Case-Based Review

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

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

References

1. CDC. Obesity task force report. 2010. Available at www.letsmove.gov/sites/letsmove.gov/files/TaskForce_on_Childhood_Obesity_May2010_FullReport.pdf. Accessed 4 Sept 2013.

2. Barlow SE, AAP Expert Committee. AAP Expert Committee Recommendations regarding prevention, assessment and treatment of child obesity. Pediatrics 2007;120:s164–92.

3. Dietz WH, Robinson TN. Overweight children and adolescents. N Engl J Med 2005;352:2100–9.

4. Centers for Disease Control and Prevention (CDC) 2012; Overweight and obesity. Available at www.cdc.gov/obesity/childhood/basics.html. Accessed 3 Sept 2013.

5. Centers for Disease Control and Prevention (CDC). Prevalence of obesity among children and adolescents: United States, trends 1963–1965 through 2009–2010. Available at www.cdc.gov/nchs/data/hestat/obesity_child_09_10/obesity_child_09_10.pdf.

6. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999–2010. JAMA 2012;307:483–90.

7. August GP, Caprio S, Fennoy I, et al; Endocrine Society. Prevention and treatment of pediatric obesity: an endocrine society clinical practice guideline based on expert opinion. J Clin Endocrinol Metab 2008;93:4576–99.

8. Holmes ME, Eisenmann JC, Ekkekakis P, Gentile D. Physical activity, stress, and metabolic risk score in 8- to 18-year-old boys. J Phys Act Health 2008;5:294–307.

9. Peeters A, Barendregt JJ, Willekens F, et al. Obesity in adulthood and its consequences for life expectancy: a life-table analysis. Ann Intern Med 2003;138:24–32.

10. Sharifi M, Marshall G, Marshall R, et al. Accelerating progress in reducing childhood obesity disparities: exploring best practices of positive outliers. J Health Care Poor Underserved 2013;24(2 Suppl):193–9.

11. Cossrow N, Falkner B. Race/ethnic issues in obesity and obesity-related comorbidities. J Clin Endocrinol Metab 2004;89:2590–4.

12. Rosenbaum M, Fennoy I, Accacha S, et al. Racial/ethnic differences in clinical and biochemical type 2 diabetes mellitus risk factors in children. Obesity (Silver Spring) 2013;21:2081–90.

13. NIDDK. National diabetes statistics, 2011. Available at http://diabetes.niddk.nih.gov/dm/pubs/statistics/. Accessed 18 Sept 2013.

14. Janz KF, Butner KL, Pate RR. The role of pediatricians in increasing physical activity in youth. JAMA Pediatr 2013:1–2.

15. Coleman KJ, Hsii AC, Koebnick C, et al. Implementation of clinical practice guidelines for pediatric weight management. J Pediatrics 2012;160:918–22.

16. Ratcliff MB, Jenkins TM, Reiter-Purtill J, et al. Risk-taking behaviors of adolescents with extreme obesity: normative or not? Pediatrics 2011;127:827–34.

17. Goldenring J, Rosen D. Getting into adolescent heads: An essential update. Contemp Pediatr 2004;21:64.

18. Eisenmann JC, Welk GJ, Ihmels M, Dollman J. Fatness, fitness, and cardiovascular disease risk factors in children and adolescents. Med Sci Sports Exerc 2007;39:1251–6.

19. Weiss R, Shaw M, Savoye M, Caprio S. Obesity dynamics and cardiovascular risk factor stability in obese adolescents. Ped Diabetes 2009;10:360–7.

20. Rizzo NS, Ruiz JR, Ortega FB, Sjostrom M. Relationship of physical activity, fitness, and fatness with clustered metabolic risk in children and adolescents: The European Youth Heart Study. J Pediatr 2007;150:388–94.

21. Story MT, Neumark-Stzainer DR, Sherwood NE, et al. Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics 2002;110(1 Pt 2):210–4.

22. Alexander SC, Ostbye T, Pollak KI, et al. Physicians’ beliefs about discussing obesity: results from focus groups. Am J Health Promot 2007;21:498–500.

23. Puhl RM, Peterson JL, Luedicke J. Weight-based victimization: bullying experiences of weight loss treatment-seeking youth. Pediatrics 2013;131:e1–9.

24. Christie D, Channon S. The potential for motivational interviewing to improve outcomes in the management of diabetes and obesity in paediatric and adult populations: a clinical review. Diabetes Obes Metab 2013. Aug 8 [Epub ahead of print].

25. Standards of medical care in diabetes--2010. Diabetes Care 2010;33 Suppl 1:S11–61.

26. Hasson RE, Adam TC, Davis JN, et al. Ethnic differences in insulin action in obese African-American and Latino adolescents. J Clin Endocrinol Metab 2010;95:4048–51.

27. Fernández JR, Redden DT, Pietrobelli A, Allison DB. Waist circumference percentiles in nationally representative samples of African-American, European-American, and Mexican-American children and adolescents. J Pediatrics 2004;145:439–44.

28. Freedman DS, Sherry B. The validity of BMI as an indicator of body fatness and risk among children. Pediatrics 2009;124 Suppl 1:S23–34.

29. Daniels SR, Khoury PR, Morrison JA. The utility of body mass index as a measure of body fatness in children and adolescents: differences by race and gender. Pediatrics 1997;99:804–7.

30. Curtis VA, Carrel AL, Eickhoff JC, Allen DB. Gender and race influence metabolic benefits of fitness in children: a cross-sectional study. Int J Pediatr Endocrinol 2012;2012:4.

31. Nightingale CM, Rudnicka AR, Owen CG, et al. Influence of adiposity on insulin resistance and glycemia markers among U.K. Children of South Asian, black African-Caribbean, and white European origin: child heart and health study in England. Diabetes Care 2013;36:1712–9.

32. Gutin B, Yin Z, Humphries MC, Hoffman WH, et al. Relations of fatness and fitness to fasting insulin in black and white adolescents. J Pediatr 2004;145:737–43.

33. Cook S. The metabolic syndrome: Antecedent of adult cardiovascular disease in pediatrics. J Pediatr 2004;145:427–30.

34. Janssen I, Katzmarzyk PT, Ross R. Body mass index, waist circumference, and health risk: evidence in support of current National Institutes of Health guidelines. Arch Intern Med 2002;162:2074–9.

35. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. September 1998. NIH Pub No. 98-4083. Available at www.ncbi.nlm.nih.gov/books/NBK2003/pdf/TOC.pdf. Accessed 29 Sept 2013.

36. Janssen I, Katzmarzyk PT, Srinivasan SR, et al. Combined influence of body mass index and waist circumference on coronary artery disease risk factors among children and adolescents. Pediatrics 2005;115:1623–30.

37. Freedman DS, Serdula MK, Srinivasan SR, Berenson GS. Relation of circumferences and skinfold thicknesses to lipid and insulin concentrations in children and adolescents: the Bogalusa Heart Study. Am J Clin Nutr 1999;69:308–17.

38. Savva SC, Tornaritis M, Savva ME, et al. Waist circumference and waist-to-height ratio are better predictors of cardiovascular disease risk factors in children than body mass index. Int J Obes Rel Metab Disorders 2000;24:1453–8.

39. Lee S, Bacha F, Gungor N, Arslanian SA. Waist circumference is an independent predictor of insulin resistance in black and white youths. J Pediatrics 2006;148:188–94.

40. Wang J, Thornton JC, Bari S, et al. Comparisons of waist circumferences measured at 4 sites. Am J Clin Nutrition 2003;77:379–84.

41. Cook S, Weitzman M, Auinger P, et al. Prevalence of a metabolic syndrome phenotype in adolescents: findings from the third National Health and Nutrition Examination Survey, 1988-1994. Arch Ped Adol Med 2003;157:821–7.

42. Ford ES, Ajani UA, Mokdad AH. The metabolic syndrome and concentrations of C-reactive protein among U.S. youth. Diabetes Care 2005;28:878–81.

43. Cruz ML, Weigensberg MJ, Huang TT, et al. The metabolic syndrome in overweight Hispanic youth and the role of insulin sensitivity. J Clin Endocrin Metab 2004;89:108–13.

44. Lee JM, Davis MM, Woolford SJ, Gurney JG. Waist circumference percentile thresholds for identifying adolescents with insulin resistance in clinical practice. Pediatric Diabetes 2009;10:336–42.

45. Li S, Chen W, Srinivasan SR, et al. Relation of childhood obesity/cardiometabolic phenotypes to adult cardiometabolic profile: the Bogalusa Heart Study. Am J Epidemiol 2012;1:S142–9.

46. Torley D, Bellus GA, Munro CS. Genes, growth factors and acanthosis nigricans. Br J Dermatol 2002;147:1096–101.

47. Mukhtar Q, Cleverley G, Voorhees RE, McGrath JW. Prevalence of acanthosis nigricans and its association with hyperinsulinemia in New Mexico adolescents. J. Adolesc Health 2001;28:372–6.

48. Brickman WJ, Huang J, Silverman BL, Metzger BE. Acanthosis nigricans identifies youth at high risk for metabolic abnormalities. J Pediatrics 2010;156:87–92.

49. Stuart CA, Pate CJ, Peters EJ. Prevalence of acanthosis nigricans in an unselected population. Am J Med 1989;87:269–72.

50. Brickman WJ, Binns HJ, Jovanovic BD, et al. Acanthosis nigricans: a common finding in overweight youth. Pediatr Dermatol 2007;24:601–6.

51. Yang HR, Kim HR, Kim MJ, et al. Noninvasive parameters and hepatic fibrosis scores in children with nonalcoholic fatty liver disease. World J Gastroenterol 2012;18:1525–30.

52. Chiarelli F, Marcovecchio ML. Insulin resistance and obesity in childhood. Eur J Endocrinol 2008;159 Suppl 1:S67–74.

53. Adam TC, Hasson RE, Lane CJ, Goran MI. Fasting indicators of insulin sensitivity: effects of ethnicity and pubertal status. Diabetes Care 2011;34:994–9.

54. Diagnosis and classification of diabetes mellitus. Diabetes Care 2013;36 Suppl 1:S67–74.

55. Nowicka P, Santoro N, Liu H, et al. Utility of hemoglobin A(1c) for diagnosing prediabetes and diabetes in obese children and adolescents. Diabetes Care 2011;34:1306–11.

56. Weiss R, Dziura J, Burgert TS, et al. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med 2004;350:2362–74.

57. Martins C, Pizarro A, Aires L, et al. Fitness and metabolic syndrome in obese fatty liver children. Ann Hum Biol 2013;40:99–101.

58. Taveras EM, Gillman MW, Kleinman KP, et al. Reducing racial/ethnic disparities in childhood obesity: the role of early life risk factors. JAMA Pediatr 2013;167:731–8.

59. Wolfgram PM, Connor EL, Rehm JL, et al. Ethnic differences in the effects of hepatic fat deposition on insulin resistance in non-obese middle school girls. Obesity (Silver Spring) 2014;22:243–8.

60. Sowa JP, Heider D, Bechmann LP, et al. Novel algorithm for non-invasive assessment of fibrosis in NAFLD. PLoS One 2013;8:e62439.

61. Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120 Suppl 4:S164–192.

62. Woolford SJ, Sallinen BJ, Clark SJ, Freed GL. Results from a clinical multidisciplinary weight management program. Clin Pediatrics 2011;50:187–91.

63. Savoye M, Shaw M, Dziura J, et al. Effects of a weight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial. JAMA 2007;297:2697–704.

64. Woolford SJ, Clark SJ, Gebremariam A, et al. Physicians’ perspectives on referring obese adolescents to pediatric multidisciplinary weight management programs. Clin Pediatrics 2010;49:871–5.

65. Lipana LS, Bindal D, Nettiksimmons J, Shaikh U. Telemedicine and face-to-face care for pediatric obesity. Telemed J Ehealth 2013;19:806–8.

66. Park MH, Kinra S, Ward KJ, et al. Metformin for obesity in children and adolescents: a systematic review. Diabetes Care 2009;32:1743–5.

67. Urrutia-Rojas X, McConathy W, Willis B, et al. Abnormal glucose metabolism in Hispanic parents of children with acanthosis nigricans. ISRN Endocrinol 2011(Epub 2011 Dec 25.).

• What is the recommended approach to intervention? When is referral warranted?

Staged Obesity Treatment

When risk factors for obesity and its associated comorbidities are detected, intervention aimed at improving long-term health outcomes is indicated. The Expert Committee advocates a staged approach depending on degree of obesity, health risks, motivation, and responses to treatment ( Table 2 ) [61]. The first 2 stages are typically performed in the primary care setting, Stage 3 in a multidisciplinary clinic, and Stage 4 in a tertiary care setting.

The initial stage, termed “Prevention Plus,” is similar to obesity prevention strategies and is focused on institution of healthy dietary and activity lifestyle habits tailored to the individual and family. Frequent follow-up and monitoring can be helpful and should be offered to families. Failure to demonstrate progress after 3 to 6 months warrants advancement to Stage 2, “Structured Weight Management,” which includes a planned diet with structured meals and snacks, reduction of screen time to 1 hour or less, 60 minutes of supervised physical activity, use of logs to document diet and activity levels, monthly follow-ups and positive reinforcement for achieving goals. Consultation with a dietician and health psychologist/counseling can be helpful at this level.

If no progress is noted after 3 to 6 months, progression to Stage 3, “Comprehensive Multidisciplinary Intervention,” is recommended. This stage emphasizes the importance of a multidisciplinary team including behavioral counselor, registered dietician and exercise specialist in addition to a medical provider. Current evidence suggests modest improvement of obesity and related comorbidities in adolescents participating in multidisciplinary weight management programs [62,63]. While these interventions can be implemented in community settings, coordination in this setting can be difficult and implementation more commonly involves weight management programs in tertiary care centers. Access to such programs can be limited by geographic accessibility, insurance coverage and physician awareness of available programs/resources [64]. Utilization of technology such as telemedicine visits is one way to overcome limited access [65]. Finally, Stage 4 “Tertiary Care Intervention”, involving discussion of pharmacologic or intensive/surgical weight loss options, can be considered for those who fail to show progression after successful intervention of previous stages.

Specialty Referral

Referral to multidisciplinary clinics specializing in childhood obesity is warranted when obesity is particularly severe, comorbidities are present at baseline, or no improvement is noted after 6 months of intense lifestyle intervention. Insulin resistance evidenced by impaired glucose tolerance (abnormal fasting or 2-hour glucose levels), HgA1C in the pre-diabetes range or higher (> 5.7%), or persistently elevated fasting insulin levels after 3 to 6 months of intensive lifestyle modification should prompt referral for consideration of metformin initiation. Metformin can reduce insulin resistance in children and may reduce progression from impaired glucose tolerance to diabetes [66]. For dyslipidemia related to metabolic syndrome, lifestyle interventions are most likely to be efficacious. Referral to preventative cardiology for consideration of pharmacologic intervention should be considered when severe hypertriglyceridemia is present (> 400 mg/dL) or LDL remains elevated after implementation of healthy lifestyle interventions. Elevations in ALT are highly specific for NAFLD and should prompt referral to gastroenterology. In addition, given the poor sensitivity of ALT for detection of early hepatic steatosis, referral might be considered when ALT is in the high normal ranges, especially in those with increased risk such as Hispanic patients [67]. Finally, when signs of obstructive sleep apnea are present, a sleep study should be performed. In summary, while specialty referral can aid targeted treatment of obesity-related morbidities, the central role of the primary care clinician in anticipating and preventing or minimizing their occurrence remains paramount.