A 7-year-old Black boy presents to his pediatrician for annual exam, accompanied by his mother. It is apparent that the child is very overweight. When asked about what he likes to do outside of school, such as sports or games he likes to play, the patient reports that he spends most of his time after school at home, either watching TV or playing video games. There is very little time for recess at school, and all the playground equipment has been removed. Similarly, the neighborhood playground has been closed for renovations for the past 6 months and there are no safe spaces nearby to play outdoors. He states that he doesn't like to run because he gets out of breath easily.
When asked about his eating habits, both the patient and his mother state that when he eats breakfast and lunch at school these meals contain little or no vegetables. After-school snacks consist of chips or cookies with a soda or chocolate milk from the corner convenience store. The patient drinks milk, chocolate milk, soda, and juice rather than water as his beverages of choice.
The patient's family consists of his parents and two older siblings (a boy and a girl). The family consumes several meals each week from fast-food restaurants. The patient's mother, who is also significantly overweight, says that the supermarket closest to them recently closed. The supermarket she now uses is only accessible by public transit, and she says that the selection of fresh fruits and vegetables there is limited and expensive. The family relies on electronic benefits transfer to purchase their food. The patient's father has been unemployed for the past 4 months. The patient's mother does shift work; her schedule therefore changes constantly, and the home routine is erratic. As a result, the family does not often eat together.
Physical exam reveals that the patient's tonsils and adenoids are at peak size relative to his oropharynx. Accumulation of fat is distributed throughout the body: the extremities, neck, and trunk. When asked, his mother does not report the child to have dry skin, sensitivity to cold, or increased urination. He has regular bowel movements. His height is normal for his age. He does not exhibit any signs of early puberty. His breathing seems a bit labored, and his heart rate is slightly elevated. His stomach, spleen, and liver are normal on palpation.
