Adolescent Obesity and Its Risks: How to Screen and When to Refer

While BMI screening is valuable, as noted above it is important to appreciate that insulin resistance (and other obesity-related comorbidities) can develop even when BMI is below the 95th percentile. Detailed history and physical examination can help identify these comorbidities of excess adiposity and guide diagnostic evaluation. Independent risk factors for insulin resistance and the development of type 2 diabetes include family history of diabetes, minority race/ethnicity, elevated waist circumference, and poor fitness level [18–20].

Further History

The patient reports skipping breakfast on most days, eats lunch at school, and snacks on chips and soda after school. Dinner is variable but usually contains carbohydrates and a protein and rarely includes vegetables. Family eats “take-out” about 3 times per week. Patient reports spending 3 hours a day watching television and playing on computer. He had gym last semester but currently reports very limited to no physical activity on most days.

• What are effective ways to raise the issue of obesity during an office visit?

Despite the strong connection of obesity with adverse health outcomes, discussion of obesity in routine office settings can be difficult and is often limited by many factors such as time, training, availability of support services, perceived lack of patient motivation, and low outcome expectations [21,22]. Perhaps most challenging is tactfully handling the stigma associated with obesity, which can make discussion awkward and difficult for patients, parents, and providers. To do this, efforts to choose words that convey a nonjudgmental message while maintaining focus on obesity as a health concern are helpful. For example, terms such as “fat” and “obese” are often perceived as stigmatizing and blaming while using the term “unhealthy weight” is less pejorative and can be motivating [23]. It can also be important to acknowledge and emphasize that some individuals are more susceptible to weight gain and its consequences than others and as a result can tolerate fewer calories without unwanted weight gain and health problems. These approaches shift the focus of the discussion toward the goal of restoring and preserving health rather than changing physical appearance without placing blame on the individual and/or family. Motivational interviewing techniques which can be performed effectively even in short office visits can help to actively engage families, reveal familial perception of obesity and assess readiness to change [2]. Their use may also improve the efficacy of other interventions [24].

Case Continued

The patient and his mother were asked if they had any concerns today, including concerns about future health. Mother expressed worry about the potential for diabetes given their family history. The clinician used this as an opportunity to discuss pertinent factors associated with insulin resistance and type 2 diabetes, including modifiable factors such as diet, fitness level, and weight.

• Should this non-obese adolescent be assessed for obesity comorbidities?

Yes. While there are multiple guidelines available for pediatric screening, all highlight the importance of obtaining individualized risk assessment to guide the extent of diagnostic workup. An Expert Committee comprised of representatives from 15 professional organizations appointed 3 writing groups to review the literature and recommend approaches to prevention, assessment, and treatment. Because effective strategies remain poorly defined, the writing groups used both available evidence and expert opinion to develop the recommendations [2]. In addition to routine blood pressure monitoring and universal lipid screening, the Expert Committee recommends obtaining additional laboratory assessment for obese children (BMI ≥ 95th percentile) including a fasting glucose and ALT/AST levels every 2 years starting at age 10 years. For overweight children (BMI > 85th percentile), the Expert Committee recommends obtaining these studies if additional risk factors are present [2]. The American Diabetes Association (ADA) recommends obtaining diabetes screening in all children classified as overweight (defined as either a BMI > 85th percentile for age and sex, weight for height > 85th percentile, or weight > 120% of ideal for height) once every 3 years beginning at age 10 or at pubertal onset (whichever is earliest) when 2 additional risk factors for diabetes are also present, including: (1) history of type 2 diabetes in a first- or second-degree relative, (2) race/ethnicity with increased risk for diabetes development (eg, Native American, African American, Latino, Asian American), (3) signs of insulin resistance or conditions associated with insulin resistance (eg, small for gestational age, polycystic ovary syndrome, hypertension) and (4) maternal history of gestational diabetes during pregnancy [25]. The ADA recommendations for diabetes screening test include either fasting plasma glucose, HgA1C, or oral glucose tolerance test [25].