determining reduction in fat weight after treatment (Appendix A2.1.3).
DIRECT MEASUREMENTS OF BODY COMPOSITION
Direct measurements of body fat content can be found using such tools as hydrodensitometry,
bioimpedance, or dual-energy x-ray absorptiometry [35]. In Chapter 4 of this text, Gordon discusses
the advantages and disadvantages of these various methods, and detailed protocols may be found
in Appendix A2.3.
LABORATORY TESTING — BASIC PANELS
Secondary assessments may include lipid profiles, total cholesterol, insulin, glucose tolerance,
glucose, glycohemoglobin, thyroid function, cortisol, and liver enzymes [47].
If the child is diagnosed with a BMI greater than 95th percentile, additional testing may be
warranted. Because pediatric overweight (BMI > 95th percentile for age and sex) is associated with
many other disease risk factors, practitioners can further define risk by checking a fasting lipid
profile (Appendix A2.2) [41]. Other potentially useful biochemical markers of comorbidities include
liver profile, and fasting glucose and insulin. It should be recognized that there are not standardized
guidelines for biochemical evaluation, especially because identification of biochemical abnormalities
will often not change therapeutic interventions.
MEASUREMENTS OF ENERGY EXPENDITURE
In some cases, measurement of resting energy expenditure may be useful to help caloric intake
goals. Resting energy expenditure can be measured through indirect calorimetry. However, it is
difficult to obtain an accurate measure because it is affected by diet, exercise, body temperature,
growth, and development [55]. In an outpatient setting, it is difficult to optimally control these
factors, and thus measurements can at best be viewed as approximations. Therefore, routine
assessment of resting energy expenditure is of limited value.
Overweight children with more severe medical problems such as obstructive sleep apnea, obesity
hypoventilation syndrome, and orthopedic problems may benefit from more aggressive dietary
strategies. If a referral is made to an overweight treatment center, it is important to identify a
program that is staffed by medical professionals experienced in the management of these serious
comorbidities. Massively overweight children without severe comorbidities, but with a history of
weight loss failures, may also benefit from consultation with a pediatric obesity center. Ariza and
colleagues [41] provide a detailed assessment and action plan for overweight children in the primary
care setting (Figure 7.3).
GENETICS
Genetic syndromes associated with pediatric obesity include Prader–Willi, Turner syndrome, or
Laurence–Moon–Bardet–Biedle [41]. Findings such as developmental delay, short stature/delayed
growth, dysmorphic features, abnormal or absent genitalia, and digital anomalies should raise
suspicion of an underlying genetic etiology and consideration of definitive testing. If any of these
conditions is suspected, referral to a geneticist or other relevant subspecialist is recommended [41].
ENDOCRINOLOGY
There are several endocrine disorders related to pediatric obesity, including primarily hypothyroidism,
type 2 diabetes mellitus, and polycystic ovary disease. Although less common, findings
indicative of Cushing syndrome, including moon facies, short stature, central obesity, and apparent
reduced lean body mass should prompt referral to an endocrinologist. If this is the case, then a
24-hour urine cortisol should be ordered [41].
Thyroid
Symptoms of hypothyroidism include constipation, cold intolerance, fatigue, and lethargy; signs
may include poor linear growth, hypotension, bradycardia, anemia, and loss of deep tendon reflexes.
If symptoms or signs of hypothyroidism are present, TSH and T4 levels should be checked, and if
these levels are diagnostic of hypothyroidism, the child should be referred to a pediatric endocrinologist
[41].
Pancreas
Insulin resistance is common with excess central (or visceral) adiposity. Insulin resistance is
associated with hyperinsulinemia, fatty liver, hypertension, and exercise intolerance. Hyperinsulinemia
in children can be associated with normal fasting glucose for some time, but with persistence,
there is progression to impaired glucose tolerance, and eventually to β-cell failure and elevated
fasting glucose and type 2 diabetes. If insulin resistance or type 2 diabetes mellitus is suspected,
fasting insulin and blood glucose levels may be obtained. Hyperglycemia is relatively insensitive
until there is frank diabetes, but if fasting glucose levels are 126 mg/dL or more, the child should
be referred to a pediatric endocrinologist for further examination [41]. The utility of fasting insulin
levels is debated, but documentation of elevation is a finding that motivates some families to make
changes, especially if there is a strong family history of type 2 diabetes [41]. An elevated fasting
insulin is also part of the constellation of findings referred to as metabolic syndrome [56].
CARDIOLOGY
During the medical examination, if the child’s blood pressure is in the 95th (or higher) percentile for
height and gender on three separate occasions, then referral to a cardiologist is suggested [41]. Chest
pain is another symptom that may require referral. Treatment of hyperlipidemia (LDL ≥ 110 mg/dl)
or dyslipidemia (e.g., metabolic syndrome), including initial diet therapy, may also be available
through preventive cardiology services, or through nutrition or endocrine subspecialists [41].
PULMONARY
Pulmonary disorders associated with significant obesity that may require rapid weight loss are
obstructive sleep apnea and obesity hypoventilation syndrome [57]. Symptoms indicative of sleep
disturbances include snoring, restless sleep, inability to sleep supine, and daytime somnolence.
Assessment ideally includes an electrocardiogram to rule out cardiomegaly, sinus dysrhythmias,
and right-side heart failure, as well as a sleep study with polysomnography to monitor for hypoxia
and cardiac function. Treatment may include supplemental oxygen or positive airway pressure, but
at least modest weight loss will also be advantageous. Clinicians should seek guidance from
pediatric pulmonologists and obesity treatment specialists [29].
One of the most common pulmonary disorders associated with pediatric obesity is asthma [58].
Asthma is a major cause of chronic pediatric illness and school absenteeism. Moreover, urban
minority children with asthma are significantly more overweight than those without asthma [59].
Results of most studies in children do not support a direct causal link between asthma and
overweight conditions during childhood [60]. Furthermore, there is insufficient evidence to indicate
that asthma precedes overweight conditions in children. Because excess weight exacerbates asthma
symptoms, especially during exercise, overweight children with asthma should be monitored closely
by a pulmonary specialist.
ORTHOPEDICS AND PHYSICAL THERAPY
There are several serious orthopedic complications that result from significant obesity during
childhood. These include slipped capital femoral epiphysis (manifested as hip or knee pain and
limited hip range of motion) and Blount’s disease (tibia vara) [29]. Referral should be made to an
orthopedic surgeon if radiography confirms either of these conditions [29]. Other related comorbidities
include spinal asymmetry, flat feet, genu varus/valgus, Legg–Calve–Perthe disease, and
degenerative arthritis. Referral may be made to a physical therapist for an initial evaluation and,
in many cases, for therapeutic strategies.
PSYCHOLOGY
Several psychological disorders are associated with pediatric obesity. Binge-eating disorder should
be suspected if the patient reports feeling unable to control food consumption. Depression is
commonly found in overweight children, especially in older youth with severe overweight conditions.
Jonides and colleagues [61] suggest that the emotional stability of the child and the family
will likely determine successful treatment outcomes. If the child displays sadness or reports
insomnia, restlessness, or hopelessness, then referral to a psychologist is essential to confirm the
diagnosis [29]. In Chapter 9 of this volume, Johnson and von Almen detail appropriate psychological
assessment for overweight children.
SOCIAL SERVICES
The negative effects of food restriction or verbal prompting to consume served food were recently
highlighted by the American Academy of Pediatrics [2]. In extreme cases, in which parental behavior
results in either food restriction and eating disorders or continued overconsumption and morbid,
life-threatening obesity, it may be necessary to refer the patient’s family to social services. Likewise,
if there is evidence of physical or sexual abuse related to the child’s overweight condition, social
services should be consulted.
NUTRITION
Adequate nutrition is vital to growth and development, and both insufficient and imbalanced food
consumption can cause nutrient deficiencies, impaired cognitive development, and growth velocity
delays [62]. Therefore, if the child’s weight condition warrants dietary intervention, referral should
be made to a registered dietician. He or she will apply U.S. Department of Agriculture caloric and
nutrient guidelines based on the child’s age, gender, and medical condition when prescribing a
weight-loss plan. A priority for dietary counseling is parent nutrition education so that family-wide
changes in food selection and preparation are encouraged [41] (Appendix A3).
EXERCISE
Pediatric health care professionals should encourage families to engage in regular physical activity
to help children achieve and maintain a healthy weight [64]. Local information concerning activity
centers, YMCAs, Boys and Girls Clubs, parks, and other recreational areas should be provided to
parents [41]. In older children with significant obesity, structured exercise guidelines are useful
[64]. Referral to a trained and certified pediatric exercise physiologist will ensure age-appropriate
physical activities for the patient.
EDUCATION
It is now widely accepted that anticipatory guidance on healthy eating habits and physical activity
should begin early and for all children (Table 7.2). Readiness for change is essential, and families
resistant to lifestyle modification should be referred to a family therapist [34]. Family histories of
obesity and related disorders increase the child’s risk of developing comorbid diseases, and the
medical consequences of such diseases should be addressed with the family [29]. Treatment success
rates improve with participation by family members and care givers. Gradual, permanent changes
to the diet and physical activity patterns of the child are more successful than transient, short-term
changes (Table 7.2) [29,34].
The BMI measurements of patients should be evaluated each year, with increased attention
paid by the physician to patterns of excessive weight gain relative to linear growth as well as to
children identified as at greater risk for overweight and obesity (Table 7.3) [2]. Patients at risk of
developing obesity-related comorbidities should be monitored closely for signs of these diseases.
Pediatricians and health care providers should routinely encourage parents in the healthy dietary
practices of breastfeeding, moderation, and appropriate portion sizes, regular fruit and vegetable
consumption, limits on sweetened beverages, and other nutritious food choices (Table 7.4) [2].
Pediatricians should also educate parents and caregivers on their roles in establishing physical
activity patterns [2]. Increased physical activity and setting limits on sedentary behaviors should
also be promoted. The success of prevention efforts will be more favorable if both dietary and
physical activity interventions are emphasized (Table 7.4).
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