(Pediatrics 2007;120:S164; Pediatrics 2007;120:S193; Pediatrics 2007;120:S229; Pediatrics 2007;120:S254)
Definition
• Calculation of body mass index (BMI) = ([weight (kg)]/[height (m)]2) recommended for screening d/t ease of calculation and correspondence with adult measures
• Age- and sex-specific BMI charts established by CDC in 2000
• BMI categories from the 2007 AAP Expert Committee report
• <5th percentile: Underweight; 5th–84th percentile: Healthy weight; 85th–94th percentile: Overweight; ≥95th percentile: Obese; ≥99th percentile: Severely obese (cutoff points for ≥99th percentile available at Pediatrics 2007;120:S164)
Prevalence & Epidemiology (JAMA 2006;295:1549; Pediatrics 2010;125:361)
• 33.6% children 2–19 yo overweight [NHANES 2003–2004] and 12–18% of 2–19 yo pts are obese, a three- to six-fold increase from 1970s
• Increased risk among African American and Hispanic populations
Selected Complications of Obesity
• Respiratory: Asthma exacerbation, OSA, cardiopulmonary deconditioning
• Cardiovascular: HTN, dyslipidemia, pulm HTN and cor pulmonale, inc risk of coronary heart disease as adult if still overweight/obese (N Engl J Med 2007;357:2329)
• GI: GERD, constipation, gallbladder disease, nonalcoholic fatty liver disease
• Endocrine: DM2, PCOS, metabolic syndrome (↑ waist circ + 2 of following: ↑ triglycerides, ↓ HDL, HTN, insulin resistance) (Pediatrics 2005;116:473)
• Orthopedic: Slipped capital femoral epiphysis, Blount’s disease, musculoskeletal stress
• Dermatologic: Intertrigo, acanthosis nigricans
• Neurologic: Pseudotumor cerebri (idiopathic intracranial hypertension)
• Psychiatric: Depression
• Premature death
Clinic Assessment
• USPSTF recommends screening all children >6 yo for obesity using BMI
• Risk factors: SGA at birth, mat gest DM, parental obesity, FHx of DM2/HL/HTN
• Assess diet and physical activity; always check BP
• Labs
• Fasting lipids: See Healthcare Maintenance section
• Fasting plasma glucose: (ADA recs [Diabetes Care 2012;34:S11])
• <10 yo and prepubertal: No routine screening
• At onset of puberty if <10 yo or starting at 10 yo: BMI >85th% (or >85% wt for height or wt >120% ideal for height) and any 2 of following: FHx of T2DM in 1st- or 2nd-degree relative; Native American, African American, Latino, or Asian/Pacific Islander ethnicity; signs of or risk for insulin resistance (acanthosis nigricans, HTN, dyslipidemia, PCOS, birth wt was SGA), or maternal diabetes or GDM during child’s gestation. Screen q3yr
• Transaminases: Biannually for all pts >95th %ile for BMI or >85th %ile w/ additional risk factors per AAP Expert Committee recs (Pediatrics 2007;120:S164), ALT more important per Endocrine Society recs (J Clin Endo Met 2008;93:4576)
Prevention (Adv Nutr 2012;3:56)
• Diet: Limit sugar-sweetened drinks, encourage fruits and veg, eat QD breakfast, limit eating out, limit portion size, encourage family meals
• Physical activity: Limit TV time ≤2 hr/d, no TV in bedroom, USDA/AAP/CDC recommendation is ≥60 min mod–vigorous physical activity QD, ↓ sedentary activities.
Treatment
• Stages of Rx per AAP Expert Committee recs
• Stage 1: Prevention plus – prev counseling as above w/ qmo f/u 3–6 mo
• Stage 2: Structured weight mgmt – dietitian referral, freq monitoring q3–6 mo
• Stage 3: Comprehensive multidisciplinary intervention – involvement of behavioral counselor and exercise specialist; qwk visits for 8–12 wk
• Stage 4: Tertiary care intervention – very low-cal diets, meds, and/or bariatric surgery for adolescents
• USPSTF recommends referral to intensive weight mgmt program (dietary, physical activity, and behavioral interventions) (Pediatrics 2010;125:361)
• Increased cardiovascular risk from childhood overweight/obesity is not permanent! Data from 4 cohorts demonstrated that non-obese adults who were overweight or obese as children had reduced risks for Type 2 DM, HTN, dyslipidemia, and atherosclerosis similar to those who had been never overweight or obese (N Engl J Med 2011;365:1876)