Obesity Flashcards
(70 cards)
1
Q
Normal or healthy weight in a pediatric population
percentiles
A
> 5th and < 85th
2
Q
Overweight in pediatric population
percentiles
A
> 85th and < 95th
3
Q
Obese in pediatric population
percentiles
A
_>_95th
4
Q
Components of Dietary and Physical Activity Assessment
A
5
Q
ROS findings in setting of pediatric obesity + possible causes
A
6
Q
Components of a physical exam in setting of pediatric overweight/obesity
A
•Blood Pressure
•Height and weight
•BMI
•Ideal body weight
•Skin
•Skinfold thickness*
- •Midarm circumference**
- •Waist circumference measurements**
- *not recommended by expert committee*
7
Q
Diagnostic evaluation
85th-94th % for weight (overweight) with and w/o risk factors
A
- No Risk factors: fasting lipids
- Risk factors: lipids, AST and ALT, fasting BG
- Risk factors: family hx obesity related dzes, elevated BP, elevated lipids, tobacco use)*
- *other tests may be ordered based on RFs - e.g., nocturnal polysomnography, OGTT, TFTs, etc*
8
Q
Diagnostic evaluation: > 95th percentile
A
Fasting lipids, AST & ALT, fasting glc
*other tests may be ordered based on RFs - e.g., nocturnal polysomnography, OGTT, TFTs, etc
9
Q
Major health risks of obesity for pediatric patients
A
- High BP and high cholesterol (RFs for CVD).
- Fatty liver disease, gallstones, GERD
- impaired glucose tolerance, insulin resistance, T2D
- Breathing problems, such as sleep apnea, and asthma.
- Joint problems and musculoskeletal discomfort.
- depression, behavioral problems, and issues in school.
- Low self-esteem, low self-reported QoL
- Impaired social, physical, and emotional functioning.
- more likely to become obese adults.
10
Q
Causes of pediatric dyslipidemia
A
- Genetic defects, including familial hypercholesterolemia, familial defective apolipoprotein B, and familial hypertriglyceridemia.
- Secondary dyslipidemia related to obesity, type 2 diabetes or drug exposures.
11
Q
How do kids differ/change in terms of lipid levels?
A
- Change through growth.
- Very low at birth and rise slowly to 2yo.
- Levels remain relatively constant: 2 years until adolescence.
- Puberty TC and LDL decrease
- then rise in the late teen years.
- Males: decrease in HDL during puberty.
- Female: HDL levels remain stable until menopause.
12
Q
Reasons we may be missing kids w/risk factors
A
Not asking
Widespread statin use in parents mask CVD risk
13
Q
Universal screening for dyslipidemia?
A
NHLBI recommends! D/t lack of accurate clinical markers to ID at risk
14
Q
When to screen lipid levels in kids?
A
- 9-11yo
- 17 to 21 yo (after HDL and LDL changes that occur during puberty)
- Nothing under 2yo, selectively at other times
15
Q
Fasting vs non-fasting lipids in kids w/no known risk factors
A
TC and HDL: preferred
can be measured accurately in non-fasting individuals making it more practical in pediatrics.
16
Q
What to do if fasting lipids are abnormal?
A
measure at least twice
Intervals between measurements should be two weeks to three months
17
Q
Non-pharm tx of hyperlipidemia in pediatric population
A
Dietary interventions
Elimination of smoke exposure
Increased activity
18
Q
Pharm tx of HLD in pediatric population
A
- Statins
- Fibric acids
- Bile acid sequestrants
- Omega-3 fish oils
*Most statins approved in kids _>_10yo
19
Q
Relationship between childhood BP and adult BP
A
Childhood BP is a predictor
20
Q
CV risks associated w/HTN in kids
A
contributes to early dvpt of CVD
21
Q
T/F
Childhood HTN is defined by normative distribution rather than clinical outcomes.
A
True
22
Q
Most important determinant of BP in kids
A
BMI
23
Q
Symptoms of HTN in kids
A
- Headache
- Seizures
- Changes in mental status
- Focal neurologic complaints
- Visual disturbances
- CV complaints indicative of HF such as CP, palpitations, cough, or SOB
24
Q
BP screening Recs
AAP
A
Begin at 3yo for routine office and emergency visits
Before 3yo if hx of neonatal complications
25
Percentiles for normal BP in kids
SBP and DBP \<90th%
26
Percentiles for prehypertension in kids
Prehypertension:
SBP or DBP ≥90th% but \<95th% or
\>120/80 mmHg
(even if \<90th% for age, gender, and height)
27
Stages 1 and 2 HTN in kids
percentiles
* Must be measured on 3+ separate occasions
* Stage 1: SBP/DBP between 95th% and 99th% + 4mmHg
* Stage 2 HTN: SBP/DBP _\>_99th% + 5mmHg
28
Follow up if pre-HTN
recheck in 6 months
29
F/U if stage 1 HTN
recheck in 2 weeks or sooner if patient is symptomatic
30
F/U if stage 2 HTN
If symptomatic: evaluate immediately
If not: evaluate w/in the week
31
Non-pharm Tx for HTN in kids
* Weight reduction
* systolic and diastolic BP falls 1 mmHg for each 1 kg lost
* Regular exercise
* Diet modifications, including salt restrictions
32
Pharm Tx for HTN: Who is a candidate?
Limited to those who are most likely to benefit
* Symptomatic HTN
* Stage 2 HTN
* Stage 1 HTN that persists despite 4-6 months of nonpharmacolgic therapy
* Patients with diabetes or dyslipidemia
33
Pharm Tx for HTN: what are your choices?
ACE/ARB
Thiazide
BB
CCB
34
most common cause of liver disease in children
obesity - non-alcoholic fatty liver disease
35
Steatosis vs NASH
* **Steatosis** - increased liver fat _without_ inflammation
* **Non-alcoholic steatohepatitis (NASH) -** increased liver fat _with_ inflammation
* not well described in kids. May --\> fibrosis, cirrhosis, and ultimately liver failure
36
Pathogenesis of fatty liver disease in kids
Not fully understood but is linked to insulin resistance
Common comorbidities: insulin resistance, dyslipidemia and hypertension.
37
Diagnosis of fatty liver disease: signs, labs, imaging, diagnostic tests
* **Signs:** RUQ pain, hepatomegaly, abdominal discomfort, weakness, fatigue or malaise.
* **Lab:** Elevation in ALT, AST, alkaline phosphate and gamma glutamyl transpeptidase.
* **Imaging:** US, MRI more accurate
* Liver biopsy indications have not been established.
38
Tx for fatty liver in kids
* Weight loss
* Emphasis on physical activity, improves insulin sensitivity
* Counsel against alcohol use
39
Orthopedic issues r/t obesity in kids
* Joint pains
* Excess sprains/strains
* Forceful falls
* Lengthier recovery time
* Back pain due to excess abdominal weight
* SCFE & Blount’s (bow-legs)
40
What is SCFE?
SCFE – Slipped capital femoral epiphysis
actually the proximal femur that slips, misnomer
UpToDate: AVN is a rare unlikely complication of SCFE - more associated with Legg Calve Perthes (typically ages 4-10yo)
41
Polycystic Ovary Syndrome (PCOS): S/S
* Obesity
* Hirsutism
* Scalp hair loss
* Treatment-resistant acne
* Menstrual irregularity
* Excessive menstrual bleeding
* Acanthosis nigricans
* Hyperhidrosis
42
H&P findings of PCOS
* Medication hx
* that mask (OCPs or systemic acne meds) or cause (androgenic steroids or antiepileptic drugs) symptoms
* Degree and distribution of sexual hair growth (Ferriman-Gallwey Score)
43
Causes of PCOS
* Unknown!
* Contributions heritable and nonheritbale intrauterine and extrauterine factors
* Insulin resistance
* Obesity\*
44
Lab / Diagnostic testing for PCOS
* Serum testosterone: total is cheaper, free is better
* DHEAS
Other possible tests: cortisol to r/o Cushing's, TSH to r/o thyroid, U/S to r/o tumor
45
Tx of PCOS
* First line: combination **OCPs!**
* Hair reduction methods and anti-androgen tx– for uncontrolled hirsutism
* Lifestyle modification is first line treatment for overweight and obesity
* Metformin: possible but role still controversial in adolescents
* abnl glc tolerance, lipid abnormalities not normalized by wt loss
* titrate to max of 2000 mg/day
46
Duration of PCOS tx
not clear
Recommendation: until gynecologically mature (5 years post menarche) or substantial wt loss
47
Longterm risks of PCOS
Increased risk for metabolic syndrome, T2D, CVD, endometrial carcinoma
48
S/S of prediabetes
* Overweight or obese (BMI _\>_85th percentile)
* Weight change, polydipsia, polyuria, blurred vision
* Clinical features associated with insulin resistance:
* Acanthosis nigricans, hypertension, dyslipidemia, s/s of PCOS
* +FHx
49
Who should be screened for T2D?
* Overweight or obese and have 2+ following:
* T2DM in a 1st or 2nd -degree relative
* High-risk racial/ethnic group: Native American, African American, Latino, Asian American, or Pacific Islander
* Signs of insulin resistance or conditions associated with insulin
* Maternal history of DM or GDM during the child's gestation
50
Diagnostic criteria for prediabetes
51
Diagnostic criteria for diabetes
52
Tx for prediabetes
* Intensive lifestyle interventions
* Weight reduction
* Dietary Interventions
* Physical Exercise
* Screened and rescreened for T2DM at least annually
* Metformin: controversial
53
OSA: S/S in kids
* Disrupted sleep
* Frequent awakening, gasping, agitated sleep, apnea, restless sleep, or sleeping in unusual position
* Parasomnias
* Nocturnal enuresis
* Snoring
* Daytime symptoms
* Mouth breathing & hyponasal speech, HA, excessive daytime sleepiness
54
OSA: PE in kids
* Most children with OSA have normal PE except:
* Adenotonsillar hypertrophy\*
* Obesity\*
* Poor growth
* High arched palate
55
Sequelae of untreated OSA in kids
* -cardiovascular complications
* -impaired growth (including failure to thrive)
* -learning problems
* -behavioral problems
* -Early diagnosis and treatment of OSA may decrease morbidity. However, diagnosis is frequently delayed.
56
OSA: grading of tonsil size in kids
57
Causes of OSA in kids
* Abnormal upper airway anatomy
* Adenoid hypertrophy
* Chronic nasal congestion
* Abnormal maxillomandibular development
* Neuromotor disease
58
Screening and diagnostics for OSA in kids
* Nocturnal Polysomnography (PSG)
* If PSG not available, referral to otolaryngologist for home sleep apnea test
* Pediatric Sleep Questionnaire
* Sleep Related Disorder Scale (SRBD)
* I’M SLEEPY screening tool
59
According to the American Academy of Sleep Medicine (AASM) A and B criteria should be present for a child to be diagnosed with OSA.
* A criteria – one or more:
* Snoring
* Labored, paradoxical, or obstructed breathing during the child’s sleep
* Sleepiness, hyperactivity, behavioral problems, or learning problems
B criteria – (PSG) demonstrates one or both:
* One or more obstructive apneas, mixed apneas, or hypopneas, per hour of sleep.
* A pattern of obstructive hypoventilation, defined as at least 25% of total sleep time with hypercapnia (PaCO2 \>50 mmHg) associated with one or more of the following:
* Snoring
* Flattening of the nasal pressure waveform
* Paradoxical thoracoabdominal motion
60
Tx of OSA in kids
* Adenotonsillectomy: 1st line if healthy
* CPAP/BiPAP: if adenotonsillectomy C/Ied or insufficient
* Watchful waiting: if mild/moderate - can re-eval in 6mo
* Adjunctive Therapies
* Weight loss
* Environmental controls
## Footnote
*follow closely for recurrence. OSA may recur after treatment and may worsen with age or weight gain*
61
Major culprits in pediatric obesity?
* **Strongest evidence:** decreased physical activity, increased sedentary screen time, increased intake sugared beverages
* **Less rigorous evidence:** skipping breakfast, reduced intake of fruit, veggies, inadequate dietary fiber, fever family meals, more fast food dining
62
Expert AAP Committee Guidelines: pediatric obesity
* 1.Eliminate consumption of sugar-sweetened beverages
* 2.Limit television & other screen time (
* 3.Encourage \>1 hr moderate to vigorous activity daily
* 4.Eat breakfast daily
* 5.Encouraging \> 5 servings fruits & vegetables/d
* 6.Limit eating out, particularly fast foods
* 7.Encourage family meals in which parents & children eat together
* 8.Limit portion size- visualized with the new USDA plate model
* Also recommended:
* 9. A diet high in fiber, rich in calcium & balanced macronutrients
* 10. Restrict highly processed, calorie-dense, nutrient-poor foods
63
Weight maintenance vs weight loss in pediatric population?
* •Weight maintenance may be appropriate in younger children, as BMI will improve with increase in height.
* •Older children and severely obese children can lose up to 2 lbs a week.
64
AAPs 4 Stage approach for Weight Mgt
* 1.Prevention Plus
* 2.Structured Weight Management;
* 3.Comprehensive Multidisciplinary Intervention; and
* 4.Tertiary Care Intervention.
65
AAP prevention plus: describe this step
Introduced for children 2 -18 years with BMI of \>85th percentile.
* Nutrition Goals:
* Eat ≥5 servings of fruits and vegetables per day
* Elimination of sugar-sweetened beverages
* Eat breakfast every day
* Eat most meals at home as a family
* Activity Goals:
* \<2 hours of TV/screen time per day (if child is \<2, NO screen time)
* More than 1 hour of physical activity per day
* Behavioral Goals
* Reinforce goals at each health care visit
* Allow child to self regulate, avoid overly strict eating regimens
* Weight goals:
* Weight maintenance with growth that results in decreasing BMI as age increases.
* Follow up monthly!
* If no improvement in BMI/weight status after 3-6 months, then advancement to stage 2 is indicated
66
AAP: structured weight management
describe this goal
* Nutrition Goals: Stage 1 plus:
* Daily eating plan, with scheduled meals and snacks (breakfast, lunch, dinner and 1-2 snacks per day)
* Emphasize foods with low energy density
* Reduce frequency and quantity of foods with high energy density (e.g., fried food, baked goods, fats, etc.)
* Limit portion size
* Set explicit behavior goals
* Activity Goals:
* Less than 1 hour of TV/other screen time daily
* More than 1 hour of supervised active play per day, to ensure activity
* Behavioral Goals
* Monitor eating and physical activities through logs
* Use positive reinforcement techniques (reward system)
* Strong parental involvement for school-aged children
* Weight goals:
* Wt. maintenance w/ growth that results in ↓BMI as age increases.
* Follow up monthly!
* If no improvement in BMI/weight status after 3-6 months, then advancement to stage 3 is indicated
67
AAP: Comprehensive Multidisciplinary Intervention
describe this goal
* Characterized by increased intensity of behavioral change strategies, greater frequency of patient-provider contact, and specialist involvement.
* Nutrition Goals: Stage 2 plus:
* Structured diet and physical activity designed for negative energy balance
* Activity Goals:
* Stage 2 supported by behavioral interventions
* Behavioral Goals
* Similar, but with increased structure and accountability
* Parent training in behavioral techniques to improve home eating and activity environment
* Weight goals:
* Wt. maintenance or gradual weight loss until BMI is in 85th percentile.
* Weight loss should not exceed 1 lb/month for children 2 to 5 years of age or 2 lb/week for older obese children and adolescents.
* Follow up weekly!
* If no improvement in BMI/weight status after 3-6 months, then advancement to stage 4 is indicated
68
AAP: 4. Tertiary Care Interventions
describe this goal
* For severely obese youths who have been unable to improve their degree of adiposity and morbidity risks through lifestyle interventions.
* Candidates should have
* attempted weight loss at the level of stage 3 (comprehensive multidisciplinary intervention),
* should have the maturity to understand possible risks associated with stage 4 interventions,
* and should be willing to maintain physical activity, to follow a prescribed diet, and to participate in behavior monitoring.
69
Modalities for tertiary interventions
pediatric obesity
Various
* highly structured diet
* medications: orlistat
* bariatric surgery.
70
When to dose statins
HS: LDL synthesis occurs at night
