Transcript Improving obesity prevention and treatment in GPS clinic

Improving obesity
prevention and
treatment in GPS clinic
H Sonali Magdo, DO
PGY 2
CHLA
Background:
Prevalence of obesity in American children1
Girls
1999-2000
13.8%
2003-2004
16%
Boys
14%
18.2%
Health consequences of
obesity in childhood5,6
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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
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Of all children who met criteria for obesity,
only 53% of visits documented obesity
69% documented an adequate dietary history
15% documented activity level
Medical history and PE
Condition
% pediatricians % PNP
Hypertension
97
95
Type II DM
38
41
Genetic
32
Syndromes
Sleep disorders 41
22
GI disorders
22
24
Orthopedic
problems
38
46
27
Survey Results:
Barriers to treatment of obesity/overweight
60
50
40
30
Always a problem
20
Frequently a problem
10
Sometimes a problem
Never a problem
0
* Lack of time Lack of support
*Lack of Lack of clinic
knowledge of guidelines
community
programs
Survey results clinic resources
Survey Results:
Intervention:
1. Lack of time to counsel patients
1. Nutritional intake form
2. Lack of clinic guidelines for
disease management
2a. Creation of chart (adapted from
Pediatric Annals article) for
reference in clinic
b. Weight check form
3. Lack of knowledge of community
programs
3. Creation of booklet compiling
community programs for
overweight/obese children in LA
Clinic flow chart
Nutritional evaluation
Height and weight measurements
BMI calculation and interpretation
Non-overweight
BMI 5th-84th %
At risk for being overweight
BMI 85-94%
Overweight
BMI > 95%
Family Patterns and Risk Assessment
Family and child eating patterns and physical activity (including screen time)
FHx: overweight, coronary artery disease, hypertension, type II DM, hypercholesterolemia
Recent weight increase or concerns
Diet and physical activity counseling and management of family dynamics with frequent follow up
Return in one year for follow up
Genetic syndromes
Developmental
Delay
Dysmorphic
Features
Abnormal or absent
genitalia
Digital anomolies
R
Assessment of At Risk and Overweight Children
Endocrine abnormalities
Poor linear growth
-Hirsutism
-Moon facies
-Acne
-Buffalo hump
-Striae
Suspect:
Suspect:
Suspect:
- Prader Willi
Hypothyroidism
Cushing’s
- Turner Syndrome
Syndrome
Check TSH, T4
If LDL > 110mg/dl Consider referral to orthopedics or
- Laurence-Moon-Check 24 hr
Bardet-Biedle
urine cortisol
Refer to genetics
Refer to endocrinology
Type II DM
- FHx: Type II
DM
-Race/ethnicity
- Signs of insulin
resistance
(HTN,
dyslipidemia,
acanthosis
nigricans, PCOS)
Check FPG, if >
126 mg/dl
Hypertension
If: BP >95% for
height and
gender on 3
separate
occasions
Dyslipidemia
+ Family hx of CV
disease <55 yrs age
OR
Parent cholesterol > 240
and/or LDL >160
OR
Child’s total cholesterol
>250 and/or LDL >160
with no family hx
Respiratory Disturbances
- Dyspnea on
exertion
- Shortness of
breath
-Obstructive
sleep apnea
- Disordered
sleep
breathing
Muscle/skeletal
abnormalities
-Spinal
asymmetry
-Flat feet
-Genu
varus/valgus
* check fasting lipid
panel in all children >10
with BMI >85%, add
AST/ALT and fasting
glucose if + risk factors
Refer to cardiology
Refer for sleep
evaluation and/or
ENT
Consider
referral to
orthopedics or
PT
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:
Clinic recommendations
Choose 2 goals/month (visit)
Goal:
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
1. Consume .>5 fruits and vegetables per
day
2. Eliminate/decrease juice and soda intake
3. Limit screen time <2 hrs/day
4. Exercise (>1 hr/day)
5. No television in room
6. Eat breakfast daily
7. Limit meals outside home
8. Eat family meals 5-6 x/week
9. Allow child to self regulate meal
avoid overly restrictive behaviors
Barlow, Sarah and the Expert Committee. Expert Committee Recommendations Regarding the Prevention, Assessment,
and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics 2007; 120; S164-S192.
Future projects
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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!
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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,
2.
3.
4.
5.
6.
1999-2004. JAMA. 2006 Apr 5 295; (13): 1549-1555.
Ariza AJ, RS Greenberg, R Unger. Childhood overweight: management approaches in young
children. Pediatric Annals. January 2004; 33(1): 33-38.
Committee on Nutrition. Cholesterol in childhood. Pediatrics. Jan 1998; 101(1): 141-147.
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.
Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease.
Pediatrics. Mar 1998; 101(3pt2): 518-525.
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.