Prepared by Garry Sigman, M.D., Director, Loyola Pediatric Weight Management Program (last revised June 2014) © 2014 Loyola University Health System. All Rights Reserved. Algorithm for the Primary Care Management of Child/Adolescent O besity BMI < 85% Start with BMI and survey of Obesity-‐related behaviors (SHAPES or another approach of practitioners choice on all patients 2-‐18 BMI 85-‐94% No CV Risks BMI 85-‐94% BMI 95-‐99% CV Risks Fasting lipid profile Prevention Counseling Utilize SHAPES Other reason to refer Primary Care Office Management • Available community-‐ based wellness activities or programs, such as Proactive Kids Program Labs: • Fasting Lipid Profile • ALT, AST • Fasting Glucose BMI 99% or BMI 35 or greater or 120% of the 95th % Type 2 DM or Stage 1, 2 HT or • • Obesity assessment visit with PCP). Review SHAPES AND MOTIVATION, Obesity specific history and physical. Visits every 4 weeks for 3-‐6 mths. PCP Visits Identify goals each visit and follow on next-‐ use Motivational interviewing approach If parents are showing motivation and want more intensive treatment after 3 visits. Pediatric Weight Management Clinic • • • • • Visits weekly for 12 weeks Multi-‐disciplinary family-‐centered approach Group activities Goal: Decrease in BMI Medication, Weight Control Surgery as necessary and appropriate Adapted from Barlow SE. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of the Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics 2007;120;S1164 2 | P a g e SHAPES is core message for all well child visits (2 years or older) Use this mnemonic at all prevention and treatment visits to connote healthy weight management for all kids and teens. (Adapted from UCSD HOPE Program) Drink skim or 1% milk only, limited fruit juice and no soda Encourage home meals at least 4 times a week and restaurant food less than 2 times a week Aim for 60 minutes a day of moderate physical activity Reduce second helpings, no extra large portion sizes, eat 5 or more servings of fruits and vegetables daily Eat breakfast daily Limit tv, video games, sitting activities to less than 2 hours a day 3 | P a g e BMI Measurement and Classification To calculate BMI • • BMI= Weight (lb)/Height(in) X Height (in) X 703 BMI= Weight (kg)/Height(cm) X Height (cm) X 10000 PERCENTILE 5-‐84% 85-‐94% 95-‐99% >99% CLASSIFICATION HEALTHY WEIGHT OVERWEIGHT OBESE EXTREME OBESITY Classification adapted from the Expert Committee Summary Report BMI 99% Cut-‐Points (kg/mxm): adapted from the Expert Committee Summary Report 4 | P a g e Cardiovascular Risk Factors Family or Personal History of CV Ds Physical Inactivity Dyslipidemia Hypertension Smoking Diabetes mellitus Obesity Metabolic syndrome Review of Systems and Physical Exam for Obesity: -‐ To be documented on initial obesity visit. Adapted from American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics; 2008. ROS: 5 | P a g e PE: Look for: PE Finding Possible Etiologies Poor linear growth Dysmorphic features Acanthosis nigricans Hirsutism and excessive acne Violaceous striae Papilledema, cranial nerve VI paralysis Tonsillar hypertrophy Abdominal tenderness Hepatomegaly Undescended testicle Limited hip range of motion Lower leg bowing Hypothyroidism, Cushing’s, Prader-‐Willi Syndrome Genetic disorders Insulin resistance Polycystic ovary syndrome Cushing’s Syndrome Pseudotumor cerebri Sleep apnea Gall bladder ds, GERD, NAFLD Non-‐alcoholic fatty liver disease NAFLD Prader-‐Willi Syndrome Slipped capital femoral Epiphysis Blount’s disease Complications and Comorbidities Obesity-‐related complications Neurological Respiratory Cardiovascular Metabolic Pseudotumor Cerebri Obstructive Sleep Apnea Syndrome, Worsened asthma Hypertension, Dislipidemia, Left ventricular dysfunction Impaired glucose tolerance, insulin resistance, Type 2 diabetes, premature adrenarche, polycystic ovary syndrome, pubertal acceleration or delay Gastrointestinal Non-‐alcoholic fatty liver disease, non-‐alcoholic steatohepatitis, Gastroesophageal reflux Musculoskeletal Blount’s disease, Slipped capital femoral epiphysis Psychological Low self-‐esteem, anxiety, depression, Eating Disorders Skin Acanthosis Nigricans, Hidredenitis Supportativa, Irritation, Inflammation 6 | P a g e Additional Testing Sleep Study PCOS Evaluation 7 | P a g e Order if BMI >85% with suggestive symptoms: snoring, daytime sleepiness, restless sleep • Any female with BMI> 85% and irregular menses and/or signs of hyperandrogenemia (hirsutism, acne) • Suggested workup: Total testosterone, Free testosterone, FSH, LH If abnormal refer to Peds Endocrine or Adolescent Medicine MOTIVATIONAL COUNSELING FOR CHILD OBESITY • • • Motivational counseling describes the most successful method of helping people change behavior and is adaptable to obesity related behaviors Utilize FRAMES for Motivational Counseling on each visit Evaluate “readiness at each visit” FRAMES F-‐ Give clear Feedback Examples of statements: Screening visit “Based on your child’s BMI I am concerned and want to talk to you about the effect on your child’s/your health” R-‐ Clarify that Responsibility to “Changing this is up to you, how do change is theirs, so no coercion you feel about discussing this further?’ A-‐ Give clear Advice if “My advice would be that we work parent/child is receptive on this over follow-‐up office visits, would you like to do that?” M-‐ Talk about Menu of options “Based on the SHAPES evaluation that they will willingly work on you filled out, which of those would you like to begin to change?” E-‐ Demonstrate Empathy “I understand that change like this is difficulty and might be hard for you” S-‐ Help develop Self-‐efficacy “you can change things if we work together” “I am impressed by your interest in this” • • Examples of statements: Follow-‐ up visits “Your child’s weight and health behaviors reported have improved, stayed the same, are still needing change.” “Further change would be up to you, what do you think?” My advice would be that we continue working on this, do you agree? “Which of the SHAPES should we address for the next visit?” “I understand what you had to do, and why you did it that way.” “I see how hard this is” “You are doing a good job” “You are making progress” “Your work so far on this shows you can be successful” Use OARS o Open–ended questions-‐ start with words like “how”, “what”, “tell me about” or “describe” o Affirm parent/child experiences and feelings respectfully and sincerely o Reflective listening by repeating (“so you’re saying ____”) rephrasing, asking for clarification and o Summarize-‐ reinforce what has been said and decided. Evaluate readiness and confidence: Ø Are you ready to make any changes (for yourself or for your child)? Ø Not ready Very ready Ø How confident are you that you can make any changes (for yourself or for your child)? Not ready Very ready 1 2 3 4 5 6 7 8 9 10 8 | P a g e ICD-‐9 Codes for Patients with Obesity: Include comorbidities and complications as primary visit codes in addition to, or instead of Obesity (278.00): ICD-‐9 CODE 783.1 783.6 SIGNS AND SYMPTOMS 405.19 Hypertension, essential (benign) Weight gain (abnormal excessive) Excessive appetite, overeating of unspecified cause Excessive appetite, hysterical Overeating, as acute reaction to stress Overeating of non-‐organic origin, bulimia, binge eating Perverted appetite of non-‐organic origin, pica Overeating, feeding disturbances of infancy Fatigue/lethargy 405.91 V81.1 Hypertension, renovascular (unspecified) Screening for hypertension 272.4 272.0 272.1 Hyperlipidemia, unspecified Hypercholesteremia, pure Hypertrycliceridemia, pure 272.2 V18.1 V77.91 Acanthosis nigricans, acquired Headache, unspecified or vascular Headache, emotional (non-‐organic origin), tension Headache, migraine (unspecified), without mention of intractable Headache, migraine (unspecified) with intractable migraine Hirsutism Nocturia Polydipsia Polyphagia Polyuria 759.81 758.0 256.4 Mixed Hyperlipidemia Family history of hyperlipidemia Screening for lipid disorders (cholesterol/HDL/other) Prader-‐Willi syndrome Down syndrome Polycystic ovary syndrome ICD-‐9 CODE 259.1 626.0 790.6 V77.1 250.0 SECONDARY DIAGNOSES/COMPLICATIONS V11.9 V21.0 ICD-‐9 CODE 278.00 278.01 Unspecified mental disorder Period of rapid growth in childhood PRIMARY DIAGNOSES (related to obesity) 250.02 250.12 250.90 251.1 Overweight/obesity (unspecified) Morbid obesity 311 313.1 307.50 259.9 V77.8 277.7 Eating disorders, unspecified Obesity of endocrine origin Special screening for obesity Dysmetabolic syndrome X 732.4 732.4 732.1 715.20 571.8 Nonalcoholic steatohepatitis 715.00 780.79 244.9 V77.0 278.8 Fatigue, general Hypothyroidism, primary or NOS Screening for thyroid disease Pickwickian syndrome (cardiopulmonary obesity) Sleep apnea, obstructive Hypertension, essential (unspecified) 574.30 574.31 575.10 577.0 Depression, NOS Disturbance of emotions specific to childhood/adolescence with misery and unhappiness Blount’s disease (tibia vara) Slipped capital femoral epiphysis Legg-‐Calve-‐Perthes disease Degenerative arthritis, secondary, localized, site unspecified Degenerative arthritis, generalized, site unspecified Gallstones (cholelithiasis) without obstruction Gallstones with obstruction Cholecystitis Pancreatitis 348.2 Pseudotumor cerebri 300.11 308.3 307.51 307.52 307.59 780.79 701.2 784.0 307.81 346.90 346.91 704.1 788.43 783.5 783.6 788.42 780.57 401.9 9 | P a g e Precocious puberty Amenorrhea (primary or secondary) Hyperglycemia, NOS Diabetes, screening Type 2 diabetes mellitus, controlled, no complications Type 2 DM, uncontrolled, no complications Type 2 DM, with ketoacidosis Type 2 DM, with unspecified complications Hyperinsulinemia REPORTING REQUIREMENTS FOR ILLINOIS MEDICAID PATIENTS REIMBURSEMENT A. In addition to ICD-‐9 or 10 Code of Obesity, require : B. Include V code to show BMI was reported i. V85.51-‐ BMI<5% ii. V85.52-‐ 5 %<BMI<85% iii. V85.53-‐85<BMI<95% iv. V85.54-‐ BMI>95% To refer patients to: 1. Loyola Pediatric Weight Management Program Clinic a. Fill out referral and fax to (708) 327-‐9132, Attn. Alessandra Shervino 2. Proactive Kids Program-‐ http://proactivekids.org/enroll-‐now 10 | P a g e 11 | P a g e