Case-Based Review

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

Journal of Clinical Outcomes Management. 2014 February;21(2)

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The use of waist circumference in routine clinical settings is complicated and limited by many factors. First, there is no universal method for waist circumference measurement. For example, the WHO recommends measurement at the midpoint between the superior iliac crest and inferior most rib, while the NIH and NHANES recommend measurement immediately above the iliac crest [40]. Since nationally representative data published by Fernandez et al [27] uses the latter method for waist circumference measurement, we recommend this method to allow for comparison of waist circumference percentile with available data for age, sex, and ethnicity. Second, while absolute waist circumference values are used as cut-offs in adulthood, in childhood use of waist circumference percentiles would be more appropriate to account for expected increases during childhood and changes related to pubertal stage. Unfortunately, a lack of standardized waist circumference percentile charts makes meaningful interpretation of waist circumference difficult. Moreover, even if standardized waist circumference percentile charts were developed, there are currently no accepted standards defining an abnormally elevated waist circumference percentile.

Many studies have identified increased metabolic risk factors associated with a waist circumference at or above the 90th percentile for age [41–43]. Based on these studies, the International Diabetes Federation uses waist circumference > 90th percentile as part of the criteria for metabolic syndrome in adolescents. While this ensures a high degree of specificity, use of waist circumference at the 75th percentile would allow for increased sensitivity. For example, Lee et al found that for insulin resistance use of waist circumference at the 75th percentile compared with the 90th percentile increased sensitivity from 61.3% to 86.1% while decreasing specificity from 91.4% to 71.5% [44]. Thus, for individuals at low risk based on history and clinical findings, a waist circumference threshold at the 90th percentile might be reasonable, while for individuals with additional risk factors for insulin resistance use of a lower waist circumference threshold (such as the 75th percentile) may be beneficial. Finally, since risk for insulin resistance and type 2 diabetes varies by race/ethnicity, which may correspond with visceral fat deposition, utilizing various threshold cut-offs based on race/ethnicity has been proposed by some. However, current data do not support this practice [44]. In summary, though there are many challenges to using waist circumference measurements in routine settings, if performed correctly determination of elevated waist circumference measurement can provide some additional information on an individual’s overall risk for complications of obesity.

Acanthosis Nigricans as an Indicator of Insulin Resistance

Insulin resistance, independent of adiposity, is associated with increased risk for type 2 diabetes, cardiovascular disease, ovarian hyperandrogenism, and certain forms of cancer [45]. Identification of insulin resistance in the clinical setting can lead to appropriate intervention (both lifestyle and, when warranted, pharmacologic) to reduce insulin resistance and improve health outcomes. Several risk factors for insulin resistance have been discussed above. Acanthosis nigricans, which is characterized by thick, velvety hyperpigmentation of the skin in intertriginous areas such as the neck and axilla, is an additional finding that is associated with insulin resistance. Its pathogenesis is felt to be related to activation of the IGF-1 receptor by high levels of circulating insulin [46]. Acanthosis nigricans is independently associated with fasting insulin levels and impaired glucose tolerance [47,48]. In addition to increased insulin resistance, one study found that 1 in 4 youths with acanthosis nigricans demonstrated abnormalities in glucose homeostasis and identified 2 individuals with diabetes who would not have been diagnosed based on fasting glucose levels alone [48]. The presence of acanthosis nigricans should alert the clinician to the likelihood of insulin resistance and prompt further investigation. Of note, the prevalence of acanthosis nigricans is increased among African American and Hispanic patients [49,50].