Obesity

Pediatric obesity is increasing at epidemic proportions. The Centers for Disease Control define “at risk of overweight” as a body mass index (BMI, kg/m²) of ≥85%ile and <95%ile for age and sex, and “overweight” as ≥95%ile for age and sex. Data from the third National Health and Nutrition Examination Survey (NHANES III) indicates that the prevalence of overweight children (6–11 years) increased from 4% in 1965 to 13% in 1999, and that of overweight adolescents (12–19 years) increased from 5% in 1970 to 14% in 1999.

Differential Diagnosis

• Exogenous obesity (most common)
  –No demonstrable disease as the cause
  –Excessive weight gain from imbalance between caloric intake and energy expenditure
  –Linear growth is robust and frequently accelerated

• Hormonal causes
  –Associated with poor linear growth
  –Hypercortisolism: Cushing syndrome is any type of glucocorticoid excess (endogenous or exogenous); Cushing disease describes pituitary ACTH overproduction
  –Hypothyroidism
  –Growth hormone deficiency

• Insulinoma
• Hypothalamic obesity
  –Tumors (e.g., craniopharyngiomas)
  –Following neurosurgery or irradiation
  –Head trauma
  –Infiltrative/inflammatory
• Genetic syndromes
  –Prader-Willi syndrome
  –Laurence-Moon-Bardet-Biedl syndrome
  –Alström syndrome
  –Cohen syndrome
  –Down syndrome
  –Carpenter syndrome
  –Grebe syndrome
  –Beckwith-Wiedemann syndrome
• Defects in metabolic/eating regulatory pathways is an area of intense investigation; multiple mutations are theoretically possible, but only a few have actually been discovered in humans
  –Congenital leptin deficiency (extremely rare)
  –Leptin resistance (more common than deficiency)
• Drugs
  –Chronic glucocorticoids
  –Neuropsychotropic medications
• Adiposogenital dystrophy syndrome

Workup and Diagnosis

• History: Age and course of onset; linear growth progression; birth and neonatal history (tone, failure to thrive); polydipsia, polyuria, polyphagia; dietary intake, physical activity; cold intolerance, constipation, dry skin, headaches; abdominal pain, onset of puberty if pubertal; developmental delay (genetic syndromes); family history of obesity and genetic disorders
• Physical exam: Vital signs (blood pressure); growth parameters (height, weight, BMI); distribution of fat, moon or coarse facies, pallor, buffalo hump, striae (Cushingoid appearance); acanthosis nigricans (dark velvety areas in skin folds; cutaneous marker of insulin resistance); abdominal masses, micropenis, hypogonadism; depressed deep tendon reflexes; in infants skin “puddling,” midline defects
• Diagnostic workup
  –24-hour urine free cortisol/creatinine ratio (best screen for Cushing syndrome)
  –MRI (hypothalamic/pituitary mass)
  –Adrenal ultrasound (if suspect adrenal mass)
  –Thyroid function tests (T4, TSH)
  –IGF-I and IGFBP-3; possibly provocative growth hormone testing (if suspect GH deficiency)
  –Genetic (FISH) testing for genetic syndromes
  –Serum leptin
• Labs: Urinalysis for glucose, serum glucose, fasting serum insulin, hemoglobin A1c
  –Fasting lipid profile, urine microalbumin

Treatment

• If syndrome or no known disease as etiology
  –Nutritional education and diet manipulation
  –Exercise regimen (energy expenditure must exceed intake)
  –Behavior modification involving family
• Hormonal etiology
  –Hormone replacement for hypothyroidism or growth hormone deficiency
  –Surgical intervention if hypercortisolism caused by tumor
  –Decrease exogeneous glucorticoids if not medically contraindicated
• Leptin treatment in leptin deficiency (therapeutic trials)
• If patient also has type II diabetes mellitus, insulin or oral medications may be required in addition to improved diet and exercise

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Obesity

Read excerpts from these other book chapters related to Obesity:

Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Obesity

• Back to symptom: Obesity: Introduction (review 254 causes)
• Next Book Extract About Obesity: OBESITY (Differential Diagnosis in Primary Care)
• All Book Extracts: All Online Book Extracts for Obesity

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: OBESITY (Differential Diagnosis in Primary Care)

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