OBESITY
TOPICS:
IDENTIFICATION OF OBESITY
IMPORTANT ELEMENTS OF THE HISTORY
SIGNIFICANT PHYSICAL EXAM FINDINGS
CODING
LABORATORY TESTS, STUDIES, AND REFERRALS
EVALUATION AND MANAGEMENT OF COMORBIDITIES
PRACTICE GUIDELINES
PREVENTION
TREATMENT
IDENTIFICATION OF OBESITY
BMI < 5th %
BMI 5th-84th %
BMI 85th-94th %
BMI 95th-98th %
BMI ≥ 99th %
Underweight ---> further medical work-up
Healthy weight ---> go to PREVENTION
Overweight
Obese
Morbidly obese (includes any BMI ≥ 40)
Cut-points for 99th % BMI based on age
Age in years
5
6
7
8
9
10
11
12
13
14
15
16
17
Boys 99th percentile BMI
20.1
21.6
23.6
25.6
27.6
29.3
30.7
31.8
32.6
33.2
33.6
33.9
34.4
Girls 99th percentile BMI
21.5
23.0
24.6
26.4
28.2
29.9
31.5
33.1
34.6
36.0
37.5
39.1
40.8
For further information see 2000 CDC growth charts for the United States
IMPORTANT ELEMENTS OF THE HISTORY
History of weight gain (age of onset; contributing factors)
Family and child’s concern about weight
Perceived causes of overweight
Consequences of overweight in child’s life
Previous attempts at weight loss
DIET AND PHYSICAL ACTIVITY:
Food preferences
Behavioral feeding problems
Meal patterns
Snacks
Sugary beverages
Eating out
Screen time
Activity patterns
Nutrition Patient Care Forms on the LPCH intranet:
Weekly food diary (7-day record of diet and activity)
Monthly exercise log
OBESITY-INDUCING MEDICATIONS:
Steroids
Anticonvulsants (valproic acid, gabapentin)
Psychiatric drugs (antipsychotics, tricyclic antidepressants, lithium)
Hormonal contraceptives
SYMPTOMS:
Headaches ---> consider pseudotumor cerebri
Snoring ---> consider sleep apnea
Daytime sleepiness ---> consider sleep apnea
Shortness of breath ---> consider congestive heart failure
Abdominal pain ---> consider GE reflux (burning pain) or NASH (RUQ pain)
Constipation
Irregular menses or amenorrhea ---> consider pregnancy, PCOS and/or hypothyroidism
Hip or knee pain ---> consider slipped capital femoral epiphysis
Back pain
Darkening of the skin on neck and/or axillae ---> consider diabetes
Nocturia or polyuria ---> consider diabetes
Poyldipsia ---> consider diabetes
Binging ---> consider an eating disorder
Purging ---> consider an eating disorder
READINESS FOR CHANGE: Prochaska and DiClemente’s Stages of Change
Precontemplation
Contemplation
Preparation
Action
Maintenance
SIGNIFICANT PHYSICAL EXAM FINDINGS
High blood pressure ---> further evaluation for hypertension
Short stature (ht < 25th %) ---> consider endocrine abnormality
Eyes: blurred disc margins ---> consider pseudotumor cerebri
Face: abnormal facies ---> consider genetic syndrome
Throat: enlarged tonsils ---> consider sleep apnea
Neck: mass ---> consider enlarged thyroid and hypothyroidism
Abdomen: RUQ tenderness ---> consider NASH
Back: buffalo hump ---> consider Cushing’s syndrome
Extremities: bowed legs ---> consider Blount’s disease
Genitalia:
precocious puberty ---> consider endocrine abnormality;
undescended testicle ---> consider Prader-Willi syndrome OMIM #176270
delayed puberty ---> consider hypothyroidism
Precocious puberty: < 8 years in girls and < 9 years 6 months in boys
Delayed puberty: no pubertal development by age 13 in girls and 14 in boys
Skin:
acanthosis nigricans ---> insulin resistance; consider diabetes
striae ---> consider Cushing’s syndrome
CODING:
WEIGHT:
Overweight (ICD-9 278.02): BMI 85th-94th %
Obese (ICD-9 278.00): BMI 95th-98th %
Morbidly obese (ICD-9 278.01) BMI ≥ 99th %
Abnormal weight gain (ICD-9 783.1)
COMORBIDITIES:
Acne (ICD-9 706.1)
Back pain (ICD-9 724.5)
Blount’s disease (ICD-9 732.4)
Constipation (ICD-9 564.00) ---> fiber-rich diet
Depression (ICD-9 296.2)
Diabetes mellitus, type 2 (ICD-9 250.02 – uncontrolled)
Disordered eating (ICD-9 307.5)
Dyslipidemia (ICD-9 272.4)
Fatty liver (ICD-9 571.8)
Gastroesophageal reflux (ICD-9 530.81)
Gynecomastia (ICD-9 611.1)
Hypercholesterolemia (ICD-9 272.0)
Hyperlipidemia (ICD-9 272.4)
Hypertriglyceridemia (ICD-9 272.1)
Hypertension (ICD-9 401.9)
Impaired fasting glucose (ICD-9 790.21)
Impaired glucose tolerance (ICD-9 790.22)
Insulin resistance (ICD-9 251.1)
Iron-deficiency anemia (ICD-9 280.9)
Irregular menses (ICD-9 626.4)
Left ventricular hypertrophy (ICD-9 746.89)
Obstructive sleep apnea (ICD-9 327.23)
Polycystic ovary syndrome (ICD-9 256.4)
Pseudotumor cerebri (ICD-9 348.2)
Slipped capital femoral epiphysis (ICD-9 732.2)
Vitamin D deficiency (ICD-9 268.9)
LABORATORY TESTS, STUDIES, AND REFERRALS
AAP GUIDELINES FOR LABS:
BMI 85th-94th % (≥ 2 years old):
Fasting lipid panel
•Repeat every 2 years
BMI ≥ 95th % (≥ 10 years old):
Fasting lipid panel
Fasting glucose
AST, ALT
• Repeat every 2 years
Also consider:
CBC
BUN, creatinine
Electrolytes
Comprehensive metabolic panel
Fasting insulin level
Free T4, TSH
High-sensitivity CRP (for assessment of inflammation and cardiovascular risk)
LH, FSH, prolactin, free and total testosterone, DHEAS, androstenedione, SHBG (for PCOS)
Leptin
MC4R (for early onset obesity)---> send-out to Athena Diagnostics
Prader-Willi FISH probe (fluorescent in-situ hybridization)
Vitamin D, 25-OH ---> if < 20 ng/ml give ergocalciferol 50,000 I.U. Qweek x 6 weeks
STUDIES:
Sleep study:
Stanford Sleep Clinic (if parasomnia present)
Pulmonary Clinic for overnight sleep study at El Camino Hospital
Exercise study at LPCH Pediatric Exercise Lab (for assessment of fitness)
Indirect calorimetry at LPCH Pulmonary Function Lab
(for assessment of resting energy expenditure and daily caloric intake)
REFERRALS: (as indicated)
Nutrition at 730 Welch Road (Ning Wan, RD)
Physical therapy
Public health nursing
Social work
Pediatric Weight Clinic at Castro Commons:
BMI ≥ 99th % (morbid obesity) and family is motivated
Medically or socially complex patient
No improvement after one year of follow-up in Primary Care Clinic
Subspecialists:
Cardiology – for left ventricular hypertrophy or heart failure
Eating disorders clinic – for severely disordered eating
ENT – for tonsillar hypertrophy
Endocrinology – for diabetes or short stature
Genetics – for hypothyroidism or Prader-Willi syndrome
Nephrology – for hypertension
Ophthalmology – for pseudotumor cerebri
Orthopedics – for Blount’s disease or slipped capital femoral epihphysis
Pulmonary – for sleep apnea
Psychiatry – for depression
Child Protective Services:
Santa Clara County: 408-299-2071
San Mateo County: 650-595-7922
Criteria: (from Child Obesity and Medical Neglect, Pediatrics January 2009)
1. High likelihood of serious harm from comorbid conditions
2. Reasonable likelihood that coercive state will result in treatment
3. Absence of alternative options
EVALUATION AND MANAGEMENT OF COMORBIDITIES
DIABETES
DYSLIPIDEMIA
HYPERTENSION
METABOLIC SYNDROME
NAFLD
PCOS
PSEUDOTUMOR CEREBRI
DIABETES:
Fasting glucose
2 hour GTT
Random glucose
NORMAL
<100
<140
IMPAIRED
100-125
140-199
DIABETES
≥126
≥200
≥200 + symptoms
Prediabetes = impaired fasting glucose or impaired glucose tolerance
Reference: American Diabetes Association Clinical Practice Recommendations 2009
DYSLIPIDEMIA
Acceptable
Borderline
Abnormal
Total cholesterol
<170
170-199
≥200
LDL
<110
110-129
≥130
Pharmacologic treatment: children ≥ 8 years old with:
Persistent elevation of LDL > 190 after diet therapy, with no other risk factors
Persistent elevation of LDL > 160 after diet therapy, with risk factors
LDL > 130 in children with diabetes
Reference: Pediatrics 2008
Lipid screening and cardiovascular health in children
American Heart Association Guidelines:
Triglycerides > 150 abnormal
HDL < 35 abnormal
HYPERTENSION:
Blood pressure norms by height and age
Blood Pressure Tables for Children
The fourth report on the diagnosis, evaluation, and treatment of high blood pressure
in children and adolescents (2004)
Prehypertension:
Hypertension:
SBP or DBP 90th to <95th % (or ≥120/80)
SBP and/or DBP ≥95th % on 3 or more occasions
Prehypertension
Stage 1 hypertension
Stage 2 hypertension
BP
90th to <95th %
95th to 99th % + 5
mm Hg
>99th % + 5 mm
Hg
FOLLOW-UP
Recheck in 6
months
Recheck in 1-2
weeks
Recheck within 1
week
DRUG Tx
Treat as per
Table 6 criteria
Treat with meds
Evaluation of confirmed hypertension:
Labs: BUN, creatinine, electrolytes, UA, UC, CBC
Studies: renal ultrasound, echocardiogram (for LVH)
For all patients: Therapeutic Lifestyle Change
Consider the DASH eating plan: Dietary Approaches to Stop Hypertension
“Table 6: Indications for Antihypertensive Drug Therapy in Children”
Symptomatic hypertension
Secondary hypertension
Hypertensive target-organ damage
Diabetes (types 1 and 2)
Persistent hypertension despite nonpharmacologic measures
METABOLIC SYNDROME
Key components from 2002 ATP III of the National Cholesterol Education Program:
Abdominal obesity
Atherogenic dyslipidemia
Raised blood pressure
Insulin resistance ± glucose intolerance
Proinflammatory state
Prothrombotic state
Promote weight loss and manage individual components
NAFLD (Non-alcoholic fatty liver disease)
Stages of fatty liver:
Steatosis
Steatohepatitis (NASH)
Fibrosis
Cirrhosis
Liver failure
Screening tests:
AST, ALT – [refer to pedi GI if markedly abnormal; repeat in 3 months if mildly
abnormal; if still abnormal refer to pedi GI]
Liver ultrasound
Diagnostic tests: (after referral to Pediatric GI)
Liver biopsy
Liver MRI
Evaluation to exclude other causes of liver disease:
Alpha-1-antitrypsin
Ceruloplasmin (for Wilson’s disease)
Antinuclear antibodies
Anti liver, smooth muscle, and kidney antibodies (for autoimmune hepatitis)
Hepatitis A, B, and C studies (for viral hepatitis)
POLYCYSTIC OVARY SYNDROME
Diagnosis by any 2 of the following:
Oligomenorrhea or amenorrhea
Elevated circulating androgens or clinical signs of androgen excess
Polycystic ovaries by ultrasound [ultrasound not necessary in most cases]
Laboratory evaluation:
LH, FSH, prolactin, DHEAS, androstenedione, SHBG, free and total testosterone
Treatment: (apart from weight loss)
Oral contraceptives – Adolescent Medicine referral
Metformin
PSEUDOTUMOR CEREBRI (also known as Idiopathic Intracranial Hypertension)
Diagnosis:
Symptoms of elevated ICP
Normal CT/MRI of the brain
Opening pressure of >250 mm in lateral decubitus position
Normal CSF composition
No other cause of intracranial hypertension
Referrals:
Ophthalmology
Neurology
Interventional Radiology (if needed for LP)
Treatment:
Carbonic anhydrase inhibitors
Serial lumbar punctures
Ventriculoperitoneal and/or lumboperitoneal shunting
Weight loss (including bariatric surgery)
PRACTICE GUIDELINES
AAP guidelines, December 2007:
Expert Committee Recommendations Regarding the Prevention, Assessment, and
Treatment of Child and Adolescent Overweight and Obesity
Academy of Eating Disorders guidelines, February 2009:
AED Guidelines for Childhood Obesity Prevention Programs
California Medical Association Foundation, 2008:
Child and Adolescent Obesity Provider Toolkit
Endocrine Society guidelines, December 2008:
Prevention and Treatment of Pediatric Obesity
National Institute for Children’s Healthcare Quality
An Implementation Guide from the Childhood Obesity Action Network
PREVENTION
AAP OBESITY PREVENTION GUIDELINES:
Limit sugar-sweetened beverages
Encourage 9 servings per day of fruits and vegetables
Eat breakfast daily
Limit eating out
Encourage family meals
Limit portion size
Eat a diet rich in calcium and high in fiber with balanced macronutrients
Encourage exclusive breastfeeding for 6 months
Limit consumption of energy-dense foods
Promote moderate to vigorous physical activity ≥ 60 minutes per day
Limit screen time to a maximum of 2 hours per day
Parent handouts:
Ounce of Prevention (from the state of Ohio and Nationwide Children’s Hospital)
TREATMENT
AAP STAGES OF OBESITY TREATMENT
OTHER TREATMENT RESOURCES:
Motivational interviewing
Eating and activity plans
Community resources
GROUP TREATMENT PROGRAMS
WEIGHT LOSS MEDICATION
BARIATRIC SURGERY
AAP STAGES OF OBESITY TREATMENT:
Stage 1:
Stage 2:
Stage 3:
Stage 4:
Prevention Plus (PP)
Structured Weight Management (SWM)
Comprehensive Multidisciplinary Intervention (CMI)
Tertiary Care Intervention (TCI)
BMI
85th-94th % + risk
95th-99th %
>99th %
Age 2-5 years
PP up to SWM
PP up to CMI
PP up to CMI
Age 6-11 years
PP up to SWM
PP up to CMI
PP, SWM, or CMI
up to TCI
Age 12-18 years
PP up to SWM
PP up to TCI
PP, SWM, or CMI
up to TCI
STAGE 1: PREVENTION PLUS
•Goal = weight maintenance to improve BMI
•Tailor follow-up to individual families
•If no improvement in BMI after 3 to 6 months advance to stage 2
Key points:
≥ 5 servings of fruits and vegetables per day
Minimize sugar-sweetened beverages (no more than 1 serving per day)
Decrease television to ≤ 2 hours per day
Be physically active ≥ 1 hour per day
Prepare more meals at home
Eat at the table as a family 5 to 6 times per week
Eat a healthy breakfast every day
Involve the whole family in lifestyle changes
Allow the child to self regulate meals and avoid over-restriction
Tailor recommendations to cultural values
STAGE 2: STRUCTURED WEIGHT MANAGEMENT
•Target diet and physical activity behaviors more intensively
•Goal = weight maintenance, but weight loss should not exceed 1 lb/month in
children 2 to 11 years old or 2 lb/week in older children
Follow up monthly
•If no improvement in BMI after 3 to 6 months advance to stage 3
Key points:
Planned diet with balanced macronutrients emphasizing low energy-density foods
Structured daily meals and snacks
Reduce television and other screen time to ≤ 1 hour per day
Planned activity 60 minutes per day
Use of logs to monitor behavior
Provide reinforcement for achieving targeted behaviors
STAGE 3: COMPREHENSIVE MULTIDISCIPLINARY INTERVENTION
•Refer to a multidisciplinary obesity care team (including a behavioral counselor,
dietitian, and exercise specialist) for a structured behavioral modification program
•Goal = weight maintenance or gradual weight loss until BMI < 85%; weight loss
should not exceed 1 lb/month in children 2 to 5 years old or 2 lbs/week in older
children
Key points:
Goal setting and contingency management
Negative energy balance
Parental participation for children < 12 years old
Systematic evaluation of body measurements, diet, and activity
Frequent visits up to weekly for 8 to 12 weeks and then monthly
STAGE 4: TERTIARY CARE
•Refer to a pediatric tertiary care weight management center with treatment to
include diet, medication, and /or surgery
WEIGHT GOALS (adapted from the AAP 2007 guidelines)
BMI
85th-94th%
95th-98th%
2-5 years old
WM or  WG
WM
≥99th%
WL of ≤ 1 pound
per month (with
BMI ≥ 21)
6-11 years old
WM
Gradual WL of 1
pound per month
WL of ≤ 2 pounds
per week
WM = weight maintenance
WG = weight gain
WL = weight loss
OTHER TREATMENT RESOURCES
MOTIVATIONAL INTERVIEWING (Miller and Rolnick)
Express empathy
Develop discrepancy
Roll with resistance
12-18 years old
WM or gradual WL
WL of ≤ 2 pounds
per week
WL of ≤ 2 pounds
per week
Support self-efficacy
Avoid argumentation
EATING AND ACTIVITY PLANS:
•MyPyramid.gov dietary plan based on age and activity level
•Plate Method: American Diabetes Association - Create Your Plate
•Glycemic index
•5210 (from Maine Medical Center):
5 or more servings of fruits and vegetables per day
2 hours or less of recreational screen time per day
1 hour or more of physical activity per day
0 sugary drinks
2008 HHS Physical Activity Guidelines for Americans
Key targets:
Aerobic activity (running, swimming, dancing, cycling, etc.)
Muscle-strengthening activity (climbing, playing tug-of-war, lifting weights, etc.)
Bone-strengthening activity (running, jumproping, basketball, etc.)
Recommendation: 60 minutes or more of physical activity daily
Mostly moderate or vigorous intensity aerobic activity with vigorous activity
≥ 3 days per week
Muscle-strengthening activity at least 3 days per week
Bone-strengthening activity at least 3 days per week
Parent handouts:
Checklists for 2-7 years old, 8-12 years old, and teens in English and Spanish
(source: Dan Delgado, MD on the AAP California Chapter 1 website)
Beverages - Sugary drinks and childhood obesity
Food labels - Read It Before You Eat It
High fiber diet - Fiber and Your Child
Organic Essentials pocket guide from the Organic Center
Serving size - What size is your serving?
Vegetarian diet - Vegetarianism
http://www.fitness.gov/kidstips.pdf -> general handout targeted for kids
http://www.nutritionexplorations.org/pdf/educators/Healthier_eating.pdf ->
handout for parents discussing how to eat from the food groups
http://www.fns.usda.gov/tn/resources/nibbles/readit_poster.pdf -> easy handout
on how to read basics of a nutrition label using the 5/20% rule
http://www.nal.usda.gov/wicworks/Sharing_Center/MO/Lets_Eat_Out.pdf ->
tips on making healthier choices at fast food restaurants, also available in spanishhttp://www.nal.usda.gov/wicworks/Sharing_Center/MO/Lets_Eat_Outsp.pdf
http://www.nche.org/2003TheKidsActivityPyramid.pdf -> colorful activity pyramid
for kids with ideas on how to get moving
http://www.dshs.state.tx.us/wichd/nut/pdf/NR00015.pdf -> handout on portion
sizes for both young children & adults in English and Spanish, pages 7 and 8
COMMUNITY RESOURCES:
Boys and Girls Club
East Palo Alto activity guide: www.epaguide.org
Farmers markets
Gardening ---> Collective Roots
Running ---> Girls on the Run
YMCA
East Palo Alto
Sequoia-Redwood City (Fit Families Program)
GROUP TREAMENT PROGRAMS:
Packard Pediatric Weight Control Program
650-725-4244
Kids 8 to 12 and 13 to 15 years old
Weekly meetings over 6 months for parents and kids
SHAPEDOWN
TOPS = Taking Off Pounds Sensibly
Weight Watchers
Parent handout: Weight Management Resources for Kids and Teens PDF
WEIGHT LOSS MEDICATION: (FDA-approved)
•Orlistat(Xenical, Alli) ≥ 12 years old
•Sibutramine (Meridia) ≥ 16 years old
BARIATRIC SURGERY:
LPCH Adolescent Bariatric Surgery Program
Refer to Weight Clinic at Castro Commons
Criteria:
Completion of growth (generally ≥ 13 years in girls and ≥ 15 years in boys)
BMI ≥ 35 with major comorbidities of obesity
BMI ≥ 40 with lesser comorbidities of obesity
For further reference see:
2004 report in Pediatrics by Inge, et al:
Bariatric Surgery for Severely Overweight Adolescents: Concerns and
Recommendations
2009 report in Obesity by Pratt, et al:
Best Practice Updates for Pediatric/Adolescent Weight Loss Surgery
WES 11/09