Obesity (pediatrics): Clinical sciences

Watch video only
Obesity refers to excessive fat accumulation in the body that is strongly associated with dyslipidemia, diabetes mellitus type 2, nonalcoholic fatty liver disease, and cardiovascular conditions.
Now, when assessing overweight and obesity, in children under two years of age, you should use weight-for-length classification, and in children above two years of age, you should use body mass index.
If your patient is presenting with chief concerns suggestive of obesity, obtain a comprehensive history and physical examination, including measurements of weight and height.
If the child is under 2 years of age, measure their length, not height. The patient’s prenatal and perinatal history may reveal risk factors, like gestational diabetes or fetal macrosomia, while family history might reveal parental obesity.
Obesity is often associated with type 2 diabetes mellitus, so always ask about the presence of polydipsia, polyphagia, and polyuria!
In some cases, history might reveal a limp and pain in the hip, groin, thigh, or knee, which is suggestive of slipped capital femoral epiphysis.
Biological female adolescents could also report irregular menstrual cycles and heavy menstrual bleedings in combination with hair loss, which is suggestive of polycystic ovary syndrome.
History might also reveal frequent snoring during sleep, which could be a sign of obstructive sleep apnea, as well as the use of medications associated with obesity, such as corticosteroids, anti-seizure medications, and antidepressants.
Next, ask for symptoms of mental health and behavioral conditions that can increase the risk of obesity, such as depression, anxiety, and disordered eating.
History could also reveal psychosocial stressors or adverse childhood experiences, like bullying, which can trigger physiologic changes that can result in weight gain.
Finally, look for social determinants that can increase the risk of obesity. For example, in under-resourced communities, children often lack access to fresh produce or safe spaces for physical activity, and those living in households with food insecurity are more likely to develop obesity.
Family and household factors that increase a child’s risk of being obese include authoritarian or permissive parenting styles, consumption of sweetened beverages and snacks, sedentary behaviors, and inadequate sleep.
Now, here’s a clinical pearl! Some children might present with an underlying genetic condition that predisposes them to obesity, such as Prader-Willi syndrome, or endocrine conditions, like hypothyroidism and Cushing syndrome!
On the physical exam, your patients will typically present with increased waist circumference, excess adiposity, and a prominent suprapubic fat pad.
Some patients might have elevated blood pressure, which is suggestive of obesity-related hypertension. Next, be sure to examine the patient’s skin!
Check for abdominal stretch marks, which are also known as abdominal striae. In obesity, stretch marks are typically narrow and pale pink to white, in contrast to Cushing syndrome, which is associated with wide purple stretch marks!
Next, examine the skin folds since local skin friction and moisture can result in superficial skin inflammation called intertrigo.
Also, look for acanthosis nigricans on the nape of the neck or in the axillae, which is suggestive of diabetes mellitus, as well as acne and hirsutism, which is suggestive of polycystic ovary syndrome.
Next, palpate the abdomen and check for liver enlargement since hepatomegaly is often associated with non-alcoholic fatty liver disease or NAFLD.
If history reveals a limp, always check for hip tenderness, which could be a sign of slipped capital femoral epiphysis. Finally, in biologically male individuals, excessive adipose tissue converts more testosterone to estradiol, which promotes the enlargement of glandular breast tissue, so these patients might present with gynecomastia.
At this point, you should suspect obesity, so your next step is to assess the patient’s age. If the child is under 2 years of age, assess their weight for length.
If the child's weight-for-length is at or above the 95th percentile for age and sex, they are overweight, so proceed with management, which primarily relies on nutrition modifications!
First, encourage exclusive breastfeeding for the first 6 months of life. After 6 months, caregivers should continue breastfeeding but in combination with complementary feeding for up to two years!
Next, the child should not be taking sugar-sweetened beverages or desserts! Finally, caregivers should avoid force-feeding because a child usually knows well when they are full, so they will display cues like shaking their head and covering their mouth.
Next, encourage regular daily activities and interactions with parents and caregivers. Children should have playful activities and avoid sedentary behaviors like watching media and television!
Now, let’s go back and take a look at children who are 2 years and older. In this case, you should assess the patient’s body mass index.
If the child’s body mass index is at or above the 85th percentile but below the 95th percentile for age and sex, they are overweight.
However, if their body mass index is at or above the 95th percentile for age and sex, diagnose obesity, which can be further classified as severe obesity if the BMI is around the 99th percentile.
Here’s a clinical pearl! In older adolescents, you can also use the adult body mass index.
In adults, a body mass index between 25 and 29.9 kilograms per square meter is considered overweight, while a body mass index of 30 or more is indicative of obesity.
Although the diagnosis of obesity hinges on body mass index, it is an imperfect individual measure. For example, professional athletes who have minimal body fat and high muscle mass end up incorrectly classified as overweight or obese.
Furthermore, certain racial and ethnic groups may experience complications of obesity at lower BMIs, while others with higher BMIs but low adiposity have a lower risk of these complications.
In all individuals, obtain additional labs to look for comorbid conditions! First, obtain a fasting lipid panel to screen for dyslipidemia, especially in children who are ten years and older.
Next, in individuals who are obese or overweight but with risk factors, such as positive family history and signs of insulin resistance, you should screen for type 2 diabetes mellitus.
So, obtain hemoglobin A1C, fasting or random blood glucose, or OGTT. Also, check for NAFLD by ordering AST, ALT, and GGT.
In individuals with oligomenorrhea and hirsutism, check androgen levels and obtain a pelvic ultrasound! Finally, if there’s elevated blood pressure, don’t forget to obtain 24-hour ambulatory blood pressure monitoring!
If the fasting lipid panel reveals elevated triglycerides and decreased HDL, diagnose dyslipidemia. Next, if the hemoglobin A1C is 6.5 percent or greater, fasting blood glucose is 126 milligrams per deciliter or greater, a random blood glucose is 200 milligrams per deciliter or greater, or blood glucose during a 2-hour OGTT is 200 milligrams per deciliter or greater, diagnose diabetes mellitus.
Individuals with obesity most commonly present with diabetes mellitus type 2. However, always rule out type 1 by ordering C-peptide levels and islet cell autoantibodies.
Normal or elevated C-peptide levels and negative pancreatic islet antibodies are suggestive of type 2 diabetes. Next, elevated ALT levels, regardless of AST and GGT levels, are suggestive of NAFLD.
However, if the labs reveal high ALT, AST, and GGT, think of progressive and severe NAFLD. Finally, oligomenorrhea and hirsutism in combination with elevated androgen levels and multiple ovarian cysts on ultrasound are suggestive of polycystic ovarian syndrome, while hypertension on a 24-hour blood pressure monitoring is suggestive of obesity-related hypertension.
Finally, let’s talk about treatment. In all children, you should start with a motivational interview by asking about the child’s and caregiver’s perception of the child’s weight and assessing the readiness to make changes.
During any weight-related discussions, use non-stigmatizing language. Explain that the child is gaining too much weight for their height and discuss how being overweight can adversely impact health.
For all patients over 6 years of age, you should recommend intensive health behavior and lifestyle treatment, which typically includes dietary recommendations, increased physical activity, and sleep optimization.
For children with obesity under 6 years of age, consider intensive health behavior and lifestyle treatment on a case-by-case basis, depending on their ability to participate in treatment.
When setting goals, use shared decision-making and support your patient’s autonomy as much as possible. Finally, be sure to manage any comorbid conditions, and, at each well-child visit, monitor your patient’s blood pressure.
In severe cases, you could consider adjunctive weight loss pharmacotherapy or surgical consultations for possible bariatric surgery.
Alright, as a quick recap… Obesity refers to excessive fat accumulation in the body that is strongly associated with dyslipidemia, diabetes mellitus, NAFLD, polycystic ovary syndrome, and hypertension.
If the child is under 2 years of age and their weight-for-length is at or above the 95th percentile for sex and age, they are overweight.
Similarly, if the child is 2 years of age and older and their body mass index is at or above the 85th percentile but below the 95th percentile for age and sex, they are overweight.
However, if they are at or above the 95th percentile for age and sex, diagnose obesity.