From the Department of Pediatrics, University of Wisconsin, Madison, WI.
Abstract
Objective: To provide information that will assist clinicians in assessing and addressing risk for obesity-related comorbidities in adolescents.
Methods: Review of the literature.
Results: Childhood obesity is a major public health concern. Prevention of obesity or early detection of its health consequences are important responsibilities or opportunities for primary care clinicians. While body mass index (BMI) screening is valuable, insulin resistance and other obesity-related comorbidities can develop even when BMI falls below the 95th percentile threshold for obesity. Detailed history and physical examination can help identify comorbidities and guide diagnostic evaluation. 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.
Conclusion: For optimal health outcomes, management of adolescent obesity and associated comorbidities is should be adapted based on an individual’s overall risk rather than BMI alone.
Case Study
Initial Presentation
A 14-year-old Hispanic male presents for a well child check.
History and Physical Examination
The patient and his mother have no complaints or concerns. A comprehensive review of systems is positive for fatigue and snoring but is otherwise unremarkable. Past medical history is unremarkable except for mild intermittent asthma. Family history is positive for type 2 diabetes in paternal grandmother and a maternal uncle and cardiovascular disease and hypertension in multiple extended family members. Both maternal and paternal grandparents are from Mexico.
Vital signs are within normal limits. Height is 160 cm (30th percentile for age), weight is 58.4 kg (75th percentile for age), and body mass index (BMI) is 22.8 kg/m 2 (85th percentile for age). Blood pressure is 127/81 mm Hg (95th percentile for age and gender). Physical exam is pertinent for acanthosis nigricans on neck and axilla and nonviolaceous striae on abdomen. Waist circumference is 88 cm (90th percentile for age and ethnicity). Otherwise, physical exam is within normal limits.
• Does this child’s physical examination findings pose a cause for concern?
Yes. A key concept is that while obesity is widespread, the adverse health complications of adiposity and overnutrition affect some children much earlier and more profoundly than others. Some children exhibit adiposity-associated comorbidities even prior to meeting obesity criteria defined by BMI. Careful history and examination can help identify those most at risk for developing adiposity-associated comorbidities, prompting earlier intervention and, when appropriate, subspecialty referral.
Obesity is caused by a complex interplay of genetic, environmental, and metabolic programming, especially early in life, and lifestyle habits [1,2]. The vast majority of obesity is due to excess nutrition leading to energy imbalance, while less than 1% is due to endocrine or syndromic causes [3]. Obesity is defined as excessive body fat and is often estimated indirectly by using a surrogate marker, BMI. Diagnostically, a BMI > 95th percentile for age on sex-specific CDC growth charts is defined as obese, while a BMI from the 85th to 94th percentile is defined as overweight [4]. Using these criteria, the prevalence of childhood obesity more than tripled in the past 3 decades [5], leading to its classification as an epidemic and public health crisis [2]. Today, an estimated 12.5 million American children are obese [5]. For adolescents specifically, the prevalence of obesity is 18.4%, with more than one-third overweight [6].
