Download Weight Management Re-check in 4 months

Pediatric Weight Management
Eliana M. Perrin, MD, MPH
Department of Pediatrics
At least visually we’re not good at
this!
Why should we use BMI?
1) Recommended by the AAP, AAFP
2) Flags risk better (Perrin, et al, J Pediatr, April, ’04)
3) Perhaps earlier intervention?
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>95%
Overweight
85-95%
At risk for
Overweight
5-85%
Healthy Weight
<5%
Underweight
State Fair Fare
Pizza, funnel cakes, candy
apples, elephant ears, chili
dogs, chocolate dipped fries,
corn dogs, bbq beef
sandwiches, onion rings, kettle
corn dogs, caramel corn,
sausages, steak sandwiches,
rib eye steaks, cotton candy,
stromboli, buffalo wings, fried
pickles, country ham biscuits,
tempura vegetables, fudge,
saltwater taffy, deep fried oreos,
and deep fried candy bars. If
you want to wash these down,
there are any number of
sweetened drink concessions
to accommodate you.
Changes in Relative Prices
300
260
240
220
200
180
160
140
120
All
Foods Author
& Beverages
Fruits
& Veg
Fresh
Fruit
& Veg (U.S. City Averages,
Fish &1983-2005)
Seafood
SOURCE:
calculations based
on the
Consumer Price Index – All
Urban
Consumers
Dairy
Carbonated Drinks
Sugar & Sweets
Fats & Oils
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
100
1983
Consumer Price Index (Base 100 in 1982-84)
280
Key element is prevention
For prenatal and newborn visits for breast-feeding moms:

Encourage breastfeeding; teach parents infant
hunger cues & to feed by cue not by the clock; discourage
bottle propping
For visits with 12-24 month olds:

Transition to solids- time to focus on the whole
family eating together & on healthy foods- fruits and
vegetables, whole grains, lean meats, cooking styles

Don’t forget beverage counseling- milk as mealtime beverage and water for thirst quenching
Encourage PA
Encourage activity for mom and dad while mom
is pregnant- walking is wonderful & good to get
into healthy family habits
Tummy time is great for babies as is exploration
play
Outside activity/ getting out of the stroller
important for toddlers!
Older children
Starting at age 2: calculate BMI % for age & gender
Assess:
Diet Behaviors
• Sweetened beverage consumption
• Frequency of dining out and family meals
• Fruit and vegetable consumption
• Consumption of excessive portion sizes
• Daily breakfast consumption
Physical Activity Behaviors
• Amount of moderate physical activity
• Level of screen time and other sedentary activities
Attitudes
• Self perception or concern about weight
• Readiness to change
• Experiences with previous attempts to lose weight
If BMI healthy….
If BMI healthy (≤ 85% for age), advise parents to:







Not force kids to clean plates
Replace whole milk w/ lower fat milk (>2yo)
Limit “screen” time & eating in front of the tv!
Limit junk food (high fat/sugary, “fast food,” soda)
Tell parents not to provide food as a comfort or
reward
Encourage active play
Substitute water and skim milk for juice,
lemonade, sweet tea, soda, etc.
What next?
If BMI is overweight or obese (≥85% for
age) or trending upward:
Follow advice from previous slide
Advise parents and child of weight
status: show them the BMI chart, talk
about future problems related to
overweight
Protect self-esteem (make your
discussion @ health as much as
possible)
Arrange follow-up visit (schedule a lot
of time)
What to do at follow up visit?
(continued)
If BMI  85% for age or trending upward,
do thorough evaluation:

History of the problem

Review of systems

Past Medical History

Social History

Family Medical History

PE

Labs

Assessment and Plan
History
When do parents/child think problems
began?
What’s the typical intake (include meals,
beverages, snacks)? – 3 day log is best
Where does that intake occur (school
lunches, babysitter’s, etc)?
How much tv, video, computer time?- 3
day log is best
What’s the typical physical activity
pattern?- 3 day log is best
Review of Systems
Significant headaches, blurred
vision (pseudotumor cerebri?)
Joint pains (SCFE? Overuse?)
Frequent urination, thirst, fatigue
(T2DM?)
Daytime sleepiness, snoring (sleep
apnea?)
Depression (which comes first?)
Menarchal status (PCO disease?)
Past Medical History
Medications (steroids)
Thyroid disease
Growth problems
Mental retardation
Hypotonia
Social History
Teasing patterns (motivation?)
Who’s on the child’s “case” at
home?
Problems in school
Depression
Suicidality
Bingeing/purging
Safety of the neighborhood
Family History
CAD (early MIs)
Hypertension
Type 2 DM
Thyroid disease
Gall bladder disease
Cushing’s
Depression
Weight patterns
PE
 Height, weight, BMI, BMI% for age and gender,
HR, BP
 Hirsuitism?
 Fundi
 Skin, hair quality
 Tonsils
 Thyroid
 Acanthosis nigricans?
 Abdominal tenderness
 Weight distribution pattern
 Tanner Stage of pubertal development/ small
penis?
 Joint evaluation
Acanthosis Nigricans
Labs
AAP recommends fasting lipids in patients >95%
BMI.
ADA recommends every other year screening
starting at 10 years of age or the onset of
puberty, whichever comes first with fasting
plasma glucose at least (consider fasting insulin
as well) for those with BMI ≥ 85th percentile for
age and sex, who *also* have any two of the
following risk factors: a positive family history of
type 2 diabetes in a first or second-degree
relative, shows sign of insulin resistance (i.e.
acanthosis nigricans, dyslipidemia, or PCOS),
has a maternal history of diabetes or GDM, or
belongs to Native American, African American,
Latino, Asian American, or Pacific Islander racial
group.
Labs continued
Consider:
Thyroid studies (T4, TSH)-particularly in
child with poor growth or parents
insistent about “glandular” problems,
Glucose tolerance test, HgA1C, C-peptide
(only if serious concerns about T2DM)
Cortisol in the patient with unusual
distribution of weight, growth problems
Anhyrdous glucose/serum 17OHP/testosterone if overweight, short,
hirsuit, and irregular menses….
Labs to worry about
LDL>130 (and if >190, refer to
cardiology)
Fasting triglyceride>110 (if >500, refer
to cardiology for treatment)
HDL<40
Fasting plasma glucose > 110
(Fasting insulin: glucose ratio that is >
1:4)
Hemoglobin A1c > 6
Hypoglycemia along with
hyperinsulinism suggests an
insulinoma rather than insulin
resistance
Intervention ideas
Make it about staying happy/healthydecrease the emphasis on weight.
Review the dietary and PA logs (STCs)
with specific attention to areas of
improvement.
Review stop light guide to foods with
the family.
Have child pick 1-2 things to change
from a list. Let it be child’s choice.
Parents to refrain from nagging.
Have family continue to keep a log.
Nutrition/psychologist referral as
needed.
Follow up!
How to make the conversation
seamless: Motivational Interviewing
What is Motivational
Interviewing?
Motivational Interviewing (MI):
• Powerful counseling tool
• Motivates & reinforces behavioral
change
• Patient - centered
• Directive method for enhancing
intrinsic motivation to change
• Helps explore & resolve ambivalence
MI (cont.)
Basic Principles:
• Uses open-ended questions
• Applies reflective listening
• Gives feedback in empowering
framework
MI USES THE FRAMES APPROACH
• Feedback – Give risks and
consequences of behavior
“It sounds like your child is watching quite a bit
of TV. Did you know that sitting down too
much can raise your child’s chance of getting
health problems later on?”
• Responsibility – Let them know it is up
to them
“Of course it is up to you and her dad to
decide whether or not you want to let her
watch this much TV.”
FRAMES
• Advice – Offer a professional
recommendation
“It’s my recommendation as someone who is
concerned about Sally’s health to have her
watch less TV, and I can help you help her cut
down on TV watching.”
• Menus – Offer a variety of strategies
“There’s many options to help Sally cut down
on TV. One option is to give her a TV budget at
the beginning of the week and let her decide
how to spend it. Another option is to say that
for each hour of TV watched, Sally needs to
spend an hour getting activity….”
FRAMES
• Empathy – Use a positive and caring
manner
“I know that it’s really hard to change a
behavior, and that it will be hard for Sally to
give up some of her favorite TV programs.”
• Self-efficacy – Communicate a “You
can do it!” approach
“I think from what you told me about your
family’s diabetes that you don’t want Sally to
get that disease, and I know that you and
Sally can work together to do this for Sally’s
long-term health. And I will help every step
of the way.”
Thank you and acknowledgments
• Cynthia Bulik
• KESMM team (especially Alice
Ammerman, Suzanne Lazorick)
• Clinical colleagues (especially
Joey Skelton)
LDL > 130
LDL 130-190
LDL > 190
Weight Management
Re-check in 4 months
Repeat for two 4 month cycles
LDL elevated for > 1 year
Weight Management
Refer to Cardiology to
begin treatment
Continue Weight Management
Nutritional Treatment (flax, fish oil)
HDL < 40
Weight
Management
Triglycerides > 110
Triglycerides 110-700
Triglycerides > 700
Weight Management
Re-check in 4 months
Weight Management
If < 500,
Continue Weight
Management
If > 500
Refer to Cardiology to
begin treatment
Triglycerides elevated for > 1 year
Nutritional Treatment (flax, fish oil)
Insulin Level ≥ 20
Glucose < 100
Glucose 100-125
Weight Management
Re-check in 4 months
Baseline 2
Hour OGTT
Glucose > 125
Re-check glucose
Obtain UA
If glucose > 125
Glucose < 100
Continue Weight
Management
Re-check q4 mos
Glucose 100-125
2 Hour OGTT
If impaired or worse,
consider treatment
Refer to Endocrine
Obstructive Sleep Apnea Screening
Any one of the following:
Two or more of the following:
•Snores ≥ 50% of time
•Headache in am
•Witnessed apnea
•Mouth breathing at night
•Excessive daytime sleepiness
•Dry mouth/sore throat in am
•Hard to wake in am
•Nocturnal enuresis
•Attention span/behavioral issues
Overnight Polysomnography
F/U with Pulmonologist
Liver
Elevated AST or ALT (>60)
CBC, Complete Metabolic Panel, PT, GGT
Any elevation
of ALT or AST
> 6 months
ALT or AST >200
or any laboratory
abnormality
Other
Continue to monitor
Hepatitis Bs Ab, Hepatitis Bs Ag, Hepatitis C Ab,
ANA, anti-actin antibody, anti-LKM antibody,
ceruloplasmin, PI typing, Liver ultrasound
If abnormal, suspicion
of liver disorder- refer
to Hepatology
Liver Biopsy
If c/w NASH,
begin Metformin
Polycystic Ovaries Syndrome
If any of the following with insulin resistance:
•Oligo- or Amenorrhea
•Hirsutism
•Acne
Yes
Begin Metformin
Weight Management
Re-check in 4 months
Improved
Not improved
DHEA-S
17-hydroxyprogesterone
Testosterone
LH, FSH
Sex Hormone Binding
Globulin
Pelvic ultrasound
2 of the 3 following:
•Oligo- or Amenorrhea
•Hirsutism- clinical or biochemical
•Severe Acne
•Abnormal hair growth
•LH/FSH > 2:1
•Elevated free testosterone
•Polycystic ovaries on imaging
(no evidence of CAD or other cause of
symptoms)
No
Continue Metformin for 8 more months
Refer to Gynecology
Hypertension
3 BP’s > 90th%
CBC, CMP, Renin assay
Urinalysis
Renal ultrasound
Refer to Cardiology
BP’s > 99th% + 5mm
CBC, CMP, Renin assay
Urinalysis
Renal ultrasound
Refer emergently to
Cardiology
Asthma Assessment
Cough
Wheezing
__daily __per week __per month __None
__daily __per week __per month __None
Timing:
Timing:
Nature:
Sputum:
Dyspnea
Chest Pain
__daily __per week __per month __None
__daily __per week __per month __None
Symptom Triggers
Weather changes__ Viral illness__ Exercise__ Pollen__ Smoke__
Other_________
Exercise Tolerance:__Normal __Limited
Nasal Congestion:___
Hives:____
Sneezing:____
Eczema:____
Pneumonia:__ Bronchitis:__ Sinusitis:__
GE Reflux Symptoms
__sour taste __heartburn
__spitting up
__emesis
OGTT
FPG