www.envisionnm.org

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www.envisionnm.org
2
Overview

• Assessment and intervention of Pediatric
  Overweight and Obesity
• Hypertension
• Dyslipidemia
• Polycystic Ovary Disease
• Non-Alcoholic Fatty Liver Disease

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Measure BMI Annually

• Measure BMI at well child visits 2-18 y.o.
• Calculate plot BMI for age and gender
• Correlate with appropriate diagnosis
• lt5 Underweight
• 5-84 Normal Weight
• 85lt95 Overweight
• 95 Obese
• (99 is a higher risk group)

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Measure BMI Percentile

• Plot BMI for age and gender
• English weight(lb) height(in) height(in)
  x703
• Metric weight(kg) height(cm) height(cm)
  x10,000
• Calculation Tools www.cdc.gov/ or
  www.nhlbisupport.com/bmi/
• BMI Wheel
• CDC Graphs
• www.cdc.gov/growthcharts/
• PDA tool www.statcoder.com

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If there was an infectious disease that had

• double - tripled in prevalence,
• was afflicting 30 of children of all ages,
• had life-long, potentially life-threatening
  impact
• Would we be acting?
• Would we take 10 sec to plot a point?

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Proposed 2009 HEDIS Measures

• The percentage of members 217 years of age who
  had an outpatient office visit and who had
  evidence of the following during the measurement
  year.
• BMI percentile assessment
• Counseling for nutrition
• Counseling for physical activity

Healthcare Effectiveness Data and Information
Set
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Measure Blood Pressure Annually

• Use a cuff large enough to cover 80 of the arm
• Diagnose hypertension using NHLBI tables
  http//www.nhlbi.nih.gov/health/prof/heart/hbp/hbp
  _ped.html or Statcoder

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Example

• 9 y.o. girl presents for WCC
• Height 134 cm
• Weight 40.7 kg
• BMI 22.5
• BP 118/77

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Example

• 9 y.o. girl presents for WCC
• Height 134 cm
• Weight 40.7 kg
• BMI 22.5
• BP 118/77
• BMI 96th percentile Obese
• BP gt95th percentile Stage 1 HTN
• (3 measurements)

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Past Medical History

• Small for gestational age
• Weight gain
• Insidious onset
• vs.
• Point-in-time onset
• Race/ethnicity

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Family History Update Regularly

• First and second degree relatives
• Obesity
• Type 2 diabetes, insulin resistance
• Cardiovascular disease
• Hypertension, Dyslipidemia
• Early deaths from heart disease or stroke
• Mother
• Gestational diabetes while pregnant with patient

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Review of Systems
Poor linear growth (Hypothyroidism, Cushings,
Prader-Willi syndrome) Anxiety, school
avoidance, social isolation (Depression)
Headaches (Pseudotumor cerebri) Nighttime
breathing difficulty /or Daytime somnolence
(Sleep apnea, hypoventilation syndrome, asthma)
Abdominal pain (GE reflux, Gall bladder disease,
constipation) Hip or knee pain (Slipped capital
femoral epiphysis) Oligomenorrhea or amenorrhea
(Polycystic ovary syndrome)
Identifiable endocrine abnormalities or syndromes
account for lt 1 of cases of overweight in
children
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Assess Behaviors and Attitudes

• Diet Behaviors
• Sweetened-beverage consumption
• Fruit and vegetable consumption
• Frequency of eating out and family meals
• Consumption of excessive portion sizes
• Daily breakfast consumption
• Physical Activity Behaviors
• Amount of moderate physical activity
• Level of screen time and other sedentary
  activities
• Attitudes
• Self-perception or concern about weight
• Readiness to change
• Successes, barriers and challenges

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Physical Examination
Poor linear growth (Hypothyroidism,
Cushings, Prader-Willi syndrome) Truncal
obesity ..(risk of CVD
Cushings) Dysmorphic features .(genetic
disorders, including PraderWilli syndrome)
Acanthosis nigricans ...(DM, insulin
resistance) Hirsutism and excessive
acne..(PCOS Cushings) Violaceous
striae .(Cushings)
Papilledema, cranial nerve VI paralysis..(ps
eudotumor cerebri) Tonsillar hypertrophy
...(sleep apnea) Abdominal
tenderness, hepatomegaly..(gall bladder disease,
GERD, NAFLD) Undescended testicle
..(Prader-Willi syndrome) Limited
hip range of motion ...(slipped capital
femoral epiphysis) Lower leg bowing
.(Blounts disease)
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Things To Look For On The Physical Exam

• Acanthosis nigricans
• (NIDDM, insulin resistance)

• Violaceous striae
• (Cushings syndrome)

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The Next Step

• Diagnose Overweight and Obese
• Screen for pre-diabetes and type 2 diabetes
• Screen for conditions associated with overweight

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Obesity
Insulin Resistance
Metabolic Syndrome
Type 2DM
Hypertension
NASH
Dyslipidemia
PCOS
Also

• Mental health issues,
• obstructive sleep apnea,
• orthopedic problems

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Laboratory Tests

• BMI 85-94 Without Risk Factors
• Fasting Lipid Profile
• BMI 85-94 Age 10 Yrs. Older With 2 Risk
  Factors
• Fasting Lipid Profile
• ALT and AST
• Fasting Glucose
• BMI gt 95 Age 10 Yrs. Older
• Fasting Lipid Profile
• ALT and AST
• Fasting Glucose
• Other Tests as Indicated by Health Risks

Every 2 Years
Every 2 Years
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Risk Factors

• Risk factors
• FHx of type 2 DM in 1st or 2nd degree relative
• Race/ethnicity (non-Caucasian)
• Maternal gestational diabetes
• Associated Conditions
• Hypertension
• Acanthosis Nigricans
• Dyslipidemia
• Polycystic Ovary Syndrome

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Lab Assessment Fasting Glucose vs. 2-hr.
Glucose

• Fasting glucose
• Sufficient screen to rule out T2DM
• Recommended by ADA and recent AMA Expert
  Committee
• 2 hr post glucose load serum glucose
• More sensitive at diagnosing pre-diabetes
• Recommended by American College of
  Endocrinologists and The Endocrine Society

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Pre-diabetes vs. Diabetes

• Pre-diabetes
• Fasting glucose 100-125 mg/dL
• 2 hr OGTT 140-199 mg/dL
• Diabetes (T2DM)
• Fasting glucose 126 mg/dL
• 2 hr OGTT 200 mg/dL

ADA. Diagnosis and Classification of Diabetes
Mellitus. Diabetes Care.200730(S1)s42-s47.
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• Overweight and Obese Screening
• Height ___________ Height percentile__________
• Weight ___________
• BMI ___________ BMI percentile
  __________
• BP __________ BP percentile
  __________
• BMI 85-94 Without Risk Factors
• ?? Fasting Lipid Profile
• BMI 85-94 Age 10 Years With 2 Risk Factors
• ?? Fasting Lipid Profile
• ?? ALT and AST
• ?? Fasting Glucose
• BMI 95 Age 10 Years Older
• ?? Fasting Lipid Profile
• ?? ALT and AST
• ?? Fasting Glucose
• ?? Other tests as indicated by health risks

• Risk Factors for T2DM
• Race/ethnicity (non-Caucasian)
• FHx T2DM in 1st or 2nd degree relative
• Mother with GDM
• Other HTN ( 95th), AN, dyslipidemia, or PCOS

Pre-diabetes Fasting glucose 100-125mg/dL 2 hr
OGTT 140-199 mg/dL Diabetes (T2DM) Fasting
Glucose 126 mg/dL 2hr OGTT 200 mg/dL Random
Glucose200
A 2 hr glucose-challenge (OGTT) is more
sensitive than fasting glucose for diagnosing
pre-diabetes.
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Carbohydrate MetabolismDefinitions

• Impaired Fasting Glucose (pre-diabetes)
• Fasting serum glucose 100-125 mg/dL
• Impaired Glucose Tolerance (pre-diabetes)
• 2-hr OGTT serum glucose 140- 199 mg/dL
• Insulin Resistance (IR)
• Often used interchangeably with IGT (although one
  can have IR and normal glucose tolerance)
• Type 2 Diabetes Mellitus (T2DM)
• Fasting serum glucose 126 mg/dL
• 2-hr OGTT serum glucose 200 mg/dL

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Pre-diabetes Treatment

• Lifestyle Modification
• Diet
• Play Hard 30-60 minutes daily!
• Goal weight loss 7 of body weight
• In adults, more effective than metformin
• Consider Metformin
• For very high BMI percentile (99th )
• Laboratory evidence nearing T2DM
• PCOS

Knowler WC, Barrett-Conner E et al. (Diabetes
Prevention Project) Reduction in the incidence of
type 2 diabetes with lifestyle intervention or
metformin. NEJM 2002346393-403
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Latest Recommendations

• Prevention, Assessment and Treatment of Childhood
  Obesity Recommendations from the AMA Expert
  Committee on Childhood Obesity.
• June 8, 2007
• www.ama-assn.org/ama/pub/category/11759.html
• NICHQ.org, Childhood Obesity Action Network

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Treatment Overview

• A Staged Approach
• 1) Prevention Plus
• 2) Structured Weight Management
• 3) Comprehensive, Multidisciplinary Intervention
• 4) Tertiary Care Intervention
• Treatment Goals
• Behavioral Goals and Parenting Skills
• Self Esteem and Self Efficacy
• BMI Velocity, Weight Loss Targets and BMI

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Treatment GoalsHealth Behaviors

• Lifelong healthy behaviors such as physical
  activity will improve health outcomes regardless
  of weight change
• Improving self esteem and self efficacy can also
  improve health outcomes
• Small consistent changes over time can make a big
  difference!
• Consistent behavioral changes averaging 110 to
  165 kcal/day may be sufficient to counterbalance
  the energy gap which leads to excess weight gain
  in some children.
• Changes in excess dietary intake may be easier to
  attain than increases in physical activity
  levels. For example, eliminating one
  sugar-sweetened beverage at 150 kcal/can vs.1.9
  hours walking for an extra 150 kcal.

Pediatrics Vol. 118 No. 6 December 2006 pp.
e1721-1733
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Treatment Goals - BMI

• The long term BMI goal will need to be
  individualized based on risk factors and genetics
• BMI lt 85 - Ideal long term goal
• BMI 85-94 - Some children can be healthy in this
  range
• Short term BMI goals will need to be
  individualized based on genetics, risk factors
  and the intensity of the intervention
• Decrease in BMI velocity
• Weight maintenance
• Weight loss
• Younger and more mildly obese children should
  change weight more gradually than older, more
  severely obese youth

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Treatment Goals - Weight Loss Targets
Excessive weight loss should be evaluated for
high risk behaviors
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A Staged Approach - Overview

• Stage 1 - Prevention Plus
• Family visits with physician or health
  professional
• Frequency individualized to family needs and risk
  factors
• Stage 2 - Structured Weight Management
• Family visits with physician or health
  professional with training in childhood weight
  management. Visits can be individual or group.
• May include visits with a dietitian, exercise
  therapist or counselor
• May include self-monitoring, goal setting and
  rewards
• Frequency monthly or individualized to family
  needs and risk factors

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A Staged Approach - Overview

• Stage 3 - Comprehensive, Multidisciplinary
  Intervention
• Multidisciplinary team with experience in
  childhood obesity
• Frequency often weekly group sessions for 8-12
  weeks with follow up
• Stage 4 - Tertiary Care Intervention (for select
  children only when provided by experienced
  programs with established clinical or research
  protocols)
• Medications - sibutramine, orlistat
• Very-low-calorie diets
• Weight control surgery - gastric bypass or
  banding (not FDA approved for children but in
  clinical trials)

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Give Evidence-Based Messages to All Families

• Dietary Intake
• Breastfeeding for the first 12 months or longer
• Limit or eliminate consumption of sugar-sweetened
  beverages
• Eat the the recommended quantities of fruits and
  vegetables
• Physical Activity
• Limit television and other screen time to no more
  than 2 hours/day
• Remove television and other screens from
  childrens bedrooms
• Moderate to vigorous physical activity for at
  least 60 minutes a day
• Eating Behaviors
• Eat breakfast every day
• Limit eating out, especially at fast food
  restaurants
• Have regular family meals
• Limit portion sizes

Prevention, Assessment and Treatment of Childhood
Obesity Recommendations from the AMA Expert
Committee on Childhood Obesity
www.ama-assn.org/ama/pub/category/11759.html
6/8/07
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A Staged Approach - Overview

• Families progress to the next stage if there has
  been no improvement in BMI/weight or velocity
  after 3-6 months and if the family is willing and
  ready.

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Overcoming Challenges

• Lack of Patient Motivation Provider Skills
• Not Enough Time
• No Reimbursement

• Empathize/Elicit - Provide - Elicit
• Motivational Interviewing
• Office Systems and Tools
• Team Based Care
• Coding Strategies
• Advocacy

Pediatrics Vol. 116 No. 1 July 2005 pp. 238-239
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ObesityAlgorithm

• Example medical risk or behavioral risk
• 10 years and older every 2 years
• Progress to next stage if no improvement in
  BMI/weight after 3-6 months and family willing
• Age 6-11yr 1 lb/month, Age 12-18yr 2 lbs/week
  average
• Age 2-5yr 1 lb/month, Age 6-18yr 2 lbs/week
  average

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• Hypertension

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Hypertension Whom to Screen

• Children over 3 y.o. at every visit
• Children lt 3 y.o. if special circumstances
• If gt90th percentile, re-check twice at same visit
• The fourth report on the diagnosis, evaluation,
  and treatment of high blood pressure in children
  and adolescents. Pediatrics 2004 114(2) 555-576

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Hypertension How to Screen

• Ideal conditions
• Manual measurement with cuff and stethoscope
• Child is resting for 5 mins
• Right antecubital fossa at heart level
• Properly fitting cuff
• Child is not on sympathomimetic medications
• Can bill as elevated BP (796.2) until dx of HTN
  is established
• The fourth report on the diagnosis, evaluation,
  and treatment of high blood pressure in children
  and adolescents. Pediatrics 2004 114(2) 555-576

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Definitions

• Hypertension 3 elevated SBP or DBP on three
  separate occasions
• Pre-hypertension BP 90th and lt95th percentile
• Stage 1 HTN BP 95th percentile to 5mm Hg above
  the 99th percentile
• Stage 2 HTN BP that is gt5mm Hg above the 99th
  percentile

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Pre-hypertension Definition and Intervention

• Definition
• BP 90th and lt95th percentile, OR
• BP gt120/80 even if lt90th ,up to 95th percentile
• Intervention
• Lifestyle modifications
• Re-check in 6 months
• Pharmacological Tx only if compelling
  complications

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HTN Lifestyle modifications

• Weight management, if indicated
• 30-60 minutes/day of moderate to vigorous aerobic
  exercise
• Reduction of sedentary activities
• Dietary modifications (DASH diet
  www.nhlbi.nih.gov/health/public/heart/hbp/dash/new
  _dash.pdf/Sachs et al. Effects on blood pressure
  of reduced dietary sodium and the Dietary
  Approaches to Stop Hypertension (DASH) diet.
  DASH-Sodium Collaborative Research Group. NEJM
  2001 Jan 4344(1)3-10

43
Stage 1 HTN Definition and Intervention

• Definition
• BP 95th percentile to 5mm Hg above the 99th
  percentile
• Re-check twice in 1-2 wks, or sooner if
  symptomatic, to establish diagnosis
• Intervention
• Evaluative work up
• Lifestyle modifications
• Pharmacological Therapy if
• HTN is symptomatic
• Secondary HTN
• Hypertensive target organ damage
• Diabetes, types 1 or 2
• Persistent HTN despite non-pharmacological
  measures

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HTN (stage 1 or stage 2) Evaluative work up

• Why
• To look for end organ damage
• To look for secondary HTN
• What
• BUN, Creatinine, electrolytes
• UA and UC
• CBC
• Renal Ultrasound
• Echocardiogram
• Retinal exam referral

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Stage 2 Hypertension Definition and Intervention

• Definition
• BP that is gt5mm Hg above the 99th percentile
• Intervention
• Evaluative work up
• Refer (as needed) within 1 wk. or immediately if
  pt. is symptomatic.
• Lifestyle modifications
• Initiate pharmacological therapy

46

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• Dyslipidemia

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Recent Article

• Lipid Screening and Cardiovascular Health in
  Childhood. Stephen R. Daniels, Frank R. Greer
  and and the Committee on Nutrition
• Pediatrics Vol. 122 No. 1 July 2008, pp. 198-208

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Dyslipidemia

• Atherogenic Lipid profile
• Increased LDL
• Low HDL levels ( 40 mg/dL)
• Increased triglycerides
• Other CVD Risk factors include
• Sedentary Lifestyle
• Hypertension
• Diabetes
• Tobacco use
• Obesity (BMI 95th)
• Family Hx of premature (age lt 55yrs) PVD or CVD

20 of 5-10 y.o. children with BMI 85 have
elevatedtotal cholesterol
American Diabetes Association. Management of
dyslipidemia in children and adolescents with
diabetes. Diabetes Care.2003262194-2197
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Dyslipidemia Whom to Screen

• Children gt2 yrs of age, and if
• Parent has total cholesterol gt240 mg/dL
• CV event lt55 yo. in father, grandfather, uncles
• CV event lt65 yo. in mother, grandmother, aunts
• Unknown FHx, but CVD risk factors present
• (HTN, diabetes, tobacco use, etc.)
• BMI is 85th

American Heart Association guidelines for primary
prevention of atherosclerotic cardiovascular
disease beginning in childhood. Circulation.
20031071562 American Diabetes Association.
Management of Dyslipidemia in children and
adolescents. Diabetes Care. 2003262194-2197
51
Dyslipidemia How to Screen

• The present guidelines
• Date back to 1992
• Always use an average of at least two screens
• Recommend total cholesterol screens for some risk
  factors and fasting profile for others.
• Have problems with
• Compliance by both the family and the provider
• Differences in race, age and gender
• Sensitivity and specificity
• Recommend treatment based only on LDL levels
• Have been augmented by newer guidelines to screen
  if child is overweight fasting lipid profile

Speiser PW, Rudolf MC, Anhalt H, et al.
Consensus Statement Childhood Obesity. J Clin
Endo Metabol.200490(3)1871-1887.
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Dyslipidemia Management

• If non-diabetic and 10 yrs old
• (Average LDL from two fasting screens)
• Ideal LDL lt110 mg/dL
• Borderline LDL 110 lt130 mg/dL
• LDL 130-159 mg/dL
• Maximize non-pharmacological management
• Consider medication if patient has diabetes
• LDL 160-189 mg/dL
• Consider medication if additional risk factors
  are present
• LDL gt190 mg/dL
• Begin medication
• Isolated fasting triglycerides gt400 mg/dL
• Begin medication

AHA. Circulation. 2003
53
Dyslipidemia Non-Pharmacological Management

• Dietary Management
• Dietary cholesterol lt200 mg/day
• Saturated fat lt7 of total calories
• Plant sterol esters, fiber, omega 3 fatty acids
• Weight reduction, if indicated
• Exercise
• 60 minutes/day of physical activity
• Tobacco cessation
• Blood glucose control (if indicated)

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Dyslipidemia Pharmacological Management

• Statins are first line in children over 10 y.o.
  or after menarche
• Low long-term compliance
• Need significant monitoring

Speiser PW, Rudolf MC, Anhalt H, et al.
Consensus Statement Childhood Obesity. J Clin
Endo Metabol.200490(3)1871-1887.
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Dyslipidemia Follow Up

• Repeat fasting lipid profile in 3 months
• Repeat in 6 months (from initial evaluation)
• At six months, if lipids are still elevated
• Screen for secondary causes
• TFTs,
• LFTs
• Renal function
• U/A
• OGTT
• Alcohol abuse

AHA. Circulation. 2003 and Mallare JT et al.
Diabetes Spectrum 2005.
56
Polycystic Ovary Syndrome(PCOS)
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Polycystic Ovary Syndrome(PCOS)

• History
• Physical Exam
• Laboratory Evaluation
• Management
• Reference Sheet

• Definition
• Etiology
• Profile
• Sequelae
• CVD Risk

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PCOS Definition

• Chronic anovulation or oligo-ovulation
• Clinical and/or biochemical signs of
  hyperandrogenism
• Exclusion of other etiologies
• Congenital adrenal hyperplasia (CAH)
• Androgen-secreting tumors
• Cushings syndrome

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PCOS Sequelae

• Persistant Anovulation
• Increased hormonal levels
• Testosterone, androstenedione, dehydroepiandostero
  ne (DHEA), dehydroepiandosterone-sulfate
  (DHEA-S), 17-hydroxyprogesterone (17-OHP),
  estrone and free estradiol, and luteinizing
  hormone (LH)
• Decreased hormonal levels
• Sex hormone binding globulin (SHBG), and
  low-normal follicle-stimulating hormone (FSH)
• Infertility
• Menstrual Irregularities
• Oligomenorrhea most common
• Amenorrhea
• Dysfunctional uterine bleeding
• Normal cycles
• Unopposed estrogen stimulation of endometrium
• Endometrial cancer increased risk is 3-fold if lt4
  menses/yr
• ? breast cancer increased risk

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PCOS Sequelae

• Hyperandrogenism
• Phenotypic progression
• Hirsutism variation with ethnicity
• Acne
• Oily skin
• Increased libido
• Clitoromegaly can be present in PCOS but needs
  rule out
• Masculinization (virilization) not consistent
  with PCOS
• Insulin Resistance
• Can be present in lean women
• Present in 40-90 of overweight women with PCOS
• Increased risk of CVD and T2DM
• Dyslipidemia
• Higher systolic blood pressure

2003 Rotterdam PCOS consensus. Fertil Steril
2004 Legro RS et al. J Clin Endocrinol Metab.
199984165-9 Legro RS et al. OBGManagement
2005 Speroff and Fritz, 2005
61
PCOS Profile

• Weight
• 35-60 are overweight
• Insulin Resistance (IR)
• Overweight women with PCOS more likely IR
• Lean women with PCOS less likely IR
• Speroff and Fritz, 2005 AACE. Endocrin Pract.
  2005

62
PCOS History

• Menstrual History
• Study Menstrual irregularity 2-4 yrs post
  menarche, 95 had PCOS
• Fernandez AR et al. J Pediatr Adolesc Gynecol
  2005
• Premature adrenarche
• Pubic hair lt8 y.o.? and lt9 y.o. ?
• Associated with low birth weight
• Changes associated with hyperandrogenism
• Physical changes
• The rapidity of onset (a time frame of months
  is not generally consistent with PCOS)
• Family History
• Autosomal dominant

63
PCOS Physical Exam

• BMI percentile
• Phenotypic changes associated with
  hyperandrogenism
• Signs of premature adrenarche
• Hirsutism
• Acne
• Clitoromegaly
• Clitorus 1cm³
• virilization is not a normal finding in PCOS.
  Think tumor or CAH
• Other physical findings associated with insulin
  resistance
• Visceral adiposity
• Acanthosis nigricans

64
PCOS Lab Evaluation

• Choices in the laboratory evaluation depend, in a
  large part, on the findings in the history and
  physical exam, i.e. the degree of androgenization
  and the rapidity of their onset.

65
PCOS Lab Evaluation

• Pregnancy test
• TSH
• r/o hypothyroidism
• Prolactin
• r/o prolactinoma
• MRI brain if 100 ng/mL
• Fasting lipid profile
• For lean and overweight women
• /- Oral glucose tolerance test
• Especially if overweight or genetic predisposition

66
PCOS Lab Evaluation, contd

• /- Fasting, 8 am 17-OHP
• r/o late onset congenital adrenal hyperplasia
• gt200 ng/dL need ACTH stim test.
• gt800 ng/dL nearly diagnostic for 21-hydroxylase
  deficiency
• /- Total testosterone, DHEA-S
• r/o androgen secreting tumor
• Testosterone levels gt 200 ng/dL, need further
  evaluation
• DHEA-S gt 700 mcg/dL, need further evaluation
• /- Dexamethasone suppression test
• If Cushings disease is suspected
• HTN, striae, buffalo hump, moon facies

67
PCOS Lab Evaluation, contd

• Pelvic Ultrasound
• Not routinely recommended
• Can screen for endometrial hyperplasia (see
  below)
• If dominant follicle (gt10 mm or corpus luteum,
  repeat scan during next cycle
• Performed on cycle days 3-5 or days 3-5 after
  progesterone induced withdrawal bleed
• /- Endometrial Biopsy for endometrial cancer
• Determined by the duration of anovulation, not
  the patients age
• If endometrium is 5-12mm may do a biopsy.
• If endometrium is gt12mm always do a biopsy

2003 Rotterdam PCOS consensus. Fertil Steril 2004
and Speroff Fritz, 2005
68
PCOS Management Issues

• Unopposed estrogen
• Menstrual Irregularity
• Endometrial cancer risk
• Hyperandrogenism
• Hirsutism
• Acne
• Infertility
• Hyperinsulinemia (insulin resistance)
• Increased risk of T2DM and CVD
• Cholesterol management
• Blood pressure management
• Tobacco cessation, etc.
• Cobin et al, Endocr Pract. 2005. and AHA.
  Circulation. 20001022284

69
PCOS Treatment

• First
• If patient has dysfunctional uterine bleeding,
  address with appropriate work-up and treatment.
• If amenorrheic, confirm that amenorrhea is
  secondary to progesterone deficiency with a
  progesterone challenge test to induce a
  withdrawal bleed.

70
PCOS Treatment

• Combined estrogen/progesterone
• OCP with 2nd or 3rd generation progesterone
  norethindrone, norgestimate, desogestral
• 4th generation Drospirenone Spironolactone
  analog (Yasmin)
• Patch or ring
• Address the endometrial risk
• Decrease the hyperandrogenism
• Improve hirsutism
• Improve lipid profile (HDL only)
• Do not address
• The hyperinsulinemia -Limited evidence that OCPs
  may worsen insulin sensitivity
• Inflammatory state -no change in IL-6 and
  adiponectin
• Body adiposity profile -further worsening

Diamanti-Kandarakis E et al. 2003. Ibenez, de
Zegher, 2004.
71
PCOS Metformin Treatment

• (850-2500 mg/day)
• Reduces hyperinsulinemia
• Reduces free androgen levels by increasing SHBG
• Restores ovulation for many women
• 13 RCTs, n543 46 of PCOS women ovulated, vs
  24 in control group

Lord JM et al. BMJ 2003327951-3.
72
PCOS Treatment

• Spironolactone (50-200mg/day)
• Addresses hyperandrogenism, ? hirsutism
• Does not affect hyperinsulinemia
• OCPs are advised to prevent pregnancy
• Provera (5-10mg daily x 14 days of every month)
• Addresses the endometrial risk
• Does not decrease androgen production by the
  ovaries
• Does not address hyperinsulinemia
• Weight Loss (gt5)
• Reduces hyperandrogenization
• Reduces hyperinsulinemia
• Restores ovulation for many women

73
Evaluation 1) TSH Prolactin
Pregnancy test 2) Lipid profile,
fasting 3) If obesity/acanthosis fasting
/or 2 hr glucose 4) If amenorrheic Provera
challenge (10 mg Provera qd x 10d) 5) /-
Total testosterone /- DHEA-S
/- 17-OH progesterone, fasting 6) If sxs
of Cushings dexamethasone suppression test
Treatment Weight loss, if indicated
Estrogen/progesterone combo Consider
metformin Refer for severe or recalcitrant
hirsutism

• Polycystic Ovary Syndrome (PCOS)
• Definition
• Persistent anovulation
• Lab/clinical evidence of hyperandrogenism
• History
• Menses
• FHx of PCOS
• Premature adrenarche
• Rapidity of onset of androgenic changes
• Hirsutism any depilatory measures
• Physical Exam
• Hirsutism
• Acne
• Clitoromegaly
• Virilization

74
Non-Alcoholic Fatty Liver Disease(NAFLD)
75
Non-Alcoholic Fatty Liver Disease

• HISTORY
• Use of alcohol, drugs, meds, herbs
• Dietary recall
• LABS
• Hepatitis panel,
• Liver function test,
• Fasting lipid profile,
• Fasting glucose and insulin
• Consider biopsy in patient for whom
• Weight loss has failed,
• LFTs remain elevated,
• US shows evidence of fatty liver,
• Signs of metabolic syndrome are present

76
Brief Pathogenesis
Insulin Resistance Overweight
N A F L D
STEATOSIS Leading cause of liver
enzyme abnormalities in teens One study 53
occurrence in overweight children
?Hepatic FFA Synthesis ?Hepatic Uptake of Fat
?Oxidation of Fat Protein Damage ?
Pro-inflammatory Cytokines
STEATOHEPATITIS
N A S H

• TIME

FIBROSIS
CIRRHOSIS
77
Eval for suspected NAFLD

• Ultrasound of the liver
• a1-antitrypsin
• Ceruloplasm
• Antinuclear antibody
• Hepatitis antibody measurements
• (Liver biopsy, if recommended by Peds GI)

78
Non-Alcoholic Fatty Liver Disease(NAFLD)

• Benign Reversible
• Associated with Overweight Insulin Resistance
• Causes elevated ALT (and AST)
• U/S can quantify steatosis, but need bx to
  detect fibrosis.
• Treatment Weight reduction of 5 in 3 mos to
  normalize ALT in overweight pediatric patients
• Predictors of fibrosis not established in
  children

79
Predictors of Fibrosis in Adults

• ALT greater than twice normal
• ASTgtALT
• At least moderate central obesity
• T2DM or impaired glucose tolerance
• Hypertension
• Hypertriglyceridemia
• In Children and Adults
• Increasing severity of metabolic syndrome
  components and longer time of abnormalities
  roughly correlate with increased liver pathology
• Biopsy is used to establish the presence of
  fibrosis. (Radiological studies not useful.)

80
Every Child Deserves To Be Healthy and Happy!