Improving obesity prevention and treatment in GPS clinic H Sonali Magdo, DO PGY 2 CHLA
Health consequences of obesity in childhood5,6 • Type II DM • Hypertension • OSA • Depression/low self esteem • Nonalcoholic fatty liver disease • SCFE • Pseudotumor cerebri
Objectives 1. Review existing literature on childhood obesity 2. Identify the obstacles faced by physicians in a general pediatrics clinic in assessing and treating children who are overweight through use of survey 3. Provide physicians in GPS clinic with resources to improve prevention/ management of overweight and obesity
Assessment of PCP management of obesity4 • Of all children who met criteria for obesity, only 53% of visits documented obesity • 69% documented an adequate dietary history • 15% documented activity level
Survey results clinic resources Survey Results: 1. Lack of time to counsel patients 2. Lack of clinic guidelines for disease management 3. Lack of knowledge of community programs Intervention: 1. Nutritional intake form 2a. Creation of chart (adapted from Pediatric Annals article) for reference in clinic b. Weight check form 3. Creation of booklet compiling community programs for overweight/obese children in LA
Clinic flow chart Adapted fromAriza AJ, RS Greenberg, R Unger. Childhood overweight: management approaches in young children. Pediatric Annals. January 2004; 33(1): 33-38.
Clinic weight check form ALTA MED WEIGHT CLINIC VISIT Place sticker here Date: Vital signs: Temp BP / (___%) HR RR ___ Weight (___%) Height____ (____%) BMI____ (_____%) Previous BMI ____ (____%) on __/__ Allergies: Medications:_____________________________ Do you see your child as ___ overweight ____ normal weight ____ underweight? Diet History: 1. How many meals a day do you eat? At the table, with whole family present? ______ 2. What is the largest meal of the day? How many snacks do you eat per day? ______ 3. How much juice do you drink? How much soda? ______ Activity History: 1. How many hrs of TV do you watch? How many hours of video games/computer time? ______ 2. How much exercise do you get? Exercise enough to sweat: how many times/week? ______ Medical History Questions: 1.Obstructive sleep apnea: Snoring? Gasping for breath at night/long pauses in breathing? _____ 2. Shortness of breath with exertion? _____ 3. Irregular/scant periods? Known history of PCOS? _______ 4. Headaches? (pseudotumor cerebri) ______ 5. Depression: Increased or decreased sleep? _______ Loss of interest in favorite activities? _______ Feelings of guilt, hopelessness, regret? ______ Low energy? ______ Difficulty concentrating? _______ Increased or decreased appetite? _______ Psychomotor retardation/agitation? _______ Suicidality? _______ (Depression= 4 of the above + feelings of depression or anhedonia for at least 2 weeks) 6. Binging/Purging? (children >8-9 yrs old) _______ Family History: 1. Race/Ethnicity: * African American *Hispanic *Asian/Pacific Islander *American Indian Caucasian 2. FHx of Type II DM in 1st or 2nd degree relative? ____ Yes No 3. FHx of obesity: Yes No One parent overweight? ______ Both parents overweight? ______ 4. FHx of cardiovascular disease: 1st or 2nd degree relative with MI, CVA, PVD, angina, sudden cardiac death before age 55? ______ Coronary arteriography + for atherosclerosis), coronary bypass, balloon angioplasty? _______ Parent with cholesterol >240? _______
Clinic weight check form Focused physical exam: HEENT: Tonsillar hypertrophy ______ Dysmorphic features _______Papilledema_____ Neck: Palpable thyroid _______ Lungs: Heart: Abdomen: Hepatomegaly ______ Skin: Acne ____ Acanthosis nigricans ____ Hirsutism _____ Striae _____ Neuro: Developmental delay ______ Musculoskeletal: Buffalo hump ______ Digital anomalies ______ Spinal asymmetry ____ Genu varum ______ Genu valgum ______ GU: Abnormal genitalia ______ Labs: Fasting glucose** Lipid panel ________ Liver function panel______ Thyroid function tests (if linear growth is poor, family hx, palpable thyroid)_____ Referrals ____ ENT (OSA, disordered sleep breathing) ____ Overnight Sleep Study ____ Cardiology (Dyspnea on exertion, LDL > 110mg/dl, + FHx, BP > 95% for height and gender on 3 visits) ____ Endocrinology ____ Orthopedics/PT(Spinal asymmetry, genu varum/valgum) ____ Genetics (DD, dysmorphic, abnormal genitalia, digital anomalies) ____ Gastroenterology ____ Comprehensive Obesity Program (Powerplay, ENERGY, Fit Families, Happy Feet) ____ Nutrition referral **Screen for diabetes: Any child/adolescent who is overweight (BMI >85%) + 2 risk factors Screening should begin at age 10 or onset of puberty if puberty occurs at a younger age. Screen every two yrs Risk factors: 1st or 2nd degree relative Race (American Indian, African-American, Hispanic, Asian/Pacific Islander) Signs of insulin resistance/conditions associated with insulin resistance: acanthosis nigricans, hypertension, dyslipidemia, PCOS Current screening guidelines call for fasting glucose. (Random glucose, 2 hr post prandial glucose, HgAIc: not part of current guidelines) Follow up visit: 1 month 2 months Signature:
Future projects • Evaluation of success of project • Survey of patients and their families • Creation of webpage linked to CHLA website to use for resources in the community • Creation of nutrition and activity handouts that are culturally sensitive
Thank you! • Susan Wu, MD • Larry Yin, MD • Hope Wills, RD • Esther Berenhaut, RD • Yvonne Gutierrez, MD
References: 1. Ogden, CL, Carroll MD, Curtin LR et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006 Apr 5 295; (13): 1549-1555. 2. Ariza AJ, RS Greenberg, R Unger. Childhood overweight: management approaches in young children. Pediatric Annals. January 2004; 33(1): 33-38. 3. Committee on Nutrition. Cholesterol in childhood. Pediatrics. Jan 1998; 101(1): 141-147. 4. Obrien SH, R Holubkov, EC Reis. Identification, evaluation and management of obesity in an academic primary care center. Pediatrics. Aug 2004; 114(2): e154-e159. 5. Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics. Mar 1998; 101(3pt2): 518-525. 6. Hoppin, AG, ES Katz, LM Kaplan, GY Lauwers. Case 31-2006: A 15-year-Old girl with severe obesity. NEJM. Oct 2006; 355(15): 1593-1602.