Chapters Transcript Wait! I'm not a Pediatric Obesity Specialist… What can I do? Jennifer Sprague, MD, PhD, discusses that many factors contribute to the development of obesity. So I'm talking to you today about pediatric obesity, recognizing that you are not pediatric obesity specialist, but there is an awful lot that you can do anyways. So I do have a disclosure. I'm a site investigator for um a pharmaceutical study with rhythm pharmaceuticals and another study with Eli Lilly Teret. So the objectives today are recognize the complex factors that contribute to development of pediatric obesity, identify which patients with obesity are at risk for comorbidities and then describe treatment strategies for obesity and common comorbidities. Now, I like to start with a side note, words are really important. Before we start thinking about obesity as a disease, we have to keep in mind that the way we interact with patients can have a really big impact on how receptive they are to the medical guidance that you're giving. And there's a lot of weight stigma in um in the community, in the medical system and that can have a lot of unintended health consequences. So weight stigma can include things like describing patients who have obesity as lazy, less intelligent thinking of them as having poor willpower, not successful. People lacking self-discipline, non compliant by giving that stigma, there can be individual health consequences. Patients may be less likely to um make healthy choices because they, with their food because they are thinking, oh, it doesn't matter. Everyone thinks I'm bad. They may be less likely to be physically active because they think they're being judged when they're in a more active environment. There's an increased risk of psychological disorders. It may change the medical care that they're even offered and they may have decreased healthcare utilization. There's also in society, an increase in bullying and me it is frequent that obesity gets treated as or thought of as a lifestyle problem and not a disease. And that can have a really big impact on your patients outcomes. There's also public health consequences, there can be disregard for societal and environmental contributors to obesity. Lack of obesity prevention programs, increase health disparities and social inequalities. And when you put all of these things together, it can increase morbidity and mortality. Now, we all would like to think that we don't have this stigma. We are not biased, but I can tell you that most of us will have some degree of implicit bias. Um Implicit bias is that subconscious bias. And so this is just citing the Harvard implicit bias test that you can take online. There's lots of different categories that you can take it for. But this particular test was for where you're gonna use the term fat here because that's what's used in the implicit bias test but fat versus thin people, um and of all takers, there is a very significant over half had a automatic preference for thin over fat. So I would encourage you to consider taking this test and be aware that you likely have some degree of implicit bias as well. It's not that you can necessarily erase that, but being aware can help you be more aware of the words that you're choosing to use things you can use to reduce bias, being aware of your bias, um appropriately sizing office furniture. So we have lots of patients who come in and our traditional chairs in our exam rooms have arms on both sides, but many of our patients won't fit in those chairs. So even choosing the chairs that don't have arms or getting the double wide chairs can make a big difference for how comfortable the patient feels in the health care setting, appropriate capacity, medical equipment like exam tables, blood pressure cuffs, um including inclusive non stigmatizing images in what you display in your office and then avoiding stigmatizing language. Um When thinking about the languages that you are using um obesity weight is a very sensitive subject. So asking permission to even begin the discussion is really important. What concerns if any do you have about your child's growth and health? Can we talk about this avoiding labeling? So you've probably heard of person first language. Um So now we don't say the diabetic patient or the diabetic, we say the patient with diabetes, the same concept here, the with obesity, the patient with obesity because the patient is not the obesity of itself itself, they have obesity. Um And then when you're both in documentation and in in communication with the patient, um trying to use more neutral words like unhealthy weight, gaining too much weight or A BM I rather than more um disparaging words like morbidly obese. So B is fat, large chubby. So I'll get off my soapbox. We're gonna go through a patient that is from my clinic that we followed for several years and kind of think about her journey and how that could relate to um you guys in rural Illinois. So this was a 12 year old girl who we initially met in January of 2017. Um she presented with Polyuria Polydipsia. She had lost 22 pounds, which she thought was in the intentional, she had been trying to lose weight for six months. Um Her PC P had ordered Baseline labs and she had a random glucose level of 300 a one c of 10%. Her exam was notable for obesity. Her weight was 279 pounds. She did not have aosis at the time but she had negative diabetes and antibodies. So we're gonna call her type two diabetes. She had an elevated A LT level. She got started on basal bolus insulin as well. As Metformin. This is her growth chart. So this is a BM I chart using the extended BM I chart in available in epic. Um So you're probably aware that greater than the 85th percentile is overweight, greater than the 95th percentile is obesity greater than 1 20% of the 95th is class two, obesity greater than 1. 40% of the 95th is class three obesity. So class two and class three are both severe obesity. Her BM I was around 1 70% of the 95th percent of diagnosis. So pretty high. So this patient, she has obesity. How are we really gonna define that? We can define it by BM. I, I'll show you that graph again on the next slide. But I also want to ask you to think about it in a different way, not just as the numbers, but to think about it as a chronic progressive disease, it's relapsing, so it'll get better, it'll get worse. It's multifactorial, it's a neurobehavioral disease where an increase in body fat, pros adipose tissue dysfunction, abnormal fat mass physical forces and that can cause adverse metabolic biomechanical and social psychosocial health consequences. I like this definition from the Obesity Medicine Association because it's really broad and it makes you think about all the factors that contribute to obesity and the consequences of obesity. This slide is showing those cut points for overweight versus obese. So again, obese is greater than the 95th percentile and this is breaking it down into those classes of obesity. Again, this is available in epic you can change that growth chart um and not have to pull it up and plot it yourself. All right. So this graph is showing obesity increase in prevalence. So this is looking at um data from the National Health Nutrition Examination survey or N Haines from the 19 sixties up to the 2000 teens. And you can see there's been a significant rise in the prevalence of obesity over time. So that in the most recent data, we're approaching 20% of the pediatric population meeting criteria for obesity. Um and that's increased across all age groups. It is similar data, but now looking at just the more the breaking down the obesity classes. So the top line is class one obesity, the greater than the 95th percentile. But the bottom two lines are class two greater than 100 and 20% or class three, greater than um 100 and 40% of the 95th percentile. And I want you to notice that these lines, well, they're still much lower than the overall obesity prevalence. Class three, obesity has more than doubled in the last, this was only from 1999 to 2014. So it went from 0.9% to 2.4%. So both we've got an increase in total obesity and we've got an increase in the severity of obesity. Ok. So this is what we normally think about when we're sort of in general conversation considering how does this play out? How do we end up with obesity? An imbalance in energy intake and energy and expenditure. Um and when we have them in balance, we stay at a body weight set point. Body is way more complicated than that. So there are so many factors that contribute to where that body weight set point wants to be. And those factors include biological things like in environment. If a baby was born small for gestational age or large for gestational age, both of those things can increase the risk of developing obesity, um gender age, other diseases, genetic susceptibility or epigenetic modification. Environmental factors like food availability, social determinants of health and many behavioral factors um including cultural um interactions with food, uh parenting styles, psychological factors. Many different things can contribute to where the body's weight wants to be and the likelihood of developing obesity and maintaining obesity if we weren't to think about it from a more hormonal and neurochemical perspective. Um This graphic while I recognize is complex, really does a nice job of laying out some of the signaling pathways that are involved in development and regulation of obesity. So this is all regulated in the hypothalamus. Um focusing on the arcuate nucleus and paraventricular nucleus. You may have heard of hormones like ghrelin, which is a hormone that signals increased hunger. Leptin is a hormone that's made by adipose tissue that um increases satiety. Um and these hormones signal in the arcuate arcuate nucleus through leptin receptors and through a pathway that you may heard referred to as MC four R receptor pathway um to decrease hunger um and regulate metabolism. So that an individual can maintain a steady body weight. There can be disruptions in these pathways that lead to genetic forms of obesity. So, obesity is very, very complex, many different factors regulating weight gain, pulling back a little bit more. This slide just highlights that as we're attempting to treat and address obesity, it's really important to keep in mind health disparities um and reaching for health equity because it is um those health inequities can increase the risk for an individual patient and often they're embedded in their environment and you risk um stigmatizing Children based on some of the factors that they can't control. Another factor that contributes to obesity is food insecurity. It's actually fairly prevalent um in patients who have obesity. And so I would encourage you to keep that in mind. Food insecurity can increase food anxiety and need to binging type behaviors. Um It can affect food choices and quality of nutrition and there's a very quick screen, the hunger, vital sign. It's just a two question screen that can be used to help pick up food insecurity. That screen is available within epic if you wanted to chart it within epic. And if you get a positive screen for 514, I think may actually be able to help you find food pantries also. Um But if not, there's a food pantry locator. Um on Saint Louis area, Food Bank, you can just plug in a zip code and they will pull up food pantries, not just for the metro area, but for a larger area too. We identify a lot of food insecurity in our patients who are seen for obesity. Ok. So now let's talk a little bit more about the medicine pieces. So what are the health consequences of obesity? We're gonna look at diabetes as a model. This is again using N Ha's data in adolescence. Um looking at the various from overweight being the lightest color, up to class three, obesity being the darkest color and the prevalence of cardiometabolic risk factors, cholesterol, blood pressure. Um and we're gonna zoom in on the diabetes risk factors. So, glycated hemoglobin and fasting glucose, glycated hemoglobin is what they're calling hemoglobin A one C you can see as the class of obesity goes of abnormalities in both of these goes up. And that is consistent with what we've seen in the incidence of type two diabetes. So now we're looking at search for diabetes in youth study. It's a multi center, it's a US multi center study. Looking at um type one and type two diabetes in the US. The first graph is type one diabetes in youth under age 19, there's slight increases over time from the early two thousands to 2012 but not a dramatic change that is different from type two diabetes. In the second graph where you can see, um the all is the purple, there's a significant trend upward, but it's more remarkable in this kind of brownish orangish color, which is the native American population and in the black triangles, which is the non Hispanic black. So you can see a really dramatic uptrend in incidence of type two diabetes that correlates well, with that increased incidence or prevalence of obesity in this youth population. And so many of these kids will get diagnosed with prediabetes. Um and some of those kids will revert actually to having normal glucose over time but not all. So what does happen to these youth? Um puberty, we know increases insulin resistance, insulin resistance is lower in adults than it is in pubertal adolescence. So this is data out of a Yale pediatric obesity clinic looking at um kids who had a BM I at least a 95 95th percentile and they did oral glucose tolerance test. They identified about, they identified 33 kids with impaired glucose tolerance. So meeting the criteria for prediabetes of those 33 kids, about half returned to normal glucose tolerance over about a year and a half, about a quarter progressed to having type two diabetes. So getting prediabetes is not an absolute thing you'll progress, some kids go back to normal but there is definitely an increased risk of progression. Sorry, I forgot I had those animations. We see a similar thing play out in the effect of pediatric obesity on adult onset type two diabetes. This was a study um out of Denmark. Um Looking at this is using a Danish Civil Service regis registration system and a National patient register. So it's looking at men only. Um But what they in this study is that in kids who in adults who had only had obesity at early childhood age seven, there was no increase in diabetes risk. Um but if they had had obesity in the teenage years, um or early adulthood, their risk increased significantly um towards getting type two diabetes. And so then the question becomes, can you prevent the complications if you lose weight? If a patient loses weight for that? We go to the diabetes prevention program study. Um This is another adult study. It was a goal of 7% weight loss, um targeting physical activity 100 and 50 minutes a week of moderate physical activity, um specific dietary changes and then some patients were treated with Metformin in addition to the lifestyle changes. Um and they saw that there was a significant reduction in progression from prediabetes to type two diabetes with just a 7% weight loss. So three years after the intervention, those who had had the lifestyle intervention had a 58% decrease in um in progression to diabetes. And even 15 years out from the study, they were no longer actively engaged in this lifestyle intervention. There was still a 24% decrease in type two diabetes. So we do believe and this is holds true in other complications of obesity, that weight loss can reduce the risk of progression of complications. So that brings me to thinking about obesity treatment as a chronic disease model that requires a longitudinal care model with non stigmatizing care. This is um this graphic comes from the pediatric obesity guidelines that were published by the A AP in early 2023. Um and really emphasizes the partnership between the patient, the family and the health care center. Um and illustrates the waxing waning course that you expect for obesity and highlights some of those really important things to keep in mind as you're trying to access care, minimize biases and stigmas promote healthy environments. Um And keep in mind some of the things that are much more difficult to control the adverse childhood experiences, racism and health inequities that you're trying to help these patients overcome. Ok. So what can you do in your initial clinical evaluation? Important things to think about are in their medical history. Do they already have known comorbidities? Are they on any obesogenic medications? Do they have normal developmental milestones or are there developmental concerns? Um looking at the weight history over time. So looking at those growth charts can really give us a lot of clues about when something changed. Should we be considering genetic causes? Should we be considering hormonal pro causes of obesity? A complete review of systems is important for the girls and men's history is important and then it's also relevant to know if family members also have obesity or if they have obesity complications, more specific in terms of beginning to think about treatment, the lifestyle history. So often we'll do a 24 hour diet recall. Um But this can also be done from a dietary perspective with food frequency questionnaires or asking about content of what they eat, location of what they eat, asking about sugary drinks, uncontrolled eating or sneaking um emotional eating from a physical activity perspective. We ask both about structured and unstructured activities, um pain and breathing limitations and then we usually take a screen time and a sleep pattern history. Um their social history, all of their mental health history is relevant. Peer relationships is relevant and disordered eating habits there while they may not meet criteria for anorexia. Um If you include a BM I criteria, we encounter a lot of kids who actually in thinking that they are trying to make themselves healthier, have stopped eating and really have an anorexic pattern of eating. So you don't want, you want to be very cautious that you're not promoting a disordered eating behavior. Um And that you're picking on it if somebody has already started that and then thinking about the support systems that they have available to them who's purchasing food. Um the involvement of family and friends, sometimes it's like a grandma who watches the kids after school that's offering very different foods than what the parents are trying to do at home. What is their living situation, their childcare situation, their cultural background and geographic location on physical exam. Um Most relevant things include height weight and BM I for anthro metrics, blood pressure, paying attention to blood pressure cuff size. Um Looking for any dysmorphic features that may make you consider a genetic or syndromic cause of obesity, skin findings that are relevant include stria and acanthosis as well as hers. Um This is an example picture of acanthosis *** cans indicating insulin resistance. Um This is a patient with a very dark purple, wide strea that you see in Cushing Syndrome. Um AT&T exam is relevant for Pablo Dema pseudotumor cerebra. Uh And do they have enlarged tonsils? Could they have a goiter? Pubertal staging is relevant. Um Thinking about PC os first time patients, it's not uncommon. We get a con consult for micro penis when it's really more just a buried prepuberal penis. Um and then orthopedic problems are also pretty common in those population. So as we then begin to think about could something besides the typical, the patient has got an unhealthy diet. There's a environmental um exposures are increasing their obesity risk is some or is something else going on endocrine disorders? We think about Cushing Syndrome, hypothyroidism, growth hormone deficiency or there's a rare disorder called R head syndrome. Um, most of these endocrine disorders that cause obesity are associated with poor linear growth in that genetic obesity where I showed you all the different hormonal signaling pathways, leptin leptin receptor PC MC four R, these are typically early onset, usually before age five and most will have hyperphagia associated with them to keep that near differential. And then there are multiple other genetic syndromes like Prader Willi Barnett beetle. Um Albright's hereditary osteodystrophy, many of these will have developmental delays, short stature, polydactyly retinopathy. They also have hyperphagia in many of them, identifying those specific causes of obesity. Secondary causes of obesity can be important because sometimes there's something you can treat directly. They have hypothyroidism. Well, that's not usually the cause of their obesity. I can definitely treat that and make things better. Um If they have a genetic disorder, sometimes there's a specific medication that will target that, that genetic disorder we also wanna consider could medications be contributing to weight gain. Um So insulin glucocorticoids, estrogen, progesterone Cipro heptad. I've actually been seeing a lot because I it's getting used um a fair amount in patients for migraines. Um So this is Periactin. Um but they may then end up with increased appetite and increased weight gain some anti seizure medications and then atypical antipsychotics like risperiDONE. Um, Abilify those increased appetite and increased weight gain. Sometimes you'll see a very abrupt change in weight trajectory and you can associate it with the started on this behavioral med at that time. Um, when possible, we like to try and choose weight neutral or negative medications if that's appropriate for whatever disorder you're treating. So, Metformin G LP one receptor agonist, lamoTRIgine, topiramate Zicam FLUoxetine are some of the preferred medications. So then we begin to think about what comorbidities go along with the obesity that your patient has. So we're gonna break it down into a few into three different categories, fat mass disease, metabolic disease, and then mental health often goes along too fat mass disease. This is things that are caused by truly the mass of the fat effect, how someone is functioning. So things like obstructive sleep apnea, asthma is worsened by obesity, intracranial hypertension, split, capital femoral sis plants disease and reflux disease, metabolic disease. We think about diabetes, prediabetes, hypertension, dyslipidemia, PC os and fatty liver disease. And then mental health, there's increased depression, anxiety, bullying, abuse, disordered, eating A DH D OK. Now, my slides are gonna go through the show you a lot of algorithms and kind of treatment strategies for the different comorbidities. So this is an algorithm coming from um those 2023 A AP guidelines on pediatric obesity. Really giving you guidance on when to begin screening um for comorbidities, you can see that all age groups, it's reasonable to, to screen with history. Um mental health screening, social determinants of health, physical examination and all ages blood pressure screening is appropriate whether overweight or obesity, um fasting lipid panel, they are primarily recommending for greater than age 10. Um but consider if less than 10 and having obesity and um diabetes screening or A LT definitely if they are above age 10, meaning they are pubertal um consider for under or for overweight. We I am often encountering those with severe obesity. So we do frequently do um metabolic screening in under age 10 but not usually before school age. So what do you do with these numbers? First, let's go through hypertension. Um So hypertension is classified based on age um and height blood pressure tables or percentiles. Um tables are available online. Um You can also look at the percentiles in epic rooming. There are apps for your phone that you can use as well to classify um the degree of blood pressure elevation. So a normal blood pressure is less than the 95th per or the less than the 90th percentile if you're less than 13, um or less than 1 20/80. If you're over 13, elevated blood pressure is gonna be greater than 90 to less than 95th percentile or if you're over 13, between 1 20/81 29/80. Um stage one hypertension is greater than the 95th percentile. Um Stage two is greater than the 95th percentile plus 12 millimeters, mercury or greater than 100 and 40. Over 90. If you make a diagnosis, hypertension, it should be an scul toy confirmed blood pressure. It shouldn't be an automated blood pressure reading. Um On three different visits. This is an algorithm coming from um pediatric hypertension guidelines. Just walking you through how to verify this elevated blood pressure. Really recommending um that the child sit and rest in a quiet room for 3 to 5 minutes before the measurement. Um the feet should be uncrossed. The blood pressure should be measured in the right arm for consistency to compare to standard tables. Um the arm should be at heart level supported and un uncovered by the cuff. Um Nobody should be speaking while they're taking the measurement and emphasizing the correct cuff size. If you get an elevated level, they do repeat the measure twice and take the average. So once you make a diagnosis of elevated blood pressure or stage one or two hypertension, this table walks you through what you're supposed to do with it. In all cases, they recommend lifestyle intervention to try and reduce the degree of blood pressure elevation. Um And the how quickly the patient needs to follow up is based on the degree of hypertension. Um So if they had normal blood pressure, they just need to be seen annually if they were elevated. So that's greater than the 90 birth percentile, they need a follow up in six months. Um And another six months later, if they're consistently having elevated blood pressure. So you're gonna think about referring typically to nephrology in our clinic. If the levels are higher, so greater than the 95th or greater than 1 30/80 then they're gonna get a 1 to 2 week follow up and then a three month follow up after that Again, considering referral. If they're persistently elevated, if there's stage three, greater than 1 40/90 you're gonna have a much sooner follow up within a week and you're gonna have a very low threshold. Probably refer right at the start to consider additional work up. And treatment. Labs may be helpful in the diagnostic evaluation. Nephrology again, is usually who helps us coordinate all of this. So, labs might include U analysis A B MP, um A renal ultrasound. Um or if the patient is less than six or if they've had an abnormal U A or abnormal renal function. And then depending on history and physical, they may get thyroid screening, drug screening, make it a sleep study. Um, sometimes a CBC or um if they've got growth delay or abnormal kidney function on their B MP. So what do they mean by lifestyle? Really? They're talking about the dash eating plan and what you're gonna see over all of these slides is all of these different diets are very much, they're very similar in what they recommend. All of the healthy lifestyle diets, recommend increasing fruits and vegetables, increasing whole grains, um generally low fat dairy, non fatty meats, increasing beans and nuts and um decreasing sodium. So this one is specific to the dash diet, but Mediterranean diet looks fairly similar. Um stoplight diet looks fairly similar. They're all kind of the same general concepts. Increase whole foods, increase fruits and vegetables, increase fiber, decrease processed food, decrease sodium intake. Ok. So let's think about diabetes and prediabetes. You're gonna encounter prediabetes much more frequently than diabetes. So, criteria for both come from the American Diabetes Association. Prediabetes is a fasting glucose between 101 20 five which we would call impaired fasting glucose. Um A two hour oral glucose tolerance test with the two hour glucose between 1 41 99. We call that impaired glucose tolerance or a hemoglobin. A one C between 5.7 and 6.4. Um, diabetes criteria is glucose greater than 1 26 2 hour glucose tolerance test of greater than 200 or random glucose above 200 with symptoms or a hemoglobin. A one C greater than 6.5. Now, I know you can't read this. So we're gonna zoom in on it. But this is what you do with all of those screening numbers. So, a one C 6.5 or greater or fasting glucose greater than 125. This is diabetes. They need treatment. They should not be sitting out in clinic waiting to get in. You should call us right away. Call us through children's direct. We will depending on the clinical picture, either ask you to send the patient to the ed, we may ask you to admit them directly or we may arrange outpatient diabetes education in a relatively short time frame within a week or two. Depending on if we think this patient has type one or type two and if they need insulin or probably don't need insulin right away, but please call us. If you think you have a patient with diabetes, we will get them in right away. Even if you've been told that they can't be seen in clinic for a month. If you talk to a physician, we will get them in. But again, you're gonna get a lot more prediabetes than you're gonna get um, a new onset diabetes. So this is what to do with the elevated A One CS. If you have an A one C between 5.7 and six, that's still a relatively low risk of progressing in a rapid time frame. If the A one C is six or higher, um, 6 to 6.4 then you're gonna have a higher rate of progression in both cases. We want lifestyle modification, educating the patient on symptoms that might prompt them to seek sooner care. Um, meaning symptoms of diabetes like polyuria, polydipsia. Um signs of dehydration and then follow up in that lower range. I would generally follow up between three and six months, generally with a repeat hemoglobin. A one C. If they're in that higher range, sometimes we will have the patient do an oral glucose tolerance test. We would definitely want to see them back and follow up in three months to repeat their hemoglobin. A one C. So what's the di the lifestyle modification for prediabetes again, looks very similar to hypertension. Um We do recommend involving a pediatric dietician. Um We encourage 60 minutes or more of vigorous physical activity every day, less than two hours of screen time a day, getting enough sleep and then illuminating sugar, sweetened beverages, five fruits and veggies a day and portion sizes. Um I'll show you later, I believe, but we often use a hand to guide us in portion sizes. So then we move on to non alcoholic fatty liver disease, which has been renamed, metabolic dysfunction, associated stoic liver disease are massed, so it's not muffled anymore. It's massed. Um This is generally picked up based on screening A LT levels. Um The upper limit of normal in screening for males in girls is an A LT of above 22 or boys above 26. So I generally just think about it as 25. It's easier to remember. Um, if their initial A LT is two times the upper limit of normal. This is really concerning, I encourage you to call pediatric gastroenterology or hepatology. Right. At the start to consider evaluation for other things. The vast majority of kids won't have that high level. They'll be less than two times the upper limit of normal, most won't have clinical symptoms of liver disease. And so you're gonna start with diet and lifestyle modification. Um, and follow up over time, there's a large differential diagnosis for pediatric, um, for fatty liver disease in Children, there can be genetic or metabolic disorders, um, including Wilson's disease, uncontrolled diabetes, lipodystrophy. Many medications can contribute to liver disease. Um, dietary causes and infectious causes are all part of the normal work up. So, if the A LT is staying more than two times the upper limit of normal called gastroenterology or hepatology and, um, get your patient seen and evaluated more comprehensively. But again, most fall into that lower range where we start with diet and lifestyle modification and a repeat A LT. Um, if A LT is remaining elevated, you would still consider referral to gastroenterology to make sure something else is not going on. So then as we think about treatment and again, looks very similar lifestyle changes, avoiding sugar, sweetened beverages, increasing, um, and promoting a healthy well balanced diet, moderate to high intensity daily exercise, less than two hours a day of screen time. There are no current a current medications approved for the treatment of mail or nil. Um, but bariatric surgery, which I'll talk a little bit more about later can be considered. Um depending on the severity of the disease and other comorbidities and then dyslipidemia as the other big complication that we think about in our screening um within dyslipidemia, we categorize it based on risk categories. So the high risk includes things like homozygous, familial hypercholesterolemia, type one and type two diabetes. Kawasaki disease with persistent aneurysms, um moderate risk, severe obesity falls in that category. Heterozygous FH hypertension, um childhood cancer survivors who've had chest radiation and then at risk has obesity, insulin resistance, chronic inflammatory diseases. Kawasaki disease with regressed aneurysm. Yes, she is busy. So this algorithm walks you through what to do at each of these levels of dyslipidemia. Um the risk groups. So the risk groups really, the important thing to keep in mind is they have different LDL goals. So the high risk group, they're targeting the lowest LDL to minimize the risk. The moderate risk groups have an LDL target of less than 130 and the just the at risk. Um generally you're not starting medication treatment if the LDL is less than 160. Um in all cases, you start with therapeutic lifestyle change and then if you're not meeting goals, you move on to table two, which walks you through starting medications. So the lifestyle recommendations, high fiber with fruits, veggies and whole grains high in polyunsaturated and mono unsaturated fats. So that includes things like canola, corn, soybeans, sunflower oil oily fish walnuts, um mono unsaturated fats is things like olive oil, canola oil, peanut oil, um avocados, um low in saturated fat, no trans fats specific to triglycerides, you wanna limit simple carbohydrates and added sugars and you wanna encourage moderate to physical to vigorous physical activity at least five hours a week. So that's consistent with an hour a day of physical activity when you're considering medication or considering referral for medication. Again, it depends on your risk category. Um So in the high risk category, if the LDL is staying above 130 with the treatment goal being less than 100 then we're gonna consider um probably starting a statin medication. That threshold goes up to um 160 if you're in the moderate risk. So this is the severe obesity without diabetes um with a goal of less than 130 the at risk really, they need to be staying above 160. Also after you've done um lifestyle intervention. So how do we go about making these lifestyle interventions? Motivational interviewing is very frequently talked about. So this is a way to engage patients with open ended questions, affirmations, nonjudgmental graphics, um try to get them to focus, elicit, provide illicit is the mo um model where you're eliciting their thoughts about something, then you're providing some feedback and then you will listen again. Um You can use healthy habits, survey, change, talk and sustain, talk in this discussion. Um The graphic here is showing a scale of 0 to 10 of importance to make change, confidence to make change. Sometimes we'll use these scales to kind of assess where a patient is in their readiness to make a change. Um You're using evoking statements, value statements, double sided and amplified reactions in your motivational interviewing process um and then helping them with planning. So, action reflection, summarizing, teach back and smart goals, um motivational interviewing is recommended at all ages as part of a comprehensive component of obesity treatment. Um and beginning after age six intensive health behavior and lifestyle treatment is the first line choice for beginning to make a um a treatment plan for a patient with overweight or obesity in patients over 12 weight loss, pharmacotherapy and or metabolic and bariatric surgery can also be considered and those discussions can be brought up right at the start of treatment. Um But I'm gonna bring you back to where we were at the beginning. Remember, this is a chronic care model. It is focused on the family and we're trying to not stigmatize. So this is a very complex long term treatment plan. And I honestly believe that you as the patient's pediatrician are best poised to long term follow these patients and help them make change over time. When we think about developing an obesity plan, we're thinking about nutrition, physical activity and behavior therapy. Also keeping in mind that some patients it may be appropriate to discuss pharmacotherapy and bariatric surgery as well in this intensive health behavior and lifestyle treatment plan. Um Keep in mind the who it's a partnership with the patient, the family and their team. So when pediatricians are really well positioned to provide prompt care to the patient because you are there and you're already seeing them to get in to see us. It may take several months. Um So what is health education and skill building but also helping them work on behavior modification and counseling. These interventions may take place in the health care setting. They may also take place in community based settings with linkage to the medical home. We know that more contact time increases the likelihood of a beneficial effect. So guidelines say treatment should last 3 to 12 months and ideally have greater than 26 contact hours. Um There's data for group formats, individual formats as well as combinations face to face interventions have more data, but there's growing evidence for virtual interventions as well. Effective components of a lifestyle intervention include the contact time, um promoting healthy eating and promoting physical activity. And then some programs also target both parents and Children may talk about stimulus control, goal setting, self monitoring, problem solving, supervised physical activity. So what do you do with that? We try to keep our messaging pretty simple. My plate is a really very simple way to present a healthy diet because it does promote those increased fruits and vegetable portions. Um and more appropriate. Um My plate uses grains, but I like to use carbs because we're gonna put potatoes and corn in the same category. Um And, but it's very easy for patients to learn and many of them will already have seen it in school. Um I had mentioned earlier the hand method for portions. So your palm is a protein portion. Your fist is a carbohydrate portion and veggies is open palms. So these are something that your patient carries with them all the time. They don't need a measuring cup or a deck of cards to carry around and it grows in relation to their own size. So you can use the same measuring tool for a toddler as you can for a teenager, their own hand. OK. And we really do emphasize with our patients that we're not putting them on a diet. We're encouraging them to adopt a healthy way of eating that they can do long term. A diet is a short term fix. They are very unlikely to stick with it long term. So we're trying to inch by inch, ease them towards um a healthier way of living long term. Um thinking about stimulus control. So, um making the healthy things easy to reach, using smaller plates to re portion things. Um So the example is you take instead of the cookie jar, you have a bowl of fruit on the counter, use the tiny plate instead of the big plate and it looks like a whole lot more food even though it's the exact same amount. Um And then we do a lot of smart goal settings, so specific measurable, achievable, realistic and timely. Um you can see the examples. We do encourage patients to review their smart goals on a regular basis um and be very concrete in what they're setting and be willing to take baby steps and then set a bigger goal as they achieve them or revisit and figure out what the barrier was. Um, and make modifications if needed. Um, um, this graphic is widely available in various formats, but it's five fruits and veggies a day, two hours or less of screen time, an hour or more of physical activity and zero sugar, sweetened beverages. Again, just a really simple, easy to carry with you message that applies to almost every patient. Ok. So that's the general lifestyle stuff. This is a really complex side. It brings you back to all those hormonal signals and I brought you back to this because this is where our medications for weight management come in. Um Pointing out that these medications are often targeting these dis disrupted, um, weight regulating or hunger regulating pathways, including the G LP ones until pyramid can affect these pathways to decrease hunger in the brain and decrease weight. Um I, this talk is not focused on those medications. It's more to be aware that they are available. So they are GOP ones as well as Kimia, which is phentermine topiramate that are FDA approved for adolescent. So age 12 and up, um, weight management. And so if you think your patient may benefit from that, they have severe obesity. Generally, technically, those medications are approved for greater than the 95th percentile, but these are chronic treatment plans. So generally I'm talking about them more often with patients who have severe obesity, meaning at least 100 and 20% of the b of the 95th percentile. Um, if they wanna consider those medications, those are patients to think about referring for more advanced treatment. Beyond exclusively lifestyle change. Bariatric surgery is also available to our adolescents who have severe obesity. Generally. Now we're talking of via my greater than 40 in someone at our center, at least age 15 is our current age cut off. Um, we do offer both Rny Gastric bypass and gastric sleeve. Um, through the, it's a um, part with Barnes, um, their weight loss surgery program, um, with a really extensive preoperative, um, both work up and intensive intervention for lifestyle change to support them in making that decision. So they work with us for at least six months before they would be approved for bariatric surgery. Um Bariatric surgery in adolescence has very similar outcomes to adults. So the average weight loss for both adults and adolescents who undergo weight loss surgery is about 30% of body weight. The best medications, um, that are approved in pediatrics. So this is gonna be W GOVI which is some magle has about a 15% BM I loss in pediatrics or weight loss in adults. Um, but you can see there's a significant weight decrease, there can be remission of type two diabetes, remission of hypertension and remission rates are higher in the adolescent compared to the adults potentially because they haven't had these comorbidities as long. Um And what, how does surgery compare to medical therapy? We have some data about type two diabetes. Um in adolescence, type two diabetes and adolescence is a very aggressive disease. And so this is data that compared adolescents who underwent bariatric surgery in the teen lab study compared to the today study, which is um medically treated adolescents with type two diabetes and the first set of bars, iste labs. The second set of bars is the today study, the medically treated. The lighter band is those who had diabetes over time and A one C greater than 6.5. And what you can see is that with the surgical intervention, the number of patients who had a diabetes level hemoglobin A one c decreased over time out to two years in the medical intervention, the A one C is increased over time. So the data that we have suggests bariatric surgery is a great treatment, a good treatment. Um for type two diabetes and youth at our center, there's um technically no strict age cut off, but insurance companies set a cut off. And because our surgeries are Barnes, our current cut off is age 15 A BM I greater than 40 without comorbidities or greater than 35 with serious comorbidities and then participation in a comprehensive lifestyle modification program that is our clinic, um including Doctor Chris Egan is our current bariatric surgeon. And so I'll circle back to our case that I introduced at the beginning. Remember this patient we had met in 2017 at her diabetes diagnosis, we really struggled a long time with her diabetes. So she still had an elevated A one C a year later, her um weight had gone up. She was on insulin and that was the first time we brought up weight loss surgery with her. At this point in time, there were no FDA approved weight loss medications for adolescents. Um She began in early 2019, her monthly medical weight loss um visit journey towards achieving the surgery. Um She did get started on Lalo Tide which is um the brand name Victoza A daily G LP one at that was around the time that it got approved for type two diabetes treatment. She continued to gain weight during that course as we were trying to control her blood sugars with insulin. In August of 2019, she underwent surgery at that point in time, her A one C was 8.1. So she still did not have good glycemic control. Um, but she very rapidly lost weight and she was able to dramatically decrease the amount of insulin that she was using. Um, though she did not come completely off of insulin, she had been on very, very high doses of insulin. So it wasn't surprising that she didn't come off. But I also will point out it's not always easy even when we achieve these really remarkable weight loss effects. Um, she had challenges with reflux and difficulty getting enough protein after surgery. And so she requires a lot of support long term, but is overall doing really really well. So in summary, there's a lot of factors that contribute developing obesity. It's important to screen for obesity as well as what could be contributing to obesity and comorbidities. Behavioral interventions work better with more contact time. You as their pediatrician can start working with them on lifestyle modification before they make it to us. Um But if you think your patient wants to consider medication or surgery, we would love to be part of their comprehensive treatment strategy. Created by Presenters Jennifer Sprague, MD, PhD Assistant Professor, Pediatrics Fellowship Director, Pediatric Endocrinology Co-director, Pediatric Health Start Program View full profile
