FAT AND SICK KIDS
From the American Academy of Family Physicians’ 2005 Scientific Assembly, San Francisco, CA
| OBESITY IN CHILDREN AND ADOLESCENTS —Leslie F. Carroll, MD, Chair, Department of Pediatrics, Sacred Heart
Hospital, and Faculty Member, Temple University School of Medicine’s Family Practice Residency Program at Sacred
Heart Hospital, Allentown, PA
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| Opening remarks: body mass index (BMI) best means for diagnosing obese children (far better than “eyeball” technique);
BMI calculated as weight (kg)/[height (m)]2
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| Definitions: overweight—BMI ≥95th percentile for age and sex; at risk for overweight—BMI between 85th and 94th
percentile; comments—BMI increases rapidly during first year of life, reaches nadir around 4 to 6 yr of age, then slowly
climbs; younger and heavier child is at time of nadir, more likely he or she will be overweight child
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| Families at risk for childhood obesity: incest and sexual abuse; low self-esteem; eating disorders; familial morbid obesity
(if both parents overweight, child has 75% chance of being overweight; if 1 parent overweight, child has 25% to 50%
chance of being overweight)
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| Evidence-based points: 1) any workable weight reduction program must include nutrition (reduce caloric intake), physical
exercise, and dealing with mental health issues; 2) type 2 diabetes now seen in young people; 3) screen overweight child
≥10 yr of age for type 2 diabetes if entering puberty and ≥2 of following present (family history of type 2 diabetes; high-
risk ethnicity, eg, American Indian, Alaskan native, black, Hispanic, Asian; presence of condition associated with insulin
resistance)
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| Prevalence: highest obesity rates among adolescents seen in Mexican-American boys and black girls; overall, 65% of
Americans overweight; 20% of overweight children diagnosed at 4 yr of age and 80% of overweight adolescents will become
obese adults
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| Risk factors: genetics—obesity polygenic disorder (>250 genes identified as involved in obesity); development of “efficient
metabolism”; prenatal factors (infants of diabetic mothers at risk for obesity); maternal nutrition and lifestyle;
failure to breast-feed (breast-feeding thwarts development of obesity); environment—eg, television watching, fast
foods, sedentary lifestyle; culture of poverty (leads to unhealthy dietary habits); family perception and modeling—
some families simply do not want to accept that child overweight or parents too restrictive; television watching—
several studies conclude excessive television watching independent risk factor for obesity
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| Consequences of childhood obesity: heart disease; hypertension; hyperlipidemia; gallbladder disease; asthma; orthopedic
problems; psychosocial issues
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| Clinical disorders associated with obesity: Prader-Willi syndrome; Laurence-Moon/Bardet-Biedl syndrome; pseudohypoparathyroidism;
Cushing’s syndrome; hypothalamic surgery or tumors; polycystic ovarian syndrome (PCOS)
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| Other obesity-related health conditions: urinary incontinence; renal disorders; strokes; increased prevalence of certain
cancers; hypertension; insulin resistance; type 2 diabetes
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| Screening children and adolescents for type 2 diabetes: BMI >85th percentile, starting at 10 yr of age or onset of puberty
plus ≥2 of following (family history of type 2 diabetes; high-risk ethnicity; signs of insulin resistance)
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| Complications of obesity: cholelithiasis; hepatic steatosis; pulmonary problems (eg, asthma, obstructive sleep apnea, pulmonary
hypertension, pickwickian syndrome); attention-deficit/hyperactivity disorder (ADHD) and enuresis; daytime somnolence;
learning disabilities; mouth breathing and snoring; pseudotumor cerebri (associated with headaches, dizziness,
double vision); orthopedic problems (eg, bowing of legs [ie, Blount disease], slipped capital femoral epiphysis)
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| Medical history: prenatal and neonatal histories; inquire if child small or large for gestational age and about mother’s nutritional
status and weight at time of delivery; ask about comorbidities and use of drugs that promote obesity (eg, corticosteroids,
antidepressants, antipsychotics, anticonvulsants); obtain family history
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| Physical examination: assess systems (check for snoring, wheezing, sleep interruptions, limp, amenorrhea, dysmorphic
features, and skin problems); probe for findings associated with rarer causes of obesity (eg, acanthosis nigricans)
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| Laboratory work-up: complete lipid profile; fasting blood glucose (BG); thyroid function test (check for hypothyroidism);
metabolic panel; second-line tests—insulin levels; liver function tests; hemoglobin (Hb)A1c ; insulin antibodies
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| Treatment goals: focus on healthy lifestyle changes (be nonjudgmental in dealing with patient); get patient involved in
weight-reduction program; comments—results best if program starts at <7 yr of age; initial goal to stop escalation of
weight gain; successful weight loss defined as ≥5% loss of initial body weight maintained for 1 yr; prevention of weight
gain involves anticipatory guidance, identification of family risk factors, identification and treatment of overweight child
and associated risk factors, and advocacy
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| Management: diet—avoid fad diets; promote lifelong diet high in fruits, vegetables, and grains and low in fat and milk
products (reduce milk consumption to <24 oz/day); no eating in front of television; plan snacks and meals; tell patient
to stop eating when hunger goes away; what to tell parents—avoid using food as reward; establish daily family
meals; offer variety of healthy foods
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 | Physical activity: limit television and computer time to <2 hr daily (no television for children <2 yr of age); encourage
fun physical activity
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| Speaker’s “Kid Shape” program: team approach; involves dietitian, social worker, and exercise physiologist; 9-wk program
involving 13 to 20 children with parents; parents taught how to prepare healthy snacks, to make exercise fun, and to deal
with social situations and ostracism at school
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| Pharmacologic therapy: available when more conservative modalities fail; most available drugs not approved for younger
children and associated with side effects
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| Bariatric surgery: last-resort therapy; try to avoid in teens; requires multidisciplinary team; key benefit permanent weight
loss; associated problems include folate and vitamin D deficiencies, iron-deficiency anemia, peritonitis, and risk for
gastric rupture and death
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| Speaker’s advice: intervene at different sites to prevent and treat obesity; work with school to improve lunch programs, to
encourage regular physical education programs, and to remove sodas and fast foods from vending machines
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| METABOLIC SYNDROME —Mary Elizabeth Roth, MD, Vice President in charge of Medical Affairs, Sacred Heart Hospital,
and Faculty Member, Temple University School of Medicine’s Family Practice Residency Program at Sacred Heart Hospital,
Allentown, PA
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| Boston study >30 yr ago: incidence of obesity in schoolchildren reduced by adding 30 min of daily exercise to curriculum
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| Crisis concern: obesity and diabetes reached epidemic proportions in American schoolchildren; metabolic syndrome of even
more concern; comment—metabolic syndrome synthesis of multiple risk factors for premature cardiovascular disease; in
2003, ≈1 in 8 schoolchildren had ≥3 risk factors for metabolic syndrome
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| Points about metabolic syndrome (syndrome X): characterized by insulin resistance; can result in mortality (mortality rate
twice that of coronary artery disease [CAD]); leads to macrovascular and microvascular problems; associated with premature
disease of vascular system, systemic inflammation, and endothelial dysfunction (pathway to CAD); remarks—normal endothelium
produces nitrous oxide and prostacyclin that help protect against platelet aggregation and thick large plaques with low-
density lipoprotein (LDL); nitrous oxide metabolism altered at cellular level in patients with insulin resistance; children <16 yr
of age with metabolic syndrome have decreased vascular flexibility; hypertension end point of metabolic syndrome, not precursor
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| Early risk factors for syndrome: normal-term child small for gestational age tends to develop insulin resistance in childhood
(common in smoking mothers); premature infants, regardless of weight; thinness during infancy, with crossover to
higher BMI around 2 yr of age; follow for development of metabolic syndrome and type 2 diabetes; regularly assess
child’s height, weight, and waist circumference
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| Diagnostic criteria in nondiabetics (3 of following): blood pressure (BP) >130/85 mm Hg; high-density lipoprotein (HDL)
<50 mg/dL in girls and <40 mg/dL in boys; triglycerides >150 mg/dL; microalbuminuria >20 mg/min; obesity (BMI
≥85th percentile in children, >30 in adults); waist circumference >40 in in boys and >35 in in girls; waist-hip ratio
>0.85; fasting BG >110 mg/dL; points—examine body with clothes off; remove heavy footwear before measuring
weight
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| Relative-risk ratio: each 0.5-unit increase in BMI increases risk for metabolic syndrome by 1.55; therefore, 38.7% of
moderately obese nondiabetic children and 49.7% of severely obese nondiabetic children have metabolic syndrome;
HDL decreases with childhood obesity; increases in insulin, triglycerides, C-reactive protein (CRP), interleukin-6, and
insulin resistance directly related to increases in BMI
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| Obesity plus acanthosis nigricans: precursor to metabolic syndrome in young boys; autosomal-dominant defect characterized
by low HDL, truncal obesity, and development of hypertension, ischemic heart disease, and usually type 2 diabetes during
young adulthood; at least 1 parent has hypertension and ischemic heart disease; characterized by early development of
dark patches
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| Diagnostic criteria in diabetics (2 of following): hypertension; dyslipidemia; obesity; elevated fasting BG >110 mg/dL;
microalbuminuria
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| Steatohepatitis: nonalcoholic fatty liver; can be due to metabolic syndrome; seen in metabolic syndrome at all ages; γ-
glutamyl transpeptidase (GGTP) most reliable diagnostic marker
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| C-reactive protein: highly predictive of cardiovascular disease in women; data limited in children
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| Examples of children at risk: teenage girl with 36-in waist, hypertension, and albuminuria (deadly combination; check for
other metabolic syndrome factors); 16-yr–old football player, weighs 240 lb, BMI of 32 , HDL <35 mg/dL, waist 42 in,
and has hypertension and albuminuria (overwhelming cardiovascular risk); 17-yr-old wrestler, 5 ft 6 in, 200 lb; 15-yr-old
pregnant patient with gestational diabetes, albuminuria, and preeclampsia (requires family intervention); young boxer
with screening BP 145/90 mm Hg, proteinuria, and fasting BG 120 mg/dL (early candidate for dialysis); 10-yr-old boy
with BMI of 31 and acanthosis nigricans (look for genetic disease)
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| Laboratory studies for metabolic syndrome: fasting BG; glucose tolerance test (GTT); postprandial glucose; CRP; alanine
aminotransferase (ALT) for steatohepatitis; urine screen for albuminuria and uric acid; fasting lipid profile; serum electrolytes;
total sialic acid; fibrinogen and plasminogen activator inhibitor (PAI)-1 (if budget unlimited); comments—uric acid elevated
in pregnancies and children at risk; elevated uric acid level in child has direct correlation with development of primary
hypertension and metabolic syndrome as measure of oxidative processes; uric acid >4 mg/dL red flag for initiating risk-reduction
program; uric acid >5 mg/dL in adolescent suggests primary hypertension
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| Polycystic ovary syndrome (PCOS): affects 6% to 10% of American women; presentation typically starts at onset of menarche;
manifestations include hirsutism, infertility, truncal obesity, and insulin resistance; polygenic disorder clustering
in certain families; affected girls typically go through puberty early; early visceral obesity, hirsutism, and
hyperinsulinism hallmarks; those affected at increased risk for cardiovascular disease; associated with aromatization
defect in cytochrome P450 aromatase gene mutation
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| Evidenced-based point: screen all girls with PCOS for glucose intolerance with 2-hr GTT and for lipid disorders with
fasting total lipid panel; use of metformin improves insulin sensitivity and weight loss
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| Comments: infertility major concern; strive to get waist <35 in (use 60-in tape measure); hyperinsulinemic state increases
appetite and truncal obesity early; metabolic syndrome evolves with lipid disorder of high very low-density lipoproteins
(VLDL), triglycerides, hypertension, and endothelial dysfunction; significant lifetime increase in type 2 diabetes;
mothers of PCOS patients have higher incidence of metabolic syndrome and type 2 diabetes; teens with PCOS should
be screened for lipids and undergo liver function tests (LFTs) before selecting method of birth control
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| Management: requires multidisciplinary approach, emphasizing glycemic and BP control, weight management, exercise
program, controlling lipids, evaluating kidneys, and pharmacologic therapy to alter microvascular damage and possibly
to prevent hypercoagulable state
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| Specific components: involve nutritionist to lower intake of fats, particularly saturated fats; promote exercise involving at least
30 min of at least moderate aerobic activity 5 days/wk; promote smoking prevention and smoking cessation; angiotensin-
converting enzyme (ACE) inhibitors for all who tolerate them and have hypertension; prescribe aspirin 81 mg daily, unless
patient allergic to aspirin; recommend use of multivitamins, especially folic acid and vitamins C and E; prescribe oral hypoglycemics
for type 2 diabetics if HbA1c >6.5%
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| Lipid control: difficult in children; LDL >88 mg/dL associated with risk; elevated triglycerides more predictive of CAD
in women than men; in healthy child, strive for total cholesterol <170 mg/dL and LDL <100 mg/dL; in children with
diabetes, aim for LDL <100 mg/dL (strive for <70 mg/dL in postpubertal children with metabolic syndrome)
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| Hypertension: in children or adolescents, start with ACE inhibitors (no long-term studies; delay or prevent progression of hypertensive
or microvascular changes in kidneys and may delay need for dialysis); thiazide diuretics second-line agents, but
watch for development of osteoporosis; β-blockers not easy option for adolescents; calcium channel blockers may help
control BP, but do nothing to reduce microalbuminuria; points—utilize adequate BP cuff in evaluating patient; reduce BP
to <120/80 mm Hg, regardless of weight and body size
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| Other points: check for albuminuria and uric acid; combination of ACE inhibitors and angiotensin receptor blockers
(ARBs) help protect kidneys, but expensive and associated with many side effects
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Educational Objectives
| The goal of this program is to educate the listener about obesity and the metabolic syndrome in children and adolescents.
After hearing and assimilating this program, the clinician will be better able to:
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| 1. Diagnose overweight and obese children and adolescents.
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| 2. Recognize the complications of childhood obesity.
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| 3. Manage children who are overweight and/or obese.
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| 4. Diagnose and treat the metabolic syndrome and its complications in young people.
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| 5. Provide care for adolescents with polycystic ovary syndrome.
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Discussed on This Program
Aspirin (many trade names)
Metformin HCl [Fortamet, Glucophage, Glucophage XR, Riomet]
Suggested Reading
Anderson PM, Butcher KE: Childhood obesity: trends and potential causes. Future Child 16:19, 2006; Burdette HL et
al: Breastfeeding, introduction of complementary foods, and adiposity at 5 yr of age. Am J Clin Nutr 83:550, 2006;
Daniels SR: The consequences of childhood overweight and obesity. Future Child 16:47, 2006; Denn D: Metabolic syndrome:
time for action. Am Fam Physician 69:2875, 2004; Dickerson LM, Carek P: Drug therapy for obesity. Am Fam
Physician 61:2131, 2000; Eliadis EE: The role of social work in the childhood obesity epidemic Soc Work 51:86, 2006;
Evans WD et al: Changing perceptions of the childhood obesity epidemic. Am J Health Behav 30:167, 2006; Faith MS et
al: Eating in absence of hunger: a genetic marker for childhood obesity in prepubertal boys? Obes Res 14:131, 2006;
Fowler-Brown A, Kahwati LC: Prevention and treatment of overweight in children and adolescents. Am Fam Physician
69:2591, 2004; Freedman DS et al: Racial and ethic differences in secular trends for childhood BMI, weight, and height.
Obes Res 14:301, 2006; Gill TP et al: The weight of evidence suggests that soft drinks are a major issue in childhood and
adolescent obesity. Med J Aust 184:263, 2006; Huerta M et al: Parenteral smoking and education as determinants of overweight
in Israeli children. Prev Chronic Dis 3:A48, 2006; Larsen L et al: Childhood obesity: prevention practices of nurse
practitioners. J Am Acad Nurse Pract 18:709, 2006; Mager DR, Roberts EA: Nonalcoholic fatty liver disease in children.
Clin Liver Dis 10:109, 2006; McCrindle BW: Do as I say, not as I do: The new epidemic of childhood obesity. Can Fam
Physician 52:284, 2006; McDougall CM, Crum JE: Changing prevalences of overweight and obesity in primary school
children—a glimmer of hope? Scott Med J 51:34, 2006; Plourde G: Preventing and managing pediatric obesity: recommendations
for family physicians. Can Fam Physician 52:322, 2006; Rosenberg B et al: Insulin resistance (metabolic)
syndrome in children. Panminerva Med 47:229, 2005; Rubenstein AH: Obesity: a modern epidemic. Trans Am Clin Climatol
Assoc 116:103, 2005; Sarti C, Gallagher J: The metabolic syndrome: prevalence, CHD risk, and treatment. J Diabetes
Complications 20:121, 2006; Schwarzenberg SJ: Obesity in children: epidemic and opportunity. Minn Med 88:62,
2005; Someshwar J et al: The obese adolescent. Pediatr Ann 53:180, 2006; Story M et al: The role of child care settings
in obesity prevention. Future Child 16:143, 2006; Vivian EM: Type 2 diabetes in children and adolescents—the next epidemic?
Curr Med Res Opin 22:297, 2006.
Faculty Disclosure
In adherence with ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Drs. Carroll and Roth were recorded September 30, 2005, at the annual Scientific Assembly of the American Academy
of Family Physicians in San Francisco, CA. The Audio-Digest Foundation thanks the speakers and the Academy for
making this issue possible.
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