Timothy Fignar, MD FAAFP

Transcription

1 Timothy Fignar, MD FAAFP

2 Council for Obesity Related Education (CORE) speakers bureau for Takeda Pharmaceuticals

3 Evaluate Health Risks Adjust Current Medications Recommend Caloric Intake Build Safe Exercise Program Behavioral Counseling Prescription / Supplements Routine Monitoring Long-term Relationship

4 INSURANCE COVERAGE Screening (Annually) USPSTF Class B Recommendation Part of the Accountable Care Act Treatment (Varies by Plan) Medicare was the FIRST to include coverage Sets number of visits, sets weight loss goals Referral for Surgical evaluation, if needed

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7 Acknowledge the current pediatric obesity epidemic and how it relates to weight issues as an adult Understand how to identify, assess and prevent obesity in pediatric patients throughout their lifespan Identify resources for providers to motivate healthy lifestyle choices for the whole family

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9 Age years <5% 10.4% 12.1% 8.4% 6-11 years 4.2% 19.6% 18.0% 17.7% years 4.6% 18.1% 18.4% 20.5% Total <5% 16.9% 16.9% 16.9% Flegal KM. JAMA Ogden CL. JAMA JAMA: 311 (8) Feb 2014.

10 JAMA. Pediatrics-2014:168(6) June.

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12 Olshansky SJ. NEJM

13 Universal assessment of obesity risk and steps to prevention and treatment. Sarah E. Barlow Pediatrics 2007;120:S164-S by American Academy of Pediatrics

14 Assess all children for obesity at all well care visits ages 2-18 years old Accurately measure height and weight Calculate BMI Make a weight category diagnosis using BMI percentile

15 BMI percentiles NOT BMI 85 th to 94 th percentile Overweight >95 th percentile Obese >99 th percentile Severe obesity Risk of Obesity at age yo >95 th percentile 20% 17-20yo >95 th percentile 60% Guo et. Al. Am J Clin Nutrition 2002; 76:

16 Cutoff Points for 99th Percentile BMI According to Age and Gender Age, yr 99th Percentile BMI Cutoff Point, kg/m 2 Boys Girls Pediatrics December 2007 vol. 120 no. Supplement 4 S164-S192 doi: /peds C

17 Universal assessment of obesity risk and steps to prevention and treatment. Sarah E. Barlow Pediatrics 2007;120:S164-S by American Academy of Pediatrics

18 Measure blood pressure (NHLBI tables) Take a focused family history Obesity 1 parent 3x risk of obesity 2 parents 13x risk of obesity Type 2 Diabetes Cardiovascular disease

19 Take a focused review of systems Symptom Anxiety, school avoidance, social isolation Depression Possible Causes Severe recurrent headaches Shortness of breath, exercise intolerance Snoring, apnea, daytime sleepiness Sleepiness or wakefulness Abdominal pain Hip pain, knee pain, walking pain Foot pain Irregular menses (<9 cycles per y) Primary amenorrhea Polyuria, polydipsia Unexpected weight loss Nocturnal enuresis Tobacco use Pseudotumor cerebri Asthma, lack of physical conditioning Obstructive sleep apnea, obesity hypoventilation syndrome Depression Gastroesophageal reflux disease, constipation, gallbladder disease, NAFLD a Slipped capital femoral epiphysis, musculoskeletal stress from weight (may be barrier to physical activity) Musculoskeletal stress from weight (may be barrier to physical activity) Polycystic ovary syndrome; may be normal if recent menarche Polycystic ovary syndrome, Prader-Willi syndrome Type 2 diabetes mellitus a Type 2 diabetes mellitus a Obstructive sleep apnea Increased cardiovascular risk; may be used as form of weight control

20 Diet History Juice Portions Frequency Breakfast Eating out Snacking

21 Activity History Television / Screen time Structured activity Unstructured activity Family History 1 st & 2 nd degree relatives determines <6yo risk

22 School History Performance Bullying Red Flags Enuresis Sleep disturbance Poor School Performance Family support/ environment

23 Assess behaviors and attitudes about change Self-perception or concerns of weight Family-perceptions of patient weight Readiness for change Successes, barriers and challenges

24 Perform a thorough physical exam System Findings Possible Explanations Anthropometric features High BMI percentile Overweight or obesity Short stature Underlying endocrine or genetic condition Vital signs Elevated blood pressure Hypertension if systolic or diastolic blood pressure >95th percentile for age, gender, and height on 3 occasions Skin Acanthosis nigricans Common in obese children, especially when skin is dark; increased risk of insulin resistance Excessive acne, hirsutism Polycystic ovary syndrome Irritation, inflammation Consequence of severe obesity Violaceous striae Cushing syndrome Eyes Papilledema, cranial nerve VI paralysis Pseudotumor cerebri Throat Tonsillar hypertrophy Obstructive sleep apnea Neck Goiter Hypothyroidism Chest Wheezing Asthma (may explain or contribute to exercise intolerance) Abdomen Tenderness Gastroesophageal reflux disorder, gallbladder disease, NAFLD a Hepatomegaly NAFLD a Reproductive system Tanner stage Premature puberty in <7-y-old white girls, <6-y-old black girls, and <9-y-old boys Extremities Apparent micropenis May be normal penis that is buried in fat Undescended testes Prader-Willi syndrome Abnormal gait, limited hip range of motion Slipped capital femoral epiphysis Bowing of tibia Blount disease Small hands and feet, polydactyly Some genetic syndromes

25 Laboratory Tests for Evaluation of Childhood Overweight & Obesity Age Overweight Obese <10 years old Lipids every 2 years Lipids every 2 years >10 years old + NO RF Lipids every 2 years Lipids every 2 years plus ALT/AST and fasting glucose >10 years old + RF (HTN, smoking, Fam Hx DM, CVD, stroke) Lipids every 2 years plus ALT/AST and fasting glucose Lipids every 2 years plus ALT/AST and fasting glucose Expert Panel on Integrated Guidelines for CV Health and Risk Reduction in Children and Adolescents 2012.

26 Universal assessment of obesity risk and steps to prevention and treatment. Sarah E. Barlow Pediatrics 2007;120:S164-S by American Academy of Pediatrics

27 WEIGHT LOSS GOALS IN KIDS Weight Percentile 2-5 yo 6-11 yo yo Healthy 5 th 84 th Maintain Maintain Maintain Overweight, no RF Overweight, +RF 85 th 94 th Maintain Maintain Maintain 85 th 94 th Maintain/ slow gain Obesity >95 th Maintain Gradual weight loss (1#/mo) Severe >99 th Gradual weight loss (1#/mo) Maintain Maintain / gradual weight loss (1#/mo) Weight loss (2#/mo) Weight loss (2#/mo) Weight loss (2#/week) Barlow et. Al. Pediatrics 2007.

28 Stage 1 Prevention Plus (PCP) Stage 2 Structured Weight Management (PCP+) Stage 3 Comprehensive/Multidisciplinary (Pediatric Weight Management Center) Stage 4 Tertiary Care Intervention *** Each stage increases frequency of visits and intensity of recommendations and management.

29 Weight Goals and Intervention Stages, According to Age and BMI Categories Age BMI Category Weight Goal to Improve BMI Percentile a Initial Intervention Stage Highest Intervention Stage <2 y Weight for height NA Prevention counseling Prevention counseling 2 5 y 5th 84th percentile or 85th 94th percentile with no health risks Weight velocity maintenance Prevention counseling Prevention counseling 85th 94th percentile with health risks 95th percentile 6 11 y 5th 84th percentile or 85th 94th percentile with no health risks 85th 94th percentile with health risks 95th 99th percentile Gradual weight loss (1 lb/mo or 0.5 kg/mo) >99th percentile Weight loss (maximum is 2 lb/wk) y 5th 84th percentile or 85th 94th percentile with no health risks Weight maintenance or slow weight gain Prevention Plus (stage 1) SWM (stage 2) Weight maintenance (weight Prevention Plus (stage 1) CMI (stage 3) loss of up to 1 lb/mo may be acceptable if BMI is >21 or 22 kg/m 2 ) Weight velocity maintenance Prevention counseling Prevention counseling Weight maintenance Prevention Plus (stage 1) SWM (stage 2) Weight velocity maintenance; after linear growth is complete, weight maintenance 85th 94th percentile with Weight maintenance or health risks gradual weight loss 95th 99th percentile Weight loss (maximum is 2 lb/wk) >99th percentile Weight loss (maximum is 2 lb/wk) Prevention Plus (stage 1) CMI (stage 3) Prevention Plus (stage 1) or stage 2 or 3 if family is motivated Prevention counseling TCI (stage 4), if appropriate Prevention counseling Prevention Plus (stage 1) SWM (stage 2) Prevention Plus (stage 1) Prevention Plus (stage 1) or stage 2 or 3 if patient and family are motivated TCI (stage 4), if appropriate TCI (stage 4), if appropriate Pediatrics December 2007 vol. 120 no. Supplement 4 S164-S192 doi: /peds C

30 Weight Goals and Intervention Stages, According to Age and BMI Categories Age BMI Category Weight Goal to Improve BMI Percentile a Initial Intervention Stage Highest Intervention Stage <2 y Weight for height NA Prevention counseling Prevention counseling 2 5 y 5th 84th percentile or 85th 94th percentile with no health risks Weight velocity maintenance Prevention counseling Prevention counseling 85th 94th percentile with health risks 95th percentile Weight maintenance or slow weight gain Prevention Plus (stage 1) Weight Prevention Plus maintenance (stage 1) (weight loss of up to 1 lb/mo may be acceptable if BMI is >21 or 22 kg/m 2 ) SWM (stage 2) CMI (stage 3)

31 Weight Goals and Intervention Stages, According to Age and BMI Categories Age BMI Category 6 11 y 5th 84th percentile or 85th 94th percentile with no health risks Weight Goal to Improve BMI Percentile a Weight velocity maintenance Initial Intervention Stage Highest Intervention Stage Prevention Prevention counseling counseling 85th 94th percentile with health risks Weight maintenance Prevention Plus (stage 1) SWM (stage 2) 95th 99th percentile Gradual weight loss (1 lb/mo or 0.5 kg/mo) Prevention Plus (stage 1) CMI (stage 3) >99th percentile Weight loss (maximum is 2 lb/wk) Prevention Plus (stage 1) or stage 2 or 3 if family is motivated TCI (stage 4), if appropriate

32 Weight Goals and Intervention Stages, According to Age and BMI Categories Age BMI Category y 5th 84th percentile or 85th 94th percentile with no health risks Weight Goal to Improve BMI Percentile a Weight velocity maintenance; after linear growth is complete, weight maintenance Initial Intervention Stage Prevention counseling Highest Intervention Stage Prevention counseling 85th 94th percentile with health risks 95th 99th percentile >99th percentile Weight maintenance or gradual weight loss Weight loss (maximum is 2 lb/wk) Weight loss (maximum is 2 lb/wk) Prevention Plus (stage 1) Prevention Plus (stage 1) Prevention Plus (stage 1) or stage 2 or 3 if patient and family are motivated SWM (stage 2) TCI (stage 4), if appropriate TCI (stage 4), if appropriate

33 Stage 1 Prevention Plus Family visits, individual/group, frequency monthly Behavioral Goals Prepare more meals at home eat out less often Eat a healthy breakfast daily eat together as family Involve the whole family in lifestyle changes self regulate Weight Goal Weight maintenance or reduced weight velocity Advance to Stage 2 (Structured weight management) if no improvement at 3-6 months.

34 Stage 2 Structured Weight Management Family visits, individual/group, frequency every 2 weeks Behavioral Goals planned diet or daily eating plan with balanced macronutrients structured daily meals and planned snacks (breakfast, lunch, dinner, and 1 or 2 scheduled snacks, with no food or calorie-containing beverages at other times additional reduction of television and other screen time to 1 hour per day planned, supervised, physical activity or active play for 60 minutes per day monitoring of these behaviors through use of logs (for example, the patient or family members can record the minutes spent watching television and can keep a 3-day recording of food and beverages consumed) planned reinforcement for achieving targeted behaviors Weight Goal Weight maintenance or weight loss Advance to Stage 3 (Comprehensive/Multidisciplinary Intervention) if no improvement at 3-6 months.

35 Stage 3 Comprehensive Multidisciplinary Family visits, individual/group, frequency weekly for 8-12wks Behavioral Goals a structured program should include, at a minimum, food monitoring, short-term diet and physical activity goal setting, and contingency management negative energy balance resulting from structured dietary and physical activity changes is planned systematic evaluation of body measurements, diet, and physical activity should be performed at baseline and at specified intervals throughout the program Supervised active plan (>=60 minutes/day) Limit screen time to <= 1 hour/day Weight Goal Weight loss 1#/month ages 2-5, 2#/week others Advance to Stage 4 Tertiary Care if no success in 3-6 months

36 Stage 4 Tertiary Care Intervention Medications Very Low Calorie Diets (VLCDs) Weight Control Surgery

37 Center for healthy weight and Nutrition Primary Care Pocket Guide to Pediatric Obesity Healthy Care for Healthy Kids: Obesity Toolkit

38 Weight= pounds BMI = 29 BMI Percentile >95 th Body Fat % Water % - 57 (Goal 40-60) BMR 2144 cal ADOLESCENT START (Calorie Counting) Weight = 194 (-15.5#) BMI = 27 BMI Percentile 90 th Body Fat % (down 13) Water % - 62 (+1 pound) BMR 2049 cal ***Diet/Exercise*** CONT (3 months)

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40 Universal assessment of obesity risk and steps to prevention and treatment. Sarah E. Barlow Pediatrics 2007;120:S164-S by American Academy of Pediatrics

41 Well Child Exam Adolescent 14 yrs old No chronic health issues

42 Universal assessment of obesity risk and steps to prevention and treatment. Sarah E. Barlow Pediatrics 2007;120:S164-S by American Academy of Pediatrics

43 No identified health problems - BROTHER

44 Universal assessment of obesity risk and steps to prevention and treatment. Sarah E. Barlow Pediatrics 2007;120:S164-S by American Academy of Pediatrics

45 No identified health problems - SISTER

46 Universal assessment of obesity risk and steps to prevention and treatment. Sarah E. Barlow Pediatrics 2007;120:S164-S by American Academy of Pediatrics

47 No identified health problems

48 Universal assessment of obesity risk and steps to prevention and treatment. Sarah E. Barlow Pediatrics 2007;120:S164-S by American Academy of Pediatrics

49 Numerous Health issues Hyperglycemia Glc101, A1c 6.3, Insulin=25. Iron-def. PCOS.

50 Universal assessment of obesity risk and steps to prevention and treatment. Sarah E. Barlow Pediatrics 2007;120:S164-S by American Academy of Pediatrics

51 Mother Morbid Obesity, Sleep Apnea, Depression, CCY- Gallstones, CRP. Father Morbid Obesity, HTN, R-Hip OA, COPD, Anemia, T2DM+Neuro, Metabolic Syndrome, Decreased Testosterone

52 Universal assessment of obesity risk and steps to prevention and treatment. Sarah E. Barlow Pediatrics 2007;120:S164-S by American Academy of Pediatrics

53 Thank you very much for your participation and attention! Locations in both ENFIELD and SOUTH WINDSOR