ReNEW clinic staff, from left to right, psychologist Jeffrey Garofano, nephrologist Tammy Brady and dietician Diane Vizthum meet in the reading room of the pediatric cardiology clinic, where patients’ echocardiograms are screened.
The multidisciplinary ReNEW clinic addresses the needs of children facing the cardiovascular comorbidities of obesity, including hypertension and heart disease.
At the first Grand Rounds in October, pediatric resident Adam DeLong updated Johns Hopkins Children’s Center faculty about the state of childhood obesity in America. The news was not promising. Nationwide, he noted, rates of childhood obesity continue to rise, affecting 18.5% of children and adolescents, or 13.7 million young people. A child who is obese at age 12, he said, has a 75% chance of being obese as an adult, with all the related and potentially lethal risk factors such as type 2 diabetes, severe hypertension, heart disease and obstructive sleep apnea. However, there are effective resources against these threats, DeLong added, including one in the pediatric cardiology clinic just down the hall from where he was presenting his update. There, a clinic focuses on children who are overweight/obese with hypertension and other comorbidities of obesity, he noted, which offers hope and some progress against the numbers.
“As a resident working with children, I feel like I’m offering stage-one interventions every week, so I wonder if what we’re doing works,” says DeLong. “But there is a lot of potential with the ReNEW clinic, its medical home model and one provider steering the ship.”
The captain of that ship — the Obesity Hypertension Clinic: Reversing the Negative Cardiovascular Effects of Weight (ReNEW) — is pediatric nephrologist Tammy Brady. Each week, she and a diverse team from child psychology, nutrition and physical therapy assess the progress of young patients with obesity-related hypertension. They also screen for obesity-related comorbidities that many of these children struggle with, including type 2 diabetes, obstructive sleep apnea, slipped capital femoral epiphyses, dyslipidemia and fatty liver disease, referring patients to collaborative partners in endocrinology, gastroenterology and pulmonary sleep medicine, among other specialties. Weight, of course, is a primary concern as patients in the clinic average between 250 and 300 pounds, and a few patients are above 400 pounds. However, in this clinic hypertension is the focus as untreated it leads to multiple other organ diseases, including early onset heart disease. Up to 25% of children who are overweight/obese — eight times as many as in the general population, stresses Brady — have high blood pressure.
“We see kids of all ages with obesity-related hypertension in the ReNEW clinic, from 5 years of age up to 21,” says Brady. “We screen these kids for early signs of heart disease related to their cardiac disease risk factors — things like abnormal heart thickening or suboptimal relaxation — because we know in adults these markers lead to arrhythmias, heart attacks and death.”
All patients in the ReNEW clinic undergo echocardiography to screen for these intermediate outcomes. For good reason, adds Brady: “The heart thickening is not just in the range where we say it’s abnormal — it’s super abnormal. Left ventricular mass index above 51 in adults is associated with four times the increased risk of cardiovascular morbidity and mortality. Not only do many of our kids have a value well above 51, some of them are 80 and 90, almost double what’s considered an increased risk in adults.”
To lower those risks, Brady and the team see patients frequently — every three months rather than every six months — to keep them on track with the treatment plan. At each 2 ½-hour visit, the pediatric dietician guides patients on nutrition and weight loss, and the physical therapist works on exercise options for patients, especially those with the obesity-related hip condition slipped capital femoral epiphysis, which can affect bone health. In addition, the behavioral psychologist consults with and refers patients with underlying mental health issues such as anxiety and depression that may be influencing their eating habits. To motivate behavior change, patients and their families collaborate with the psychologist to set meaningful and attainable goals. Goals can range from exercising and eating vegetables at least once a day to eliminating fast food.
“I would say 60%–70% of our patients make some meaningful progress in goal attainment from one session to the next,” says behavioral psychologist Jeffrey Garofano.
Garofano plays another essential role in the clinic as chief adherence officer, motivating and tracking patients’ compliance with prescribed medications, diet, exercise and CPAP (continuous positive airway pressure) machine use for patients with obstructive sleep apnea (OSA).
“The behavioral psychologist is the biggest value added in this clinic,” says Brady. “In a typical clinic schedule, I am not allotted the time to address mood disorders and barriers, and do appropriate motivational interviewing and counseling. So I have a person with me able to focus on those key elements for behavior change and set realistic goals while I concentrate on patients’ risk stratification, blood pressure, side effects of medications and other medical issues.”
One of those other medical issues is OSA, which is common among individuals who are obese. Pediatric pulmonologist and sleep specialist Laura Sterni notes that with the rise in childhood obesity she is seeing “more and more patients” with OSA, which like obesity can exasperate hypertension and contribute to cardiovascular issues.
“A lot of the complications that you get from obesity alone — heart disease, hypertension, metabolic syndrome — you also see with sleep apnea alone,” says Sterni. “Put them together, and it’s unfortunately a perfect storm.”
Research is another tactic against this storm. Related recently published papers include one co-authored by Brady, Sterni and Garofano that shed further light on the link of OSA to left ventricular hypertrophy (LVH) in children who are obese and have hypertension. Severe OSA was associated with 14 times greater odds of LVH, and those with the most severe OSA had the greatest risk of this pathologic cardiac remodeling (Journal of Clinical Hypertension 2019;21:984-990). The take-home message? Screening for OSA should be a consistent part of the evaluation and care of patients with hypertension, a practice at the ReNEW clinic.
Similarly, a paper co-authored by Brady revealed the association between mood disorders, hypertension and cardiovascular disease among children who are overweight/obese. Demonstrating a “high burden” of mood disorders among children diagnosed with hypertension, they concluded that improved methods for earlier diagnosis and treatment of mood disorders, a nontraditional cardiovascular disease risk factor, may positively influence their cardiovascular health (Journal of Clinical Hypertension 2018;20:1268-1275).
In another approach, the ReNEW clinic partners with community groups such as the YMCA to offer patients and their families trial memberships funded by the Thomas Wilson Foundation. The group has also financed a video to show patients and families who may live in unsafe neighborhoods how to exercise in small spaces at home, and provided scales for patients.
“Kids will come in and have no idea whether they gained or lost weight,” says Brady. “Without that monitoring you can’t have successful weight loss.”
Multiple clinical services, evidence-based medicine, continuing research, and community partnerships, Brady stresses, are all vital to the success of the clinic and patients’ progress. However, at the heart of the clinic in Brady’s eyes is its open connection and communication with patients and families. There are no cookie-cutter answers, says Brady, pointing to the challenges of childhood obesity amid the isolation of the coronavirus.
“One of the reasons I love my specialty is that our patients really identify with us and will ask these broader questions to help us guide them,” says Brady. “We’re still learning, but they’re putting a lot of faith in our responses. We try to make sure we are communicating effectively, which can be hard when you’re talking about a pandemic. But working together, we’re figuring out ways to motivate these kids and families.”
Still, pointing to issues such as food insecurity in poor neighborhoods and the increasing prevalence of comorbid conditions associated with obesity and hypertension, Brady would like to expand patient services even more.
“My dream … I would love to have a multidisciplinary obesity center where the kids could see all of the people they need — the endocrinologist, the gynecologist, the sleep specialist — and get all the services along with prevention.”
For more information, visit the Obesity Hypertension Clinic: Reversing the Negative Cardiovascular Effects of Weight (ReNEW).