able to participate in classroom setting Only address obesity related issues SMA Pre-visit Referral by PCP Reviewed By NP Added to wait list Clerk calls to schedule Patient arrives SMA Workflow Process Chart Clerk check-in & consents Clerk enrolls pt in MyChart Clerk schedules virtual visit MA gets VS and gives pt PAM nutritionist / PNP- visit Follow-up NP send first f/u NP sends 2 nd Virtual Visit- NP and MA NP sends 3 rd NP sends 4 th THE SOCIETAL AND INDIVIDUAL COST OF FAILING TO ADDRESS THE OBESITY EPIDEMIC IS HIGH. THIS MAY BE THE FIRST GENERATION OF U.S. CHILDREN TO HAVE A SHORTER LIFE SPAN THAN THEIR PARENTS (DANIELS, 2009). Repeat SMA and f/u for 4 class series 5

6 QUESTIONS? 6