Pediatric Obesity: Clinical Decision Tools*

Transcription

1 Pediatric Obesity: Clinical Decision Tools* Contributing clinicians from the Be Forever Fit Program at Harbor-UCLA in partnership with UniHealth Foundation: Gangadarshni Chandramohan, MD 1 ; Sudhir Anand, MD 1 ; Ruey K. Chang, MD 2 ; George Gershman, MD 3 ; Catherine S. Mao, MD 4 ; Peter Tieh, MD 4 ; Suzanne Rizi Mokhtari, MD 5, MPH; Annie Hsueh, PhD 6 ; Astrid Reina, PhD 6 ; Jennifer K. Yee, MD 4. *Adapted from decision tools created by the UCLA UniHealth-Fit for LA project 1 Department of Pediatrics, Division of Nephrology, Harbor-UCLA Medical Center 2 Department of Pediatrics, Division of Cardiology, Harbor-UCLA Medical Center 3 Department of Pediatrics, Division of Gastroenterology, Harbor-UCLA Medical Center 4 Department of Pediatrics, Division of Endocrinology, Harbor-UCLA Medical Center 5 Department of Pediatrics, Division of Hospitalist Medicine, Harbor-UCLA Medical Center 6 Department of Psychiatry, Division of Psychology, Harbor-UCLA Medical Center 1) General Obesity Management 2) Blood Pressure 3) Lipids with addendums 3a and 3b 4) Liver Function Tests 5) Diabetes Screening 6) Polycystic Ovary Syndrome 7) Mental Health with addendum handouts

2 General Obesity Management Assess Behaviors & Attitudes -Document: Motivation, Eating (e.g. 24 hr recall), Physical Activity, Sedentary Time -Consider using patient lifestyle log Assess Medical Risks 1) Family History, 2) Review of Systems, 3) Physical Examination (BMI, BP 1 ) Underweight BMI <5% Healthy Weight BMI 5-84% Overweight BMI 85-94% Obese BMI 95-98% BMI 99% Evaluation for health risks related to underweight Health Risks Yes Check fasting lipid profile 2, AST/ALT 3, fasting glucose and insulin levels, HbA1c 4 No If BMI 95% & additional risks: Get additional tests Prevention and Counseling: -Empathize/Elicit Provide Elicit. -Assess action step + Self-efficacy (Confidence Level), Motivate. STAGE 1: Prevention Plus Health Weight, BMI without risk Maintain weight velocity - Reassess in 1 year BMI 85-94% + Risk - Maintain weight /decrease velocity - Reassess q3-6 mos BMI 95-98% Maintain weight or gradual loss - Reassess q3-6 mos STAGE 2: Structured Weight Management BMI 99% Gradual to moderate wt loss - Reassess q3-6 mos If no improvement after 3-6 mos and family willing STAGE 3: Comprehensive Multidisciplinary Intervention Consider Referral to BFF 1 -See BP Guidelines (Pg 2.) 2 -See Lipid Guidelines (Pg 3.) 3 -See NASH Guidelines (Pg 4) 4 -See Diabetes Screen Guidelines (Pg 5) STAGE 4: Tertiary Care Intervention Consider Bariatric Surgery Referral for BMI >40 or >50 + co-morbidites If BMI >95% + no improvement after 3-6 mos and family willing Page 1

3 Blood Pressure Measurement (children> 3 yrs) Normal BP Systolic and diastolic <90% Pre-hypertension Systolic +/or diastolic 90% but <95% OR BP >120/80 Hypertension Systolic +/or diastolic BP >95% Therapeutic Lifestyle Changes Stage I HTN Systolic +/or diastolic 95 th but <99 th % +5mmHg Stage 2 HTN Systolic +/or diastolic 99 th % +5mmHg Repeat BP in 2mo Ambulatory Home BP monitoring Repeat BP over 3 visits & 4 extremity BPs over 2 weeks BP>95%ile Therapeutic Lifestyle Changes Ambulatory Home BP monitoring Therapeutic Lifestyle Changes BP 95% Stage I HTN path or Stage II HTN path *Diagnostic Workup with eval for targetorgan damage 90% BP 95% Still BP 90% Therapeutic Lifestyle Changes BP<90% Consultation or Referral to Nephrology for further work-up Monitor q 6mo Diagnostic Workup with eval for target-organ damage* Secondary HTN Rx Specific for Cause BP 95% Ambulatory Home BP monitoring **Drug Rx Primary HTN Therapeutic Lifestyle Changes Normal BMI or Overweight BP 95% BP 95% *Diagnostic Workup with eval for target-organ damage AND Consider Nephrology referral Secondary HTN Rx Specific for Cause **Drug Rx Primary or Secondary HTN Overweight Normal BMI or Therapeutic Lifestyle Changes BP 95% *Diagnostic workup: consider electrolytes, CBC, U/A, fasting glucose, cardiac ECHO, FLP, renal u/s w/ dopplers, thyroid function tests, urine catecholamines, drug screen, polysomnography, retinal exam **Drug therapy indications: include symptomatic HTN, secondary HTN, hypertensive target-organ damage, DMI or II, persistent HTN despite nonpharmacology measures Consider ACE inhibitors (ACEI) for patients with BP 90%ile while being worked up Use ACEIs with caution among women of reproductive age Monitor potassium and creatinine while on ACEIs Ambulatory blood pressure monitoring monitors BPs over 24 hr period, looking for normal variation in BPs The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents Updated 04/10/14 Page 2

4 LIPID SCREENING *CVD risk factors: FH of dyslipidemia or early CVD ( <55, <65); BMI 85%ile; BP > 95%ile; Cigarette smoking; Diabetes Mellitus. See Disease Specific Guidelines if a personal history of: Cardiac disease, Kidney Disease, Inflammatory Disease, HIV/AIDS Check cholesterol values if: Age 2 yo: Only if familial hypercholesterolemia or signs of high cholesterol Age 2 years: Selective Screening Age 9 yo: Consider universal Screening for those with no risk factors (2011 NHLBI guidelines) 2-9 yo: If BMI > 95%ile ( or other high risk conditions or risk factors*) If child has had cholesterol screening tests in the past, and values were normal: recheck every 3-5 yrs 9-21 yo: If BMI > 85% ( or other high risk conditions or risk factors*) Check Fasting Lipid (Total chol, LDL, TG) Test Once between ages 9-11 yo AND Once between ages yo This is controversial, non fasting lipids ok for initial universal screen If non fasting are high; check 2 fasting lipids and use average. LDL <190: If normal BMI, no RF* Lower Risk (High BMI with no other RF) Higher Risk (Higher BMI with other RF*) Target Values : LDL-Chol = 130 TG<130 Non-HDL-C<140 Total Chol<200 LDL-Chol = 100 TG<90 Non-HDL-Chol <120 Interventions: Not Within Acceptable Range Within Acceptable Range Therapeutic Lifestyle changes for weight management. [Consider plant sterols] Consult Cardiology if values very elevated (e.g. LDL>500, or TG>400) and delay in referral likely Plant Sterols, esp. if Tchol>200 or LDL>130 Fiber (dose = age in yrs + 5gm/day; max dose 20g/day) Flax seed oil (1tsp/day) or ground flaxseed Oatmeal: decreases hepato-enteric circulation of lipids Therapeutic Lifestyle changes & Plant Sterols Low Saturated fat diet Daily physical exercise <2 hours per day sedentary activity (eg. Screen time) weight loss if needed Recheck FLP after 6 months Recheck after 3-5 years depending on success with weight changes. Within Acceptable Range Not Within Acceptable Range Updated 2/27/14 Continue Treatment and Recheck after 2 yrs Consider Cardiology Referral for possible medication management Page 3

5 CVD Risk Factors Diabetes mellitus Family history of: Cigarette smoking early CVD event ( <55 or < 65 years old) OR HTN (BP 95 th percentile) parent with total cholesterol 240 mg/dl OR BMI 85 th percentile known dyslipidemia Lipid Screening By Age Age 1-9 check fasting lipid panel if family h/o CVD, parent w/ dyslipidemia or child has other risk factors or high-risk condition Age universal screen w/ non-fasting or fasting lipid panel Non-fasting: calculate non-hdl cholesterol: TC-HDL If non-hdl 145 mg/dl ± HDL <40mg/dL Obtain fasting lipid panel twice (separated by 2 wks) & average OR Fasting lipid panel If LDL cholesterol 130 mg/dl ± non-hdl cholesterol 145 mg/dl ± HDL cholesterol 40 mg/dl ± triglycerides 100 mg/dl If < 10 y, 130 mg/dl if 10 y: Repeat fasting lipid panel, average result Age check fasting lipid panel if family h/o CVD, parent w/ dyslipidemia or child has other risk factors or high-risk medical condition Age universal screen w/ non-fasting or fasting lipid panel Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, NHLBI. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report. Pediatrics Dec;128 Suppl 5:S Addendum 3a

6 Screening Fasting Lipid Panel Lipid Screening in Childhood Recommended for all children older than 2 years of age with any of the following risk factors: Positive family history of dyslipidemia or premature CVD event (men<55 or women <65 years old) Unknown family history Diabetes mellitus Cigarette smoking HTN (BP 95 th percentile) BMI th percentile BMI 95 th percentile Interpreting Lipids Panels The American Heart Association suggests abnormalities TG > 150 mg/dl HDL < 35 mg/dl No TG or HDL recommendations from the NCEP (National Cholesterol Education Program) LDL>95 th percentile range for age or HDL<5 th percentile range for age are abnormal Retest every 3-5 years if levels are within normal range Medications Recommended LDL Concentrations for Pharmacologic Treatment of Children 8 Years of Age* Patient Characteristics Recommended Cut Points No other risk factors for CVD LDL is persistently >190 mg/dl despite diet therapy * Other risk factors present, including obesity, HTN, smoking, or FamHx premature CVD Children with diabetes mellitus LDL is persistently >160 mg/dl despite diet therapy Pharmacologic treatment should be considered when LDL 130 mg/dl * Pharmacologic intervention < 8 years of age is only for severely elevated LDL (>500 mg/dl) as in familial hypercholesterolemia Follow more aggressive treatment of LDL in children with DM, renal disease, congenital heart disease, collagen vascular disease, or cancer survivors. Goal of medications is to lower LDL<160 mg/dl, or <130 mg/dl, or <110 mg/dl when there is strong family history of CVD or with other risk factors such as obesity, DM, or metabolic syndrome. Statins inhibit cholesterol synthesis and increase LDL clearance Monitor CK levels (rhabdomyolysis) and LFTs,(hepatic side effects) Fiber supplements can help reduce plasma LDL Supplemental fiber dose = child s age in years + 5 gm (max 20 gm/day) Plant sterols (additive found in orange juice, yogurt drinks, dietary supplements) decrease absorption of dietary cholesterol but decrease absorption of fat-soluble-vitamins and beta carotene Daniels and Greer, Lipid Screening and Cardiovascular Health in Childhood, Pediatrics, 2008,122:198 Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, NHLBI. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report. Pediatrics Dec;128 Suppl 5:S Addendum 3b

7 NAFLD=Non Alcoholic Fatty Liver Disease Definition: Histologic findings of macrovascular steatosis on liver biopsy Diagnosis: Elevated ALT/AST ratio (2:1 ) and steatosis in absence of other causes of fatty liver Age: >10yrs Age: 3-19yrs BMI 85-94% & Risk Factors* BMI >95% AST and ALT *use highest of two values < Repeat every 2 years Lifestyle interventions and repeat LFTs in 6 months <50 Repeat annually 50 (e)consult Peds GI GOAL: Loss of 10% excess body weight, normalized AST/ALT *Caution: rapid weight loss is associated with cholelithiasis Normal Values (U/L) Age AST ALT Infant y y y y y Adult M Adult F 7-35 NAFLD Prevalence: 9% all children, up to 80% obese children +Predictor elevated ALT in obese children: Male, Hispanic, elevated BMI +Predictor NASH to Fibrosis: Obesity, Insulin Resistance Complications: Fibrosis leading to Cirrhosis Risk factors: DM, obesity, acanthosis, family history *GGT: 1-15y 0-23 U/L Adult Male: Adult Female: 7-32 Page 4

8 Diabetes Screening Fasting Glucose Levels HbA1c <100 Normal Recheck based on BMI Guidelines Elevated. Confirm that glucose was fasting. (e)consult Pediatric Diabetes 126 Elevated, suggests diabetes. Confirm lab was fasting. If random >200, proceed 5.6 Normal Reassess and recheck in 12 mos Mildly elevated Risk factor assessment Abnormal Repeat HbA1c, check one month three times a week pre and postprandial glucose, or order 2 hr OGTT, (e)consult Peds Endo 6.5 Highly suggestive of DM Repeat HbA1c,, do 2 hr OGTT, draw GAD65 and islet cell antibodies. (e)consult Peds Diabetes. Risk Factors Polyuria, polydipsia Unexplained weight loss High risk ethnic group (African American, Hispanic, SE Asian) Family History + DM2 On antipsychotics 0-1 Positive Reassess in 3-6 months Oral Glucose Tolerance Test Interpretation 2 positive Order 2 hr OGTT, or check one month three times a week pre and postprandial glucose and consider metformin; (e)consult Peds Diabetes 2 hour: <140 Normal 2 hr: Abnormal. Impaired glucose tolerance Any result 200 Abnormal glucose tolerance, response in diabetic range Reassess patient according to BMI guidelines (e)consult Peds Diabetes (e)consult Peds Diabetes Page 5

9 PCOS *Rotterdam Criteria 1.Chronic anovulation (amenorrhea or oligomenorrhea, ie, >35d/cycle or <6-9menses/yr, >2yr after menarche) 2.Hyperandrogenism (hyperandrogenemia with elevated testosterone, DHEAS or androstenedione, or progressive hirsutism) 3.Polycystic ovaries (characteristic follicular appearance and volume>10 ml) **Pharmacotherapy Options Metformin (esp if obese): Start 500mg PO daily for 2 weeks, then 500 mg PO bid. Increase to 850mg PO BID as tolerated at next visit, then increase further to 1000mg PO BID (max for years) Hormonal agents:; NuvaRing and Ortho-Evra patch also ok Antiandrogens: Spironolactone Yes BMI >95%ile? Concern for PCOS? Send AM Labs: DHEA-S, androstenedione, free testosterone (will include total), 17-OH progesterone, TSH and total T4, fasting glucose, prolactin. Add FSH, LH, estradiol if amenorrhea present. Consider abdominal ultrasound Fulfills 3/3 Rotterdam criteria* for PCOS? No Fulfills 2/3 Rotterdam criteria*? (Hyperandrogenism and anovulation) Yes No Yes No Yes Send Additional Labs (lipid panel, fasting glucose and insulin, Hb A1c) Labs Abnormal? No Encourage Weight Maintenance PCOS probable, but not confirmed Consider DDx (late onset CAH, prolactinoma, thyroid dysfunction, Turner s) Start Pharmacotherapy ** and (e)consult Pediatric Endocrinology Encourage 5-10% Weight Loss Consider Pharmacotherapy** if Symptoms Persist (e)consult Pediatric Endocrinology if ovulatory dysfunction continues >2 yrs after menarche (e)consult Pediatric Endocrinology Bremer, A. Polycystic Ovary Syndrome in the Pediatric Population. Metabolic Syndrome and Related Disorders. 2010; 8(5): Carmina E, Oberfield SE, Lobo RA. The diagnosis of polycystic ovary syndrome in adolescents. Am J Obstet Gynecol 2010;203:201.e1-5 Brufani,C et al. Use of metformin in pediatric age. Pediatric Diabetes.2011;12(6): Diamanti-Kandarakis, E. PCOS in adolescents. Best Practice &Clinical Obstetrics and Gynaecology. 2010; 24(5): Hart, R et al. Extent of metabolic risk in adolescent girls with features of PCOS. Fertil Steril. 2011;95(7): Sultan C, Paris F. Clinical expression of polycystic ovary syndrome in adolescent girls. Fertil Steril 2006:86(Suppl):56. Page 6

10 Mental Health