Pediatric Obesity: Health Implications

Question 1

Overweight: definition of childhood weight status

Answer 1

• BMI of age and sex between 85th and 94th percentiles
• Only 50% of these children have excess adiposity
• This is the “yellow light” range when you need to watch them

Question 2

“Obese” and “severe obesity” definitions

Answer 2

• Obese: BMI > 95%ile
• Severe/morbid obesity: BMI > 99%ile

Question 3

Use of BMI-for-age charts

Answer 3

• Have to use a chart for children
• “Eyeballing” it is usually wrong

Question 4

Epidemiology of childhood obesity

Answer 4

• 2 –> 19 years old: 18% of children obese
• Rates may be levelling off
• 25-30% of children in overweight + obese range
• Rates differ by ethnicity
  
  • Higher in American Indian, African American, Latino populations
• Income difference accounts for most of this ethnic variation
• Increases with age

Question 5

Comorbidities associated with childhood obesity: pulmonary

Answer 5

• Obstructive sleep apnea (OSA)
  
  • Need to fix hypoxia and monitor ventilation
• Obesity hypoventilation syndrome
• OSA –> hypercapnia + hypoxia –> pulmonary HTN –> right sided heart failure

Question 6

Comorbidities associated with childhood obesity: cardiovascular

Answer 6

• Atherosclerosis shown to begin very early
• Metabolic symptoms
• Dyslipidemia
• Hypertension
• Coagulopathy
• Chronic inflammation
• Endothelial dysfunction

Question 7

Comorbidities associated with childhood obesity: endocrine

Answer 7

• Acanthosis nigricans - sign/result of excess insulin
• Type 2 DM
• Polycystic ovarian syndrome
  
  • Hyperandrogenism + oligomenorrhea +/- polycystic ovaries
  • Cysts may not develop until woman is in 20s or 30s
  • Defined by < 9 periods/year, hyperandrogenism, hirsuitism, acne
• Hypothyroid
  
  • Associated with poor linear growth

Question 8

Comorbidities associated with childhood obesity: gastrointestinal

Answer 8

• Non-alcoholic fatty liver disease
  
  • 10-25% of obese youth affected
  • Elevated ALT
  • Steatosis may –> fibrosis and cirrhosis
  • Characterized by vague, recurrent abdominal pain
• GERD
• Gallstones: relatively uncommon
  
  • Associated with rapid weight loss
• Constipation/encopresis: very common in children with low fiber diet

Question 9

Comorbidities associated with childhood obesity: neurologic/ophthalmologic

Answer 9

• Pseudotumor cerebri:
  
  • Papilledema
  • Peripheral vision loss possible
  • Headache (am > pm, while supine)
  • 1/100,000
  • Refer to neuro

Question 10

Comorbidities associated with childhood obesity: orthopedic

Answer 10

• Slipped capital femoral epiphysis (SCFE)
  
  • Femoral head not in line with hip
  • Crush and strain on femoral head
  • Looks like “ice cream fell off of the cone”
  • Immobilize –> dx with X-ray
  • Weight loss so it doesn’t happen in other hip
  • Presents as hip, groin, or knee pain, limp with leg held in external rotation
• Blounts disease
  
  • Progressive bowing of the hips
  • Crush and strain on medial femoral condylar growth plates
  • Only the lateral growth plate can grow –> progressive bowing

Question 11

Comorbidities associated with childhood obesity: psychiatric

Answer 11

• Depression/anxiety
  
  • May lead to worsening obesity if untreated
  • Full psychosocial review including mood, school performance, peer and family relationships
• Eating disorder
  
  • Routinely assess for binging +/- purging behavior in teenagers
  • Teenagers can have very unrealistic weight loss goals
  • 1 lb per week-month is okay

Question 12

Key components of assessment (5)

Answer 12

1. Plot BMI at least yearly > 2 years of age
2. Assess
   
   • Targeted diet and activity history
   • Family history of CVD risk factors and obesity
3. ROS for comorbidities
4. Physical exam for comorbidities
5. Labs in patients 2-10 years old with + family history or CVD risk factors / patients who are 10+ years old and obese:
   
   • Fasting lipids
   • Glucose
   • ALT
   • HbA1c

Question 13

Family history assessment

Answer 13

• Severe obesity –> single gene disorders
  
  • 10-12 are actually known
  • Rare - most in notably abnormal children
• CVD risk factors
  
  • Early MI
  • T2DM
  • HTN
  • Hyperlipidemia/dyslipidemia

Question 14

Components of motivational interviewing (6)

Answer 14

OARRrRS

1. Open-ended questions
2. Affirmations
3. Reflections –> make them think again
4. Roll with resistance –> resist the urge to tell them what to do
5. Reframing
6. Summaries

Question 15

Treatment principles: diet

Answer 15

• Yes:
  
  • fruits and vegetables
  • low fat dairy
• No:
  
  • sweetened drinks
  • fast food (any eating out)
  • childhood snacks (poorly satiating carbohydrates)
  • large portion sizes
  • eating frequently
• 5-2-1-0 rule
  
  • 5 fruits and veggies
  • < 2 hours screen time
  • > 1 hour activity
  • 0 sugar-sweetened beverages

Question 16

Treatment principles: how to eat

Answer 16

• Schedule meals and snacks
• Meals and snacks regularly (every 3 hours)
• Breakfast every morning
• Don’t stop eating or skip meals

Question 17

Treatment principles: lifestyle

Answer 17

• Moderate physical activity > 60 minutes per day
  
  • Infants: no TV, parents promote movement
  • Preschool: outdoor time and non-TV time
  • School-age: PE and recess, after-school free play
• Sedentary time << 2 hours
  
  • TV, video games, computer, texting
• Neighborhood resources/safety