“To eliminate the gap between what is and what can be in health care for all children.”

1. “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

2. Assessment and intervention of Pediatric Overweight and Obesity Hypertension Dyslipidemia Polycystic Ovary Disease Non-Alcoholic Fatty Liver Disease Overview

3. 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

4. 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

5. 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?

6. 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

7. 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

8. 9 y.o. girl presents for WCC Height = 134 cm Weight = 40.7 kg BMI = 22.5 BP = 118/77 Example

9. 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

10. Small for gestational age Weight gain Insidious onset vs. Point-in-time onset Race/ethnicity Past Medical History

11. 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

12. 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

13. 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

14. 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)

15. Acanthosis nigricans (NIDDM, insulin resistance) Violaceous striae (Cushing’s syndrome) Things To Look For On The Physical Exam

16. Diagnose Overweight and Obese Screen for pre-diabetes and type 2 diabetes Screen for conditions associated with overweight The Next Step

17. Obesity Insulin Resistance Metabolic Syndrome Type 2DM Hypertension NASH Dyslipidemia PCOS Also: Mental health issues, obstructive sleep apnea, orthopedic problems

18. 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

19. 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

20. 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

21. 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.

22. 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.

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. Treatment Goals - Weight Loss Targets * Excessive weight loss should be evaluated for high risk behaviors

30. 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

31. 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

32. 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

33. 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.

34. 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

35. 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

37. Hypertension

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

47. Dyslipidemia

48. 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

49. 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

50. 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