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Subject: Obesity, Pediatric
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Children ≥2 years of age
BMI 85–94%: overweight
BMI 95–98% or BMI ≥30 kg/m2: obese
BMI ≥99%: severe obesity. Severe obesity has also been defined as BMI ≥120% of the 95th%.
BMI reference standards are not available for children <2 years of age. In this age group, overweight is defined as weight-for-length ≥95% for age and sex.
2 to 19 years of age: 17%
2 to 5 years of age: 8.9% obese
6 to 11 years of age: 17.5% obese
12 to 19 years of age: 20.5% obese
No difference in prevalence by gender
Highest rates among black and Hispanic youth
Severe obesity: 5.8%
Obesity is most often a multifactorial condition with several risk factors:
Maternal obesity in pregnancy
Maternal history of gestational diabetes
Intrauterine growth retardation
Rapid weight gain in first 6 months of life
Low socioeconomic status
Obesity with developmental delay and/or dysmorphic features: Bardet- Biedl syndrome, Cohen syndrome, Prader-Willi syndrome
Obesity with poor linear growth: Cushing syndrome, hypothyroidism
Encourage exclusive breastfeeding at prenatal visit and support breastfeeding throughout the 1st year of life.
In formula-fed infants, watch for signs of overfeeding and rapid weight gain in 1st year of life. Educate families on the difference between hunger and oral suck reflex. Avoid rice cereal in the bottle.
Recognize parental obesity as a significant risk.
Incorporate early nutrition and activity counseling.
Careful attention to BMI (and weight-for-length for children <2 years) with intensive counseling for children crossing percentiles
Stress importance of portion size and nutrient-rich foods (fruits and vegetables) as infants transition to a solid diet
Daily physical activity; limit screen time.
Short-term energy regulation: adaptation of meal size in response to energy needs. Hypothalamic neurons modulate sensitivity of nucleus tractus solitarius (NTS) neurons to satiety signals adjusting for changes in body fat mass.
Long-term energy regulation: Hypothalamus senses and integrates energy balance signals including hormones such as insulin, leptin, ghrelin, and nutrients such as fatty acids, amino acids, and glucose.
A negative feedback regulator—plays an important role in energy homeostasis.
Communicates to hypothalamus changes in energy balance and fuel stored as fat
Increased fat mass results in increased leptin signaling which limits energy intake and supports energy expenditure.
Decreased leptin promotes increased food intake, positive energy balance, and fat accumulation.
Derived from the stomach, it is the only known peripherally acting orexigenic hormone. It stimulates appetite.
All other gut-derived hormones are anorectic and limit food, optimize digestion and absorption, and avoid overfeeding.
Insulin sensitizing, anti-inflammatory, and antiatherogenic
Increased visceral fat results in reduced levels of adiponectin and increased proinflammatory milieu leading to insulin resistance and endothelial dysfunction. This predisposes to metabolic syndrome, diabetes, and atherosclerosis.
Excessive caloric intake: calorie-rich foods and beverages consumed preferentially over nutrient-rich foods. Portion size is inappropriately large for age.
Low-caloric expenditure: excessive sedentary time with TV, computers, video games, and handheld devices; limited daily physical activity
Type 2 diabetes mellitus
Polycystic ovarian syndrome (PCOS)
Low vitamin D level
Nonalcoholic fatty liver disease (NAFLD)
Nonalcoholic steatohepatitis (NASH)
Gastroesophageal reflux (GER)
Slipped capital femoral epiphysis (SCFE)
Blount disease (tibial bowing)
CNS: pseudotumor cerebri
Mood disorder: anxiety and depression
Birth history: birth weight, maternal gestational weight gain, gestational diabetes
Growth history: weight trajectory and age where percentiles were crossed
Medical and/or social stressors
Medical history: asthma, medications, obesity comorbidities
Parental concern and desire for change and willingness to modify family’s behavior
Child’s concern and motivation (as age appropriate)
Sugar-sweetened beverages consumed
Frequency of fruits and vegetables
Frequency and type of snack foods
Frequency of fast food
TV viewing during meals
Recognition of satiety
Binge eating with or without loss of control
Total screen time including phone and handheld devices
Duration, intensity, and frequency of physical activity
Sleep duration and pattern
Previous attempts at weight loss
Medication use (prescribed and over-the-counter [OTC])
Weight loss programs
Review of systems
Headache: pseudotumor cerebri
Snoring/pauses in breathing, daytime somnolence: obstructive sleep apnea (OSA)
Abdominal pain: reflux, gallstones
Joint pains: hip pain (SCFE)
Social isolation, emotional eating, behavior difficulties: depression
Skin color changes (acanthosis nigricans)
Irregular menses/amenorrhea: PCOS
Polydipsia, polyuria: diabetes
Anthropometrics: weight, height, BMI, and BMI percentile
Blood pressure for age, sex, and height percentile
General physical findings suggestive of endocrine or genetic condition
Head, ears, eyes, nose, throat (HEENT)
Tonsillar hypertrophy and narrow pharyngeal opening
Poor aeration, wheezing
Genitourinary: Tanner stage
Range of motion at hips
Abnormal curvature of lower leg
Mood: Assess for evidence of depression.
Bullying, social isolation
BMI 85th to 94th percentile without risk factor: fasting lipid profile
BMI 85th to 94th percentile age ≥10 years with risk factors: fasting lipid profile, ALT, AST, fasting glucose
BMI ≥95th percentile age ≥10 years: fasting lipid profile, ALT, AST, fasting glucose, other tests as indicated by health risks
Polysomnogram: history of snoring with pauses in breathing, narrow pharyngeal airway, or tonsillar hypertrophy (OSA)
AP and frog-leg views of the hips: knee pain or hip pain, limitation or pain with internal rotation of hip (SCFE)
Knee and lower extremity radiographs: abnormal curvature of the lower extremities, especially asymmetry (Blount disease)
Echocardiogram: hypertension (LVH)
Ambulatory blood pressure monitoring: elevated blood pressure/hypertension
Abdominal ultrasound: elevated LFTs or abdominal pain (NAFLD, gallstones)
Head CT: headache and papilledema on ocular exam (pseudotumor cerebri)
Lipid panel: Obese children often have elevated LDL and triglycerides and low HDL.
High LDL ≥130 mg/dL
0 to 9 years old ≥100 mg/dL
10 to 19 years old ≥130 mg/dL
Low HDL <40 mg/dL
ALT value >2 times normal or >60 IU/L merits gastroenterology consult.
Fasting glucose ≥126 mg/dL or random glucose ≥200 mg/dL supports a diagnosis of diabetes and warrants endocrinology consult.
HgbA1c ≥6.5% diagnostic of diabetes
Fasting glucose ≥100 mg/dL or HgbA1c ≥5.7% and ≤6.4% indicates impaired fasting glucose and a prediabetic state.
Prevention and treatment include healthy lifestyle behavior: Goal is to start with small incremental changes in lifestyle.
Eliminate consumption of sugar-sweetened beverages including juice and sports drinks.
Encourage nonfat milk and water.
Increase servings of nutrient-rich foods such as fruits and vegetables with every meal and for snacks.
Avoid skipping meals.
Reduce eating out or takeout foods.
Encourage family meals.
Educate families about portion size as soon as solids are started and in early childhood.
Advise 1 hour per day of moderate physical activity.
Limit screen time to <2 hours a day.
Weight loss goals
Weight maintenance may be appropriate in younger children, as BMI will improve with increase in height.
Older children and severely obese children should aim to lose up to 2 lb a week.
Limits nutrient absorption
Side effects: abdominal pain, oily stools, flatulence, fat-soluble vitamin deficiencies; self-limited success, poor compliance
5% weight loss, similar to placebo
Not recommended for routine use
Adolescents with a BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with concomitant comorbidities such as diabetes and hypertension
Lack of sustained weight loss on supervised weight-reduction program for 6 to 12 months
Physical, emotional, and cognitive maturity
Assess BMI monthly and achievement of dietary and physical activity goals.
Follow patient more frequently with weight gain and/or refer for nutrition counseling or a weight management program at a tertiary care center.
Refer to subspecialist with diagnosis of accompanying comorbidities.
Success is greater in younger children and children with lower BMIs.
Better success if whole family is involved in healthy lifestyle change
Better success with self-monitoring
Less success with severe obesity
Poor prognosis if untreated mental health issues and/or lack of motivation
Barlow SE; for Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(Suppl 4):S164–S192. [View Abstract on OvidInsights]
Daniels SR. Complications of obesity in children and adolescents. Int J Obes (Lond). 2009;33(Suppl 1):S60–S65. [View Abstract on OvidInsights]
Ogden CL, Carroll MD, Fryar CD, et al. Prevalence of obesity among adults and youth: United States, 2011–2014. NCHS Data Brief. 2015;(219):1–8. [View Abstract on OvidInsights]
Spear BA, Barlow SE, Ervin C, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120(Suppl 4):S254–S288. [View Abstract on OvidInsights]
278.00 Obesity, unspecified
783.1 Abnormal weight gain
278.01 Morbid obesity
V85.53 Body Mass Index, pediatric, 85th percentile to less than 95th percentile for age
V85.54 Body Mass Index, pediatric, greater than or equal to 95th percentile for age
E66.9 Obesity, unspecified
R63.5 Abnormal Weight Gain
E66.8 Other obesity
E66.09 Other obesity due to excess calories
Z68.53 Body mass index (BMI) pediatric, 85th percentile to less than 95th percentile for age
Z68.54 Body mass index (BMI) pediatric, greater than or equal to 95th percentile for age
E66.01 Morbid (severe) obesity due to excess calories
414916001 obesity (disorder)
238131007 overweight (finding)
161833006 abnormal weight gain (finding)
450451007 Overweight in childhood (finding)
238136002 Morbid obesity (disorder)
Q: How do I broach such a sensitive topic with families?
A: Review growth charts at every well-child visit and discuss any concerning increase in BMI. Describe in terms of healthy weight and the need to avoid comorbidities which become more likely with increasing BMI.
Q: How do I counsel a family not interested in making lifestyle changes?
A: Discuss the risk that an unhealthy BMI poses for the child. Describe small simple changes the family can make to alleviate this risk. Avoid assigning blame. Abnormal lab values may motivate a family to make changes.