8/5/2016. Objectives. Disclosures. Managing Childhood Obesity. Understand the scope of and influence family lifestyle has on child health

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1 Managing Childhood Obesity Bill Stratbucker, MD, MS August 5, 2016 Objectives Understand the scope of and influence family lifestyle has on child health Clarify the role of the child healthcare provider in improving family lifestyle Describe best practices in treatment of the consequences of poor family lifestyle Disclosures No financial relationships to disclose Could mention off label use of medications 1

2 Pediatric Obesity Medicine Key Concepts No scary statistics Physician s role, communication Growth charts, BMI plotting, weight gain trajectories Nutrition and activity basics Labs, lipids Communication Readiness to change, motivational interviewing Follow-up options, Staged treatment Family Mental Health Screening Trajectory Communication These Things Matter 2

3 Family Matters Role modeling Values Preferences Styles Support Structure Routines Limits 3

4 Sleep Onset Quantity Quality Environment Timing Location Habits Related concerns Nutrition Hunger Water Quality Quantity Frequency Speed Location Mental Health Matters Depression Anxiety ADHD Medications Self-esteem Bullying Substances Abuse 4

5 Activity Quantity Quality Intensity Frequency Range Limitations Limits and Zeros Screens Treats Soda/pop Smoking Screening Matters FNPA, Family Nutrition and Physical Activity Assessment Social determinants of health Food insecurity Psychological concerns ACE, Adverse Childhood Experiences Development and Preliminary Validation of a Family Nutrition and Physical Activity Assessment, Ihmels, et. al, Int J Behav Nutr Phys Act, 2009 Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd ed. Hagan JF, Shaw JS, Duncan PM, eds. Elk Grove Village, IL: American Academy of Pediatrics;

6 Social Determinants of Health We Care Project 10 Family Psychosocial Problems Alcohol abuse Childcare Depression Domestic violence Drug abuse Homelessness risk Inadequate food supply Low education (< high school) Smoking Unemployment Addressing Social Determinants of Health at Well Child Care Visits: A Cluster RCT, A Garg, et. al, Pediatrics, Jan Food Insecurity 1. Within the past 12 mo, we worried whether our food would run out before we got money to buy more. (Yes or No) 2. Within the past 12 mo, the food we bought just didn t last and we didn t have money to get more. (Yes or No) Promoting Food Security for All Children, Council on Community Pediatrics, Committee on Nutrition, Pediatrics, Vol. 136, Issue 5, Nov

7 Pediatric Symptom Checklist Parent and youth versions 17 or 35 items Improve recognition and treatment of psychosocial problems in children Behavior/mood School performance Relationships Excessive weight gain Dyslipidemia Symptoms 7

8 Dyslipidemia Guidelines Practice protocols Definitions Diagnosis Severity Etiology Treatment Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report, Pediatrics, Vol. 128, Suppl. 5, Dec. 2011, s213-s256. Dyslipidemia Screening starts at birth with family history Smoking, dyslipidemia, CVD<55yrMale or <65Female, Diabetes, Obesity Nutrition, activity, sleep, mental health, SDH, ACE High risk groups starting at age 2 (non-fasting) Chronic kidney disease, Hypertension, Kawasaki s, HIV, Lupus, JIA/JRA, Hypothyroidism Clinical judgement if < age 9 with obesity or significant known family history Dyslipidemia Patient with obesity starting at age 9, non-fasting, POC in clinic if available (Consider initial A1C, CMP, TSH) All patients age 9-11, non-fasting and again at age Fasting lipid panel if non-fasting is over referral threshold Frequency can be based on initial results Repeated measurements rarely helpful 8

9 Dyslipidemia Treatment first-line is lifestyle counseling, 6-12 months Fish oil supplements for hypertriglyceridemia Statin for LDL elevation Homozygous familial hypercholesterolemia, LDL > 500 Heterozygous, 1/500, LDL Consider referral to specialist if: Non-HDL > 145 HDL < 30 LDL > 130 if diabetes, >160 if 2 risk factors, >190 without risk factors TG > 250 Excessive Weight Gain Diagnosis Onset Severity Etiology Co-morbidities Treatment Trajectory Matters Growth Charts Use with families Accuracy Trajectory Phenotypes Response to treatment 9

10 Clinical Tracking of Severly Obese Children: A New Growth Chart, Gulati, Kaplan, Daniels, Pediatrics, Vol. 130, Num 6, Dec Pediatric Obesity Severity Classes Class 1 obesity, 95 th %ile 120%ofthe95 th %ile Class 2 obesity, 120%ofthe95th%ile 140% Class 3 obesity, over 140%ofthe95th%ile Flegal, Skinner, Skelton 10

11 Clinical Tracking of Severly Obese Children: A New Growth Chart, Gulati, Kaplan, Daniels, Pediatrics, Vol. 130, Num 6, Dec Obesity Trajectory A Overweight at 2 years old, BMI 90 th %ile Early adiposity rebound Chronic excessive weight gain Modified by puberty (accelerates or decelerates) Assumes appropriate stature Obesity Trajectory B Healthy weight established early in life Normal adiposity nadir and rebound Distinct onset of excessive weight gain Assumes appropriate stature 11

12 Obesity Trajectory C Obesity at 2 years old Normal timing of adiposity nadir and rebound Weight gain trajectory is reassuring Assumes appropriate stature Treatment of Obesity Establish weight gain phenotype Consider etiologies Look for co-morbidities Sleep apnea, HTN, PCOS, Headache, Asthma Lab screening Dyslipidemia, Diabetes, Fatty Liver, Thyroid Consider urgency Utilize resources Assess for family/patient readiness Set appropriate and realistic expectations Prioritize and negotiate goals and follow-up Talking about obesity (or communication matters) Be sensitive, non confrontational Consider the age of the child <7: talk to parent 7-11: talk to both 12-19: talk to teen, then parent Conversation starters Ask permission: May we take a few minutes to talk about your child s weight? How do you feel about your child s weight? Relate weight to health Use open-ended questions What s hard for you about getting your child to eat healthy foods or be active? Avoid certain terms: obese, obesity, morbid, severe Use excessive weight Review and support 12

13 Communication Matters Between colleagues Patient-first language Weight bias Chart documentation Diet: Good Motivational interviewing Negotiation Goal setting SMART Specific, Measurable, Accountable, Realistic, Time-bound Definition of Success Patient outcomes Slow weight gain, stop, lose, normal range BMI Improved fitness, body fat %, Resp. function, QOL Co-morbid conditions Diagnosed, Treated, Resolved by BMI change Improved mental health Diagnosed, Treated, Resolved by BMI change Improved family health Potential Outcomes No trajectory change Rapid BMI increase BMI centile and z-score increases Maintain BMI centile Change trajectory Decrease BMI z-score Maintain BMI Level off trajectory Reduce BMI centile, z-score Reduce BMI Downward trajectory 13

14 Obesity Guidelines 2007 Barlow, Pediatrics Staged obesity prevention/treatment Prevention (assessment and diagnosis) Stage I or Prevention Plus (assessment, diagnosis and treatment) Stage II Stage III Stage IV Stage 1 Treatment Prevention Plus Family visits with primary care provider Frequency individualized to family needs and risk factors Monthly recommended Tailored goal setting and plan Involve those who are ready for change Use motivational interviewing and cultural competency Focused messaging Monitoring of behavior changes and BMI If motivated family but no improvement in 3-6 months move to Stage 2 treatment if available Stage 2 Treatment Structured Weight Management Family visits with health professional with training in childhood weight management. Visits can be individual or group. Include visits with a dietitian, exercise therapist Includes: self-monitoring goal setting rewards Frequency: Follow-up Ongoing regular visits If motivated family and no improvement in 3-6 months move to Stage 3 treatment if available 14

15 Stage 3 Treatment Multidisciplinary childhood obesity team Behavior modification Goal setting Self monitoring Systematic measurement Frequency Monthly visit with physician/psychologist and team Weekly group sessions for weeks with follow up (longer = better outcomes) Barlow, Pediatrics, Multidisciplinary Obesity Care Team Medical: MD/DO, APP Nutrition: RD Behavioral Therapy: PsyD, LMSW Physical Activity: Exercise Physiologist, PT Care Coordination: RN, LMSW, or Health Educator Pediatric subspecialties Bariatric Surgeon (Stage IV) Modified from: Barlow, S Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics, These Things Matter Family Mental Health Screening Trajectory Communication 15

16 Thank You!! Questions and Discussion Case 1 13 year old girl Mom concerned about patient s weight gain Was a little bit of a problem but now worse Menstrual cycles irregular with onset 9 months ago Eat pretty healthy, like everyone else. Always active Has as a 15 year old brother who they say is skinny and can eat anything he wants and not gain weight Exam acne, SMR 3 x 2 Case 1 Labs TSH 5.2 (normal range ) Free T (normal range ) Total cholesterol = 155 LDL cholesterol = 78 HDL cholesterol = 36 Triglycerides = 169 A1C = 5.4 ALT = 28 AST = 22 16

17 Obesity Trajectory A Overweight at 2 years old, BMI 90 th %ile Early adiposity rebound Chronic excessive weight gain Modified by puberty (accelerates or decelerates) Assumes appropriate stature Case 2 15 year old boy Wants school form for football Exam normal Normal non-fasting lipids age 11 Obesity Trajectory C Obesity at 2 years old Normal timing of adiposity nadir and rebound Weight gain trajectory is reassuring Assumes appropriate stature 17

18 Case 3 10 year old boy Mom not too worried as everyone in family is heavy School performance is poor, missing days for headaches Napping after school frequently ROS reveals bedwetting sometimes at night History of asthma, exercise induced no current symptoms, no medications Exam reveals s/p tonsillectomy age 5, snoring SMR 1 x 2, BP 138/82 Dandruff, dental caries Case 3 labs TSH 3.35 Total cholesterol 185 HDL 38 LDL 105 TG 265 ALT 54 (normal range < 40) AST 38 A1C 5.8 (prediabetes ) Obesity Trajectory A Overweight at 2 years old, BMI 90 th %ile Early adiposity rebound Chronic excessive weight gain Modified by puberty (accelerates or decelerates) Assumes appropriate stature 18

19 Case 4 14 year old girl Poor sleep onset, no snoring Parents divorced last year Menstrual cycles normal Positive PHQ-9 depression screen Exam normal Started Zoloft 6 months ago Case 4 labs TSH 2.47 Total cholesterol 155 HDL 42 LDL 88 TG 140 ALT 18 AST 14 A1C 5.2 Obesity Trajectory B Healthy weight established early in life Normal adiposity nadir and rebound Distinct onset of excessive weight gain Assumes appropriate stature 19

20 The Case 5 8 year old girl at PCP office for a well child visit with mom Well known to practice Mom has concerns about weight gain Growth Historic growth chart BMI Age 2 Age 4.5 Age 5.5 Age 6.5 Age

21 The Plan Labs (CMP, CBC, TSH, Free T4) and Monthly weight checks July = 192 pounds Aug = 199 pounds,?sleep apnea, tonsil hypertrophy, pulm referral The Follow-up visit September, 212 pounds Knee pain Asperger s Household stress, food diary, labs (glucose, lipids, insulin, cortisol, A1C, TSH, Free T4, 2hr OGTT), possible referral to endocrinology Growth Growth chart June to September Height up 0.5 inch Weight up 26 pounds 21

22 BMI Age 2 Age 4.5 Age 5.5 Age 6.5 Age 8.5 Age 8.7 The Endocrinology visit November Eval for Type II DM (A1C = 6.4) No polyuria, polydipsia, weight loss. No headaches, visual disturbances, abdominal pain, constipation, urinary or pulmonary problems. Started pubic hair one year ago Started breast development one year ago Exam: AN neck, axilla, arms, knuckles, knees, Tanner III and III, breast may be mostly fatty tissue Weight gain most likely secondary to excessive caloric intake. Return in 6 months, consider Metformin at that time. The Pulmonary visit February (6 month wait) Eval for possible sleep apnea Lifelong snoring Cyanotic and gasping at times Oct Feb Allergies Falls asleep during school Sleep study April, severe OSA, directly admitted for T&A Day 7 at home bleeding epidsode, Aeromed to Grand Rapids for surgical intervention 22

23 The Endocrine follow-up visit April Did not follow-up with dietitian No exercise due to T&A On metformin Gained 17 pounds since Nov. visit, now 226#, BMI 43.8 AST 19, ALT 52, A1C 5.2 Ordered LH 3.4, FSH 1.1, estradiol 23, glucose 103 BMI Age 2 Age 4.5 Age 5.5 Age 6.5 Age 8.5 Age 8.7 September The MRI of the Brain 3.3 x 2.1 x 2.3 cm solid and cystic hypothalamic neoplasm. Optic chiasm spared Satellite lesions Almost certainly represents astrocytic neoplasm Biopsy confirmed hypothalamic pilocytic astrocytoma, or ganglioglioma 23

24 Z scores Mean BMI z-score = 2.37 Program Results: Behaviors Change in FNPA Survey Score Variable Baseline Follow Up Change FNPA raw score (20-80) * FNPA percent score (0-100) * 86.2% of participants improved their FNPA score Program Results: Anthropometry Mean changes in indicators of weight status Variable Baseline Follow Up Change BMI (kg/m 2 ) BMI z-score * BMI percentile (%) * Percent Body Fat (%) * Fat Mass (kg) Fat-Free Mass (kg) * * Statistically significant reduction (p<0.05) 24

25 Program Results: BMI Centiles 71% of participants reduced their BMI percentile (i.e., reduced BMI trajectory) Variable Baseline Follow Up Change BMI (kg/m 2 ) BMI z-score BMI percentile (%) Percent Body Fat (%) Program Results: BMI Reduction 51% of participants reduced their BMI Variable Baseline Follow Up Change BMI (kg/m 2 ) BMI z-score BMI percentile (%) Percent Body Fat (%) Fat-free mass: 3.1 kg Fat mass: -3.3 kg Program Results: Biomarkers Blood lipid changes in patients with elevated risk Total Cholesterol Triglycerides Baseline Follow Up 25

26 PSC 8/5/2016 Program Results: Biomarkers Blood lipid changes in patients with elevated risk LDL 36.3 HDL 40.2 Baseline Follow Up Mean Total/HDL ratio among those with elevated risk changed from 5.5 to 4.6 (AHA recommends <5.0) Results: Psychosocial Health Mean change in Pediatric Symptom Checklist (PSC) High-Risk Normal High-Risk Normal * * Parent Reported Patient-Reported * Statistically significant change (p<0.05) Baseline Follow Up Definition of Success Co-morbid conditions Diagnosed, Treated, Resolved by BMI change Blood pressure Sleep Constipation/GERD Headaches Asthma Vitamin D deficiency/anemia Menstrual irregularity Fatty liver Pre-diabetes, Type II DM Metabolic syndrome, lipid abnormalities, hyperinsulinism, acanthosis nigricans 26

27 Definition of Success Improved mental health Diagnosed, Treated, Resolved by BMI change Pediatric Symptom Checklist Depression Anxiety ADHD Trauma, grief, loss ODD Self esteem Bullying Self efficacy, confidence Definition of Success Improved family health Weight/BMI change Improved nutrition and activity Family communication Parenting skills Mental health Smoking cessation Published outcomes Effectiveness of Weight Management Interventions in Children: A Targeted Systematic Review for the USPSTF Pediatrics published online Jan 25, 2010; Evelyn P. Whitlock, Elizabeth A. O'Connor, Selvi B. Williams, Tracy L. Beil and Kevin W. Lutz 27

28 Published outcomes Whitlock 2010: Comprehensive behavioral interventions of medium-to-high intensity were the most effective behavioral approach with 1.9 to 3.3 kg/m 2 difference favoring intervention groups at 12 months. More limited evidence suggests that these improvements can be maintained over the 12 months after the end of treatments and that there are few harms with behavioral interventions. Whitlock 2010 Published outcomes USPSTF 2005, no sufficient evidence for screening for overweight in children 2008 Whitlock AHRQ review of 4 trials showing positive results USPSTF decides to update the 2005 review 11 trials, age 4-18 with wt. outcomes, 6 good, 5 fair, small (3 with >40 pts.) 3 mod-high intensity programs (26-75, >75hours) 3 very-low intensity programs (<10 hours) pooled showed short term sig. Limited evidence showing reduction in risk factors do not occur (other than reduction in insulin resistance in mod-high intensity programs) No evidence of harm Evidence-based Guidelines Expert Committee Recommendations Regarding the Prevention, Assessment and Treatment of Child and Adolescent Obesity. Pediatrics, Dec

29 Laboratory Tests Glucose Lipid panel Liver enzymes A1C OGTT Vitamin D Insulin Thyroid function CBC, Ferritin PCOS (LH, FSH, estrodiol, DHEAS, testosterone) Cortisol (24 hour urine collection) Genetic testing Urine microalbumin CRP 29