Adolescent Obesity and Its Risks: How to Screen and When to Refer
Journal of Clinical Outcomes Management. 2014 February;21(2)
References
Childhood obesity is associated with both short- and long-term morbidities including insulin resistance and type 2 diabetes, hypertension, dyslipidemia, asthma, obstructive sleep apnea, psychosocial problems, and decreased quality of life [7,8]. Obese children, particularly older children and adolescents, are more likely become obese adults [2,7]. Obesity in adulthood is associated with both significant morbidity and premature death [9]. Individual characteristics such as lifestyle habits, fitness level, and genetic predisposition influence the likelihood of development of both obesity and associated comorbidities [10].
The burden of obesity and its associated comorbidities are not equally distributed among racial/ethnic and socioeconomic groups. Hispanic and non-Hispanic black children are much more likely to be obese and overweight than non-Hispanic white children [6]. Low socioeconomic status is associated with increased rates of obesity in certain subgroups, including adolescents [2]. In addition, certain ethnic/racial minorities are more likely to develop obesity-associated comorbidities, such as insulin resistance, type 2 diabetes, and non-alcoholic fatty liver disease (NAFLD). With regard to insulin resistance and development of type 2 diabetes, the risk is greatest in Native Americans, but there is also increased risk in Hispanic/Latinos, non-Hispanic blacks, and Asian Americans as compared with non-Hispanic whites [11–13]. Collectively, these findings highlight the need for individualized assessment and the importance of obesity prevention and early intervention to improve long-term health outcomes. Primary care providers play a pivotal role in this process of preventing, identifying and treating childhood obesity and associated comorbidities [14]. In the case history, the child’s ethnicity, family history, and borderline overweight BMI indicate a high risk for future obesity-related morbidity and a critical opportunity for prevention intervention.
• What are the initial steps a practitioner can take to address overweight and obesity?
To encourage the development of healthy lifestyles and prevention of obesity, dietary and exercise counseling should be routinely provided as part of anticipatory guidance to all children and families regardless of weight status. It is critical to recognize individuals at high risk for becoming obese starting early in life. Risk factors for obesity in healthy weight children include rapid crossing of BMI percentiles, obese parent(s), maternal history of gestational diabetes during pregnancy, ethnicity, sedentary lifestyle, and excessive caloric intake [2]. Identification of these high-risk individuals can prompt more intensive counseling and early intervention with the goal of preventing the development of obesity and its complications. The use of automated BMI calculation and electronic medical records can facilitate identification of overweight and obesity status when already present and improve counseling rates [15].
When obesity is present, a careful history, review of the growth curves, and physical examination can differentiate nutritional obesity from less common organic etiologies ( Table 1 ). History should include assessment of sleep, mood, headaches, energy, respiratory issues, polyuria and polydipsia, joint pain, review of dietary habits, activity level, screen time and, in girls, menstrual irregularity and hirsutism. Because adolescents with extreme obesity have similar rates of risk taking behaviors and in some instances exhibit higher risk behaviors than their peers [16], obtaining a psychosocial assessment remains important. Utilizing a screening tool such as the HEEADSSS (Home, Education, Eating, Activities, Drugs/alcohol, Sexuality, Suicide/depression and Safety from injury and violence (www2.aap.org/pubserv/PSVpreview/pages/Files/HEADSS.pdf) can be helpful to obtain this history effectively and efficiently [17] while simultaneously highlighting dietary and activity habits. This tool may also help identify potential obstacles to lifestyle intervention such as an unsafe environment or limited access to healthy food options. Finally, a family history focused on obesity and obesity-related comorbidities, including insulin resistance and diabetes, hypertension, hyperlipidemia, cardiovascular disease, and stroke, should also be obtained.
Obesity due to excess nutrition is typically associated with linear growth acceleration that occurs subsequent to and to a lesser degree than the percentile shift in weight gain. A declining height velocity associated with obesity, therefore, is concerning and should prompt investigation for endocrine disease such as hypothyroidism, glucocorticoid excess, and growth hormone deficiency. Additional factors that warrant further investigation and/or referral include growth trajectory significantly below genetic potential, developmental delay, and dysmorphic features. A complete physical examination should be performed to evaluate for signs consistent with these conditions (eg, violaceous striae in glucocorticoid excess, microcephaly, and small hands/feet in Prader-Willi syndrome), and signs of obesity-associated comorbidities (eg, acanthosis nigricans). Accurate height, weight, BMI calculation, and blood pressure assessment using an appropriately sized cuff are essential.
