8/27/18

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USE OF A SHARED MEDICAL APPOINTMENT FOR PEDIATRIC

OBESITY

Catherine Lux, DNP,RN,CPNP-PC

DISCLOSURES:Nothing to disclose

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OBJECTIVES:

• Discuss socioeconomic and demographic factors relating to the pediatric obesity epidemic.

• Discuss the complications and comorbidities of obesity in the pediatric population—what makes childhood obesity different?

• Discuss clinical workup of the overweight or obese child.

• Discuss treatment options for the pediatric population.

• Discuss the implementation of a Shared Medical Appointment for primary treatment of obesity in children.

• Availability of High Glycemic Index Foods

• “Portion Distortion”

• Decreased sleep time

• Screen Time

• Media Influence

• Sedentary Lifestyles

• Built Environment-food and exercise deserts

• Obesogenic chemical exposure

• Epigenetics

ENVIRONMENTAL CAUSES

Children are especially vulnerable to poor nutrition and intake of empty calories. The NHANES revealed that the top dietary energy sources for children aged 2-18 years were, in order, grain deserts, pizza, and soda.

(Reedy & Krebs-Smith, 2010, p. 1)

According to the USDA, “the consumption of sugar sweetened beverages is the single largest contributors of calories and added sugar in the American diet”

(IOM, 2012, p. 167).

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• “The concept that environmental and nutritional influences during critical periods in development, particularly during gestation, can have permanent effects on an individual’s predisposition to obesity and metabolic disease”

• Kish, W. et al. (March 13, 2015) Definition; epidemiology; and etiology of obesity in children and adolescents. UpToDate. www.uptodate.com.

METABOLIC PROGRAMMING

•Gestation• Adiposity Rebound- 3 to 7 years

• Puberty

PERIODS OF BIOLOGIC VULNERABILITY:

ADIPOSITY REBOUND

• Hormonal changes--obese children tend to gain abnormally more weight during the 9-12 year range, when puberty is activating hormonal changes that cause increased adipose tissue development

• Social behaviors--increasingly sedentary pursuits, peer pressure, self-esteem issues, and more independence re dietary choices, risk taking behaviors.

PUBERTY-THE “PERFECT STORM”

• A key trigger for puberty and weight gain

• First discovered in 1994

• Adipocytokine—a substance that is secreted by adipose tissue

• Signals to the hypothalamus that sufficient energy is present

• Leptin deficiency signals a starvation state and hunger.

• Insulin seems to inhibit leptin from signaling satiety, promoting increased fat stores.

• This process may be developmentally necessary in order to trigger menses in girls, as leptin deficiency precludes pubertal onset

ADOLESCENT HORMONES: LEPTIN

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MEDICAL CONDITIONS ASSOCIATED WITH OBESITY

1. genetic disorders (Rare ): short stature, developmental delay

2. Sleep apnea: consistent snoring, daytime somnolence., hypertrophic tonsils, behavior issues

3. Hypertension: elevated blood pressure on 3 separate occasions, (appropriate cuff size/technique|)

4. Silent conditions: lipids, diabetes, NAFLD

5. PCOS: fewer than 9 menses per year

6. Orthopedic issues: Blount’s, tibial bowing, Slipped capital femoral epiphysis (hip or knee pain, limp)

• BMI-current status and trend• ROS—pattern of weight gain, comorbidities• History-family, psychosocial, diet, eating

patterns (questionnaire)• Physical Exam• Labs• Patient education and counseling

CLINICAL EVALUATION

ACANTHOSIS NIGRICANS

DIABETES

Overweight (BMI ≥ 85th percentile)

Plus any two of the following risk factors

Family history of type 2 diabetes in 1st or 2nd degree relatives

Race/ethnicity (African-American, Hispanic, Native –American, Pacific Islander)

Insulin resistance signs (acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovary syndrome)

Maternal diabetes during gestation

Start at age 10 or onset of puberty (whichever is earlier)

Fasting glucose OR hemoglobin A1c

Screen every 3 years

HYPERTENSION

• Measure annually starting age 3 years• 3 elevated measures are needed for diagnosis

• New data tables (data from children with healthy weight)

• Elevated blood pressure (formerly pre-hypertension) 90th %ile

• ≥ 13 years: 120/80• Hypertension stage 1 à 95th %ile

• Hypertension stage 2 à 95th %ile + 12 mmHg

DYSLIPIDEMIA

• Fasting lipids • Age 2-8 years if BMI >=95% or CV risk factors

• 9-11 years—EVERYONE AT LEAST ONCE

• 12-16 years

• BMI5-85% +CV risk

• BMI >= 85%

• 17-21years—EVERYONE AT LEAST ONCE

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NAFLD SCREEN

• Screen with ALT

• Age 2-8 years if BMI >/= 95%

• Age 9-21 years • if BMI 85-95% + risk factors

• If BMI >/=95%

• Vitamin D• Serum 25(OH) Vit D

• Levels < 20-25 deficient

• Vitamin D trapped in adipose tissue

• Thyroid

• Rarely causative factor

• Short stature, disrupted growth velocity

• Mildly elevated TSH more common in obese children

• Goiter

OTHER LABS

• Staged approach based on level of obesity and comorbidity

• Lifestyle modification-diet, exercise—dose effect

• Assessment of food and exercise patterns

• goal setting

• Nutritional education

• Medications not recommended currently for pediatric populations

• Investigative therapies

TREATMENT

B A R L O W S E . E X P E R T C O M M I T T E E R E C O M M E N D A T I O N S R E G A R D I N G T H E P R E V E N T I O N , A S S E S S M E N T A N D T R E A T M E N T O F C H I L D A N D A D O L E S C E N T O V E R W E I G H T A N D O B E S I T Y :

S U M M A R Y R E P O R T . P E D I A T R I C S . 2 0 0 7 ; 1 2 0 ( S U P P L 4 ) : S 1 6 4 - S 1 9 2 .

TIME CONSTRAINTS

• Time spent on health supervision topics in children 2 – 10 y

• Diet counseling 42 seconds (interquartile [IQ] 21-85)

• Growth 15 seconds (IQ 7-31)• Physical activity 12 seconds (IQ 5-22)• Martin. J Pediatr 2008;153:706

• A way to deliver enhanced patient education while providing individual disease management in a cost-effective way (Schmucker, 2006).

• AKA Group Medical Appointment (GMA)

• Made up of three components:

• Group setting

• Patient interactions and opportunity for peer support

• One-on-one clinical encounter with provider

SHARED MEDICAL APPOINTMENT (SMA)

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STAFFING

• Multidisciplinary team including:

• Facilitator (nurse, nutritionist, pharmacist, patient educator, etc.)

• Provider

• Nurse

• Support/clerical staff

• Lab*

• Scribe*

• Pharmacist*

*optional

BENEFITS

• Increase face time with provider

• Increase access for patients

• Provide accesss to multidisciplinary team

• Provide increased patient education

• Enlist patient peer support for disease management

• Improve outcomes

• Maximize provider efficiency and productivity

• Decrease provider burnout

(Schmucker, 2006)

ORIGINS OF SMA

• Credited to Dr. Edward Noffsinger of Kaiser in California

• Nurse practitioners were using this model previously

• “cluster visits”

• 1970’s

• Well baby visits

(Morse, 2009)

REQUIREMENTS FOR PARTICIPATION

• Current clinic patient

• Had physical within past year

• Recommended labs and work up for obesity

• School aged

• Able to participate in classroom setting

• Only address obesity related issues

Referral by PCP

Added to wait list

Clerk calls to schedule

ReviewedBy NP

SMA Workflow Process Chart

Patient arrives

Clerk check-in & consents

Clerk enrolls pt in MyChart

Clerk schedules virtual visit

MA gets VS and gives pt PAM

nutritionist / PNP- visit

NP send first f/u email

NP sends 2nd

email

NP sends 3rd

email

Virtual Visit-NP and MA

NP sends 4th

email

Repeat SMA and f/u for 4 class series

Pre-visit

SMA

Follow-up

THE SOCIETAL AND INDIVIDUAL COST OF FAILING TO ADDRESS

THE OBESITY EPIDEMIC IS HIGH.

THIS MAY BE THE FIRST GENERATION OF U.S. CHILDREN TO HAVE A

SHORTER LIFE SPAN THAN THEIR PARENTS

(DANIELS, 2009).

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QUESTIONS?

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