Overweight

COMPETENCY- The resident should be able to:

1. Define the definition of being overweight in children
2. Understand the best screening tools for identifying overweight and patients
3. Develop a differential diagnosis for the causes of being overweight in children and
adolescents.
4. Devise a therapeutic plan for the child who is overweight as well as prevention strategies for
children at risk for developing obesity.
CASE- A mother and her 11-year-old son present to your clinic for an initial well child check.
The mother says everything is going fine, but admits he could probably lose a few pounds. She
realizes he should eat healthier foods, but he often demands fast food
and she does not have much time to prepare dinner for them. Although his grades have been
slipping recently, he is doing fairly well in school; however, he tends to play video games or
watch TV for at least 5 hours every day. He enjoys playing basketball, but the
mother worries about letting him go outside by himself in their neighborhood. The mother also
wonders if he might develop diabetes, since she has diabetes and many others in the family are
obese. His height is 54 inches (he has always been a little short, and his mom is short) and his
weight is 110 pounds (BMI= 26.5, >97%).

QUESTIONS1. What is the definition of being overweight in children?

2. What causes children to be overweight?
3. What is the differential diagnosis of overweight children?
4. What are the health risks of overweight children?
5. How can we screen for risk of obesity in children?
6. What are the current strategies for the treatment of overweight children?
1. What is the definition of being overweight in children?
Overweight*

BMI >95%

At risk for becoming overweight

BMI 85-95%

Obesity (in adults)

BMI > or equal to 30
* there is no specific criteria for the definition of obesity in children
In a recent study by the National Health and Nutritional Examination surveys (NHANES) showed
that 15.3% of children between 6-11 years old and 15.5% of children 12-19 years old were
considered overweight. Another 15% between the ages of 5-19 were considered to be at risk for
becoming overweight. (AAP)
2. What causes obesity?
The pathogenesis of being overweight is thought to be multifactorial including genetic,
environmental and behavior factors. In general, children with obese or overweight parents are at
increased risk for obesity and should be followed closely for the development of obesity from an
early age. However, with dramatically rising obesity rates nationwide (with certain

neighborhoods in Chicago having some of the highest), any child is potentially at risk and
screening should be done for all patients at every visit.
Studies have shown that parental obesity more than doubles the risk of adult obesity in children
younger than 10 years old, whether or not they are obese at that age. Elevated BMIs >95% even
at 3 years of age is a risk factor for obesity as an adult which is compounded if there is an obese
parent. The probability of childhood obesity persisting into adulthood is estimated to increase
from approximately 20% at 4 years of age to approximately 80% by adolescence (AAP).
The role of genetics has shown some interesting results when comparing twins and adopted
children. Studies of twins suggest that there is a strong genetic component with the heritability of
obesity to be between 40-70%, with concordance of 0.7-0.9 for monozygotic twins and 0.35-0.45
for dizygotic twins. The BMI of adopted children compared to the BMI of their biologic parents
as opposed to the adoptive parents show more similarity with their biologic parents. Mutations in
leptin, leptin receptor, neuropeptide Y, pro-opiomelanocortin, prohormone convertase 1 and
melanocortin receptor MC4R have been identified to be linked to obesity. However, these
advances in the genetic component of obesity does not explain the rapid rise of obesity over the
past 30 years to the epidemic we see today (Pediatrics in Review).

3. What is the differential diagnosis of obesity?

Although the majority of children and adolescents have primary or exogenous (lifestyle) obesity,
genetic syndromes, hypothalamic tumors or endorcrinopathies can present with being overweight
as the initial symptom. Red-flags that may indicate a genetic syndrome are early age of onset of
severe obesity (although Prader Willi boys tend to start off with failure to thrive), developmental
delay, vision and/or hearing problems. Hypothyroidism or adrenal excess are endocrinologic
causes of obesity that should be considered if other signs or symptoms co-exist, such as
thermoregulatory problems or hypertension. It is very important to recognize that exogenous
obesity often results in increased height-for-age, wheras a child with a genetic or endocrine
problem may have short stature.

Endocrine disorders

Cushing syndrome
Hypothyroidism
Pseudohypoparathyroidism
Type 2 diabetes
PCOS

Genetic syndromes

Prader-Labhard-Willi syndrome
Bardet-Biedel syndrome
Cohen syndrome
Beckwith-Weidemann syndrome
Alstrom syndrome

CNS disorders

Hypothalamic tumor
Trauma
Inflammation

Miscellaeous

Drug induced (eg, risperidone, tricyclic antidepressants)

Binge eating disorder
Bulimia nervosa

(Pediatrics in Review)

4. What are the health risks of being overweight?

Whether part of a genetic syndrome, endocrine dysfunction or simply from eating too much,
being overweight is clearly associated with medical problems involving nearly every organ
system:
Cardiovascular

HTN, elevate total cholesterol, High LDL, low HDL, MI, stroke,
metabolic syndrome

Respiratory

sleep apnea, upper respiratory infections, restrictive lung disease,

asthma

Orthopedic

SCFE, Blount disease, Legg-Calve-Perthes disease, degenerative

arthritis, coxa vara

Dermatologic

intertrigo, furunculosis, acanthosis nigricans

Immunologic

impaired cell-mediated immunity, PMN killing capacity and

macrophage maturation

Gastrointestinal

gallstones, hepatic steatosis, steatohepatitis, GERD

Endocrine

early puberty onset, early adrenarche, increased androgens in females,

decreased androgens in males, dysmenorrhea, PCOS, increased fasting
insulin and insulin/glucagon release, peripheral insulin resistance,
metabolic syndrome

5. How can we screen for the risk of obesity in children?

Measure the BMI every visit on growth chart, after 2 years old
Quickly review lifestyle history for high yield items: juice, fast food, milk, exercise,
TV/Wii/Playstation/Xbox, hobbies/activities
If the pt has an elevated BMI, follow every 3-4 months while implementing one lifestyle
change at every visit.
If the BMI > 95, consider a lipid panel and fasting glucose

6. What are the current strategies for the treatment of primary obesity?
Approach the family early
o Involve the whole family
o Emphasize health risk related to obesity and the many benefits to be gained by

losing weight
o Approach the family in a compassionate and non-judgmental way
o Make simple but well defined alterations in lifestyle and behavior
cutting out soda and juice, limiting TV/video game times to 1-2h per day,

30 minute walks 2-3 times per week

o Continue counseling and encourage in regular follow-up visits
o Encourage taking part in community-based or city-run exercise programs and
activities

o Emphasis should be on preventing further weight gain as opposed to weight loss.

he child is likely to still be growing and a small weight loss or even weight
maintenance may actually represent a large difference in BMI.
Interventions
o Refer to a nutritionist
o If there is suspicion of underlying causes of obesity such as a genetic or
endocrine disorder, refer to an endocrinology obesity specialist
o The physical exam should include a blood pressure as well as monitoring for
sequelae of being overweight including but not limited to orthopedic, endocrine
and respiratory issues.
o Labs to consider:
fasting glucose
HbA1c
lipid panel
Online resources
o AAP: http://www.aap.org/obesity
o Department of Health and Human Services (DHHS): http://www.healthierus.gov
o CDC: http://www.cdc.gov/nccdphp/dnpa/obesity
o Educational DVDs from the DHHS: http://www.ahrq.gov/child/dvdobesity.htm

REFERENCES:
1. American Academy of Pediatrics, Committee on Nutrition. Prevention of
Pediatric Overweight and Obesity. Pediatrics, 2003; 112: 424-430.
2. American Academy of Pediatrics, Committee on Nutrition. Pediatric Obesity,
Ch.33 in Pediatric Nutrition Handbook, 5th Edition. Ronald Kleinman, Editor. 2004.
3. Bariatric Surgery for Severely Overweight Adolescents: Concerns and Recommendations.
Pediatrics. 2004; 114: 217 223.
4. CDC BMI-for-age and growth charts: http://www.cdc.gov/growthcharts/
5. James, J, Thomas, P, Cavan, D and Kerr, D. Preventing Childhood Obesity by Reducing
Consumption of Carbonated Drinks: Cluster Randomised Controlled Trial. BMJ, May 2004;
328:1237.
6. Schneider MB, Brill SR. Obesity in Children and Adolescents. Pediatrics in Review.
2005;26:155-162.

Duri Yun
Siri Greeley
Advisor: Dr. Heather Johnston