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“To eliminate the gap between what is and what can be in health care for all children.” “To eliminate the gap between what is and what can be in health care for all children.” www.envisionnm.org Assessment and intervention of Pediatric Overweight and Obesity Hypertension Dyslipidemia

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slide1

“To eliminate the gap between what is and

what can be in health care for all children.”

“To eliminate the gap between what is and

what can be in health care for all children.”

www.envisionnm.org

overview
Assessment and intervention of Pediatric Overweight and Obesity

Hypertension

Dyslipidemia

Polycystic Ovary Disease

Non-Alcoholic Fatty Liver Disease

Overview
measure bmi annually
Measure BMI at well child visits 2-18 y.o.

Calculate & plot BMI% for age and gender

Correlate with appropriate diagnosis:

<5% Underweight

5-84% Normal Weight

85<95% Overweight

≥95% Obese

(≥99% is a higher risk group)

Measure BMI % Annually
measure bmi percentile
Plot BMI% for age and gender

English: [weight(lb) ÷ height(in) ÷ height(in)] x703

Metric: [weight(kg) ÷ height(cm) ÷ height(cm) ] x10,000

Calculation Tools: www.cdc.gov/ or www.nhlbisupport.com/bmi/

BMI Wheel

CDC Graphs:

www.cdc.gov/growthcharts/

PDA tool: www.statcoder.com

Measure BMI Percentile
if there was an infectious disease that had
If there was an infectious disease that had…
  • double - tripled in prevalence,
  • was afflicting 30% of children of all ages,
  • had life-long, potentially life-threatening impact…

Would we be acting?

Would we take 10 sec to plot a point?

proposed 2009 hedis measures
The percentage of members 2–17 years of age who had an outpatient office visit and who had evidence of the following during the measurement year.

• BMI percentile assessment

• Counseling for nutrition

• Counseling for physical activity

Proposed 2009 HEDIS* Measures

* Healthcare Effectiveness Data and Information Set

measure blood pressure annually
Use a cuff large enough to cover 80% of the arm

Diagnose hypertension using NHLBI tables http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htmlor Statcoder

Measure Blood Pressure % Annually
example
9 y.o. girl presents for WCC

Height = 134 cm

Weight = 40.7 kg

BMI = 22.5

BP = 118/77

Example
example9
9 y.o. girl presents for WCC

Height = 134 cm

Weight = 40.7 kg

BMI = 22.5

BP = 118/77

BMI = 96th percentile = Obese

BP = >95th percentile = Stage 1 HTN

(3 measurements)

Example
past medical history
Small for gestational age

Weight gain

Insidious onset

vs.

Point-in-time onset

Race/ethnicity

Past Medical History
family history update regularly
First and second degree relatives

Obesity

Type 2 diabetes, insulin resistance

Cardiovascular disease

Hypertension, Dyslipidemia

Early deaths from heart disease or stroke

Mother

Gestational diabetes while pregnant with patient

Family History: Update Regularly
slide12

Review of Systems

• Poor linear growth (Hypothyroidism, Cushing’s, Prader-Willi syndrome)

•Anxiety, school avoidance, social isolation (Depression)

• Headaches (Pseudotumor cerebri)

• Nighttime breathing difficulty &/or Daytime somnolence (Sleep apnea, hypoventilation syndrome, asthma)

• Abdominal pain (GE reflux, Gall bladder disease, constipation)

• Hip or knee pain (Slipped capital femoral epiphysis)

• Oligomenorrhea or amenorrhea (Polycystic ovary syndrome)

Identifiable endocrine abnormalities or syndromes account

for < 1% of cases of overweight in children

assess behaviors and attitudes
Diet Behaviors

Sweetened-beverage consumption

Fruit and vegetable consumption

Frequency of eating out and family meals

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

Successes, barriers and challenges

Assess Behaviors and Attitudes
slide14

Physical Examination

• Poor linear growth ……(Hypothyroidism, Cushing’s, Prader-Willi syndrome)

•Truncal obesity ……………………………………..(risk of CVD; Cushing’s)

• Dysmorphic features ….(genetic disorders, including Prader–Willi syndrome)

• Acanthosis nigricans ….……………………………..(DM, insulin resistance)

• Hirsutism and excessive acne…….………………….……(PCOS; Cushing’s)

• Violaceous striae …………………….……………………………(Cushing’s)

• Papilledema, cranial nerve VI paralysis…….………….(pseudotumor cerebri)

• Tonsillar hypertrophy ………………………….…………………..(sleep apnea)

• Abdominal tenderness, hepatomegaly..(gall bladder disease, GERD, NAFLD)

• Undescended testicle ………………………………..(Prader-Willi syndrome)

• Limited hip range of motion ……………...(slipped capital femoral epiphysis)

• Lower leg bowing ………………………………………….(Blount’s disease)

things to look for on the physical exam
Acanthosis nigricans

(NIDDM, insulin resistance)

Violaceous striae

(Cushing’s syndrome)

Things To Look For On The Physical Exam
the next step
Diagnose Overweight and Obese

Screen for pre-diabetes and type 2 diabetes

Screen for conditions associated with overweight

The Next Step
slide17

Obesity

Insulin Resistance

Metabolic Syndrome

Type 2DM

Hypertension

NASH

Dyslipidemia

PCOS

Also:

Mental health issues,

obstructive sleep apnea,

orthopedic problems

laboratory tests
BMI 85-94% Without Risk Factors

Fasting Lipid Profile

BMI 85-94% Age 10 Yrs. & Older With 2 Risk Factors

Fasting Lipid Profile

ALT and AST

Fasting Glucose

BMI >= 95% Age 10 Yrs. & Older

Fasting Lipid Profile

ALT and AST

Fasting Glucose

Other Tests as Indicated by Health Risks

Laboratory Tests

Every 2 Years

Every 2 Years

risk factors
Risk factors

FHx of type 2 DM in 1st or 2nd degree relative

Race/ethnicity (non-Caucasian)

Maternal gestational diabetes

Associated Conditions

Hypertension

Acanthosis Nigricans

Dyslipidemia

Polycystic Ovary Syndrome

Risk Factors
lab assessment fasting glucose vs 2 hr glucose
Fasting glucose

Sufficient screen to rule out T2DM

Recommended by ADA and recent AMA Expert Committee

2 hr post glucose load serum glucose

More sensitive at diagnosing pre-diabetes*

Recommended by American College of Endocrinologists and The Endocrine Society

Lab Assessment: Fasting Glucose vs. 2-hr. Glucose
pre diabetes vs diabetes
Pre-diabetes

Fasting glucose 100-125 mg/dL

2 hr OGTT 140-199 mg/dL

Diabetes (T2DM)

Fasting glucose ≥ 126 mg/dL

2 hr OGTT ≥ 200 mg/dL

Pre-diabetes vs. Diabetes

ADA. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care.2007;30(S1):s42-s47.

slide22
Overweight and Obese: Screening

Height ___________ Height percentile__________

Weight ___________

BMI ___________ BMI percentile__________

BP __________ BP percentile __________

BMI 85-94% Without Risk Factors

􀂃 Fasting Lipid Profile

BMI 85-94% ≥ Age 10 Years With 2 Risk Factors

􀂃 Fasting Lipid Profile

􀂃 ALT and AST

􀂃 Fasting Glucose

BMI ≥ 95% Age 10 Years & Older

􀂃 Fasting Lipid Profile

􀂃 ALT and AST

􀂃 Fasting Glucose

􀂃 Other tests as indicated by health risks

Risk Factors for T2DM:

  • Race/ethnicity (non-Caucasian)
  • FHx T2DM in 1st or 2nd degree relative
  • Mother with GDM
  • Other: HTN (≥ 95th%), AN, dyslipidemia, or PCOS

Pre-diabetes:

Fasting glucose: 100-125mg/dL

2 hr OGTT: 140-199 mg/dL

Diabetes (T2DM)

Fasting Glucose: ≥126 mg/dL

2hr OGTT: ≥200 mg/dL

Random Glucose≥200

A 2 hr glucose-challenge (OGTT) is more sensitive

than fasting glucose for diagnosing pre-diabetes.

carbohydrate metabolism definitions
Impaired Fasting Glucose (pre-diabetes)

Fasting serum glucose 100-125 mg/dL

Impaired Glucose Tolerance (pre-diabetes)

2-hr OGTT serum glucose = 140- 199 mg/dL

Insulin Resistance (IR)

Often used interchangeably with IGT (although one can have IR and normal glucose tolerance)

Type 2 Diabetes Mellitus (T2DM)

Fasting serum glucose ≥126 mg/dL

2-hr OGTT serum glucose ≥200 mg/dL

Carbohydrate Metabolism:Definitions
pre diabetes treatment
Lifestyle Modification

Diet

Play Hard 30-60 minutes daily!

Goal: weight loss 7% of body weight

In adults, more effective than metformin

Consider Metformin

For very high BMI percentile (≥99th %)

Laboratory evidence nearing T2DM

PCOS

Pre-diabetes:Treatment

Knowler WC, Barrett-Conner E et al. (Diabetes Prevention Project) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. NEJM 2002;346:393-403

latest recommendations
Prevention, Assessment and Treatment of Childhood Obesity: Recommendations from the AMA Expert Committee on Childhood Obesity.

June 8, 2007

www.ama-assn.org/ama/pub/category/11759.html

NICHQ.org, Childhood Obesity Action Network

Latest Recommendations
treatment overview
A Staged Approach

1) Prevention Plus

2) Structured Weight Management

3) Comprehensive, Multidisciplinary Intervention

4) Tertiary Care Intervention

Treatment Goals

Behavioral Goals and Parenting Skills

Self Esteem and Self Efficacy

BMI Velocity, Weight Loss Targets and BMI %

Treatment Overview
treatment goals health behaviors
Lifelong healthy behaviors such as physical activity will improve health outcomes regardless of weight change

Improving self esteem and self efficacy can also improve health outcomes

Small consistent changes over time can make a big difference!

Consistent behavioral changes averaging 110 to 165 kcal/day may be sufficient to counterbalance the energy gap which leads to excess weight gain in some children.

Changes in excess dietary intake may be easier to attain than increases in physical activity levels. For example, eliminating one sugar-sweetened beverage at 150 kcal/can vs.1.9 hours walking for an extra 150 kcal.

Treatment GoalsHealth Behaviors

Pediatrics Vol. 118 No. 6 December 2006 pp. e1721-1733

treatment goals bmi
The long term BMI goal will need to be individualized based on risk factors and genetics

BMI < 85% - Ideal long term goal

BMI 85-94% - Some children can be healthy in this range

Short term BMI goals will need to be individualized based on genetics, risk factors and the intensity of the intervention

Decrease in BMI velocity

Weight maintenance

Weight loss

Younger and more mildly obese children should change weight more gradually than older, more severely obese youth

Treatment Goals - BMI
treatment goals weight loss targets
Treatment Goals - Weight Loss Targets

* Excessive weight loss should be evaluated for high risk behaviors

a staged approach overview
Stage 1 - Prevention Plus

Family visits with physician or health professional

Frequency individualized to family needs and risk factors

Stage 2 - Structured Weight Management

Family visits with physician or health professional with training in childhood weight management. Visits can be individual or group.

May include visits with a dietitian, exercise therapist or counselor

May include self-monitoring, goal setting and rewards

Frequency monthly or individualized to family needs and risk factors

A Staged Approach - Overview
a staged approach overview31
Stage 3 - Comprehensive, Multidisciplinary Intervention

Multidisciplinary team with experience in childhood obesity

Frequency often weekly group sessions for 8-12 weeks with follow up

Stage 4 - Tertiary Care Intervention (for select children only when provided by experienced programs with established clinical or research protocols)

Medications - sibutramine, orlistat

Very-low-calorie diets

Weight control surgery - gastric bypass or banding (not FDA approved for children but in clinical trials)

A Staged Approach - Overview
give evidence based messages to all families
Dietary Intake

Breastfeeding for the first 12 months or longer

Limit or eliminate consumption of sugar-sweetened beverages

Eat the the recommended quantities of fruits and vegetables

Physical Activity

Limit television and other screen time to no more than 2 hours/day

Remove television and other screens from children’s bedrooms

Moderate to vigorous physical activity for at least 60 minutes a day

Eating Behaviors

Eat breakfast every day

Limit eating out, especially at fast food restaurants

Have regular family meals

Limit portion sizes

Give Evidence-Based Messages to All Families

Prevention, Assessment and Treatment of Childhood Obesity: Recommendations from the AMA Expert Committee on Childhood Obesity; www.ama-assn.org/ama/pub/category/11759.html; 6/8/07

a staged approach overview33
A Staged Approach - Overview
  • Families progress to the next stage if there has been no improvement in BMI/weight or velocity after 3-6 months and if the family is willing and ready.
overcoming challenges
Overcoming Challenges
  • Lack of Patient Motivation & Provider Skills
  • Not Enough Time
  • No Reimbursement
  • Empathize/Elicit - Provide - Elicit
  • Motivational Interviewing
  • Office Systems and Tools
  • Team Based Care
  • Coding Strategies
  • Advocacy

Pediatrics Vol. 116 No. 1 July 2005 pp. 238-239

obesity algorithm
ObesityAlgorithm
  • Example – medical risk or behavioral risk
  • 10 years and older every 2 years
  • Progress to next stage if no improvement in BMI/weight after 3-6 months and family willing
  • Age 6-11yr = 1 lb/month, Age 12-18yr = 2 lbs/week average
  • Age 2-5yr = 1 lb/month, Age 6-18yr = 2 lbs/week average
hypertension whom to screen
Hypertension: Whom to Screen
  • Children over 3 y.o. at every visit
  • Children < 3 y.o. if special circumstances
  • If >90th percentile, re-check twice at same visit

The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004; 114(2): 555-576

hypertension how to screen
Hypertension: How to Screen
  • Ideal conditions
    • Manual measurement with cuff and stethoscope
    • Child is resting for 5 mins
    • Right antecubital fossa at heart level
    • Properly fitting cuff
    • Child is not on sympathomimetic medications
  • Can bill as “elevated BP” (796.2) until dx of HTN is established

The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004; 114(2): 555-576

definitions
Definitions:
  • Hypertension = 3 elevated SBP or DBP on three separate occasions
  • Pre-hypertension: BP ≥ 90th and <95th percentile
  • Stage 1 HTN: BP ≥95th percentile to 5mm Hg above the 99th percentile
  • Stage 2 HTN: BP that is >5mm Hg above the 99th percentile
pre hypertension definition and intervention
Pre-hypertension: Definition and Intervention
  • Definition
    • BP ≥ 90th and <95th percentile, OR
    • BP >120/80 even if <90th ,up to 95th percentile
  • Intervention
    • Lifestyle modifications
    • Re-check in 6 months
    • Pharmacological Tx only if compelling complications
htn lifestyle modifications
HTN: Lifestyle modifications
  • Weight management, if indicated
  • 30-60 minutes/day of moderate to vigorous aerobic exercise
  • Reduction of sedentary activities
  • Dietary modifications (DASH diet: www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf/Sachs et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group.NEJM 2001 Jan 4;344(1):3-10
stage 1 htn definition and intervention
Stage 1 HTN: Definition and Intervention
  • Definition
    • BP ≥95th percentile to 5mm Hg above the 99th percentile
    • Re-check twice in 1-2 wks, or sooner if symptomatic, to establish diagnosis
  • Intervention
    • Evaluative work up
    • Lifestyle modifications
    • Pharmacological Therapy if
      • HTN is symptomatic
      • Secondary HTN
      • Hypertensive target organ damage
      • Diabetes, types 1 or 2
      • Persistent HTN despite non-pharmacological measures
htn stage 1 or stage 2 evaluative work up
HTN (stage 1 or stage 2): Evaluative work up
  • Why:
    • To look for end organ damage
    • To look for secondary HTN
  • What
    • BUN, Creatinine, electrolytes
    • UA and UC
    • CBC
    • Renal Ultrasound
    • Echocardiogram
    • Retinal exam referral
stage 2 hypertension definition and intervention
Stage 2 Hypertension: Definition and Intervention
  • Definition
    • BP that is >5mm Hg above the 99th percentile
  • Intervention
    • Evaluative work up
    • Refer (as needed) within 1 wk. or immediately if pt. is symptomatic.
    • Lifestyle modifications
    • Initiate pharmacological therapy
recent article
Lipid Screening and Cardiovascular Health in Childhood. Stephen R. Daniels, Frank R. Greer and and the Committee on Nutrition

Pediatrics Vol. 122 No. 1 July 2008, pp. 198-208

Recent Article
dyslipidemia
Atherogenic Lipid profile:

Increased LDL

Low HDL levels (≤ 40 mg/dL)

Increased triglycerides

Other CVD Risk factors include:

Sedentary Lifestyle

Hypertension

Diabetes

Tobacco use

Obesity (BMI ≥ 95th%)

Family Hx of premature (age < 55yrs) PVD or CVD

Dyslipidemia

20% of 5-10 y.o. children with BMI ≥85% have elevatedtotal cholesterol

AmericanDiabetes Association. Management of dyslipidemia in

children and adolescents with diabetes. Diabetes Care.2003;26:2194-2197

dyslipidemia whom to screen
Children >2 yrs of age, and if:

Parent has total cholesterol >240 mg/dL

CV event <55 yo. in father, grandfather, uncles

CV event <65 yo. in mother, grandmother, aunts

Unknown FHx, but CVD risk factors present:

(HTN, diabetes, tobacco use, etc.)

BMI% is ≥85th%

Dyslipidemia: Whom to Screen

American Heart Association guidelines for primary prevention of atherosclerotic cardiovascular disease beginning in childhood. Circulation. 2003;107:1562

American Diabetes Association. Management of Dyslipidemia in children and adolescents.

Diabetes Care. 2003;26:2194-2197

dyslipidemia how to screen
The present guidelines

Date back to 1992

Always use an average of at least two screens

Recommend total cholesterol screens for some risk factors and fasting profile for others.

Have problems with

Compliance: by both the family and the provider

Differences in race, age and gender

Sensitivity and specificity

Recommend treatment based only on LDL levels

Have been augmented by newer guidelines to screen if child is overweight: fasting lipid profile

Dyslipidemia: How to Screen

Speiser PW, Rudolf MC, Anhalt H, et al. Consensus Statement: Childhood Obesity. J Clin Endo & Metabol.2004;90(3):1871-1887.

dyslipidemia management
If non-diabetic and ≥ 10 yrs old:

(Average LDL from two fasting screens)

Ideal LDL <110 mg/dL

Borderline LDL 110 <130 mg/dL

LDL 130-159 mg/dL

Maximize non-pharmacological management

Consider medication if patient has diabetes

LDL 160-189 mg/dL

Consider medication if additional risk factors are present

LDL >190 mg/dL

Begin medication

Isolated fasting triglycerides >400 mg/dL

Begin medication

Dyslipidemia: Management

AHA. Circulation. 2003

dyslipidemia non pharmacological management
Dietary Management

Dietary cholesterol <200 mg/day

Saturated fat <7% of total calories

Plant sterol esters, fiber, omega 3 fatty acids

Weight reduction, if indicated

Exercise

60 minutes/day of physical activity

Tobacco cessation

Blood glucose control (if indicated)

Dyslipidemia: Non-Pharmacological Management
dyslipidemia pharmacological management
Statins are first line in children over 10 y.o. or after menarche

Low long-term compliance

Need significant monitoring

Dyslipidemia: Pharmacological Management

Speiser PW, Rudolf MC, Anhalt H, et al. Consensus Statement: Childhood Obesity. J Clin Endo & Metabol.2004;90(3):1871-1887.

dyslipidemia follow up
Repeat fasting lipid profile in 3 months

Repeat in 6 months (from initial evaluation)

At six months, if lipids are still elevated

Screen for secondary causes:

TFTs,

LFTs

Renal function

U/A

OGTT

Alcohol abuse

Dyslipidemia: Follow Up

AHA. Circulation. 2003 and Mallare JT et al. Diabetes Spectrum 2005.

polycystic ovary syndrome pcos57
Definition

Etiology

Profile

Sequelae

CVD Risk

Polycystic Ovary Syndrome(PCOS)

History

Physical Exam

Laboratory Evaluation

Management

Reference Sheet

pcos definition
Chronic anovulation or oligo-ovulation

Clinical and/or biochemical signs of hyperandrogenism

Exclusion of other etiologies

Congenital adrenal hyperplasia (CAH)

Androgen-secreting tumors

Cushing’s syndrome

PCOS: Definition
pcos sequelae
Persistant Anovulation:

Increased hormonal levels

Testosterone, androstenedione, dehydroepiandosterone (DHEA), dehydroepiandosterone-sulfate (DHEA-S), 17-hydroxyprogesterone (17-OHP), estrone and free estradiol, and luteinizing hormone (LH)

Decreased hormonal levels

Sex hormone binding globulin (SHBG), and low-normal follicle-stimulating hormone (FSH)

Infertility

Menstrual Irregularities

Oligomenorrhea – most common

Amenorrhea

Dysfunctional uterine bleeding

Normal cycles

Unopposed estrogen stimulation of endometrium

Endometrial cancer increased risk is 3-fold if <4 menses/yr

? breast cancer increased risk

Speroff and Fritz, 2005; Coulam et al Obstet Gynecol 1983

PCOS: Sequelae
pcos sequelae60
Hyperandrogenism

Phenotypic progression:

Hirsutism – variation with ethnicity

Acne

Oily skin

Increased libido

Clitoromegaly can be present in PCOS but needs rule out

Masculinization (virilization) not consistent with PCOS

Insulin Resistance

Can be present in lean women

Present in 40-90% of overweight women with PCOS

Increased risk of CVD and T2DM

Dyslipidemia

Higher systolic blood pressure

PCOS: Sequelae

2003 Rotterdam PCOS consensus. Fertil Steril 2004; Legro RS et al. J Clin Endocrinol Metab. 1999;84:165-9; Legro RS et al. OBGManagement 2005; Speroff and Fritz, 2005

pcos profile
Weight

35-60% are overweight

Insulin Resistance (IR)

Overweight women with PCOS more likely IR

Lean women with PCOS less likely IR

Speroff and Fritz, 2005; AACE. Endocrin Pract. 2005

PCOS: Profile
pcos history
Menstrual History

Study: Menstrual irregularity 2-4 yrs post menarche, 95% had PCOS

Fernandez AR et al. J Pediatr Adolesc Gynecol 2005

Premature adrenarche

Pubic hair <8 y.o.♀ and <9 y.o. ♂

Associated with low birth weight

Changes associated with hyperandrogenism

Physical changes

The rapidity of onset (a time frame of “months” is not generally consistent with PCOS)

Family History

Autosomal dominant

PCOS: History
pcos physical exam
BMI percentile

Phenotypic changes associated with hyperandrogenism

Signs of premature adrenarche

Hirsutism

Acne

Clitoromegaly

Clitorus ≥1cm³

virilization is not a normal finding in PCOS. Think tumor or CAH

Other physical findings associated with insulin resistance

Visceral adiposity

Acanthosis nigricans

PCOS: Physical Exam
pcos lab evaluation
Choices in the laboratory evaluation depend, in a large part, on the findings in the history and physical exam, i.e. the degree of androgenization and the rapidity of their onset.PCOS: Lab Evaluation
pcos lab evaluation65
Pregnancy test

TSH

r/o hypothyroidism

Prolactin

r/o prolactinoma

MRI brain if ≥ 100 ng/mL

Fasting lipid profile

For lean and overweight women

+/- Oral glucose tolerance test

Especially if overweight or genetic predisposition

PCOS: Lab Evaluation
pcos lab evaluation cont d
+/- Fasting, 8 am17-OHP

r/o late onset congenital adrenal hyperplasia

>200 ng/dL need ACTH stim test.

>800 ng/dL nearly diagnostic for 21-hydroxylase deficiency

+/- Total testosterone, DHEA-S

r/o androgen secreting tumor

Testosterone levels > 200 ng/dL, need further evaluation

DHEA-S > 700 mcg/dL, need further evaluation

+/- Dexamethasone suppressiontest

If Cushing’s disease is suspected

HTN, striae, “buffalo hump,” “moon facies”

PCOS: Lab Evaluation, cont’d
pcos lab evaluation cont d67
Pelvic Ultrasound

Not routinely recommended

Can screen for endometrial hyperplasia (see below)

If dominant follicle (>10 mm or corpus luteum, repeat scan during next cycle

Performed on cycle days 3-5 or days 3-5 after progesterone induced withdrawal bleed

+/- Endometrial Biopsy for endometrial cancer

Determined by the duration of anovulation, not the patient’s age

If endometrium is 5-12mm may do a biopsy.

If endometrium is >12mm always do a biopsy

PCOS: Lab Evaluation, cont’d

2003 Rotterdam PCOS consensus. Fertil Steril 2004 and Speroff & Fritz, 2005

pcos management issues
Unopposed estrogen

Menstrual Irregularity

Endometrial cancer risk

Hyperandrogenism

Hirsutism

Acne

Infertility

Hyperinsulinemia (insulin resistance)

Increased risk of T2DM and CVD

Cholesterol management

Blood pressure management

Tobacco cessation, etc.

Cobin et al, Endocr Pract. 2005. and AHA. Circulation. 2000;102:2284

PCOS: Management Issues
pcos treatment
First:

If patient has dysfunctional uterine bleeding, address with appropriate work-up and treatment.

If amenorrheic, confirm that amenorrhea is secondary to progesterone deficiency with a progesterone challenge test to induce a withdrawal bleed.

PCOS: Treatment
pcos treatment70
Combined estrogen/progesterone

OCP with 2nd or 3rd generation progesterone: norethindrone, norgestimate, desogestral

4th generation: Drospirenone = Spironolactone analog (Yasmin)

Patch or ring

Address the endometrial risk

Decrease the hyperandrogenism

Improve hirsutism

Improve lipid profile (HDL only)

Do not address

The hyperinsulinemia -Limited evidence that OCPs may worsen insulin sensitivity

Inflammatory state -no change in IL-6 and adiponectin

Body adiposity profile -further worsening

PCOS: Treatment

Diamanti-Kandarakis E et al. 2003. Ibenez, de Zegher, 2004.

pcos metformin treatment
(850-2500 mg/day)

Reduces hyperinsulinemia

Reduces free androgen levels by increasing SHBG

Restores ovulation for many women

13 RCTs, n=543: 46% of PCOS women ovulated, vs 24% in control group

PCOS: Metformin Treatment

Lord JM et al. BMJ 2003;327:951-3.

pcos treatment72
Spironolactone (50-200mg/day)

Addresses hyperandrogenism, ↓ hirsutism

Does not affect hyperinsulinemia

OCPs are advised to prevent pregnancy

Provera (5-10mg daily x 14 days of every month)

Addresses the endometrial risk

Does not decrease androgen production by the ovaries

Does not address hyperinsulinemia

Weight Loss (>5%)

Reduces hyperandrogenization

Reduces hyperinsulinemia

Restores ovulation for many women

PCOS: Treatment
slide73
Polycystic Ovary Syndrome (PCOS)

Definition

∙ Persistent anovulation

∙ Lab/clinical evidence of hyperandrogenism

History

∙ Menses

∙ FHx of PCOS

∙ Premature adrenarche

∙ Rapidity of onset of androgenic changes

∙ Hirsutism – any depilatory measures

PhysicalExam

∙ Hirsutism

∙ Acne

∙ Clitoromegaly

∙ Virilization

∙ Premature adrenarche, if pre-menarchal

Evaluation

1) · TSH

· Prolactin

· Pregnancy test

2) · Lipid profile, fasting

3) · If obesity/acanthosis:

fasting &/or 2 hr glucose

4) · If amenorrheic: Provera challenge

(10 mg Provera qd x 10d)

5) · +/- Total testosterone

· +/- DHEA-S

· +/- 17-OH progesterone, fasting

6) · If sxs of Cushing’s:

dexamethasone suppression test

Treatment

· Weight loss, if indicated

· Estrogen/progesterone combo

· Consider metformin

· Refer for severe or recalcitrant

hirsutism

non alcoholic fatty liver disease
HISTORY:

Use of: alcohol, drugs, meds, herbs

Dietary recall

LABS:

Hepatitis panel,

Liver function test,

Fasting lipid profile,

Fasting glucose and insulin

Consider biopsy in patient for whom:

Weight loss has failed,

LFTs remain elevated,

US shows evidence of fatty liver,

Signs of metabolic syndrome are present

Non-Alcoholic Fatty Liver Disease
brief pathogenesis
Brief Pathogenesis

Insulin Resistance & Overweight

N

A

F

L

D

STEATOSIS

•Leading cause of liver enzyme abnormalities in teens

•One study: 53% occurrence in overweight children

↑Hepatic FFA Synthesis

↑Hepatic Uptake of Fat

↑Oxidation of Fat

Protein Damage

↑ Pro-inflammatory Cytokines

STEATOHEPATITIS

N

A

S

H

TIME

FIBROSIS

CIRRHOSIS

eval for suspected nafld
Ultrasound of the liver

α1-antitrypsin

Ceruloplasm

Antinuclear antibody

Hepatitis antibody measurements

(Liver biopsy, if recommended by Peds GI)

Eval for suspected NAFLD
non alcoholic fatty liver disease nafld78

Non-Alcoholic Fatty Liver Disease(NAFLD)

•Benign & Reversible

•Associated with Overweight & Insulin Resistance

•Causes elevated ALT (and AST)

•U/S can quantify steatosis, but need bx to detect fibrosis.

•Treatment: Weight reduction of ≥5% in 3 mos to normalize ALT in overweight pediatric patients

•Predictors of fibrosis not established in children

predictors of fibrosis in adults
ALT greater than twice normal

AST>ALT

At least moderate central obesity

T2DM or impaired glucose tolerance

Hypertension

Hypertriglyceridemia

In Children and Adults:

Increasing severity of metabolic syndrome components and longer time of abnormalities roughly correlate with increased liver pathology

Biopsy is used to establish the presence of fibrosis. (Radiological studies not useful.)

Predictors of Fibrosis in Adults
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