Download NHLBI report

*Look for Obesity-Associated Complications
 Type 2 diabetes
 Insulin resistance syndrome
 Nonalcoholic fatty liver
disease ( NAFLD)
 Polycystic ovary syndrome
 Skin
 Acanthosis nigricans
 Stretch Marks
 Rashes, Boils
 Idiopathic intracranial
hypertension
 Pulmonary disorders
 Obstructive sleep apnea
 Hypoventilation syndrome
 Hypertension
 Dyslipidemia
 Proteinuria
 Orthopedic
 Blount’s disease
 Slipped capital femoral
epiphysis
 Arthropathy
 Psychological: depression, self
esteem
 Gallbladder disease
Approach to Obesity
Primordial
Prevention
 BMI<85th
 Infant of at
risk mother
Primary
prevention




BMI >85th
Cardio vascular risk ( HTN,
Atherosclerosis)
Metabolic risks (Diabetes)
Other: Endocrine, ortho, sleep…
Secondary
prevention
 BMI >85th
 Disease is established.
Prevention of Organ
damage.
Expert Panel, 2011
http://www.nhlbi.nih.gov/files/docs/guidelines/peds_guidelines_full.pdf
Cardio-Metabolic risk
and other complications
GENES
BMI
Environment
BMI
The Overweight or Obese but
Metabolically Healthy patient
• Weight and BMI are not automatically
synonymous with increased cardio metabolic
risks. Genetic background is a major variable.
• Weight and BMI are the red flag which triggers
evaluation for Cardio-Metabolic risks and
Mechanical complications
BMI AND CARDIO-METABOLIC RISK
Cardio-Metabolic
risks
BMI
From
85th
to….
INSULIN RESISTANCE, HYPERINSULINEMIA,
PREDIABETES, DIABETES.
Disease Timeline
Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary
Report. Sarah E. Barlow, MD, MPH.
Insulin resistance/Type 2 Diabetes: screening of the
asymptomatic Pediatric patient
Who
Guidelines
Tests/ frequency
Pt ≥ 10 years old or onset of puberty with
a BMI≥ 85th percentile + 2 criteria
Expert Panel on
Integrated
Guidelines for
cardiovascular
health and risk
reduction in
children and
adolescent. 2012.
 Fasting Blood
Glucose every 2
years
 Fasting Insulin
level. ( above NL
values)
►FMHx of DM first and second
degree relatives
►High risk group (African
American, Hispanic American,
native Americans and pacific
Islanders)
►Symptoms of Insulin resistance:
Acanthosis, HTN, dyslipidemia,
PCOS, NAFLD)
( predictive in children but
not in adolescentPediatrics, 2014)
 FG/FI <7
 Suggest OGTT
Same with another at risk Group : SGA and a
family history of Gestational Diabetes
ADA, Diabetes
care. 2014
 Hg A1c
 Fasting Glucose
 Oral Glucose
Tolerance tests.
Same +: extreme Obesity
World Journal of
Diabetes.
European
Guidelines.2013
 OGTT
 Hg A1c
ATHEROSCLEROSIS/CV RISKS FOR CORONARY AND
PERIPHERAL VASCULAR DISEASES.
Children from age 2 may need to be evaluated or treated as
time span for CV event has shortened to 20-25 years
From the third decade
Atherosclerosis: The lipid story
What tests? : Lipid Panel
Who
Guidelines
Tests/
frequency
2-8 and 11-16 year old
►FMHx of Cardiovascular
event in first and second
degree relatives under the
age of 55(males)and
65(females)
►Parent with a TC ≥ 240
mg/dl
►child has Diabetes,BMI≥
95th, smokes cig.
►One Moderate to high risk
condition
Expert Panel on
Integrated
Guidelines for
cardiovascular
health and risk
reduction in
children and
adolescent.
2012.
Fasting Lipid
profile
9-11 and 17-21 years old
► universal screening
 Non Fasting
– Total C minus HDL-C= Non HDL-C
– LDL-C calculation is not reliable
non fasting.
 Fasting:
–
–
–
–
LDL-C
HDL-C
Triglycerides
Total Cholesterol
Fasting or Non
fasting Lipid
profile
High level Risk factors for early CV
event
Moderate level Risk factors for early
CV event
Stage 2 HTN: ≥ 99th percentile +
5mmh/hg
BMI≥ 97TH
High risk condition: renal failure,
DM(1-2), heart transplant, Kawasaki
with aneurysm
Stage 1 HTN
BMI≥ 95th
HDL-C≤ 40mg/dl(males) or 50mg/dl (
females)
Moderate –risk condition (nephrotic
syndrome, chronic inflammatory
conditions, HIV, Kawasaki with
regressed aneurism)
HYPERTENSION
HTN prevalence in the pediatric population:
Increased BPs in 2% to 5% of American
children and adolescents
30%
BMI≥90th
5%
total
0.025%
HTN
HTN2
44%
BMI≥99th
Left Ventricle (Cardiac) Remodeling
Left ventricular hypertrophy
Left ventricular Failure
20
18
16
14
12
10
8
Increases Left ventricular Mass
6
4
2
0
pre HTN
HTN
HTN 5 years
HTN stage 2
HTN stage 2 5 years
Hemoglobin A1c:
Diabetes diagnosis: Adult guidelines by the ADA








Glycolated hemoglobin reflects 3 months of average blood glucose.
In 2010, A1c > or = 6.5%.
Or Fasting plasma glucose (FPG) $126mg/dL (7.0 mmol/L).
Or Two-hour plasma glucose $200 mg/dL (11.1 mmol/L) during an
oral glucose tolerance test (OGTT).
Or In a patient with classic symptoms of hyperglycemia or
hyperglycemic crisis, a random plasma glucose $200 mg/dL (11.1
mmol/L).
In the absence of unequivocal hyperglycemia, result should be
confirmed by repeat testing
Caution: Laboratory values refer to adult standards
A1C:
 NL <5.7%
 Prediabetes: 5.7-6.4
 Diabetes: 6.5% or greater.
A1c in asymptomatic children or
adolescent screened for Diabetes
1) Hg A1c is falsely increased in iron deficiency
anemia or unreliable in hemoglobinopathies
2) Not reliable ( more variability in serum blood
glucose at early stages of hyperglycemia)
3) No cut off presently for Pediatric age group
4) At present A1c at 6.5% does not indicate
automatically Diabetes in children specifically
in the absence of UNEQUIVOCAL
hyperglycemia (>200mg)
*Select appropriate BP cuff size, *auscultation is preferred, *replicate
measurement and *average the numbers. Hypertension is diagnosed with
persistent elevation
( 4th report on the Diagnosis, Evaluation, and Treatment of High Blood
Pressure in Children and Adolescents, 2013)
Systolic /
Diastolic
Classifica
tion
Evaluation
Other co-morbidities
( the MetSyn)
End organ target
(use SOB:786.05)
90-95th
Pre HTN
Ambulatory BP
(white coat HTN:
ICD9 796.2, )
Lipid Profile, fasting
Insulin
Fasting Blood Glucose
95th-99th+5
Replicate X2
Stage 1
HTN
Basic work up: CBC,
renal Panel, U/A
Lipid Profile, fasting
Insulin
Fasting Blood Glucose
Cardiac Echo
EKG
99th+5
Replicate X3
Stage 2
HTN
Treat and evaluate:
cardiac, Renal,
Endocrine, Tumor
Lipid Profile, fasting
Insulin
Fasting Blood Glucose
Cardiac Echo
EKG
Other Cardio
Metabolic risks
BMI
From
85th
to….
From a GI specialist perspective, this is a diagnosis of exclusion after we rule out other causes. This can be extensive. Only a
liver biopsy can determine these different levels of liver disease.
BMI >85th percentile
1) Asymptomatic: ALT
(CMP)during screening.
2) Symptomatic: ALT/ US
BMI + NAFLD= look for
Metabolic syndrome
 Lipid profile
 Insulin resistance
 Blood Pressure
Menstrual period: the “other Vital sign”
absence, increased flow ( 3 pads/day),
painful, irregular, delay between
telarche and menarche…
BMI + abnormal menses +/- hair growth
1) Serum Total Testosterone, Free testosterone, SBG
2) Measure Insulin resistance
(fasting Insulin Level, FBG, Hg A1c)
3) LH/FSH ( optional, >3:1)
4) Pelvic ( surface) US if indicated
SPECIAL CASES
Acanthosis Nigricans
Acanthosis Nigricans = evidence of hyperinsulinemia
hence insulin resistance
(my suggestions based on American Diabetes Association guidelines for
diabetes screening of asymptomatic patients)
BMI
Family history
> 85th % or >25
+
> 85th % or >25
No family history
Tests
A1c, Fasting Insulin, Fasting Glucose
for diabetes,
Suggest strongly a 2 hours Oral
Gestational Diabetes, Glucose tolerance test. (With or
Insulin resistance such without insulin level.)
as PCOS
Fasting
Non fasting
A1c, Glucose, insulin
A1c, Glucose,
Also perform a Lipid profile Fasting or non Fasting, to complete evaluation of the
Metabolic Syndrome. ALT/AST every 2 years in patient ˃˃10 years
ABDOMINAL PAIN
Abdominal Pain in the Patient with
elevated BMI
symptoms
Possible Dx
Testing
RUQ/epigastric
NAFLD / Hepatomegaly
Abdominal US
Cholecystitis ( with or
without stones)
Abdominal US
Generalized Abdominal
pain
Constipation
KUB (L sided/rectal
masses)
Vomiting (acute or
recurrent)
Pancreatitis
(secondary to
hypertriglyceridemia)
Abdominal CT scan
Amylase, lipase,
triglycerides level (usually
around 1000mg/dl)
Lower abdominal Pain
+ abnormal period
Consider PCOS
Pelvic Ultrasound