This article is part of a CME/CE certified activity. The complete activity is available at: /viewprogram/32316

Size: px

Start display at page:

Download "This article is part of a CME/CE certified activity. The complete activity is available at: /viewprogram/32316"

Tabitha Randall
5 years ago
Views:

1 This article is part of a CME/CE certified activity. The complete activity is available at: /viewprogram/32316 CME/CE Information CME/CE Released: 01/31/2012; Valid for credit through 01/31/2013 Target Audience This activity is intended for clinicians such as physicians, nurse practitioners, school nurses, and dietitians as well as coaches, teachers, and daycare providers. Goal The goal of this activity is to review comorbidities associated with pediatric obesity and provide strategies for their prevention and management. Learning Objectives Upon completion of this activity, participants will be able to: Identify serious obesity-related comorbidities and the risk factors that are associated with their development in children who are overweight or obese. Describe specific strategies used by clinicians who successfully diagnose and manage obesity-related comorbidities in children Credits Available Physicians - maximum of 0.75 AMA PRA Category 1 Credit(s) Nurses ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology) All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Accreditation Statements For Physicians Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Medscape, LLC designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity. Medscape, LLC staff have disclosed that they have no relevant financial relationships. Contact This Provider For Nurses 1 of 17 3/1/12 1:57 PM

2 Medscape, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Awarded 0.75 contact hour(s) of continuing nursing education for RNs and APNs; none of these credits is in the area of pharmacology. Accreditation of this program does not imply endorsement by either Medscape, LLC or ANCC. Contact This Provider For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact CME@medscape.net Instructions for Participation and Credit There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board. This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit, you must receive a minimum score of 70% on the post-test. Follow these steps to earn CME/CE credit*: Read the target audience, learning objectives, and author disclosures. Study the educational content online or printed out. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. Medscape Education encourages you to complete the Activity Evaluation to provide feedback for future programming. You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates by accessing "Edit Your Profile" at the top of your Medscape homepage. *The credit that you receive is based on your user profile. Hardware/Software Requirements To access Medscape Education users will need A computer with an Internet connection. Internet Explorer 6.x or higher, Firefox 2.x or higher, Safari 2.x or higher, or any other W3C standards compliant browser. Adobe Flash Player and/or an HTML5 capable browser may be required for video or audio playback. Occasionally other additional software may be required such as PowerPoint or Adobe Acrobat Reader. 2 of 17 3/1/12 1:57 PM

3 As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest. Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content. Author Amy R. Sternstein, MD Assistant Clinical Professor, Ohio State University College of Medicine; Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio Disclosure: Amy R. Sternstein, MD, has disclosed no relevant financial relationships. Dr. Sternstein does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States. Dr. Sternstein does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States. Editor Kristin M. Richardson Senior Scientific Director, Medscape, LLC Disclosure: Kristin M. Richardson has disclosed no relevant financial relationships. Gina K. Kaeuper Freelance Scientific Director, Knoxville, TN Disclosure: Gina K. Kaeuper has disclosed no relevant financial relationships. Laura A. Feiker Clinical Editor, Medscape, LLC Disclosure: Laura A. Feiker has disclosed no relevant financial relationships. CME Reviewer 3 of 17 3/1/12 1:57 PM

Nafeez Zawahir, MD CME Clinical Director, Medscape, LLC Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships. Nurse Planner Laurie E.

4 Nafeez Zawahir, MD CME Clinical Director, Medscape, LLC Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships. Nurse Planner Laurie E. Scudder, DNP, NP Nurse Planner, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC Disclosure: Laurie E. Scudder, DNP, NP, has disclosed no relevant financial relationships. An Ounce of Prevention is Worth a Pound: Shaping the Habits that Shape the Child CME/CE Amy R. Sternstein, MD Posted: 01/31/2012 Download Slides Slide 1. Amy R. Sternstein, MD: Hello, I am Dr Amy Sternstein. I am assistant clinical professor in the Department of Pediatrics at the Ohio State University College of Medicine and a staff physician at the Center for Healthy Weight and Nutrition at Nationwide Children s Hospital in Columbus, Ohio. Welcome to this audio Webcast titled, An Ounce of Prevention is Worth a Pound: Shaping the Habits that Shape the Child. The purpose of this presentation is to show how healthcare providers can counsel on nutrition and physical activity for all well children, regardless of their weight, as well as provide obesity management if 4 of 17 3/1/12 1:57 PM

5 overweight or obesity is identified. Slide 2. An Ounce of Prevention is Worth a Pound ( Ounce of Prevention ) is an Ohio- based community health program designed to help provide healthy weight achievement and maintenance in children. Ounce of Prevention resources can be utilized in multiple settings due to the easy age-specific design; therefore, this activity is not exclusively intended for clinicians such as physicians or nurse practitioners. School nurses and dieticians as well as other allied care providers are welcome to integrate this information into their individual mentoring or caregiving role. The good news is that in most circumstances obesity can be prevented starting at birth, even if the prenatal history has put the child at risk. Ounce of Prevention aims to achieve this goal. 5 of 17 3/1/12 1:57 PM

depending on the severity of the disease. This presentation will address only the initial stage.

6 Slide 3. In the December 2007 Pediatrics supplement, the AAP expert committee outlined stages of obesity prevention and management depending on the severity of the disease. This presentation will address only the initial stage. We will first focus on prevention measures using the Ounce of Prevention program. It is intended for all children regardless of their weight. Then we will move on to stage 1 obesity management using a real patient as an example. Slide 4. 6 of 17 3/1/12 1:57 PM

Despite growing evidence that obesity may start at infancy, if not prenatally, the 2011 Institute of Medicine report, Early Childhood Obesity Prevention Policies, clearly states that obesity

7 Despite growing evidence that obesity may start at infancy, if not prenatally, the 2011 Institute of Medicine report, Early Childhood Obesity Prevention Policies, clearly states that obesity prevention efforts have paid relatively little attention to children under age 5. Therefore, the Ounce of Prevention program has been created especially to start at birth, and follows the typical well-child schedule. This ensures multiple opportunities to instruct parents on how to safely establish a wide variety of nutritious foods without overfeeding and encourage daily activity. The secret to directing parental advice is to follow developmental milestones and anticipate what the family will introduce next. Ounce of Prevention is a collaborative effort initially created in 2006 to provide materials focusing on nutrition and physical activity guidance starting from birth. The partners on the project from its inception include the Ohio Chapter of The AAP, the Ohio Department of Health, the Ohio Dietetic Association, and American Dairy Counsel, Mideast. The current version was updated in 2010, spanning from birth to 18 years, with the addition of a Spanish acculturated version. All of the Ounce of Preventionmaterials, in color and black and white, are free and available online. Slide 5. The Anticipatory Guidance summary tip sheet is specifically designed to summarize the messages from birth to 6 years. Each visit has a corresponding age-specific parent handout, which can be personalized with the child s growth parameters. Since families often see multiple providers during well childcare, this can also assist in keeping a permanent record in the patient s chart so any provider can follow the patient s progress in subsequent well-child visits. 7 of 17 3/1/12 1:57 PM

activity advice, and a blank section for note taking by either the healthcare provider or the parent.

8 Slide 6. Each age-specific parent handout has a place to document the child s name, date, and growth parameters, plus 4 divided sections: food for thought, feeding advice, physical activity advice, and a blank section for note taking by either the healthcare provider or the parent. Other Ounce of Preventionhandouts cover additional nutrition topics such as age-appropriate healthy servings. These include separate handouts for ages 2 to 3, 4 to 8, 9 to 13, and 14 to 18 years. For children younger than 2 years, you will find appropriate servings on the age-specific, well-child parent handout. Other available topics include healthy snacking, healthy bones, and sports nutrition. 8 of 17 3/1/12 1:57 PM

Slide 7. For more information and free downloads of all PDF files in both English and Spanish, please refer to any of these listed websites. 1,2,3,4 Slide 8.

9 Slide 7. For more information and free downloads of all PDF files in both English and Spanish, please refer to any of these listed websites. 1,2,3,4 Slide 8. Now let us look at an example of obesity management identified as stage 1. MA is a 6-year-old female. As you can see on her growth chart, her weight of 108 pounds is clearly above the 95 th percentile. Her height is 49 inches, which is at the 90 th percentile, and her BMI is 31, which is above the 95 th percentile. She lives in a single parent household with a limited income and there is family history of diabetes as well as dyslipidemia. Her physical exam is unremarkable except for obesity. 9 of 17 3/1/12 1:57 PM

As illustrated in the BMI growth chart, children may have a higher BMI as a toddler but should get thinner again during the preschool years.

10 Slide 9. Remember, BMI is an excellent screening tool but not a diagnostic test. It is simply a proxy for adiposity. Accordion-like changes in BMI occur throughout childhood, and until the child has stopped growing his or her body shape cannot be assessed by a static number. As illustrated in the BMI growth chart, children may have a higher BMI as a toddler but should get thinner again during the preschool years. Therefore, it is essential to look for either the physiologic nadir that occurs around 4 years or lack of a nadir, which was missed in our particular 6-year-old example. This is an important step for early identification of at-risk children and it allows interventions to bring about change when children tend to be more receptive. 10 of 17 3/1/12 1:57 PM

Slide 10. Another obesity pattern is illustrated by this BMI graph. This child has an expected decrease in BMI as a preschooler, but his weight trajectory significantly changed after school entry.

11 Slide 10. Another obesity pattern is illustrated by this BMI graph. This child has an expected decrease in BMI as a preschooler, but his weight trajectory significantly changed after school entry. Slide 11. Our 6-year-old patient has a significant family history of diabetes and dyslipidemia. It is essential to place the BMI in context. Creating a risk profile not only includes a targeted family history, but a targeted review of systems and an evaluation to identify comorbidities. In addition to a physical exam, it is essential to obtain a diet and physical activity history. Acanthosis nigricans, which can be a sign of insulin resistance, is a very disturbing skin change seen in our patients. This sign, however, can provide an excellent opportunity for counseling on diabetes risk. 11 of 17 3/1/12 1:57 PM

Our 6-year-old patient falls in the category of having a BMI greater than the 95 th percentile with risk factors.

12 Slide 12. Once you have established the risk profile, the next question is: When is it appropriate to check labs? The expert committee (of the AAP) summary recommendations provide guidelines and algorithms for lab evaluations. Our 6-year-old patient falls in the category of having a BMI greater than the 95 th percentile with risk factors. Slide 13. Other lab considerations come from the endocrinology literature. Here the ADA recommendations call for 12 of 17 3/1/12 1:57 PM

13 checking a fasting glucose with a BMI greater than 85 th percentile with specific risk factors. These are similar to the expert committee recommendations, just a bit more specific. Slide 14. Our 6-year-old patient had an abnormal lipid profile with elevated cholesterol of 205 mg/dl, low HDL (the good cholesterol), and an elevated triglyceride level of 188 mg/dl. The rest of her lab results, her fasting glucose and liver functions, are normal. The abnormal values can improve with simple dietary counseling once you have obtained a dietary history. 13 of 17 3/1/12 1:57 PM

, High Five for Kids, and Keep ME Healthy in Maine. Slide 16.

14 Slide 15. To assess our patient s diet and activity history, the Healthy Habits survey is an excellent place to start. It is available online in versions for ages 2 to 9 and 10 to 18 at These tools have been adapted from Let s Go!, High Five for Kids, and Keep ME Healthy in Maine. Slide 16. The expert committee also identified 10 evidence-based messages to help guide nutrition and activity counseling. All 10 of these messages have been included in the Ounce of Prevention program. 14 of 17 3/1/12 1:57 PM

Slide 17. Here are some counseling tips. I have found that counseling is most effective when focused on health as opposed to specific weight-loss goals.

15 Slide 17. Here are some counseling tips. I have found that counseling is most effective when focused on health as opposed to specific weight-loss goals. It is essential to start by assessing the degree of interest via motivational interviews using open-ended questions, then prioritize your time by counseling the families who are the most interested and motivated to change. Other families may surprise you and may return after having moved further along the motivation continuum at a later date. It is important to attempt 3 to 6 months of counseling with close follow-up using the 10 evidence-based messages. Slide 18. It is also crucial to set realistic treatment goals. Often, this just means a decrease in weight velocity or weight maintenance with height growth, which will result in a corresponding decrease in BMI. As I stated in the beginning of this presentation, it is possible to see a significant drop in BMI with short-term counseling. These families are so appreciative, but more importantly, it creates a tremendous boost in the child s self-esteem. 15 of 17 3/1/12 1:57 PM

16 Slide 19. Thank you for your efforts in prevention as well as obesity management and for participating in this activity. Remember that this is just 1 of 3 parts required for completion of this CME or CE program. Please listen to all 3 parts to earn your CME or CE credit. Also, check Medscape Education often to continue to participate in the Children s Health, Fitness, and Nutrition Initiative. To proceed to the online CME or CE test, please click on the Earn CME/CE Credit link on this page. Thank you again. Supported by an independent educational grant from Sanford Health. This article is part of a CME/CE certified activity. The complete activity is available at: /viewprogram/ An Ounce of Prevention is Worth a Pound Web site. Accessed January 4, An Ounce of Prevention is Worth a Pound program page. Nationwide Children's Hospital Web site. Accessed January 4, An Ounce of Prevention is Worth a Pound program page. Healthy Ohio Web site. Accessed January 4, An Ounce of Prevention is Worth a Pound program page. American Dairy Association Mideast Web site. Accessed January 4, Disclaimer The material presented here does not necessarily reflect the views of Medscape, LLC, or companies that support educational programming on These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or employing any therapies described in this educational activity. Medscape Education of 17 3/1/12 1:57 PM

17 Contents of Clinical Insights: Prevention and Management of Obesity-Related Comorbidities in Children [/viewprogram/32316] All sections of this activity are required for credit Comorbidities in Childhood Obesity: A Special Focus on Type 2 Diabetes Mellitus [/viewarticle/757307] Eating for 2: Maternal Nutrition and Childhood Obesity [/viewarticle/757304] An Ounce of Prevention is Worth a Pound: Shaping the Habits that Shape the Child [/viewarticle/757306] This article is part of a CME/CE certified activity. The complete activity is available at: /viewprogram/ of 17 3/1/12 1:57 PM

From Medscape Education Family Medicine The National Quality Strategy and You: How CMS Quality Measures Affect Policy and Practice CME

www.medscape.org This article is a CME certified activity. To earn credit for this activity visit: http://www.medscape.org/viewarticle/803358 From Medscape Education Family Medicine The National Quality