“I’ve been how shocked by how complex these patients are. When there is a significant overweight or obesity problem the only way to succeed is to involve the whole family. And don’t forget about the role of mental health. That is a significant part of overweight and obesity,” Many of the psychiatric disorders that overweight and obese children and teenagers show results from learned family behaviors, Dr. Brady said.
Another U.S. clinic specifically targeted at obese children and adolescents also sees many patients with hypertension at the University of Minnesota, a program begun in about 2010 that now has treated more than 1,000 patients including “hundreds” with comorbid hypertension, as well as similar numbers with comorbid hyperlipidemia and comorbid diabetes , said Dr. Steinberger.
“There are very few of these programs in the U.S.; it is not widely available. The cardiovascular health promotion effort should include this approach because for the primary care physician there is insufficient time or expertise to do these evaluations and treatments. You need a group of clinicians with the needed expertise,” she said. “Our multidisciplinary approach to treating comorbidities like hypertension, dyslipidemia and elevated glucose uses specialists for each of these areas as well as dieticians, social workers, and other specialists.
“In general, when the primary care physician does not have the resources to further evaluate and treat overweight or obesity they should be able to refer the patient to a program like this. It is never too soon to refer and treat. To treat overweight you need to involve the whole family. Most children do not ‘grow out’ of overweight or obesity. The overweight or obese child will generally grow up to be the overweight or obese adult,” Dr. Steinberger said.
Targeting the greatest hypertension risk
The growing trend to focus multidisciplinary resources on hypertension in the overweight or obese pediatric patient may exemplify part of a new era of targeted attention for pediatric blood pressure screening.
“We have a hard time measuring blood pressure in kids, we know the importance of obesity [in causing hypertension] and we also know that first-line management for most hypertensive patients is non-drug, lifestyle interventions. Therefore, is it possible that a greater good can be achieved by addressing lifestyle and all the health issues that would reduce the risk for hypertension, such as making sure all children engage in more movement and exercise and get off devices rather than medicalizing the problem” with frequent blood pressure measurement, wondered Howard Trachtman, MD, a pediatric nephrologist at New York University.
Dr. Howard Trachtman
“Routinely screening blood pressure in every child and adolescent is very burdensome and carries the potential cost of inconvenience and mislabeling errors. Could clinicians focus on the children and adolescents who really are at risk of high blood pressure? Can we use the EMR and alerts to make sure that repeated measures of blood pressure are done only when needed, after we identify who is at greatest risk?
“We need to become more precise in defining who is it in the age range of 8-17 years old who needs to be regularly screened for high blood pressure so we can focus our resources on these people and better avoid mislabeling and causing anxiety” for the many children and adolescents who have a very low risk for having hypertension, said Dr. Trachtman. He said that he is currently collaborating on a study that is examining whether data contained in a patient’s EMR can help in improving blood pressure assessment.
“We need to keep an open mind about who might have hypertension, but there are good data that it tracks with waist circumference, hypertriglyceridemia, and insulin resistance. The more of these you have the greater your risk. This is the kind of productive research I’m talking about, to determine whether you can be more thoughtful in identifying who is at risk of high blood pressure and who needs more systematic screening. Targeting blood pressure screening to overweight or obese kids is a step toward trying to be more methodical. The USPSTF statement should be a spur to pediatric nephrologists to make our case for blood pressure screening more cogently and to collect better data so that when we speak about this it is not based on speculation or extrapolation but on data,” Dr. Trachtman said.
“There are no arguments against optimizing health and reducing risk factors in all children, but that is not an acceptable rationale for not measuring blood pressure and attending to elevated levels in children,” responded Dr. Falkner. Dr Trachtman’s proposal to reduce health risks in all children “is a public health issue whereas the issue of detecting and managing hypertension in childhood is a clinical issue” faced by physicians as they see individual patients, she said.