Diseases » Prader-Willi syndrome

Obesity

Obesity: Excerpt from The 5-Minute Pediatric Consult

Sandra Gibson Hassink, MD

George A. Datto III, MD

Obesity - BASICS

Obesity - description

A chronic disease defined as having an excess of body fat. Body mass index (BMI), which is defined as weight in kilograms divided by height in meters squared, is accepted as a proxy measurement of adiposity in children.

• Children <2 years of age:

  Weight for length >95% for age: Obese

• Children >2 years of age:
  • BMI <5%: Underweight
  • BMI 5–85%: Normal weight
  • BMI 85–95%: Overweight
  • BMI >95%: Obese
  • BMI 95–99%: Obese
  • BMI >99%: Morbid obesity

Obesity - general prevention

• Prevention of gestational diabetes: Children of diabetic pregnancies have a greater risk of obesity and diabetes.
• Prevention of intrauterine growth retardation: Infants with intrauterine growth retardation are at increased risk of later obesity and cardiovascular disease; this risk is enhanced in infants and children who have had rapid weight gain or “catch up growth.”
• Encourage breastfeeding: There is a response effect on reduction of risk of obesity in children who have been breastfed.
• Early preventive counseling in patients with obese parents
• Early preventive counseling in children crossing BMI percentiles
• Promotion of nutrition guidelines, free play, and limited screen time in the general population

Obesity - epidemiology

Obesity - prevalence

2004 data:

• 6–11 years of age: 18.8%
• 12–19 years of age: 17.1%
• Highest rates in Native American and Hispanic children
• 61% of overweight children have at least 1 additional risk factor for heart disease

Obesity - risk factors

• Intrauterine environment:
  • Gestational diabetes
  • Intrauterine growth retardation
• Obese parents:
  • 1 obese parent: 40% chance of having an obese child. 2 obese parents: 70% chance of having an obese child
• Low socioeconomic status/minority ethnic groups
• Limited intake of fruits and vegetables
• Postnatal environment:
  • Television viewing >2 h/d
  • Consumption of sugared beverages

Obesity - pathophysiology

Complex gene–environment–behavior interaction:

• Hypothalamus: Appetite regulation. Energy balance is regulated at the hypothalamic level. Neuropeptide regulation of hunger and satiety with input from cortical stimuli and gut hormone secretion. Energy stores and energy expenditure are regulated with input from leptin on energy stores and regulation of energy expenditure via the sympathetic nervous system.
• Adipose cells: Cytokines. Adipose tissue produces leptin (energy regulation) and adiponectin (cardiovascular risk).
• Tumor necrosis factor-α (inflammation)
• Psychobehavioral

Obesity - etiology

Energy imbalance:

• Excessive caloric intake: High caloric foods readily available in large portions and often preferred by children
• Inadequate caloric expenditure: Television, video games, and computers part of child’s daily activities

Obesity - associated conditions

• Type 2 diabetes mellitus
• Hypertension
• Dyslipidemia
• Metabolic syndrome
• Sleep apnea
• Asthma
• Polycystic ovarian syndrome
• Nonalcoholic steatohepatitis
• Slipped capital femoral epiphysis
• Blount disease (tibial bowing)
• Binge eating disorder
• Depression
• Low self-esteem

Obesity - DIAGNOSIS

Obesity - signs & symptoms

Obesity - history

• Obesity trigger:
  • Age at which weight gain started
  • Family or patient stress
  • Life events
• Parents’/Patient’s beliefs:
  • Level of concern and motivation
  • Self-assessed reasons for weight gain
  • Previous attempts at weight control
• Family history:
  • Weight of parents
  • Obesity comorbidities in family
• Lifestyles:
  • Eating behaviors:
    • Age-appropriate meal structure
    • Sugared beverage (juice, soda, sports drink) consumption
    • Snacks: Frequency and content
  • Physical activity:
    • Hours of screen time from TVs, handheld devices, game stations, computers
    • Sports participation
    • Time outdoors
• Parenting skills:
  • Hunger management
  • Role modeling
  • Ability to set boundaries
• Obesity review of symptoms:
  • CNS: Pseudotumor
  • Respiratory: Sleep apnea, asthma
  • GI: Reflux
  • Orthopedics: Slipped capital femoral epiphysis (SCFE)/Blount disease
  • Psychology: depression, attention deficit hyperactivity disorder (ADHD), anxiety, school difficulties
  • Skin: Acanthosis nigricans
• Prior interventions:
  • Ask about prior use of diet pills, laxatives.
  • Ask family about previous or current complementary and alternative medicine (CAM) weight loss products they have tried.

Obesity - physical exam

• Anthropometrics:
  • Weight, height
  • BMI
  • Blood pressure
• General:
  • Short stature
  • Dysmorphic features
  • Developmental delay
• Head, eyes, ears, nose, and throat (HEENT):
  • Papilledema
  • Tonsillar hypertrophy
• Cardiopulmonary:
  • Breath sounds
  • Heart murmur
• Abdomen: Hepatomegaly
• Genitourinary: Tanner stage
• Musculoskeletal:
  • Joint range of motion
  • Limp
• Skin:
  • Acanthosis nigricans
  • Hirsutism
  • Striae
• Psychological:
  • Mood: Assess for evidence of depression.
  • Affect

Obesity - tests

• Body composition: Excessive fat confirmation
  • Skin fold measurement
  • Bioelectric impedance analysis: Clinical estimate of basal metabolic rate and lean body mass
  • Indirect calorimetry: Clinical use in determining dietary requirements; calculates basal metabolic rate
• Comorbidity confirmation:
  • Sleep study: Sleep apnea
  • Hip x-rays: Role of SCFE
  • Knee and lower extremity x-rays: Role of Blount disease
  • Echocardiogram (ECHO): Hypertension
  • 2-hour glucose tolerance test for diabetes mellitus
  • Liver ultrasound, xenon scan: Nonalcoholic steatohepatitis (NASH)
  • Chromosomes: If dysmorphic features are present on examination

Obesity - lab

Metabolic screening (fasting specimens) should be done on all obese patients:

• Lipid profile: Cholesterol, HDL, and triglycerides
• Glucose
• Liver function tests to assess for liver disease
• Thyroid tests, cortisol, insulin, androgens (as indicated)

Obesity - differencial diagnosis

Diseases in which obesity may be a component:

• Hypothalamic obesity
• Cushing syndrome
• Hypothyroidism
• Growth hormone deficiency
• Down syndrome

Obesity - TREATMENT

Obesity - general measures

Early obesity recognition and treatment to prevent further excessive weight gain and obesity complications. Weight loss and comorbidity treatment when clinically appropriate

• Effective communication with patient and family:
  • Nonblaming
  • Using growth charts as visual aids
  • Be positive that change can occur
• Supply developmentally appropriate nutrition and activity information
• Identify energy balance abnormalities
• Support parents in planning and in making lifestyle changes:
  • Set goals
  • Enhance parenting skills related to developing structure, setting boundaries, maintaining consistency, communication, knowledge of child development

Obesity - diet

Improve/Change dietary habits:

• Encourage age-appropriate eating:
  • Review frequency of eating
  • Review portion sizes
• Discuss access to food
• Discuss family meals
• Limit sugared beverage consumption
• Limit amount of junk food in house
• Increase fruit and vegetable intake
• Have parents model healthy eating habits
• Encourage parents to work with day care, school, and extended family on supporting dietary changes

Obesity - activity

Improve/change activity habits:

• Limit total screen time (television, video games, and computer) to a maximum of 2 h/d.
• When possible, add structured physical activity into daily routine.
• Encourage non-weight-bearing activities, such as swimming or stationary bike riding, which may be easier for the severely deconditioned patient.
• Help family find opportunities for increased activity in both the child’s school and community.

Obesity - medication

• Appetite suppressant:
  • Sibutramine (Meridia): Approved for children older than 16:
    • Side effects: Hypertension, constipation
    • Modest weight loss as compared to placebo
    • No long-term studies on safety or efficacy
    • Must be used concurrently with nutrition and exercise program
    • Not recommended for routine use
• Lipase inhibitor:
  • Orlistat (Xenical):
    • Side effects: Abdominal pain, oily stools, flatulence
    • Minimal weight loss as compared to placebo
    • Not recommended for routine use

Obesity - surgery

Gastric bypass/banding surgery may be appropriate for some adolescent patients with BMI >40 and severe comorbid conditions, including the following:

• Diabetes mellitus
• Sleep apnea
• Disabling orthopedic complications

Obesity - FOLLOW UP

Initially monthly to assess weight and behavioral change:

• Intensify follow-up with weight gain
• Spread out visits when efficacy of treatment has been established.

Obesity - disposition

Obesity - issues for referral

Comorbidities that do not improve with reductions in BMI, or complications beyond a provider’s expertise: Refer to appropriate specialist/pediatric obesity center.

Obesity - prognosis

• Better prognosis in younger and less obese patients
• Better prognosis in patients and families who maintain ability to self-monitor health habits and maintain physical activity
• Long-term prognosis is guarded in morbidly obese patients.

Obesity - complications

• Medical emergencies:
  • SCFE
  • Nonketotic hyperosmolar hyperglycemia
  • Cor pulmonale
  • Diabetic ketoacidosis
  • Pulmonary emboli
• Acute but generally nonemergent:
  • Hypertension
  • Sleep apnea
  • Gallstones
  • Type 2 diabetes
  • Polycystic ovarian syndrome
  • Gastroesophageal reflux
  • Asthma
  • Blount disease
• Chronic:
  • Dyslipidemia
  • Psychosocial issues
  • Increased risk of cardiovascular disease
  • Increased mortality of all causes in adulthood

Obesity - bibliography

1. Dietz WH, Robinson TN. Overweight children and adolescents. N Engl J Med. 2005;350(20):2100–2109.
2. Inge TH, Krebs NF, Garcia VF, et al. Bariatric surgery for severely overweight adolescents: Concerns and recommendations. Pediatrics. 2004;114(1):217–223.

Obesity - CODES

Obesity - icd9

• 277.7 Metabolic syndrome
• 278.0 Obesity
• 278.1 Morbid obesity

Obesity - FAQ

• Q: How do I start addressing a child’s weight?
• A: Review the height, weight, and BMI charts as part of the visit routine. Discuss family history in light of obesity and comorbidities, and link to the child’s risk. Make obesity risk assessment part of the visit.
• Q: What do I do if family is not interested in addressing the child’s weight?
• A: Introduce your concern about the child’s health, ask the family to think about their priorities for the child and family, help make links to good nutrition and activity habits (motivational interviewing).
• Q: How early can I start managing a child’s weight?
• A: Attention to good nutrition and activity starts even before birth, at the prenatal visit. Parents need to see this as part of every interaction with their child’s pediatrician.

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Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Prader-Willi syndrome

• Back to disease: Prader-Willi syndrome: Introduction
• Next Book Extract About Prader-Willi syndrome: Short Stature (The 5-Minute Pediatric Consult)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

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More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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