The Case of Maria Gonzales
Medicine Across the Lifespan
University of KansasSchool of Medicine
CASE MATERIAL
DAY 1, PART 1Maria Gonzales is brought to her pediatrician’s office by her mother for her annual exam. Her mother has no concerns about Maria’s health or development. She is an 8 year old Hispanic female currently in the third grade at a local parochial school. She is progressing nicely with her schoolwork and is not a behavioral problem. Maria’s mother reports that the school nurse sent a letter home explaining that she had passed her vision and hearing screening tests but that she was overweight and at risk for obesity. She is obviously offended by this information and explains that Maria has always been “big boned” and that she does not agree with the school nurse’s assessment.
PMH
Maria was born at 41 6/7 weeks gestation to her G1P0 mother by spontaneous vaginal delivery. She weighed 4068 gms at birth and had APGAR scores of 7 and 9. Her mother was not employed at the time of this pregnancy and did not seek prenatal care until the day of delivery. She describes the pregnancy as uneventful.
Maria has had all of her childhood vaccinations and no hospitalizations since birth. She does not take any prescription medications and other than recurrent ear infections as a small child has been healthy.
Social History
Maria’s parents divorced when she was an infant. She is an only child. She lives in a home with her mother, her mother’s sister and her great aunt. She has no contact with her father. She attends third grade in a nearby parochial school. Her mother and aunt smoke in the home. Her mother takes pride in her ability to provide for Maria despite financial constraints and describes herself as a “protective parent.” Maria took ballet lessons from age 5-7 and has played softball for the last two summers.
Developmental History
Maria met all developmental milestones on target.
Family History
Mother, alive, age 29. Obese. Diagnosed with diabetes and hypertension 6 years ago
Father, alive, age 31. No known chronic illnesses
Maternal Grandmother, deceased at age 58 of renal failure. Had diabetes, hypertension, asthma
Maternal Grandfather, alive, age 60. Hypertension
Paternal Grandmother, alive, age 62. Unknown medical history
Paternal Grandfather, deceased at age 55. Myocardial infarction
Physical Exam
Vital signs: T 98.4, Pulse 86, BP 130/80, R 18, ht 50.3 inches, wt 80 pounds
General- Well developed/ well nourished Hispanic female child in no acute distress
HEENT- TMs with good color and position, conjunctiva pink, oropharynx clear, moist mucosal membranes, Neck- No thyromegaly, no masses
CV- RRR without murmur, rub, gallop
Chest- Clear to auscultation bilaterally
Abdomen- rounded, soft, nontender, no organomegaly or masses
GU- Tanner stage I
Musculoskeletal- Joints nontender, no scoliosis, muscle strength and mass age appropriate. Full range of motion throughout
Skin- No rashes or open lesions
Neuro- Alert, appropriate, vision and hearing screening wnl /
LEARNINGOBJECTIVES
At the conclusion of Part 1 students should be able to:1) Discuss the potential barriers to acceptance of childhood obesity by parents
2) Calculate BMI
3) Plot height, weight and BMI on a pediatric growth chart
4) Explain why adult BMI tables are not valid for pediatric patients
5) Interpret the findings of data from pediatric growth curves
6) Summarize the epidemiologic trends in childhood obesity
7) Discuss the risk criteria for high birth weight infants
8) List the contributing factors for obesity
9) Discuss the long-term effects of childhood obesity
10) Describe the health consequences of exposure to second hand smoke on children
11) Summarize the physical and psychological consequences of childhood obesity /
DISCUSSION QUESTIONS
1)What do you make of Maria’s mom’s reaction to the letter from the school nurse about Maria’s weight and risk for obesity?2)What is Maria's BMI? Can adult BMI tables be used to evaluate obesity risk in children? BMI=22.2 According to adult BMI tables, Maria would have a normal BMI. (Below 18.5= underweight; 18.5-24.9=normal; 25.0-29.9=overweight;30.0 and above=obese. However, adult BMI tables are not valid for children as BMI is age and sex-specific. Instead, BMI tables that are age and sex specific are useful to evaluate percentile rankings.
3)Plot Maria’s height, weight and BMI on a growth chart using the CDC website. weight 95th percentile, height 50th percentile, BMI greater than 95th percentile ( well off the growth chart)
4)What are the normal cutoffs for BMI in children? The interpretation of BMI in children is evaluated as a percentile ranking that is both age and sex-dependent. The cutoffs according to the CDC are: Underweight=less than 5th percentile; Healthy weight= 5th percentile to less than 85th percentile; At risk of overweight= 85th percentile to less than 95th percentile; overweight=95th percentile or greater.
5)Summarize the epidemiologic trends in childhood obesity. From the CDC website at Overweight is a serious health concern for children and adolescents. Data from two NHANES surveys (1976–1980 and 2003–2004) show that the prevalence of overweight is increasing: for children aged 2–5 years, prevalence increased from 5.0% to 13.9%; for those aged 6–11 years, prevalence increased from 6.5% to 18.8%; and for those aged 12–19 years, prevalence increased from 5.0% to 17.4%.1
6)What is significant about Maria's birth weight? High Birthweight (HBW) is defined as a birthweight of >4000 grams or 8.8 lbs. This reflects the WIC Nutrition Risk Criteria (IOM, 1996) which is based on a generally accepted intrauterine growth reference > the 90th percentile weight for gestational age at birth (ACOG Technical Bulletin, 1991). High birthweight usually occurs in full-term or post-term infants but can occur in preterm infants. HBW puts infants at increased risk for birth injuries such as shoulder dystocia and infant mortality rates are higher among full-term infants who weigh more than 4000 grams than infants weighing between 3000 and 4000 grams. (ACOG technical bulletin). From the CDC website at High Birthweight in a newborn is associated with: risk of birth injury including shoulder dystocia, hypoglycemia shortly after delivery, childhood obesity, increased lifetime risk for DMII
7)What are likely contributing factors to Maria's weight problem? Summarized from CDC website at 1) Genetic factors-certain genetic characteristics may increase an individual’s susceptibility to overweight. However, the rapid rise in the rates of overweight and obesity in the general population in recent years cannot be attributed solely to genetic factors. The genetic characteristics of the human population have not changed in the last three decades, but the prevalence of being overweight has tripled among school-aged children during that time. 2) Behavioral Factors- a) excessive and/or unhealthy food intake b) Lack of physical activity and sedentary activities 3) Environmental Factors- a) within the home b) within the school c) within childcare d) within the community
8)What health concerns do you have for Maria's future? Overweight children and adolescents are at risk for health problems during their youth and as adults. For example, during their youth, overweight children and adolescents are more likely to have risk factors associated with cardiovascular disease (such as high blood pressure, high cholesterol, and Type 2 diabetes) than are other children and adolescents. Overweight children and adolescents are more likely to become obese as adults. For example, one study found that approximately 80% of children who were overweight at aged 10–15 years were obese adults at age 25 years.3 Another study found that 25% of obese adults were overweight as children. The latter study also found that if overweight begins before 8 years of age, obesity in adulthood is likely to be more severe. From the CDC website at
9)What affects, if any, does Maria's second-hand smoke exposure have on her health?On September 18, 2007, the Surgeon General reemphasized that secondhand smoke causes premature death and disease in children and that US children are more heavily exposed to secondhand smoke than nonsmoking adults. The 2006 Surgeon General's report noted that 60 percent of US children aged 3-11 years—nearly 22 million young people—are exposed to secondhand smoke.
According to the Surgeon General:
• Because their bodies are developing, infants and young children are especially vulnerable to the poisons in secondhand smoke.
• Both babies whose mothers smoke while pregnant and babies who are exposed to secondhand smoke after birth are more likely to die from sudden infant death syndrome (SIDS) than babies who are not exposed to cigarette smoke.
• Mothers who are exposed to secondhand smoke while pregnant are more likely to have lower birth weight babies, which makes babies weaker and increases the risk for many health problems.
• Babies whose mothers smoke while pregnant or who are exposed to secondhand smoke after birth have weaker lungs than other babies, which increase the risk for many health problems.
• Secondhand smoke exposure causes acute lower respiratory infections such as bronchitis and pneumonia in infants and young children.
• Secondhand smoke exposure causes children who already have asthma to experience more frequent and severe attacks.
• Secondhand smoke exposure causes respiratory symptoms, including cough, phlegm, wheeze, and breathlessness, among school-aged children.
• Children exposed to secondhand smoke are at increased risk for ear infections and are more likely to need an operation to insert ear tubes for drainage.
• Children aged 3-11 years have cotinine levels (a biological marker for secondhand smoke exposure) more than twice as high as nonsmoking adults.
• Children who live in homes where smoking is allowed have higher cotinine levels than children who live in homes where smoking is not allowed.
From the CDC website at
1)What are some of the physical and psychological consequences of childhood obesity? Consequences
2)Childhood overweight is associated with various health-related consequences. Overweight children and adolescents may experience immediate health consequences and may be at risk for weight-related health problems in adulthood.
3)Psychosocial Risks
4)Some consequences of childhood and adolescent overweight are psychosocial. Overweight children and adolescents are targets of early and systematic social discrimination.39 The psychological stress of social stigmatization can cause low self-esteem which, in turn, can hinder academic and social functioning, and persist into adulthood.40
5)
6)Cardiovascular Disease Risks
7)Overweight children and teens have been found to have risk factors for cardiovascular disease (CVD), including high cholesterol levels, high blood pressure, and abnormal glucose tolerance.39 In a population-based sample of 5- to 17-year-olds, almost 60% of overweight children had at least one CVD risk factor while 25 percent of overweight children had two or more CVD risk factors.2
8)
9)Additional Health Risks
10)Less common health conditions associated with increased weight include asthma, hepatic steatosis, sleep apnea and Type 2 diabetes.
11)
12)Asthma is a disease of the lungs in which the airways become blocked or narrowed causing breathing difficulty. Studies have identified an association between childhood overweight and asthma.41, 42
13)Hepatic steatosis is the fatty degeneration of the liver caused by a high concentration of liver enzymes. Weight reduction causes liver enzymes to normalize.39
14)Sleep apnea is a less common complication of overweight for children and adolescents. Sleep apnea is a sleep-associated breathing disorder defined as the cessation of breathing during sleep that lasts for at least 10 seconds. Sleep apnea is characterized by loud snoring and labored breathing. During sleep apnea, oxygen levels in the blood can fall dramatically. One study estimated that sleep apnea occurs in about 7% of overweight children.43
15)Type 2 diabetes is increasingly being reported among children and adolescents who are overweight.44 While diabetes and glucose intolerance, a precursor of diabetes, are common health effects of adult obesity, only in recent years has Type 2 diabetes begun to emerge as a health-related problem among children and adolescents.45 Onset of diabetes in children and adolescents can result in advanced complications such as CVD and kidney failure.45 From the CDC website at
The Case of Maria Gonzales
Medicine Across the Lifespan
University of KansasSchool of Medicine
CASE MATERIALDay 1, Part 2
Maria Gonzales returns to clinic after many years lost to follow-up in your office. She is now 15 years old, a sophomore at a local high school. She has received sporadic medical care for acute childhood illnesses over the years but has not followed with a primary physician. She comes in today with her mother.
PMH: Diagnosed with childhood obesity at the age of 8. No hospitalizations since birth. She has taken antihistamines periodically for the last 3 years for environmental allergies that are more problematic in the spring and summer months. She first menstruated at age 13. Her cycles are very irregular, about 5 cycles a year. She had ACL repair to her right knee last summer and feels that her function is back to normal after outpatient rehabilitation.
SH: Maria plays softball for her high school team. She is a pitcher and hopes to receive a softball scholarship for college. She dances with a local group that celebrates Mexican culture through dance and music. She is an average student in school and receives additional tutoring for her poor math performance. She has a close group of female friends that she occasionally sees outside of school. She has not had a boyfriend, although she would like to have one. She denies any sexual activity. Her mother describes herself as a “strict parent”. Maria is not allowed to attend most parties and tends to socialize primarily with family outside of school. She denies that she has ever tried alcohol, cigarettes, marijuana or other drugs. She has not started driving education.
PE: Vitals- T98.7, P90, BP 142/90,R 20, Wt 206 pounds, Ht 5ft 5inches
Gen- Obese young woman in no acute distress
HEENT- TMs with good color and position, conjunctiva pink, anicteric sclera, OP clear, slightly dry mucosal membranes. Teeth in good repair, moderate acne on cheeks, mild hirsuitism noted to face.
Neck- Supple, no cervical lymphadenopathy, no thyromegaly
CV- Regular rate and rhythm. No murmurs, strong pedal and radial pulses
Chest- Clear to auscultation bilaterally
Abdomen- obese in a centripetal distribution, soft, nontender, nondistended
PE:
EXT- no edema, brisk capillary refill
Musculoskeletal- Strength +5/5 in all extremities, muscle mass wnl, Joint exam wnl, No scoliosis
Breast- Tanner stage 4
GU-Tanner stage 4
Skin- Multiple skin tags noted along neckline. Acanthosis nigricans in axillae, and inguinal region, stria noted on abdomen and thighs
Neuro- No focal deficits
Laboratory Studies
Chem 7
Serum Creatinine 0.8 mg/dL (0.6 - 1.1)
BUN 16 (7 go 24 mg/dL)
Sodium 138 (136-144mEq/L)
Potassium 4.0 (3.7-5.2mEq/L)
Bilirubin, Conjugated 0.2mg/dL (0.3)
Fasting glucose 106 mg/dL (60-110)
HgbA1C 5.2 (4.0-6.0%)
Fasting Lipid Panel
Total Chol 246 mg/dL
HDl 50 mg/dL
VLDL 54 mg/dL
LDL 142 mg/dL
Triglycerides 240 mg/dL / LEARNING OBJECTIVES
1) Calculate BMI
2) Plot weight, height and BMI on a pediatric growth chart
3) Interpret the results of the data from a pediatric growth chart
4) Describe the association between childhood obesity and development of diabetes in adulthood
5) Define metabolic syndrome and list the diagnostic criteria of this disorder
6) Interpret the clinical significance of physical exam findings of acanthosis nigricans, multiple skin tags, stria
7) Describe polycystic ovarian syndrome and its clinical characteristic / DISCUSSION QUESTIONS
- What is Maria's BMI? BMI-34.3. Obese by adult BMI tables.(Below 18.5= underweight; 18.5-24.9=normal; 25.0-29.9=overweight;30.0 and above=obese. However, adult BMI tables are not valid for children as BMI is age and sex-specific. Instead, BMI tables that are age and sex specific are useful to evaluate percentile rankings.
- Plot Maria's weight, height and BMI on a pediatric growth chart. Weight greater than 97%; height between 50th and 75th percentile. BMI well above 95th percentile.
- What health risks are associated with this BMI?Overweight children and adolescents are at risk for health problems during their youth and as adults. For example, during their youth, overweight children and adolescents are more likely to have risk factors associated with cardiovascular disease (such as high blood pressure, high cholesterol, and Type 2 diabetes) than are other children and adolescents. Overweight children and adolescents are more likely to become obese as adults. For example, one study found that approximately 80% of children who were overweight at aged 10–15 years were obese adults at age 25 years.3 Another study found that 25% of obese adults were overweight as children. The latter study also found that if overweight begins before 8 years of age, obesity in adulthood is likely to be more severe.From the CDC website at
- List Maria's risk factors for developing diabetes.
- Does Maria have metabolic syndrome?The metabolic syndrome (syndrome X, insulin resistance syndrome) consists of a constellation of metabolic abnormalities that confer increased risk of cardiovascular disease (CVD) and diabetes mellitus (DM). The criteria for the metabolic syndrome have evolved since the original definition by the World Health Organization in 1998, reflecting growing clinical evidence and analysis by a variety of consensus conferences and professional organizations. The major features of the metabolic syndrome include central obesity, hypertriglyceridemia, low HDL cholesterol, hyperglycemia, and hypertension. In general, the prevalence of metabolic syndrome increases with age. The highest recorded prevalence worldwide is in Native Americans, with nearly 60% of women ages 45–49 and 45% of men ages 45–49 meeting National Cholesterol Education Program, Adult Treatment Panel III (NCEP:ATPIII) criteria. In the United States, metabolic syndrome is less common in African-American men but more common in Mexican-American women. Based on data from the National Health and Nutrition Examination Survey (NHANES) III, the age-adjusted prevalence of the metabolic syndrome in the United States is 34% for men and 35% for women. (