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The power of change
1. A Clinical Case Presentation
The Power of Change: A Case of a
Adolescent with Multiple Medical
Condition
Alejandro E. Legarda III MD
First Year Resident
DFCM
2. Objectives
• To present an adolescent with hypertension and obesity
and its correlation to Metabolic syndrome and PCOS
• To discuss the differential diagnosis for high BP in the
young
• To discuss the approach to management of adolescent
with hypertension, obesity and the diagnose syndromes
• To present short-term and long-term wellness plan
appropriate for the patient's condition
3. Patient Profile
EJ
13 years old
Single
Roman Catholic
Incoming 3rd year high school student
Chief Complaint
ELEVATED BLOOD PRESSURE
4. Clinical History
Five years
prior to
consult
(2007)
• The patient was then eight years old
and sought a consult due to her re-
occurring erythematous vesicular
lesions.
• Upon consultation, she was diagnosed
with Post-streptococcal
glomerulonephritis. The patients was
admitted in the hospital for a week due
to this condition.
• Patient was documented to suffer from
hypertension. Nifedipine was prescribed
to control and manage her
hypertension.
After hospitalization, patient felt well again. No follow-up consult was
recommended to the patient.
5. Three years
prior to
consult
(2009)
• The patient started gaining
weight as food intake severely
increased.
• Patient’s BP was taken annually
in school and showed elevated
blood pressure.
• The increased blood pressure
readings was simply ignored by
the patient and her parents,
thus resulting in progressive,
uncontrolled weight gain.
Clinical History
6. Two weeks prior to
consult
• Patient sought consultation at the UP-PGH
Dermatological Department for her vesicular
lesions.
• Patient featured an incidental finding of 160-90
blood pressure reading.
• Assessment reveals:
Acne vulgaris with etiology related to PCOS
Hypertension secondary to (1) PCOS (2)
Cushing’s Syndrome (3) Insect bite hyper
sensitivity reaction
Patient was given:
• Amlodipine (5mg./tab) OD
• Benzoyl Peroxide gel OD
• Tretinoin cream for the face
• Cloxacilin (500mg./tab) for 7 days
• Mupirocin Bethamethasone ointment ITD
• Sunscreen
• mild soap
Clinical History
Patient was referred to Pedia adolescent, hence the consult.
7. Clinical History
At Consult (March 26, 2012)
Patient was seen at the
Pedia Adolescent Clinic
9. Past Medical History
(-) Asthma
(-) Allergy
(-) Pulmonary Tuberculosis
(-) Bronchial asthma
No Accident and injury
Hospitalizations:
Admitted for (+) PSGN (2007) and Dengue Fever (2009)
Surgeries:
There was no previous surgery
Medications:
Co-amoxiclav for her recurrent skin infections
10. OB/GYNE History
Menarche: January 2011
Irregular flow occurring only 3x since her
menarche
Lasting 4-5 days, Pads 2-4 a day
No dysmenorrhea
No sexual contact
11. Birth and Maternal History
Patient was born full-term via spontaneous
vaginal delivery at a local hospital delivered by
an obstetrician with no known feto-maternal
complications.
12. NUTRITIONAL HISTORY
Patient was breastfed for 3 months and then shifted
to bottle feeding of Bona milk every 3 to 4 hours
starting at 4 months old up to 12 months old.
Complementary feeding was started at 6 months
old.
Patient would skip breakfast but would have 2
snacks before a heavy lunch. She would have 2 heavy
meriendas, e.g.,2 hamburgers/hotdogs or cups of ice
cream .Most of the food she eats are either fried or
salty and plenty of desserts. She loves to drink cola.
13. Immunization History
Childhood Vaccinations
Bacillus Calmette-Guerin (BCG), one dose
Hepatitis B vaccine, three doses
Diptheria Pertussis Tetatnus (DPT), three doses
Oral Polio Vaccine, thress doses
Measles, one dose
15. Personal and Social History
Home:
- lives with parents and four siblings in Imus, Cavite
-good relationship with parents and siblings
Education:
-Incoming third-year high school student
-With above-average grades
- has close set of friends in school
Activities:
-Favorite past time– eating
-Loves eating street foods and junk foods
-Spends most of her free time in front of the TV or
computer
-Not involved in any outdoor activities such as sports
16. Personal and Social History
Drugs:
-No history of cigarette or alcohol use
-Denies use or history of use of illicit drugs
Sexual:
-Does not showcase any consciousness with body weight and
shape
-Patient has not attempted to change her appearance
-Currently no relationship with the opposite sex
Suicidal Tendencies:
-Patient exhibits no signs or episodes of depression or suicidal
ideation
Safety:
-Patient together with her family lives in a peaceful and orderly
community with minimum crime rate
- uses public transportation to commute
-Not a member of a gang or sorority
17. Physical Examination
General Survey:
Awake, alert, coherent, in pain, not in cardio-respiratory distress
(-) muscle wasting
(-) moon face
(-) proximal muscle weakness
(-) buffalo hump
Vital Signs:
Blood Pressure: 150/90(>99th percentile)
Heart Rate: 75 beats/minute
Respiratory Rate: 18 breaths/minute
Temperature: 36.8 C
19. Physical Examination
Head and Neck:
Anicteric sclerae, pink conjunctivae,
pupils 2-3mm OU reactive to light,
(+) Short leg length
(+) Acanthosis nigricans,
(-) masses, (-) cervical lymphadenopathy,
(-) anterior neck mass
(-) tonsillopharyngealcongestion,
(-) neck vein engorgement, (-)ear discharge
20. Physical Examination
Chest and Lungs:
Equal chest expansion, no deformities,
no lesions, clear breath sounds,
(-) crackles/rales/wheezes
Heart:
Adynamic precordium, distinct heart sounds,
apex beat at 5th intercostal space left midclavicular line,
regular rate and rhythm, no murmurs
21. Physical Examination
Abdomen:
flabby
(+) Striae lower abodomen
no deformities
no lesions
Soft normoactive bowel sounds
(-)masses or tenderness
liver span 8 cm right midclavicular line
intact Traube’s space
no costo-vertebral angle tenderness
22. Physical Examination
Extremities
pink nailbeds
full and equal pulses
no cyanosis/clubbing/ edema
no crepitations
no limitation of passive and active motion
on both upper extremities
(-) shooting pain on straight leg raise of
both lower extremities
(-) limitation of motion due to pain
no crepitations on hips, knees or ankles
no joint swelling or deformities
(-) Pain on active leg raise of both
lower extremities
23. Physical Examination
Neuro Exam
Cranial Nerve (CN) Examination
CN I –intact gross olfaction
CN II –pupils 2-3 mm OU briskly reactive to light
CN III,IV,VI –full range of extraocular muscle movement
CN V –brisk corneals, good masseter tone,
CN VII –no facial asymmetry, no altered taste
CN VIII –intact gross hearing, no lateralization on Weber Test
CN IX –no altered taste, can swallow
CN X –can swallow
CN XI –good symmetrical shrug
CN XII –can protrude tongue, no deviation
24. Physical Examination
Sensory
Pain: Intact on all dermatomes
Light Touch: Intact on all dermatomes
Vibratory: Intact on all dermatomes
Motor
Normal Gait
Good muscle tone, no atrophy, no limb size discrepancy
Full motor strength on both upper extremities
Tanner Stage 3
External genitalia with dark, coarse
curly hair spreads over mons pubis
Elevation of Breast contour; areolae enlarged
25. Salient Features of the Case
SALIENT FEATURES OF THE CASE
A 13-year old female
Chief complaint of elevated blood pressure
History of hypertension ,DM and Obesity
Previous history of renal disease (+) poluyuria, (+)
polyphaga.
Amenorrhea
Obesity
Anthropometrics: Height: 157 cm, Weight: 96.5 kg, Body
Mass Index: 40.7 kg/m2 (Z score: 2.58),
(+) Short neck length
(+) Acanthosis nigricans nape area,
Flabby abdomen with (+) Striae
26. Initial Impression
Hypertension, Stage II-- etiology to be
determined
Acne Vulgaris probably secondary to PCOS
DM suspect
Obese, Type 2
Amenorrhea secondary to PCOS
28. Therapeutics
Continue the following medications:
Cloxacillin 500 for 7 days
Tretnoin Cream for the face
Mupirocine Betamethasone ointment, TID
Sun screen use
Mild soap use
Start Amlodipine 5mg once a day
30. European Society of Hypertension
The study mentioned childhood BP has been shown to
track into adulthood
Unlike adults, the diagnostic criteria for elevated BP in
children are based on the concept that BP in children
increases with age and body size, making it impossible to
utilize a single BP level to define hypertension.
31. The recommended method is auscultatory.
Use K1 for systolic BP and K5 for diastolic B.
If the oscillometric method is used, the monitor needs to be validated
and if hypertension is detected by the oscillometric method, it needs to
be confirmed using the auscultatory method.
The Use the appropriate cuff size according to arm width (40% of the
arm circumference) and length (4_8 cm, 6_12 cm, 9_18 cm, 10_24 cm,
to cover 80–100% of the individual’s arm circumference).
Specific recommendations for office BP
measurement in children and adolescents
34. Systolic and diastolic ambulatory blood pressure
(systolic/diastolic) values for clinical use
35. Task Force for Blood Pressure in Children, the Fourth Report on
the Diagnosis, Evaluation, and Treatment of High Blood
Pressure in Children and Adolescents
The normal BP in children is defined as SBP and DBP less than
90th percentile for age, sex and height.
Hypertension is defined as SBP and/or DBP persistently 95th
percentile or more, measured on at least three separate occasions
with the auscultatory method.
Rule out White-coat (or isolated office) and masked (or
isolated ambulatory) hypertensions
38. FAMILY HISTORY
Hypertension
Cardiovascular and cerebrovascular disease
Diabetes mellitus
Dyslipidemia
Obesity
Hereditary renal disease (Policystic kidney disease)
Hereditary endocrine disease (pheochromocytoma
glucocorticoid-remediable aldosteronism, multiple
endocrine neoplasia type 2, von Hippel–Lindau)
Syndromes associated with hypertension (neurofibromatosis)
Clinical Data To Note
39. Clinical Data To Note
PERINATAL HISTORY
Birth weight, gestational age, oligohydramnios,
anoxia, umbilical artery catheterization
PREVIOUS HISTORY
Hypertension
Urinary tract infection, renal or urological disease
Cardiac, endocrine (including diabetes) or neurological
disease
Growth retardation
Symptoms suggestive of secondary hypertension
Dysuria, thirst/polyuria, nocturia, hematuria
Edema, weight loss, failure to thrive
Palpitations, sweating, fever, pallor, flushing
Cold extremities, intermittent claudication
Virilization, primary amenorrhea and male pseudohermaphroditism
Symptoms suggestive of target organ damage
Headache, epistaxis, vertigo, visual impairment
Facial palsy, fits, strokes
Dyspnea
41. Physical Examination To Note
Height
Weight
Body mass index
External features of syndromes/conditions associated with
hypertension
Neurofibromatosis
Klippel–Trenaunay–Weber
Feuerstein–Mims
Von Hippel–Lindau
Multiple endocrine neoplasia
Pseudoxanthoma elasticum
Turner,
William
Marfan
Cushing
Hyperthyroidism,
Lupus
Vasculitis
Congenital adrenal hyperplasia
Data to record:
42. Physical Examination
Data to Record
Cardiovascular examination
Pulse and BP measurement in both arms and legs
Bruits/murmurs – heart, abdomen, flanks, back,
neck, head
Signs of left ventricular hypertrophy or cardiac failure
Abdomen
Masses – Wilms, neuroblastoma, pheochromocytoma, autosomal
dominant and recessive polycystic kidney disease, multicystic kidney
displasia, obstructive uropathy
Hepatosplenomegaly – autosomal recessive polycystic kidney disease
Neurological examination
Fundoscopy for hypertensive changes and retinal
amartoma (von Hippel–Lindau)
Evidence of VIII nerve palsy
Other neurological defects including stroke
44. Patient PE Presentation
Significant Anthropometrics:
Height: 157 cm
Weight: 96.5 kg,
Body Mass Index: 40.7 kg/m2 (Z score: 2.58)
(+) Short neck length
(+) Acanthosis nigricans nape area
Flabby abdomen with (+) Striae
(+) Acne
Other details were none pertinent
45. Target Organ Damage To Note
Heart
Blood Vessels
Kidney
Neuro
Fundoscopy
46. Heart
Left Ventricular Hyperthrophy (LVH) remains to date the most
thoroughly documented form of end-organ damage caused by
hypertension in children and adolescents.
47. Blood Vessels
Morphological changes of the arterial wall, thickening of the intima-media
complex.
Children with familial hypercholesterolemia have higher IMT
Overweight and obesity are associated with increased IMT in children with or
without essential hypertension.
48. Kidney
Hypertension-related renal damage is based
on a reduced renal function or an elevated
UAE. Proteinuria is a marker of glomerular
damage in primary and secondary
glomerulopathies. An indication for BP-
lowering interventions.
Microalbuminuria (20–300mg/g creatinine,
2–30 mg/mmol creatinine, 30–300 mg/day,
20–200mg/min) has been shown to predict the
development of diabetic nephropathy .
Overt proteinuria (>300 mg/day) indicates
the existence of established renal parenchymal
damage.
49. Neuro and Fundoscopy
Cerebral seizures, stroke, visual
impairment and retinal vascular changes are
complications associated with severe
hypertension.
Fundoscopy was also done in because in
a study of 97 children and adolescents with
essential hypertension, found that 51%
displayed retinal abnormalities, as detected
from direct ophthalmoscopy.
50. Obesity and Hypertension
Using the 2000 CDC growth charts, at risk of overweight
for ages 2 to 20 years overweight is defined as a Body
Mass Index (BMI)-for-age between the 85th and the 95th
percentiles.
Overweight in children is defined as a BMI-for-age at or
above the 95th percentile on the charts.
BMI is weight in kilograms divided by height in meters
squared (kg/m2).
BMI is used differently to define overweight in children
and adolescents than it is in adults. In children and
adolescents, BMI changes with age and gender.
51. Obesity and Hypertension
Overweight children and adolescents are at
increased risk for various chronic diseases
in later life.
The psychosocial consequences of
overweight are significant. Overweight in
children has been linked to social
discrimination, a negative self-image in
adolescence that often persists into
adulthood, parental neglect, and behavioral
and learning problems.
52. Obesity and Hypertension
Being overweight is probably the most
important of the conditions associated with
elevated BP in childhood and accounts for
more than half the risk for developing
hypertension.
Adiposity is the most powerful risk factor
for higher BP.
Waist circumference (abdominal obesity)
has been shown to play a role.
Dietary habits like high salt intake, have
been implicated as factors favoring higher BP
values.
53. Obesity and Hypertension
The CDC mentions the Common Medical
Consequences of Overweight (Dietz,
1998)
hyperlipidemia
glucose intolerance
hepatic steatosis
cholelithiasis
sleep apnea
Obesity
hypoventilation syndrome
hypertension
a variety of orthopedic complications
54. Laboratory Investigations
Full blood count
Plasma sodium, potassium and
calcium, urea, creatinine
Fasting plasma glucose
Serum lipids (cholesterol, LDL
cholesterol, HDL
cholesterol)
Fasting serum triglycerides
Urinalysis plus quantitative
measurement of
microalbuminuria
and proteinuria
Renal ultrasound
Chest Xray, ECG and 2-D
echocardiography
Routine tests that have to be performed in all
hypertensive children
55. Recommended additional
screening tests
Plasma renin activity, plasma aldosterone concentration
Urine and plasma catecholamines or metanephrines
Tc99 dimercaptosuccı´nic acid scan
Urinary free cortisol
More sophisticated tests that should await results of
above screening
Color Doppler ultrasonography
Captopril primed isotope studies
Renal vein renin measurements
Renal angiography
I123 metaiodobenzylguanidine scanning
Computed tomography/ Magnetic resonance imaging
Urine steroid analyses and more complex endocrine
investigations
Molecular genetic studies (Apparent mineralocorticoid
excess, Liddle’s syndrome, etc)
56. SECONDARY HYPERTENSION
Sustained hypertension can be
classified as secondary when a
specific cause can be found, then
it can be corrected with specific
intervention.
There should be work-up should
be done if hypertension .
60. APPROACH TO MANAGEMENT
Non pharmacologic Strategy Recommendations:
GOALS:
BMI<85th percentile: Maintain BMI to prevent becoming
overweight
BMI 85–95th percentile: Weight maintenance (younger children)
or gradual weight loss in adolescents
To reduce BMI to <85th percentile
BMI>95th percentile: Gradual weight loss (1–2 kg/
month) to achieve value <85th percentile
61. GENERAL RECOMMENDATIONS
Moderate to vigorous physical aerobic activity--40 min, 3–5
days/week and avoid more than 2 hours daily of sedentary
activities
Avoid intake of excess sugar, excess soft drinks, saturated fat
and salt and recommend fruits, vegetables and grain products
Implement the behavioural changes (physical activity and diet)
tailored to individual and family characteristics
Involve the parents/family as partners in the behavioural
change process
Provide educational support and materials
Establish realistic goals
Develop a health-promoting reward system
Competitive sports participation should be limited
only in the presence of uncontrolled stage 2 hypertension
62. For my patient…
A. Counseling and Implement Behavioural Change
1.CEA(Catharsis Education Action): Patient
2.Motivational Interviewing- Pre Contemplation stage
3. CEA(Catharsis Education Action): : Parents
63. Counseling and Implement
Behavior Change: CEA Patient
Patient was not so much concerned of her
weight.
She doesn’t know the risk and the health
issues regarding hypertension.
She was not aware why she came to PGH for
consult and really wanted to go home.
She was also not aware her that being
overweight has some health risks as well.
64. Use of Motivational Intervierwing
Transtheoretical Model, "process involving progress through a series of
stages:"
Precontemplation (Not Ready)-"People are not intending to take action
in the foreseeable future, and can be unaware that their behaviour is
problematic.”
Contemplation (Getting Ready)-"People are beginning to recognize that
their behaviour is problematic, and start to look at the pros and cons of their
continued actions.“
Preparation (Ready)-"People are intending to take action in the immediate
future, and may begin taking small steps toward behaviour change.“
Action – "People have made specific overt modifications in modifying their
problem behaviour or in acquiring new healthy behaviours.“
Maintenance – "People have been able to sustain action for awhile and are
working to prevent relapse."
65.
66. Use of Motivational
Intervierwing
Motivational Interviewing- Pre Contemplation stage
Patient was on pre -contemplation stage at that time and I
was hoping to make her aware and give her insight to bring
her to the stage where she can contemplate.
When I asked about her hypertension, she said she knew
had it for years but no one told her about the dangers.
67. B. Counseling and Implement
Behavior Change
3. CEA: Parents
The parents are also unaware of the risk of hypertension and
the eating habits and lifestyle that increase her obesity.
They couldn’t believe that this would happen at her age.
The whole family is at risk since everyone except the wife is
obese.
68. My Management Plan for the
Patient…
Non-pharmacologic strategies
A. Counseling and Behavior Change- Done
B. I advised the patient to have Regular BP monitoring at home
C. Physical Activity: I mentioned to the patient to start to lessen
sedentary activities and start to walk more around the subdivision and
play with pets. A Exercise program was not done yet as I want for the
patient to reach the preparation/action
D. Eating Habits: Change of eating was advised. The Patient love to
skip breakfast and lessen snack intake.
E. A Diet Program: I was planning to put the patient into a low
Energy Diet of 2000kcal C350 P75 F 35 from a 3022kcal diet on the
next follow up
69. Approach to Medical
Management on Hypertension
Pharmacologic/Therapeutic Strategies
Aside from the non-pharamacologic strategies, I had a dilemma
on how will I use therapeutic strategies for my patient
EVIDENCE FOR THERAPEUTIC
MANAGEMENT
Reduce mortality and sequelea in life-threateningconditions
Reduce left ventricular hypertrophy
Reduce urinary albumin excretion
Reduce rate of progression to end-stage renal disease
70. Approach to Medical
Management on Hypertension
Therapeutic management of hypertension
Indications for Antihypertensive Drug Therapy in Children Symptomatic Hypertension
Secondary hypertension
Hypertensive target-organ damage
Diabetes (types 1 and 2)
Persistent hypertension despite non-pharmacologic
measures
>99 percentile BMI
71.
72. Approach to Medical Management
on Hypertension
Therapeutic Management
Treating Hypertension with drugs are most indicated in end organ
damage of the Heart and Kidney/Renal
Effect to Organ Damage:
In the Heart, Regression of LVH was reported in three children with
essential hypertension receiving enalapril, in 19 children with primary
and secondary hypertension treated with ramipril for 6 months, and in
65 children with chronic kidney disease (CKD) stage 2–4 receiving
ramipril for up to 2 years.
In Renal:
the Effect of Strict Blood Pressure Control and ACE Inhibition on
Progression of Chronic Renal Failure in Pediatric Patients (ESCAPE) trial,
which has shown efficient BP and proteinuria reduction for the ACE
inhibitor ramipril in 352 children with CKD
73. Approach to Medical
Management on Hypertension
Monotherapy
Choice of anti-hypertensive agents ACEIs
Angiotensin receptor antagonists (ARBs)
Calcium antagonists
Beta-blockers
Diuretics
Combination therapy
In children with renal disease, monotherapy is often not sufficient to
achieve adequate BP control. Therefore, early combination therapy is
required. The best choices of antihypertensive drug combinations are
those recommended in the ESH/ESC 2007 Guidelines .
74. Clinical conditions for which specific
antihypertensive drug classes are
recommended or contraindicated
77. Initial Management summary
Non-pharmacologic strategies
Counseling and Behavior Change- Done
B. I advised the patient to have Regular BP monitoring at home
C. Physical Activity: I mentioned to the patient to start to lessen
sedentary activities and start to walk more around the subdivision and
play with pets. A Exercise program was not done yet as I want for the
patient to reach the preparation/action
D. Eating Habits: Change of eating was advised. The Patient love to
skip breakfast and lessen snack intake.
E. A Diet Program: I was planning to put the patient into a low
Energy Diet of 2000kcal C350 P75 F 35 from a 3022kcal diet on the
next follow up
79. 1st Follow-up April 2012
Maintained BP 150/90…no decrease in BP despite
of Amlodipine 5mg tablet.
Started to jog for several minutes around the
house and roam around the area with her dog.
Lessened her calorie intake thanks to the parents
modifying the food menu at home. Parents started
to prepare healthier food with less salt content.
Parents have been very supportive.
Siblings stopped eating with the patient for snacks
and joined the patient in jogging as well.
One of her sibling, who still was a bad influence to
her was transferred to their grandmother’s house.
80. 1st Follow-up April 2012
1st Follow-up April 2012
Results
Hgb:139, Hct 0.432, Plt 356
WBC 8.7
Urinalysis : Dark yellow,
1.030, RBC 0-2, WBC 3-4 EC
3+ Sugar (-) Albumin (-)
CXR: Normal Chest Findings
Thyriod FT4- 20.6, Free T3-
5.5, TSH IRM 6.1
Glucose 6.4, BUN 3.30, Crea
45.5, Chole 5.0, Trigly 5.01
HDL 0.98, LDL 1.74, AST 38,
ALT 46, Albumin 42 Calcium
2.44, Na- 138, K 4.8
ECG- Sinus Rhythm, Within
Normal Limits
Whole Ab Ultrasound: normal
With the current labs results, I
was able to rule out many
etiology of hypertension
including the secondary ones
however there was elevation in
Triglyceride and there was
Impaired Fasting Glucose
81. 1st Follow-up April 2012
Previous Salient Features…
SALIENT FEATURES OF THE
CASE
13-year old female
Chief complaint of elevated
blood pressure
History of hypertension ,DM and
Obesity
Previous history of renal disease
(+) poluyuria, (+) polyphaga.
Amenorrhea
Obesity
(+) Short neck length
(+) Acanthosis nigricans nape
area,
(+) Striae
New Finding from the
Diagnostics
Impaired Fasting
Glucose
Elevated Triglyceride
Ruled out
Cardiovascular, Renal
and some secondary
etiology
82. 1st Follow-up April 2012
Hypertension stage II
secondary to
1) Obesity
2) Metabolic Syndrome
T/c PCOS sedondary to
Metabolic Syndrome
Hyperlipidemia
Impaired Fasting Glucose
83. METABOLIC SYNDROME
Group of characteristics:
Most expert groups define metabolic syndrome as the presence of three or
more of the following characteristics in a person:
Obesity, especially in the abdominal area
(defined by some groups as a waist size greater than 94 to 102 cm (38 to 41
in) in men or greater than 80 cm (32 in) in women)
Impaired fasting glucose
(fasting blood sugar of 100 to 125 mg/dL or 5.6 to 7 mmol/L)
Increased blood pressure
(130/85 or higher) or if you take medicine for high blood pressure
Increased fasting levels of triglycerides
(greater than 150 to 180 mg/dL or 1.7 mmol/L) or decreased fasting HDL
cholesterol (less than 40 mg/dL or 1 mmol/L for men or 50 mg/dL or 1.3
mmol/L for women)
84. METABOLIC SYNDROME IN
CHILDREN AND ADOLESCENTS
Definition
Metabolic syndrome also occurs in children and adolescents but
there is no consensus on the definition
The International Diabetes Federation (IDF) definition of
metabolic syndrome in children 10 to 16 years old is
similar to that used by the IDF for adults, except that the
definition for adolescents uses ethnic-specific waist
circumference percentiles and one cutoff level for HDL rather
than a sex-specific cutoff.
For children 16 years and older, the adult criteria can be
used.
For children younger than 10 years of age, metabolic
syndrome cannot be diagnosed, but vigilance is recommended if
the waist circumference is ≥90 percentile.
85. METABOLIC SYNDROME IN
CHILDREN AND ADOLESCENTS
Risk factors
Among obese children, the
prevalence of the metabolic
syndrome is high and
increases with worsening
obesity.
The prevalence of metabolic
syndrome is high among
obese children and
adolescents and increases
with the severity of the
obesity, and with central
adiposity in particular.
86. Clinical Implications of
Metabolic Syndrome
The definition of metabolic
syndrome may be clinically
useful for risk stratification and
therapeutic intervention in
pediatrics. However, lifestyle
modification that emphasizes
reduction of established risk
factors, such as promotion of
exercise, weight loss, and
smoking cessation, is the main
therapeutic goal in obese
children and adolescents,
regardless of a metabolic
syndrome diagnosis.
87.
88. METABOLIC SYNDROME
TREATMENT
Reduce or eliminate underlying problems (eg, obesity, lack of activity) by losing
weight and becoming more active.
Treat cardiovascular risk factors, such as high blood pressure and cholesterol, if
these problems persist despite losing weight and exercising.
Weight loss
The Mediterranean diet is high in fruits, vegetables, nuts, whole grains, and
olive oil
The DASH (Dietary Approaches to Stop Hypertension) The DASH diet requires
you to eat no more than 2400 mg of sodium per day, four to five servings of
fruit, four to five servings of vegetables, two to three servings of low-fat dairy
products, and all foods must contain less than 25 percent total fat per serving.
Lifestyle modification — Prevention or reduction of obesity, particularly
abdominal obesity, is the main therapeutic goal in patients with the metabolic
syndrome
Exercise — . The standard exercise recommendation is a daily minimum of 30
minutes of moderate-intensity (such as brisk walking) physical activity.
Increasing the level of physical activity appears to further enhance the
beneficial effect
89.
90. METABOLIC SYNDROME and
Polycystic Ovary Syndrome
(PCOS)
PCOS and Metabolic Sydnrome originally was described by
Stein and Leventhal as the association of amenorrhea with
polycystic ovaries, and variably, hirsutism and obesity
It is now recognized that PCOS represents a spectrum of
disease characterized primarily by the following features:
Cutaneous hyperandrogenism (eg, hirsutism, treatment-
resistant acne, and/or pattern balding [androgenetic alopecia]
Menstrual irregularity (eg, oligo- or amenorrhea, or irregular
bleeding)
Polycystic ovary
Obesity and insulin resistance
93. Polycystic ovary syndrome
(PCOS)
Three sets of diagnostic criteria have been
proposed for the diagnosis of PCOS in adults.
In adolescents, using the NIH diagnostic criteria
in most cases.
PCOS risk criterion proposed by the Androgen
Excess and PCOS Society (AES), alternatively
defined as hyperandrogenism and a polycystic
ovary, be considered as indicative of risk for
PCOS rather than as diagnostic.
97. PCOS DIFFERENTIAL
DIAGNOSIS
Congenital adrenal
hyperplasia Nonclassic
Classic CAH due to 21-
hydroxylase deficiency
Classic CAH, and to a
lesser extent nonclassic
CAH,
Ovarian steroidogenic
blocks
Other adrenal disorders
Cushing's syndrome
include central obesity,
dorsal fat pad,
hypertension, easy
bruising, striae, and
proximal muscle
weakness.
Hyperprolactinemia
Acromegaly
Virilizing tumors
Thyroid dysfunction
Drugs
Disorders of sex
development
Idiopathic
98. DIAGNOSTIC CRITERIA
Cutaneous signs of hyperandrogenism (eg,
hirsutism, persistent acne, and/or pattern
alopecia)
Menstrual irregularity (eg, oligo- or amenorrhea,
or irregular bleeding)
Polycystic ovary syndrome
Obesity and insulin resistance
99. DIAGNOSTIC APPROACH.
Evidence of hyperandrogenism — The criterion of
clinical hyperandrogenism is satisfied by
hirsutism or other cutaneous signs of
hyperandrogenism.
Evidence of ovarian dysfunction
Exclusion of non-PCOS causes of
hyperandrogenemia
Additional evaluation after the diagnosis of PCOS
100. TESTING FOR ANDROGEN
EXCESS
Total testosterone
Free testosterone
Dehydroepiandrosterone sulfate (DHEAS)
Ultrasonography
Endocrine Test
Prolactin
Thyroid function
Insulin-like growth factor-I
Serum cortisol
Early-morning 17-hydroxyprogesterone
101. Manifestations of Polycystic Ovary Syndrome in
Approximate Proportion to their Relative
Incidence and Coincidence
ANOVULATORY
SYMPTOMS
OBESITY
HIRSUTISM,ACNE,
ALOPECIA
102. Pathogenesis
Intraovarian androgen excess appears to be
responsible for both anovulation and the formation of
multiple ovarian "cysts" because of stimulated
excessive growth of small follicles and hindrance of the
maturation of the dominant follicle.
There is vigorous debate about whether this pathologic
process is primarily a disorder of pituitary gonadotropin
secretion or a disorder of ovarian and/or adrenal
steroidogenesis.
PCOS may result from a metabolic disorder that
includes insulin resistance.
Abnormal pituitary function
Abnormal steroidogenesis
Extrinsic factors contributing to dysregulated
steroidogenesis
103. Abnormal Pituitary Function
Increased LH relative to FSH was the
first laboratory abnormality identified in
classic PCOS. Elevated LH levels occur
in about half of PCOS patients. Elevated
LH is thought to play a role in the
pathogenesis of PCOS by increasing
androgen production and secretion by
ovarian theca cells.
Patients with PCOS have an increased
LH pulse frequency and amplitude.
Obesity seems to attenuate the increase
in LH pulse amplitude, in part because
the pituitary gonadotropes of obese
women with PCOS produce LH isoforms
that are rapidly metabolized.
104. Abnormal Steroidogenesis
Alternative hypothesis that PCOS is due to intrinsic
ovarian dysfunction. This hypothesis considers that
primary functional ovarian hyperandrogenism (FOH)
is the essence of PCOS.
The intraovarian level of androgens in FOH is higher
than in most adrenal causes of androgen excess and
results in excessive growth of small ovarian follicles
while inhibiting follicular maturation and
development of the dominant follicle.
These result in the polycystic appearance of the
ovary and the anovulatory symptoms.
105. Extrinsic factors Contributing to
Dysregulated Steroidogenesis
The insulin/insulin-like growth factors (IGF)
system is capable of acting in synergy with trophic
hormones, contributing to ovarian or adrenal
excess androgen production.
In the ovary, insulin acts in conjunction with LH to
enhance androgen production and reverse the LH-
induced down-regulation of LH binding sites.
Insulin and IGFs increase the activities of multiple
steroidogenic enzymes in both the ovaries and
adrenal glands.
This suggests that the hyperandrogenemia and
obesity of PCOS are mechanistically linked.
106. Treatment for PCOS in
adolescents is directed at
the following clinical
manifestations:
Menstrual irregularity
Cutaneous
hyperandrogenism, primarily
hirsutism and acne
Obesity and insulin resistance
107. TREATMENT FOR PCOS
Menstrual irregularity should
be treated in adolescents with
PCOS because chronic
anovulation increases the risk
of developing endometrial
hyperplasia, which is
associated with endometrial
carcinoma. In addition,
anemia can result from
dysfunctional uterine bleeding
or menorrhagia.
108. TREATMENT FOR PCOS
The combination oral contraceptive pill (OCP), which contains estrogen
and progestin, usually is the first-line treatment for adolescents with
PCOS and menstrual irregularity, especially in patients with cutaneous
signs of androgen excess.
OCPs induce regular menstrual periods with a higher degree of
reliability than other forms of treatment.
Progestin inhibits endometrial proliferation, preventing hyperplasia.
Estrogen inhibits the activity of the hypothalamic-pituitary-gonadal
axis, reducing ovarian androgen production as well as increasing serum
sex hormone binding globulin (SHBG) levels.
OCP therapy also will normalize androgen levels within 18 to 21 days.
After three months, the efficacy of treatment is assessed by evaluating
clinical symptoms and androgen levels. If the treatment is effective, as
a general rule, OCPs should be continued until the patient is
gynecologically mature (five years postmenarcheal).
109. TREATMENT FOR PCOS
Limitations — The role of OCPs in the management
of PCOS in adolescents may be limited for several
reasons:
OCP therapy may make weight loss more difficult to
attain because it promotes salt and water retention.
The patient may believe the treatment is curative
and defer a definitive diagnostic work-up.
OCPs do not permit conception if and when it is
desired.
In perimenarcheal girls with short stature who have
open epiphyses, OCPs are contraindicated because
OCPs contain growth-inhibitory amounts of
estrogen.
111. OBESITY AND INSULIN
RESISTANCE
The treatment of obesity
improves ovulation, acanthosis
nigricans, androgen excess,
and cardiovascular risk in
patients with PCOS.
Weight reduction is indicated in
obese patients with PCOS as
part of a program to reduce
cardiovascular risk factors.
Diet and exercise are the
first-line treatment for
obese adolescents with
PCOS as for obese individuals
without PCOS.
112. Insulin Resistance
Obesity is of major importance in the insulin resistance of PCOS,
although insulin resistance is disproportionate to the degree of
adiposity. Insulin resistance is commonly manifested as
acanthosis nigricans
The biguanides, of which metformin is the only one available in
the US are thus a potential adjunct in the treatment of PCOS;
thiazolidinediones also are effective in reducing insulin levels,
but have raised safety concerns, as discussed below.
Although their mechanisms of action differ, both metformin and
thiazolidinediones reduce insulin concentrations, promote
ovulation, and lower androgen levels
Metformin is the only one of these agents that we currently use
in adolescents with PCOS because of concerns of weight gain
and rare hepatic and possible cardiac toxicity with
thiazolidinediones.
Randomized, placebo-controlled trials in adolescents and adults
have shown that metformin significantly increases the frequency
of menses and ovulation (by about 50 percent), and lowers
testosterone levels (by about 20 percent).
113. Pharmacologic Management
Changed Amlodipine 5mg to
Losartan 50mg/tab as
there was no change for
one month.
Prevent target organ damage
and decreased fluid
retention
1st Follow-up April
2012
114. MY USE COUNSELING/MOTIVATIONAL
INTERVIEW
I once again asked the patient how she was doing.
How did she feel about the diet change? I asked if
she was fully aware and really understood her
condition.
“ok lang” “Ginagawa ko rin dahil sa mama ko.”
I asked her if she still remembers what I told her
about the health risks involved with hypertension
and obesity.
She said “Opo doc, naala ko naman.”
I asked her if her overweight condition made her
conscious with her appearance, she said NO during
the 1st consult, but she did admitted that it started
to beome a concern especially when some of her
classmates teases her. She also wanted to be
noticed by her crush.
115. BEHAVIOR CHANGE TOOL AND
DECISIONAL BALANCE
TECHNIQUE
I asked her what are her goals in life.
She said she wants to work as an engineer
and have a family for own. She wants to
travel and meet lots of new friends.
I asked her what does eating to much and
having a sedentary lifestyle has to do with
her dream...
“Magkakasakit ako palagi at baka palagi
nasa hospital”.
116. BEHAVIOR CHANGE TOOL AND
DECISIONAL BALANCE
TECHNIQUE
I used the Decisional Balance technique for
my patient….
117. Decisional Balance
"reflects the individual's relative weighing
of the pros and cons of changing.“
Decision making was conceptualized by
Janis and Mann as a "decisional balance
sheet" of comparative potential gains and
losses.“
Decisional balance measures, the pros
and the cons, have become critical
constructs in the Transtheoretical Model
Sound decision making requires the
consideration of the potential benefits
(pros) and costs (cons) associated with a
behavior's consequences.
118. Decisional Balance
Decisional balance is one of the
best predictors of future
change. TTM research has
found the following
relationships between the pros,
cons, and the stage of change
across 48 behaviors and over
100 populations studied.
The cons of changing outweigh
the pros in the Pre-
contemplation stage.
The pros surpass the cons in
the middle stages.
The pros outweigh the cons in
the Action stage
120. BEHAVIOR CHANGE TOOL AND
DECISIONAL BALANCE
TECHNIQUE
She then realized that she
would have to change.
The patient is now willing to
change hence I made a
treatment plan to target
obesity hence decreased
incidence of hypertension.
123. APPROACH ON TREATMENT TO
OBESITY
According the AAP’s Recommendations for
Treatment of Child and Adolescent Overweight and
Obesity—
Comprehensive interventions that include
behavioral therapy along with changes in nutrition
and physical activity are the most closely studied
and seem to be the most successful approaches to
improving long-term weight and health status.
124. APPROACH ON TREATMENT TO
OBESITY
In the study…showed a guideline on how to treat
and manage adolescent obesity based on
1. Nutritional Treatment
2. Macronutrient Therapy
3. Food Behaviors
4. Dietary Interventions
5. Physical Activity and Reducing Sedentary
Activities
6. Behavioral Approaches
7. Other Interventions
8. Recommendations of Stages of Treatment
125. APPROACH ON TREATMENT TO
OBESITY
Nutritional Treatment
In the guideline, it reviewed nutritional treatment for our patient
to decrease obesity which included:
Fruits and Vegetables
Fruit Juice
Sweetened Beverage
Dairy Food
Calcium
Dietary fiber
Eight studies evaluating the relationship between fruit and/or
vegetable intake and body weight were reviewed. All had mixed
results but two studies found an inverse association with
adiposity.
127. Glycemic index
Glycemic index (GI) has been proposed to affect
body weight regulation and risk for obesity-
associated complications.80 The GI is defined as the
area under the glucose dose-response curve after
consumption of 50 g of available carbohydrate from a
test food, divided by the area under the curve after
consumption of 50 g of available carbohydrate from a
control food (either white bread or glucose).
Short-term feeding studies indicated that hunger and
cumulative food intake were greater 3 to 5 hours
after a high-GI versus low-GI meal, controlled for
macronutrient and energy contents.
128. FOOD BEHAVIORS
In terms of the FOOD BEHAVIORS of our patient
Breakfast Skipping
Snacking
Eating Out
130. PHYSICAL ACTIVITY
It used these measurements to calculate physical
activity levels, as follows:
physical activity level-total energy and
expenditure/basal metabolic rate.
131. Amount of Physical Activity
The American Academy of Pediatrics recommends
that 30 minutes of this activity occur during the
school day. Very obese children may need to start
with shorter periods of activity and gradually increase
the time spent being active.
Reducing Sedentary Activities
Television Viewing and Obesity
133. The AAP guideline provided a systematic approach which to manage
obesity patients. The staged-care process is divided into 4 stages,
that is:
(1) Prevention Plus (healthy lifestyle changes)
(2) Structured weight management
(3) Comprehensive multidisciplinary intervention
(4) tertiary care intervention.
135. NONPHARMACOLOGIC PLAN
A. Use Prevention Plus Stage 1 Intervention
Using the algorithm, our patient is at the >99 percentile hence a
Prevention Plus Stage 1 interventions should be based on the
family’s readiness to change and include the following:
1. Consumption of 5 servings of fruits and vegetables per day
2. Minimization or elimination of sugar-sweetened beverages
3. Limits of 2 hours of screen time per day, no television in the
room where the child sleeps, and no television viewing
4. 1 hour of physical activity per day
Physical activity can be increased gradually for sedentary
children. Children may be unable to achieve 1 hour of activity
per day initially but can gradually increase activity to reach 1
hour/day.
136. B. Stricter implementation on the Diet
Low Energy Diet of 2000kcal C350 P75 F 35
from a 3022kcal diet and a strict decrease of
salt content.
C. Establishing an exercise plan
Jogging at their area for 40 min starting from
moderate to vigorous aerobic-based physical
activity 3–5 days/week.
NONPHARMACOLOGIC PLAN
139. 2nd follow-up May 2012
S> Weight loss of 8 pounds for 2 monthS.
Lessen of BP from 150/90 to 130/80…
No OB consult yet.Patient was advised to take OB
consult in the near future.Patient still has no
menstruation.
Management
Maintain medicines and continued diet and
exercise plan.
Stop Losartan
I also advised that their family; the parents and
her brothers and sisters to seek consult for the
obesity problem as well.
140. 3rd Follow-up August 2012
Patient had weight loss of 2 pounds but having
trouble to maintain diet and exercise during
the school year due to the availability of food
and temptations. BP lowered to 120/80.
Patient started to play badminton with family
and still continue to jog if she has free time.
Plan:
Advise to have a more structured diet and
exercise to adapt to school by having a list of
food to eart in day. Patient was advised to
have cooked food from home
144. WELLNESS PLAN FOR THE
PATIENT
Lifestyle
Continue the Prevention Plus Plan for our patient
with a advice increase Physical and outdoor
activities.
Screening
Patient was advised an annual screening to detect
organ damage and risk of other disease like Type
II Diabetes
Immunizations- Influenza vaccine yearly, Varicella
vaccine.
145. GOING BACK TO THE PATIENT
The good news is that the
patient’s BP is at 120-130/80-90.
Patient hasn’t made substantial
weight loss, but the good thing is
that during the past three
months her lifestyle changed
dramatically when compared
alongside the years that she was
excessively eating. She started
to gain self-confidence since the
change of eating habits. The
family changed their eating
habits and have modified their
lifestyle accordingly too.
146. Insight
Holistic care
Interrelationship of Diseases
The Importance of Lifestyle for being Healthy
Counseling and Motivation Behavior change as
part of being a Doctor
The power of change
Caring for patient is not a shot deal, have to do
lots of follow-up and evaluation
Importance of education and value formation in
children and adults ( School and Government)
147. Insight
Suggestions:
Comprehensive Government Plan to Educate and
Change the Lifestyle of our Youth
Insight (slide)
My message to everyone…
As doctors, we are privileged to have the power
to change lives. Let us go forth and use this
opportunity to be an instrument towards positive
change.
