Assessing and managing child and adolescent obesity

Transcription

1 Assessing and managing child and adolescent obesity Boden Institute, November 2017 Louise A Baur University of Sydney: Discipline of Child & Adolescent Health, Sydney Medical School, The Children s Hospital at Westmead, Sydney: Weight Management Services louise.baur@health.nsw.gov.au

2 Obesity A serious chronic relapsing disease For children and adolescents: It s common Australia - 6-8% obesity (1:4 overweight/obesity)* More common in the socially disadvantaged The rate of severe obesity has increased* It can be serious Prevention is vital So, too, is effective management of those already affected International Obesity Taskforce definition. See: Garnett, Baur, Cowell. Obesity Reviews 2011; 12: ; Garnett SP et al. PLOS ONE 2016; 11: e

3 So what are some of the factors to consider in assessing and managing affected children and young people in clinical practice?

4 Can you recognise risk?

5 Can you see risk? Are these children affected by underweight, healthy weight, overweight or obesity? Age 3 y 3 weeks Age 4 y 4 weeks Age 4 y Photos from UC Berkeley Longitudinal Study, 1973; AND

6 Can you see risk? Are these children affected by underweight, healthy weight, overweight or obesity? Age 3 y 3 weeks BMI >95 th centile Obesity Age 4 y 4 weeks BMI 10 th centile Healthy weight Age 4 y BMI 85 th -95 th centile Overweight Photos from UC Berkeley Longitudinal Study, 1973; AND

7 Recognising the child with overweight or obesity ( above a healthy weight ) routinely measure height & weight plot BMI on a BMI-forage chart: Example: Girl aged 6 years Weight 33 kg Height 120 cm BMI 22.9 kg/m 2 x (>>97th centile for age; obesity range)

8 Same child 6 months later Family-focused lifestyle intervention Weight unchanged Height 123 cm ( 3 cm) BMI now 21.8 kg/m 2

9 What about central fat distribution?

10 Central fat distribution Central fat distribution associated with increased cardio-metabolic risk children, adolescents & adults Waist may be technically difficult to measure in some people with obesity McCarthy HD. Int J Obes 2006; 30: ; Garnett SP et al. Int J Obes 2008; 32,

11 Waist:height ratio Easy to calculate Values >0.5 (for people >6 y) associated with increased cardio-metabolic risk McCarthy HD. Int J Obes 2006; 30: ; Garnett SP et al. Int J Obes 2008; 32,

12 Waist:height ratio Easy to calculate Values >0.5 (for people >6 y) associated with increased cardio-metabolic risk Keep your waist to less than half your height McCarthy HD. Int J Obes 2006; 30: ; Garnett SP et al. Int J Obes 2008; 32,

13 Practice Points Measure height and weight routinely Plot BMI on a BMI for age chart Waist:height ratio Useful for almost all age groups

14 Are patients with overweight or obesity being seen in general practice?

15 In Australia, of every 200 children presenting to their family doctor, 60 are overweight or obese (23 obese) and 1 is offered weight management intervention BEACH data set, Annual national random survey of 1,000 family doctor surgeries (data on 100 consecutive patients, of all ages); , >40,000 children aged 2-17 years, Self-reported heights & weights; Cretikos M et al, Medical Care 2008; 46: ; background prevalence of O&O 23-25%

16 In Australia, of every 200 children presenting to their family doctor, 60 are overweight or obese (23 obese) and 1 is offered weight management intervention BEACH data set, Annual national random survey of 1,000 family doctor surgeries (data on 100 consecutive patients, of all ages); , >40,000 children aged 2-17 years, Self-reported heights & weights; Cretikos M et al, Medical Care 2008; 46: ; background prevalence of O&O 23-25%

17 In Australia, of every 200 children presenting to their family doctor, 60 are overweight or obese (23 obese) and 1 is offered weight management intervention BEACH data set, Annual national random survey of 1,000 family doctor surgeries (data on 100 consecutive patients, of all ages); , >40,000 children aged 2-17 years, Self-reported heights & weights; Cretikos M et al, Medical Care 2008; 46: ; background prevalence of O&O 23-25%

18 What Australian family doctors say are the barriers to primary care management of paediatric obesity Lack of time Lack of reimbursement Lack of parent/patient motivation Lack of effective interventions Lack of support services Complex/difficult problem Parent/child sensitivity Inadequate training Results of focus groups with Australian family doctors (general practitioners) King L et al. British Journal of General Practice 2007; 57:

19 Even young children (2-4y) with obesity are more likely to be hospitalised than their healthy weight peers Children with obesity, vs healthy weight: Total healthcare costs 1.6 times higher 2.6 times more likely to be hospitalised Hospitalised for: Ear, nose & throat; Respiratory Hayes A et al. Obesity 2016; 24: Analysis of Healthy Beginnings Trial cohort. Data linkage study.

20 Children and young people affected by overweight or obesity aren t just presenting to primary care It s a similar issue in secondary and tertiary care and in other countries as well

21 Practice Point Children and adolescents with obesity present frequently to clinical services

22 Raising the issue of a child s weight with the family

23 Raising the issue: 1 You are seeing a child for an apparently unrelated reason (e.g. asthma, otitis media) and think the child may have a weight issue.. How do you raise the issue?

24 Raising the issue: 1 You are seeing a child for an apparently unrelated reason (e.g. asthma, otitis media) and think the child may have a weight issue.. How do you raise the issue? Clinical practice guidelines recommend. Routinely measuring height & weight, calculating BMI, and plotting on growth chart Discussing growth chart sensitively with parent/young person Australian NHMRC Clinical Practice Guidelines for the Management of Overweight & Obesity Barlow SE and the Expert Committee of the AAP. Pediatr 2007; 120:S164-S192

25 I ve plotted weight adjusted for height here on the growth chart. You can see that it s above the healthy range for age. Does that surprise you?. Would you like to discuss it? Then recommend a further consultation to start addressing the weight issue Could the primary reason for the consultation be related to weight? (e.g. asthma, enuresis, fracture, lower limb pain, sleep disturbance ) If so, then highlight its importance x Are there existing problems associated with excess weight? Start to explore or investigate these

26 Raising the issue: 2 You re seeing a child whose BMI is obviously in the obesity range, but you have a weight issue yourself How do you raise the issue?

27 Raising the issue: 2 You re seeing a child whose BMI is obviously in the obesity range, but you have a weight issue yourself How do you raise the issue? Clinical practice guidelines recommend. Routinely measuring height & weight, calculating BMI, and plotting on growth chart Discussing growth chart sensitively with parent/young person Think in terms of any health issue. If you had high blood pressure, acne or diabetes would that stop you discussing these issues with your patient? Use language with which you are comfortable

28 Language and tone Don t use: Euphemisms: chubby, plump Rule words: should, must, ought But The adjective obese Instead: Talk about above the healthy range Re-phrase e.g. Have you had any thoughts/concerns about your child s weight before now? Use however e.g. your child is growing well, however

29 Language and tone Don t: Be accusatory or dismissive Spring it on them Use I told you so stories Use I lost weight by just. stories Instead: Be empathetic Be respectful Be culturally sensitive Use sensitive language people often prefer overweight or weight problem Put it into context Allow some face saving

30 Practice Points Use the growth chart to raise the issue sensitively Is your patient above a healthy weight? Think about the language you use

31 What should I look out for on history and examination?

32 Clinical assessment You are seeing a child with obesity. What do you enquire about on history or look for on examination? Any red flags?

33 Assessment - history General history Pregnancy details including birth weight & maternal gestational diabetes Early medical history Ethnicity Weight history History of obesity - onset and development Previous interventions Current and previous dieting Impact of obesity on young person & family Baur LA et al Nature Rev Gastroenterol Hepatol 2011 Complications history Psychological effects bullying, teasing Knee or hip pain Menstrual history (girls) Exercise tolerance Constipation, enuresis Sleep disturbances Family history Ethnicity BMI of first degree relatives Family history of obesity, premature heart disease, diabetes, obstructive sleep apnoea, bariatric surgery, disordered eating

34 Assessment lifestyle history Physical activity Including transport to/from school, organised activities, after-school and weekend activities, incidental activity TV/screens history How many TVs are in the house? In the bedroom? Hours of small screen recreation (TV, DVD, ipad, gaming consoles, computer etc etc!) per day weekdays and weekends? Pattern of screen use eg during meals Baur LA et al Nature Rev Gastroenterol Hepatol 2011 Dietary history Usual eating patterns (incl snacking, sneaking food, bingeeating), Breakfast consumption, fast food intake, sweetened drinks, Family routines around food & eating Sleep history Weekday versus weekends Sleep duration and sleep routines

35 Assessment clinical examination Organ system Skin Neurological Head and neck Cardiovascular Respiratory Gastrointestinal Musculoskeletal Endocrine Other Physical findings of note Acanthosis nigricans, skin tags, hirsutism, acne, striae, intertrigo, pseudogynaecomastia Benign intracranial hypertension, flat affect (depression) Large tonsillar size, obstructed breathing Hypertension (ensure appropriate cuff size), tachycardia Exercise intolerance, wheeze (asthma) Hepatomegaly (NAFLD), abdominal pain (gallstones, reflux) Flat feet; groin pain and painful gait (slipped capital femoral epiphysis); tibia vara; lower limb arthralgia and joint restriction Extensive striae, hypertension, buffalo hump, pubertal staging, reduced growth velocity Short stature, dysmorphism, developmental delay Baur LA et al Nature Rev Gastroenterol Hepatol 2011

36 Acanthosis nigricans Thickened pigmented skin Flexures, base of neck May be indicative of insulin resistance Especially in patients with pigmented skin Photos per courtesy Dr S Srinivasan, The Children s Hospital at Westmead, Sydney

37 Clinical examination findings requiring further assessment Short stature Abnormal physical stigmata Developmental disability Visual disturbance or headache Red flag! Baur LA et al Nature Rev Gastroenterol Hepatol 2011

38 Practice Points Red flags: short stature, visual disturbance/ headaches, dysmorphism, developmental disability Don t forget to enquire about screens and sleep duration/ quality.

39 When should I organise clinical investigations?

40 Clinical investigations You are seeing a child with obesity. What factors would influence your decision to organise further investigations? Which ones?

41 When to investigate? Age: adolescents > younger children Higher levels of BMI (especially central obesity) High risk family history: 1 st and 2 nd degree relatives with premature heart disease, type 2 diabetes/gestational diabetes, dyslipidaemia, sleep apnoea, bariatric surgery etc Higher risk ethnic groups: Aboriginal & Torres Strait Islanders, Pacific, Maori, Indian sub-continent, Mediterranean & Middle-Eastern, South-East Asian, Native American, African Clinical suggestion of co-morbidities 2003 Australian NHMRC Clinical Practice Guidelines for the Management of Overweight & Obesity Barlow SE and the Expert Committee of the AAP. Pediatr 2007; 120:S164-S192

42 What investigations? Initial fasting blood tests (others dependent upon results): Glucose Liver function tests (ALT, AST) Lipids (triglycerides, HDL cholesterol, LDL cholesterol) [Consider insulin - some controversy)] [Thyroid function tests] Consider referral for sleep assessment Other investigations that MAY be warranted: oral glucose tolerance test, liver ultrasound 2003 Australian NHMRC Clinical Practice Guidelines for the Management of Overweight & Obesity Barlow SE and the Expert Committee of the AAP. Pediatr 2007; 120:S164-S192

43 Results for Peter aged 15 y BMI 36, waist 110 cm, waist:height ratio 0.62, Greek ethnic origin, acanthosis nigricans. Strong family history of diabetes (father), obesity (both parents) and sleep apnoea (father)

44 Results for Peter aged 15 y BMI 36, waist 110 cm, waist:height ratio 0.62, Greek ethnic origin, acanthosis nigricans. Strong family history of diabetes (father), obesity (both parents) and sleep apnoea (father) Fasting lipid profile Triglycerides 2.2 mmol/l (normal range [NR] <1.7) Total cholesterol 5.1 mmol/l (NR <5.5) HDL cholesterol 0.7 mmol/l (NR >0.9) Fasting insulin & glucose Insulin 247 pmol/l (~40 mu/l)* Glucose 4.8 mmol/l Insulin:glucose 51.5** No IGT on OGTT * Insulin mu/l x 6 Insulin pmol/l **Insulin:glucose (pmol/mmol) ratio >15 consistent with insulin resistance (Vuguin P et al. J Clin Endocrinol Metab 2001; 86: )

45 Results for Peter aged 15 y BMI 36, waist 110 cm, waist:height ratio 0.62, Greek ethnic origin, acanthosis nigricans. Strong family history of diabetes (father), obesity (both parents) and sleep apnoea (father) Fasting lipid profile Triglycerides 2.2 mmol/l (normal range [NR] <1.7) Total cholesterol 5.1 mmol/l (NR <5.5) HDL cholesterol 0.7 mmol/l (NR >0.9) Fasting insulin & glucose Insulin 247 pmol/l (~40 mu/l)* Glucose 4.8 mmol/l Insulin:glucose 51.5** No IGT on OGTT Liver function tests Normal apart from raised ALT 85 U/L (NR 10-50) Liver ultrasound Diffuse increase in fatty liver, consistent with fatty liver; gall bladder and common bile duct normal * Insulin mu/l x 6 Insulin pmol/l **Insulin:glucose (pmol/mmol) ratio >15 consistent with insulin resistance (Vuguin P et al. J Clin Endocrinol Metab 2001; 86: )

46 Results for Peter aged 15 y BMI 36, waist 110 cm, waist:height ratio 0.62, Greek ethnic origin, acanthosis nigricans. Strong family history of diabetes (father), obesity (both parents) and sleep apnoea (father) Fasting lipid profile Triglycerides 2.2 mmol/l (normal range [NR] <1.7) Total cholesterol 5.1 mmol/l (NR <5.5) HDL cholesterol 0.7 mmol/l (NR >0.9) Fasting insulin & glucose Insulin 247 pmol/l (~40 mu/l)* Glucose 4.8 mmol/l Insulin:glucose 51.5** No IGT on OGTT Liver function tests Normal apart from raised ALT 85 U/L (NR 10-50) Central obesity with: Dyslipidaemia Insulin resistance Non-alcoholic fatty liver disease Liver ultrasound Diffuse increase in fatty liver, consistent with fatty liver; gall bladder and common bile duct normal * Insulin mu/l x 6 Insulin pmol/l **Insulin:glucose (pmol/mmol) ratio >15 consistent with insulin resistance (Vuguin P et al. J Clin Endocrinol Metab 2001; 86: )

47 Practice Point Consider investigations in adolescents, and in those with more severe obesity, a concerning family history, higher risk ethnicity, or suspicion of co-morbidities

48 Common or garden obesity can be responsive to treatment provided it is made available!

49 Published in 2009 Subsequently updated as 6 separate reviews

50 Previous systematic reviews family-based lifestyle interventions can be effective 2009 Cochrane Review*: Family-based, lifestyle interventions with a behavioural program.. provide significant and clinically meaningful decreases in overweight in both children and adolescents compared to standard care or self-help, in the short- and medium-term 2012 systematic review # : Lifestyle interventions: produce significant weight loss effects compared to no-treatment control or usual care; and also lead to significant improvements in LDL cholesterol, triglycerides and fasting insulin * Oude Luttikhuis H et al. Interventions for treating obesity in children. Cochrane Database of Systematic Reviews 2009, Issue 1.. # Ho M et al. Effectiveness of lifestyle interventions in overweight children: a systematic review of randomised controlled trials. Pediatrics 2012; 130:e1647-e1671.

51 And now there are 6 updates in !!

52 Multicomponent interventions vs control; 6 y; change in BMIz At end interv n (6-12 mo.) 6-8 mo. post interv n Colquitt JL et al. Cochrane, 2016

53 Meta-analysis of the effect of lifestyle interventions versus no treatment or wait-list control on: LDL cholesterol (mmol/l) Insulin resistance (HOMA-IR) Ho M et al. Pediatrics 2012; 130:e1647-e1671; HOMA-IR homeostatic model of assessment - insulin resistance

54 So does treatment work? Yes lifestyle intervention can provide a modest to moderate level of medium- to long-term success in treatment-seeking patients with obesity. provided it is made available! however.

55 however There are still many research questions to be addressed : What level of intensity is needed, and when? What works in different settings e.g. primary care, tertiary care? What works best for different age groups? Especially adolescents!!! How best to treat special patient groups e.g. developmental disability, other disabilities? What strategies would best help Indigenous young people, or specific culturally and linguistically diverse groups? What is the most cost-effective form of therapy? What works for long-term maintenance treatment? How best to integrate phone coaching, SMS, new media? What is the role of bariatric surgery?

56 however There are still many research questions to be addressed : What level of intensity is needed, and when? What works in different settings e.g. primary care, tertiary care? What works best for different age groups? Especially adolescents!!! How best to treat special patient groups e.g. developmental disability, other disabilities? What strategies would best help Indigenous young people, or specific culturally and linguistically diverse groups? What is the most cost-effective form of therapy? What works for long-term maintenance treatment? Phew!! How best to integrate phone coaching, SMS, new media? What is the role of bariatric surgery?

57 and there are often many barriers to providing treatment services in real-life settings Barrier Poverty Culturally & linguistically diverse patients Learning disabilities & developmental disorders Illiteracy Family in crisis Psychiatric disorders Potential intervention strategy Focus on low-cost food alternatives Provision of low cost physical activity alternatives Culturally sensitive weight management advice Greater family involvement Intensive practical interventions Involvement of specialist support services Minimise/eliminate written material Simple key messages Frequent phone support Crisis intervention Case management until the situation stabilises Additional support services Mental health treatment & support services Case management until the situation stabilises Minshall GA, Davies F, Baur LA. Behavioral management of pediatric obesity. In: Ferry RJ Jr (Ed). Management of Pediatric Obesity and Diabetes. New York: Humana Press; 2011

58 Can brief advice work in weight management? Lancet study with UK GPs and adult patients

59 Lancet 2016; 388: UK GPs Patients with obesity randomly assigned to: Support: Patient referred to weight management group (meet weekly for 12 weeks). If referral accepted, GP ensured that first appointment was made and offered follow-up Advice: GP advised the patient that their health would benefit from weight loss 1º outcome: weight change at 12 months 2º outcomes: patients views helpful, appropriate? GP attended 90 minute online training course (mainly filmed consultations)

60

61

62 High levels of perceived helpfulness and appropriateness in both groups (overall 81%) Less than 1% thought it not helpful or appropriate

63 Practice Point A behaviourally informed, GPdelivered, opportunistic intervention is acceptable to patients and can be helpful with weight loss

64 So what are some of the simple initial strategies to be discussed with the young person or family of an affected or young person?

65 Initial management You are seeing a child or adolescent with obesity. What are some of the initial strategies you might explore or recommend?

66 To be discussed later. See also resources at: pro.healthkids. nsw.gov.au

67 What is required for adolescents? Medications? Other strategies

68 Going back to Peter, aged 15 y BMI 36, waist 110 cm, waist:height ratio 0.62, Greek ethnic origin, acanthosis nigricans. Strong family history of diabetes (father), obesity (both parents) and sleep apnoea (father) Fasting lipid profile Triglycerides 2.2 mmol/l (normal range [NR] <1.7) Total cholesterol 5.1 mmol/l (NR <5.5) HDL cholesterol 0.7 mmol/l (NR >0.9) Fasting insulin & glucose Insulin 247 pmol/l (~40 mu/l)* Glucose 4.8 mmol/l Insulin:glucose 51.5** No IGT on OGTT Liver function tests Normal apart from raised ALT 85 U/L (NR 10-50) Liver ultrasound Diffuse increase in fatty liver, consistent with fatty liver; gall bladder and common bile duct normal * Insulin mu/l x 6 Insulin pmol/l **Insulin:glucose (pmol/mmol) ratio >15 consistent with insulin resistance (Vuguin P et al. J Clin Endocrinol Metab 2001; 86: )

69 Case scenario: Peter aged 15 y Presentation: Peter is brought by his mother who is concerned about Peter s weight. She worries he will have the same problems as his father. Peter isn t concerned about his weight, but says he wants to get more fit, to help his soccer. Family history: Strong family history of diabetes (father, paternal grandparents), obesity (parents, other family members), sleep apnoea (father). Clinical examination: BMI 36, waist 110 cm, waist:height ratio 0.62, acanthosis nigricans Other history: Skips breakfast, eats takeaways, ++screen time, fairly sedentary, soccer training and game

70 Question

71 Issues to consider

72 Pharmacotherapy in obesity is limited. May be a useful adjunct to lifestyle intervention In adolescents with obesity consider orlistat (gastrointestinal lipase inhibitor) in the context of a lifestyle change program Needs to be weighed up against the potential for adverse events (bloating, faecal leakage, steatorrhoea etc) Many adolescents find side-effects unacceptable Consider metformin in adolescents with obesity and evidence of clinical insulin resistance (acanthosis nigricans, PCOS, hyperinsulinaemia etc) Use will be off-label Oude Luttikhuis H et al. Cochrane Database of Systematic Reviews 2009, Issue 1 Quinn S et al. Obesity Reviews 2010

73 What then?

74 Keeping on, supporting your patients What strategies can you use to help your patients with ongoing weight management?

75 Keeping on, supporting your patients What fits your skill-set and practice, and local resources? Frequent regular follow-up initially Role of phone coaching, SMS reminders Role of practice nurse? Referral to other therapists e.g. dietitian, clinical psychologist, exercise professional, medical Monitor, monitor, monitor behaviours, plus weight (in those who are treatment-seeking) This will be discussed further

76 Obesity and the chronic disease care pyramid Tertiary care facilities & special obesity clinics; specialist teams; key worker case manages & joins up care Level 3 Complex patients Case management Secondary level care facilities; multidisciplinary teams; group programs Level 2 High risk patients Care management Self-care supported by general practitioners, other 1 o care, group programs Level % of patients with o wt/obesity Self-care & community based care Primary prevention & health promotion

77 Obesity and the chronic disease care pyramid Tertiary care facilities & special obesity clinics; specialist teams; key worker case manages & joins up care Secondary level care facilities; multidisciplinary teams; group programs Level 3 Level 2 High risk patients Care management Complex patients Case management All parts of the pyramid are needed. What is available in your region? Self-care supported by general practitioners, other 1 o care, group programs Level % of patients with o wt/obesity Self-care & community based care Primary prevention & health promotion

78 Thank you!