Pediatric Obesity Conference. Disclosure 4/11/2016. Learning Objectives. An Overview of Pediatric Obesity Co-Morbidities for the Primary Care Provider

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1 Pediatric Obesity Conference An Overview of Pediatric Obesity Co-Morbidities for the Primary Care Provider Ashley Weedn, MD, MPH, FAAP Assistant Professor Medical Director, Healthy Futures Clinic Department of Pediatrics University of Oklahoma College of Medicine Disclosure Under Accreditation Council for Continuing Medical Education guidelines disclosure must be made regarding financial relationships with commercial interests within the last 12 months. Ashley Weedn, MD, MPH I have no financial relationships or affiliations to disclose. Learning Objectives Upon completion of this presentation, participants should be able to improve physician competence, performance and patient outcomes by being able to: 1. To recognize the various clinical implications of pediatric obesity 2. To identify both emergent and chronic co-morbidities of pediatric obesity 3. To describe the evaluation for common obesity co-morbidities 4. To recognize national guidelines for management of common comorbidities of pediatric obesity in primary care 1

2 BMI Percentiles Validity in children Correlates with adiposity 1 Correlates with adult adiposity 2 Correlates with cardiovascular risk factors 3 and longterm mortality 4 Overweight Obese 1 Field AE, Obes Res, Freedman DS, Pediatrics, Freedman DS, J Pediatr, Must A, Int J Obes, 1999 Essential components: medical assessment for pediatric obese children Diet Physical activity Family history Review of systems Physical examination Goals: 1. Identify targets for behavior change 2. Assess risk for co-morbidities Co-morbidities 2

3 Co-morbidities Pseudotumor Cerebri Raised intracranial pressure (ICP) with normal cerebrospinal fluid and brain parenchyma Incidence: <1:100,000 among children Risk factors: females, years, NH whites, medications Symptoms: HA; +/- vomiting, visual changes, pulsatile tennitus, shoulder/neck pain Exam findings: +/-papilledema, visual field defects Dx: CT/MRI; LP (open pressure > 250mmH 2 0) -dx of exclusion after other causes of ICP are eliminated Management: Acetazolamide, neurology and ophthalmology referrals; weight control Complication: visual impairment or blindness Brara SM, J Pediatr, 2012 Pseudotumor Cerebri Key points: Always ask about occurrence of headaches, especially in obese postpubertal girls A fundoscopic exam should be a routine part of the examination of the obese child with a HA and ICP symptoms 3

4 Co-morbidities Slipped Capital Femoral Epiphysis Characterized by displacement of the proximal femoral epiphysis from the metaphysis Incidence: ~11:100,000 in all children Risk factors: early adolescence, boys, Hispanics & blacks Symptoms: limp, complaints of dull, aching groin, thigh, or knee pain (referred by obturator nerve); no preceding trauma Exam findings: motion of the hip in abduction and interior rotation is limited on exam Dx: AP view of pelvis and frog leg to include both hips (compare hips) Management: Orthopedics referral for surgical intervention; weight control Lehmann, J Pediatr Orthop, 2006 Blounts disease Pathologic deformity resulting from disruption of normal cartilage growth at the medial aspect of the proximal tibial physis Incidence: ~ 11:100,000 children Risk factors: 2-4 year olds; adolescent, blacks, boys Mild varus (10 degrees) in obese child can cause growth retardation of medial tibial physis Symptoms: knee pain Exam findings: bowed legs; tibial torsion Dx: Bilateral lower extremity x-rays Management: orthopedics referral, weight control, surgery Complications: deformity, leg length discrepancy Gettys, Orthop Clin N Am,

5 Common musculoskeletal conditions Ankle pain and sprains PT referral Foot pain and pes planus Orthotics referral Key Points: A thorough hip, knee, ankle, and foot exam should be a routine part of the evaluation and follow-up of every obese child c/o pain and/or abnormal gait For obese children with musculoskeletal complaints, caution recommendation of exercise before thorough exam and/or referral to physical therapy Co-morbidities Obstructive sleep apnea Disordered breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal sleep patterns Prevalence: 37-59% of obese children Symptoms: snoring, irregular breathing pauses or gasping, daytime somnolence, enuresis, school and behavioral problems Exam findings: +/- tonsillar hypertrophy Dx: polysomnography (AHI > 1) Management: Intranasal steroids + referral to ENT (T&A) +/- referral to sleep medicine specialist (CPAP) Complications: CVD: Pulmonary HTN RVH Systemic HTN LVH Marcus CL, Pediatrics,

6 Obstructive sleep apnea Key points: Obtain a detailed sleep history on all obese children: ask specifically about sleep disturbances, snoring, and sleep position OSA should be considered in obese children with poor school performance and concentration difficulties Asthma Obesity associated with asthma; unclear temporal relationship Obesity as an independent predictor? Children s Health Study: 3792 children in California from Obese children with new-onset asthma Overall Incidence Rate (IR): 31.4 Boys > Girls (IR: 36.6 vs IR: 25.6) Overall Relative Risk (RR) = 1.6 (1.1,2.4) Boys > Girls (RR: 2.3 vs. 1.1) Gilliland FD, Am J Epidemiol, 2003 Asthma Symptoms: wheeze, cough (notably with activity), chest pain, altered activity patterns, slowing down Exam findings: +/- wheeze Dx: HISTORY, PFTs Management: Albuterol (prior to activity) +/- inhaled steroids; goals is to optimize control in every obese, asthmatic child Key points: - obese children, if inactive, may not report symptoms unless specifically asked - as exercise increases, symptoms may emerge 6

7 Co-morbidities Nonalcoholic fatty liver disease (NAFLD) Accumulation of macrovesicular fat in hepatocyes Prevalence of NAFLD (NHANES )1 Obese females 27% with NAFLD Obese males 48% with NAFLD Prevalence of NASH: 20-25% of obese children 2 Risk factors: Hispanic and Native Americans; males Symptoms: typically asymptomatic Exam findings: +/- hepatomegaly Screening labs: LFTS Dx: elevated AST/ALT; fatty liver on ultrasound; liver bx *Must rule out other potential liver etiology* 1 Welsh, J Pediat, Tazawa, Act Paeditr, 1997 Nonalcoholic fatty liver disease (NAFLD) Management: weight control (with focus on decreasing sugar, fructose, transfats from diet); referral to GI when ALT > 100 Complications: - Correlated with T2DM (50% of T2DM with NAFLD) - Progressive: NAFLD NASH Cirrhosis - Independent risk factor for CVD Estrada, Childhood Obesity,

8 NAFLD Algorithm Source: Children s Hospital Association Consensus Statements for Comorbidities of Childhood Obesity, Childhood Obesity, 2014 Cholelithiasis Prevalence: unknown; 50% of cholecystitis in adolescents associated with obesity 1 Risk factors: females, birth control 2 Symptoms: abdominal pain, +/- nausea, vomiting, fatty food intolerance Exam findings: +/- RUQ tenderness; typically none Dx: abdominal ultrasound Management: Referral to surgery Key Point: Gallbladder disease should be considered in the differential dx of persistent abdominal pain in obese adolescents 1 Crichlow, Am J Dig Dis, Koebnick, J Pediatr Gastroenterol Nutr, 2012 Co-morbidities 8

9 Insulin resistance Prevalence: - 20% obese children have impaired fasting glucose (IFG 1 ); - 25% of obese children with impaired glucose intolerance (IGT) 1 ; - obese children 12.6 higher odds of higher insulin levels vs. nonobese children 2 Risk factors: minorities, maternal GDM, family history Symptoms: polyphagia, +/- nocturia, typically asymptomatic Exam findings: acanthosis nigricans, +/- central adiposity Dx: Fasting glucose mg/dl OGTT: Glucose 140 mg/dl HbA1c Management: weight control +/- metformin 1 Sinha, N Engl J Med, Juonala, N Engl J Med, 2011 Progression from Euglycemia to T2DM Insulin resistance Complications: progression to T2DM - Insulin level > 30 (35% progress to diabetes) - Glucose level > 100 (30% progress to diabetes) - 45% of newly dx diabetic cases in children; correlated with obesity, particularly rapid weight gain in early childhood - Associated with adult cardiovascular disease Key point: reversible with weight control offers an opportunity to discuss health risk of lifestyle behaviors with families ADA, Diabetes Care,

10 Polycystic Ovarian Syndrome Prevalence: 7% among adolescents 1 Risk factors: maternal family history Symptoms: menstrual irregularity Exam findings: hirsuitism, +/- acne Dx: Rotterdam criteria presence of 2/3 2 - hyperandrogenism (clinical or biochemical) - ovulatory dysfunction (irregular menses) - polycystic ovaries - dx of exclusion (rule out other causes of hyperandrogenism) Management: OCP + weight control +/- metformin; referral to endocrinology and/or adolescent medicine Complications: T2DM, Hidradenitis Suppurativa, infertility 1 Anderson AD, Semin Repro Med, Legro RS, Clin Endocrinol Metab, 2013 PCOS Diagnostic Algorithm Source: Children s Hospital Association Consensus Statements for Comorbidities of Childhood Obesity, Childhood Obesity, 2014 Co-morbidities 10

11 Dyslipidemia Prevalence: 39% of obese children 1 Most common lipid abnormality in obese children and adolescents: high TG and low HDL (atherogenic dyslipidemia) - accelerates atherosclerosis Symptoms: none Exam findings: none Dx 2 : fasting lipid panel LDL 130 HDL < 40 Triglycerides: TG 100 (<10 years of age) TG 130 ( 10 years of age) Management 2 : Diet, activity; refer to endocrinology or cardiology for LDL > 250 and TG > Kit BK, JAMA Pediatr, Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents, Pediatrics, 2011 Dyslipidemia Algorithm - TG Decrease refined carb intake; replace with whole grains, vegetables, fruit Avoid sugar-sweetened beverages Avoid trans fats; limit saturated fats Increase fish consumption Source: Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents, Pediatrics, 2011 Dyslipidemia Algorithm - LDL Source: Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents, Pediatrics,

12 Risk Factors for Dyslipidemia Management (+) Family Hx: myocardial infarction, sudden cardiac death in 1 st or 2 nd -degree relative 55 years for males and 65 years for females High Level RFs Obesity (BMI 97 th percentile) Hypertension requiring drug therapy Presence of high-risk conditions Cigarette smoker Moderate RFs Hypertension no drug therapy HDL cholesterol 40 mg/dl Presence of moderate-risk conditions Obesity (BMI percentile 95 th and 97 th ) T1DM and T2DM Chronic kidney disease Kawasaki disease with aneuryms Chronic inflammatory disease HIV infection Nephrotic syndrome KD s/o aneurysms Key points: Dyslipidemia Obtain lipid panel as part of obesity assessment Dietary management in conjunction with RD Reversible with weight control offers an opportunity to discuss health risk of lifestyle behaviors with families Hypertension Prevalence: 20% of obese children have elevated blood pressure Symptoms: +/- HA, fatigue, blurred vision, dizziness; typically asymptomatic Exam: auscultation (ensure appropriate size of BP cuff) Dx: Determined by blood pressure percentiles from pediatric BP charts based on gender, age, and height percentile 90 th BP percentile (Pre-hypertension) 95 th BP percentile (Stage 1 HTN) 99 th BP percentile + 5 mmhg (Stage 2 HTN) - Confirm by manual auscultation - 3 separate BP measurements; average measurements 1 Kit BK, JAMA Pediatr, 2015; 2 Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents, Pediatrics,

13 Hypertension Management: - Rule out secondary causes (renal) of HTN: CBC, BMP, and UA - If elevated BP persists x 3 visits, refer to cardiology or nephrology to assist with pharmacotherapy - Weight control, with emphasis on diet - Cardiovascular Health Integrated Lifestyle Diet (CHILD diet) Key points: - Pediatric hypertension is underdiagnosed - Remember to obtain blood pressure on all obese patients, beginning at 3! Source: Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents, Pediatrics, 2011 Hypertension Algorithm Source: Children s Hospital Association Consensus Statements for Comorbidities of Childhood Obesity, Childhood Obesity, 2014 Simple table to identify children needing further evaluation of blood pressure Source: Kaelber, Pediatrics,

14 Left ventricular hypertrophy Thickening of the muscle of the left ventricle of the heart LVH prevalence: 30% of obese children with HTN vs. 18% in non-obese children with HTN Associated with obesity and HTN Dx: ECHO Complications: Independent risk factor for CVD Daniels SR, Int J Obesity, 2009 Cardiovascular disease Obesity in childhood consistent predictor of adult heart disease Bogalusa Heart Study Muscatine Study Childhood Determinants of Adult Health Study (CDAH) Cardiovascular Risk in Young Finns Study (YFS) Risk factors for CVD Age Risk factors Lesion 5-15 yr Obesity Elevated insulin levels yr Obesity Dyslipidemia Hypertension Insulin resistance 14

15 Health consequences of obesity Childhood obesity is a predictor of increased rate of death, mainly due to an increased risk of cardiovascular disease (CVD) Must et al., NEJM, 1992 Olshansky, et al, NEJM, 2005 Baker et al., NEJM, 2007 Franks et al, NEJM, 2010 Co-morbidities Psychological morbidity Depression Anxiety Low self esteem Teasing/bullying Binge eating disorder Impaired quality of life! Screen by using validated questionnaires (BASC or Peds QL) don t rely on self or parental report Refer to psychological services 15

16 Summary: Targeted review of systems Cardiovascular: chest pain Pulmonary: exercise intolerance, snoring, daytime somnolence Endocrine: polyuria, polydipsia, polyphagia, hirsuitism, menstrual irregularity, cold intolerance GI: abdominal pain MS: joint pain, limp Neurological: headaches Psychosocial: self esteem, social isolation, anxiety Summary: Physical Examination Finding Elevated blood pressure Acanthosis Irregular menstrual cycle Papilledema Tonsillar hypertrophy Abdominal Pain Hepatomegaly Limited hip range of motion Lower leg bowing Flat affect Possible Cause Hypertension Insulin resistance, T2DM PCOS Pseudotumor cerebri Obstructive sleep apnea GERD, NAFLD, gallbladder dz NAFLD/NASH SCFE Blounts Depression Summary: Laboratory evaluation Age BMI Percentile Recommended lab < 10 years 85 th %tile Fasting lipids 10 years 85 th -94 th & Fasting lipids no risk factors 10 years 85 th -94 th & Fasting lipids + 2 risk factors Fasting glucose + OR ALT & AST 95 th %tile *other labs/studies as indicated by ROS or physical exam Barlow, Pediatrics,

17 Resources Children s Hospital Association Consensus Statements - Lipid abnormalities - Abnormal liver enzymes - Hypertension - Polycystic Ovary Syndrome NHLBI: Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents - Available at: Key Points Promptly identify obesity comorbidities requiring immediate attention: - Pseudotumor cerebri - Type 2 Diabetes - Slipped capital femoral epiphysis - Blounts - Obstructive sleep apnea - Cholelithisasis Evaluate for chronic obesity co-morbidities on a regular basis, especially for child with continued weight gain: - Prediabetes - PCOS - NAFLD - GERD - Dyslipidemia - Hypertension - Musculoskeletal pain - Depression, anxiety Key Points All comorbidities require intensive lifestyle changes with focus on weight management; most are reversible; family engagement is key! Refer to community resources (dietitian, physical therapist, and psychology) for support Refer to specialty clinics for further evaluation and management 17

18 References Barlow SE, and Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120 Suppl 4:S Estrada E, et al. Children s Hospital Association consensus statements for comorbidities of childhood obesity. Childhood Obesity. 2014; 10: August GP, et al. Prevention and treatment of pediatric obesity: an Endocrine Society clinical practice guideline based on expert opinion. J Clin Endocrinol Metab Dec;93: References Legro RS, et al. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. Clin Endocrinol Metab. 2013;98: Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128 Suppl 5:S Marcus CL, et al. Clinical practice guideline: Diagnosis of management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130: