Approach to Overweight: Beyond the Basics
Approach to Overweight: Beyond the Basics
My patient is an 11-year-old girl, height 60 in, weight 175 lb. Her hemoglobin A1c is 5.0, C-peptide 5.0. The TSH, T3, and T4 are normal. She has achieved menarche and has regular periods. She has no signs or symptoms of hypoglycemia. She has been started on a calorie-restricted diet and an exercise program. Her family life is good, and her parents are nurturing without being overbearing. Medically, where should I go from here?
David Chorley, DO
The current epidemic of childhood and adolescent obesity has appropriately raised physicians' attention to this problem. Recent publication of body mass index [BMI = wt(kg)/ht(m)] charts for children and adolescents have made it easier to identify children who are "at risk of becoming overweight" (BMI between 85th and 95th percentile for age and sex) and those who are "overweight" (BMI > 95th percentile). The BMI of this child is 34.4, well above the 95th percentile.
Assessment of the overweight child is aimed at distinguishing the child with a disease or syndrome causing obesity from the child with so-called "exogenous" obesity, related both to genetics and to caloric intake in excess of output, and at identifying the overweight child with features of the "metabolic syndrome."
Questions in the medical history should include: has the child always been overweight or is this a relatively new problem?; has linear growth been normal?; does she have a previously diagnosed syndrome associated with obesity (eg, Prader-Willi syndrome)?; has there been any illness or surgery that has obesity as a potential complication?; if appropriate, has menarche been reached (so that growth is nearly complete for females)?; and what are the eating habits and patterns of daily activity? A family history of obesity, dyslipidemia, hypertension, type 2 diabetes mellitus, or early cardiovascular disease may point to significant future risk for the child.
In addition to height and weight, a general physical exam should note Tanner stage of pubertal development and any features suggestive of a syndromic obesity. Particular findings related to complications of obesity may include hypertension; acanthosis nigricans, a sign of hyperinsulinism due to insulin resistance; or hirsutism, a possible sign of polycystic ovary syndrome. Most pathologic conditions that cause obesity also cause growth failure, while exogenous obesity is associated with relatively good growth.
If the history and physical examination suggest a specific etiology for obesity, then confirmatory laboratory tests should be done and appropriate intervention undertaken. Thyroid studies might be helpful in the child who has been experiencing weight gain while failing to grow. Hemoglobin A1c and C-peptide may be useful baseline studies in the new-onset diabetes patient. Hypoglycemia associated with hyperinsulinism suggests an insulinoma rather than a reaction to insulin resistance.
When the diagnosis is exogenous obesity, appropriate studies include blood pressure, fasting blood glucose and insulin to screen for subclinical type 2 diabetes mellitus and/or hyperinsulinism, fasting lipid profile (total, LDL, HDL cholesterol, triglycerides) to screen for dyslipidemia, and liver function studies (AST, ALT) to screen for liver dysfunction associated with long-standing obesity. A testosterone level might identify polycystic ovary syndrome in the adolescent girl with hirsutism or amenorrhea. An abnormal screening test would indicate the need for further evaluation and specific interventions.
Appropriate initial intervention includes exactly what was done in this case. An age-appropriate, calorie-restricted diet, with specific goals regarding the child's weight, should be instituted. This often requires the help of a nutritionist. Success depends on both the child and family agreeing to the program. A suitable exercise program should be encouraged, but it is often difficult to get a sedentary child to exercise. Simply reducing allowed television time might encourage more physical activity in some children. Family-oriented behavior therapy may be an important useful adjunct for many families. There are limited roles for appetite suppressants and other medications, such as insulin sensitizers like metformin, that may be considered in conjunction with diet and exercise in very overweight children.
My patient is an 11-year-old girl, height 60 in, weight 175 lb. Her hemoglobin A1c is 5.0, C-peptide 5.0. The TSH, T3, and T4 are normal. She has achieved menarche and has regular periods. She has no signs or symptoms of hypoglycemia. She has been started on a calorie-restricted diet and an exercise program. Her family life is good, and her parents are nurturing without being overbearing. Medically, where should I go from here?
David Chorley, DO
The current epidemic of childhood and adolescent obesity has appropriately raised physicians' attention to this problem. Recent publication of body mass index [BMI = wt(kg)/ht(m)] charts for children and adolescents have made it easier to identify children who are "at risk of becoming overweight" (BMI between 85th and 95th percentile for age and sex) and those who are "overweight" (BMI > 95th percentile). The BMI of this child is 34.4, well above the 95th percentile.
Assessment of the overweight child is aimed at distinguishing the child with a disease or syndrome causing obesity from the child with so-called "exogenous" obesity, related both to genetics and to caloric intake in excess of output, and at identifying the overweight child with features of the "metabolic syndrome."
Questions in the medical history should include: has the child always been overweight or is this a relatively new problem?; has linear growth been normal?; does she have a previously diagnosed syndrome associated with obesity (eg, Prader-Willi syndrome)?; has there been any illness or surgery that has obesity as a potential complication?; if appropriate, has menarche been reached (so that growth is nearly complete for females)?; and what are the eating habits and patterns of daily activity? A family history of obesity, dyslipidemia, hypertension, type 2 diabetes mellitus, or early cardiovascular disease may point to significant future risk for the child.
In addition to height and weight, a general physical exam should note Tanner stage of pubertal development and any features suggestive of a syndromic obesity. Particular findings related to complications of obesity may include hypertension; acanthosis nigricans, a sign of hyperinsulinism due to insulin resistance; or hirsutism, a possible sign of polycystic ovary syndrome. Most pathologic conditions that cause obesity also cause growth failure, while exogenous obesity is associated with relatively good growth.
If the history and physical examination suggest a specific etiology for obesity, then confirmatory laboratory tests should be done and appropriate intervention undertaken. Thyroid studies might be helpful in the child who has been experiencing weight gain while failing to grow. Hemoglobin A1c and C-peptide may be useful baseline studies in the new-onset diabetes patient. Hypoglycemia associated with hyperinsulinism suggests an insulinoma rather than a reaction to insulin resistance.
When the diagnosis is exogenous obesity, appropriate studies include blood pressure, fasting blood glucose and insulin to screen for subclinical type 2 diabetes mellitus and/or hyperinsulinism, fasting lipid profile (total, LDL, HDL cholesterol, triglycerides) to screen for dyslipidemia, and liver function studies (AST, ALT) to screen for liver dysfunction associated with long-standing obesity. A testosterone level might identify polycystic ovary syndrome in the adolescent girl with hirsutism or amenorrhea. An abnormal screening test would indicate the need for further evaluation and specific interventions.
Appropriate initial intervention includes exactly what was done in this case. An age-appropriate, calorie-restricted diet, with specific goals regarding the child's weight, should be instituted. This often requires the help of a nutritionist. Success depends on both the child and family agreeing to the program. A suitable exercise program should be encouraged, but it is often difficult to get a sedentary child to exercise. Simply reducing allowed television time might encourage more physical activity in some children. Family-oriented behavior therapy may be an important useful adjunct for many families. There are limited roles for appetite suppressants and other medications, such as insulin sensitizers like metformin, that may be considered in conjunction with diet and exercise in very overweight children.
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