Care of the Pediatric Obese
Patient: A Practical Approach
Lisa L Watson, CPNP
Clinical Operations Lead
Duke Healthy Lifestyles
Financial Disclosures
 I have no financial disclosures (unfortunately)…
By the end of this talk, I hope you…
 See obesity for what it is – a sign of what’s really
going on
 Treat obesity as a chronic illness that requires followup and ongoing changes in treatment
 Realize that confrontational measures often backfire
 Have an increased appreciation for how hard it is to
lose weight
 Come away with at least one concrete way you can
help these kids
Why Should We Care
Retrieved from http://www.mozartinshape.org/misvsobesity/whymis.php?id=ch02 on October 17, 2013
Obese kids have similar quality of life
scores as kids with cancer…
JAMA. 2003 Apr 9;289(14):1813-9.
Health-related quality of life of severely obese children and adolescents.
Results: Compared with healthy children and adolescents, obese children and
adolescents reported significantly (P<.001) lower health-related QOL in all domains
(mean [SD] total score, 67 [16.3] for obese children and adolescents; 83 [14.8] for
healthy children and adolescents). Obese children and adolescents were more likely to
have impaired health-related QOL than healthy children and adolescents (odds ratio
[OR], 5.5; 95% confidence interval [CI], 3.4-8.7) and were similar to children and
adolescents diagnosed as having cancer (OR, 1.3; 95% CI, 0.8-2.3). Children and
adolescents with obstructive sleep apnea reported a significantly lower health-related
QOL total score (mean [SD], 53.8 [13.3]) than obese children and adolescents without
obstructive sleep apnea (mean [SD], 67.9 [16.2]). For parent proxy report, the child or
adolescent's BMI z score was significantly inversely correlated with total score (r = 0.246; P =.01), physical functioning (r = -0.263; P<.01), social functioning (r = -0.347;
P<.001), and psychosocial functioning (r = -0.209; P =.03).
Epidemic within an epidemic
 Childhood obesity has more than doubled in the past 30
years.
 By comparison, the proportion of children classified as
“severely obese” has tripled.
 Currently 4% of all children fall in this category.
 By 2030, overall obesity in the US is expected to increase
by 31% while severe obesity is expected to increase by
130%.
Ogden CL et al. Journal of the American Medical Association 2014;311(8):806-814.
National Center for Health Statistics. Health, United States, 2011: U.S. Department of HHS; 2012.
National Institutes of NHLBI, 2010.
IOM, Dietz W et al, Roundtable on Childhood Obesity, 2014.
Skelton et al, Archives, 2009.
Finkelstein E, American Journal of Preventative Medicine, 2012.
Why is this SO Hard?
This isn’t rocket science…..
……it’s harder
Why is this SOOOO Hard?
Retrieved from: https://www.google.com/search?q=metabolic+pathways&espv=2&biw=1204&bih=631&source=lnms&tbm=isch&sa=X&ved=0CAYQ_AUoAWoVChMIzOHo-ccyAIVg5qACh34SQsh&dpr=1#imgrc=wNHhoHn8yZWQGM%3A, September 29, 2015.
A Calorie is NOT a Calorie
 Continued misconception:
 Food intake – Energy expenditure = Net weight gain
Example
Multiple systems regulate weight
Hormonal Control
a) Adipokines
b) Gastrointestinal peptides
Neural Control
a) Homeostatic system (metabolic brain)
b) Hedonic system (emotional brain)
c) Cognitive brain
Environmental Control
a) Stress
b) Circadian rhythm
c) Thermoregulation and BAT
d) Microbiota
e) Infection
Berthoud et al, Physiology, 2008, 23 75-83
Adipose Tissue IS an Organ
 Old Definition: An inert tissue
 “Adipose tissue, or fat, is an anatomical term for loose
connective tissue composed of adipocytes. Its main role
is to store energy in the form of fat, although it also
cushions and insulates the body.”
-Google
Adipose Tissue IS an Organ
 New Definition: A dynamic metabolic organ
 Adipose tissue, or fat, is a dynamic and varied endocrine
organ comprised of several cell types. Its physiology and
functions are, in part, distribution-dependent. A
complex interplay of neurohormonal factors determines
its synthesis, breakdown, and storage.
Ahmed, N. (2015). Pathophysiology of Obesity, Blackburn Course in Obesity Medicine
The Adipocyte: An Endocrine Factory
Over 600 adipokines have been identified!
Retrieved from
https://www.google.com/search?q=adipose+tissue&es_sm=93&source=lnms&tbm=isch&sa=X&ved=0CAcQ_AUoAWoVChMI3MuqlZGgyAIVBpACh26Iwvh&biw=1204&bih=631#imgdii=fLywxRLs6Eo33M%3A%3BfLywxRLs6Eo33M%3A%3Bup7D8Hkg30_eAM%3A&imgrc=fLywxRLs6Eo33M%3A,
September 30, 2015.
So Now We’re Here…Now What?
 Step 1: Broach the topic of obesity with the family
 Step 2: Find out what’s important to the patient (it’s
usually NOT their health)
 Step 3: Take a lifestyle history
 Step 4: Check for Comorbidities
 Step 5: Treat Comorbididities and use motiviational
interviewing to encourage lifestyle/behavioral change
 Step 6: Manage expectations, keep engaged,
reevaluate, refer
STEP 1
How to Breach the Topic of Obesity
with the Patient and Family
Talking About BMI
 BMI: weight (kg) / [height (m)]2
 Talk about it as a way of predicting future
health, not weight. (ie “The BMI is your
health number.”)
 Predicts risk of future heart disease,
diabetes, etc.
 Think of it like a stop light
 Refer to the child’s BMI as a zone
(green zone, yellow zone, red zone)
 AVOID language like healthy weight,
overweight, obese
 Don’t necessarily want to lose weight.
May just need to stabilize rate of weight
gain.
 Remind them it’s not all about the numbers
Retrieved from
http://prowellness.vmhost.psu.edu/prevention/understanding_risk/
bmi on November 2, 2013
Step 2: Find out what’s important to
your patient
 What would be better or easier if you lost weight? If
you can make one thing in your life better, what
would it be?
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Sports
Clothes
Friends
Feeling better
Less teasing
Step 3:
Take a lifestyle history
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5 vegetables and fruits
3 meals a day
2 no more than 2 hours of screen time
1 hour of daily activity
Almost none of the sugary stuff
Sleep
Eating behaviors (eating quickly, second helpings, what
does it feel like when they’re full, food sneaking/seeking
behaviors)
STEP 4:
Rule Out Comorbidities
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Insulin Resistance (prediabetes)/Diabetes
Heart Disease
Nonalcoholic Fatty Liver Disease (NAFLD)
Kidney Disease
Musculoskeletal Abnormalities
Endocrine Abnormalities
Reproductive issues
Psychological Disorders
Genetic Causes
Tests to Consider
 Blood Pressure Screen:
 Check 2 BPs with each visit (use average of the two)
 If high, double check manually
 Diabetes Screen:
 Fasting glucose, insulin, HgbA1c
 Cholesterol Screen:
 Fasting lipid panel with calculated LDL
 HS CRP
 NAFLD Screen:
 ALT, AST
 Thyroid Screen:
 TSH
 Other Screens:
 Uric Acid
 25-OH Vit D
 Urine Microalbumin
Insulin Resistance / Type 2 Diabetes
Fasting Labs:
Glucose: >100 or
Insulin >17
A1c: 5.7-6.4 insulin resistance
A1c 6.5 or > is T2DM
Look for acanthosis in nuchal folds, axilla, groin
How to treat IRS
 For all levels of insulin resistance:
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Decrease CHO
Increase protein (EVERYTIME they eat they need a protein)
Increase exercise
Consider low carbohydrate diet
 A1c >6% - treat with metformin to prevent progression to T2DM
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Start metformin 500mg PO with dinner x 1 week. If tolerating well, increase to 1000mg
daily. May go as high as 2 grams daily
Refer to Healthy Lifestyles
 A1c > 6.5% - still start metformin, add BID glucose checks and
endocrine referral (page them), and refer to Healthy Lifestyles
 Start metformin 500mg PO with dinner x 1 week. If tolerating well,
increase to 1000mg daily. May go as high as 2 grams daily
Heart Disease
 Fasting lipid panel with calculated LDL:
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Total Cholesterol < 170
LDL < 130
HDL > 40 (ideally > 60)
Triglycerides < 110
High Sensitivity C-Reactive Protein (predicts risk of
athelerosclerosis)
 < 0.3 Low risk
 0.3-0.5: Moderate risk
 >0.5: High risk
How to Treat High Cholesterol
DO NOT RECOMMEND LOW FAT! When you take fat out of
food, sugar content rises. Leads to worsening lipid profiles.
Instead:
 Hyperlipidemia:
 LDL >160mg/dL refer to lipid clinic for consideration of statins
 Low HDL (HDL < 40mg/dL):
 Increase exercise, avoid partially hydrogenated oils
 Hypertriglyceridemia (Triglycerides > 110mg/dL):
 Decrease CHO intake
 Mixed Dyslipidemia (any combo of the above, but usually
Triglycerides > 100mg/dL, HDL < 40mg/dL):
 Total Cholesterol > 170mg/dL and/or LDL > 130mg/dL <
160mg/dL:
How to Treat Elevated HS CRP
 HS CRP > 0.3 mg/dL (at any risk level)
 Encourage anti-inflammatory diet by decreasing CHO
 Increase exercise
 Repeat in 6 to 12 months
How to Treat Elevated
BP/Hypertension
 You’ve already had 2 great talks about this.
 
Nonalcoholic Fatty Liver Disease
 Caused by excessive central adiposity
 ALT > 40U/L
 Need to rule out other causes (ie infectious,
autoimmune)
 Hispanic males most susceptible
Retrieved from
https://www.google.com/search?q=fatty+
liver&biw=1600&bih=759&source=lnms&
tbm=isch&sa=X&sqi=2&ved=0CAYQ_AUo
AWoVChMIupDynuahyAIVAY0NCh2K2wH
1#imgrc=FIjlp6jITXsVnM%3A October 1,
2015
How to Treat NAFLD
 Decrease central adiposity
 Low carbohydrate diet
 Increase exercise
 Refer to GI if ALT elevated longer than 12 months or if
ALT > 90U/L.
Vitamin D
 There is NO agreed upon guideline for norms and
supplementation
 Vitamin D Deficiency: < 20ng/mL
 Supplement vitamin D3 2000 IU daily; take with adequate
calcium source
 Recheck in 8 weeks
 Vitamin D Insufficiency: 20-30ng/mL
 Daily MVI
When to suspect an intrinsic/genetic
cause?
 S/Sx of endocrine dysfunction
 i.e. signs of hypothyroidism, dorsocervical fat pad, moon
facies, hypogonadism
 Consider TSH, 8AM cortisol, testosterone, endocrine
referral
 Dysmorphic features
 Consider FISH and genetic referral
 Early onset obesity before the age of 5 years old
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Leptin Deficiency
MC4R Mutation
Prader Willi
Consider genetic referral
Physical Exam
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Acanthosis
Striae
“Buffalo hump”, “moon facies”
Tonisillar hypertrophy, swollen turbinates
Liver hypertrophy
Genu Varus/Genu Valgum
Pes planus
Panniculosis/Panniculitis
Acanthosis
Retrieved from http://escholarship.org/uc/item/6fj340w2 on November 2, 2013.
Striae
Retrieved from http://pictures.doccheck.com/com/photo/15948-striae-distensae-stretch-marks on October 1, 2015
Buffalo Hump & Moon Facies
Retrieved from
http://www.plasticsurgeryportal.com//articles/buffalohump-removal-surgery/318 on
November 2, 2013.
Retrieved from
http://jofem.org/index.php/jofem/article/view/5/16 on
November 2, 2013.
Tonsilar Hypertrophy
Swollen Turbinates
Retrieved from
http://emedicine.medscape.com/article/868925-overview on November
2, 2013.
Retrieved from http://chandrajayasuriya.com/?q=node/43 on
November 2, 2013.
Genu Valgum
Genu Varus

Retrieved from http://bowlegs.com.ua/deforming_arthrosis.htm on November 2, 2013.
Pes Planus
Retrieved from http://www.eurolab.ua/skin-beauty/915/ on November 2, 2013.
Panniculosis

Retrieved from http://www.dermis.net/dermisroot/en/39760/image.htm on November 2, 2013.
OBESITY IS JUST A SIGN OF WHAT’S
REALLY GOING ON
 Don’t forget to assess for social stressors, trauma,
bullying, depression, anxiety (both in the child and in
the parent)
 PHQ, PSC, SCARED screens
If you do not get a hold of the psychological component,
you will not get a hold of the obesity…
Remember – you don’t know the
whole story
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Parents working 2 jobs
Homelessness
Risk of deportation
Violence
Unsafe neighborhoods
Depression/Anxiety
Chronic Illness
Food Insecurity
Poverty….poverty…poverty
Build Your Team – this takes a
multidisciplinary approach
 PT – consider exercise fitness testing, aquatic
therapy. (Remember, these kids are deconditioned.
Your first job is to keep them safe and injury free).
 RD – partner with a dietician to help guide the
families in lifestyle changes
 Mental Health – help the family overcome underlying
issues and stress
Duke Healthy Lifestyles
 Referral based clinic
 Child must have BMI > 95th%
 Multidisciplinary team
 Medical providers, dieticians, PT, LPC
 Access to Bull City Fit
 Assess and manage comorbidities related to pediatric
obesity
 Use MI to guide patients and families toward healthy
change
Questions?
 Contact me anytime
 Lisa.watson@duke.edu
 (919) 684-1297 (office)
 (919) 620-5394 (appointment)