Newsletters

Healthy Child Fall/Winter 2004

Evaluation of the Obese Child

HENRY ANHALT, D.O., FAAP, FACOP, FACE, CDE
DIRECTOR, DIVISION OF PEDIATRIC ENDOCRINOLOGY,
SAINT BARNABAS MEDICAL CENTER

Childhood obesity represents the greatest health threat to our children since the disappearance of polio. In the United States, nearly half of all adults and children are overweight, and over 30 percent of children are obese. It is estimated that 40,000,000 adults are overweight, causing 300,000 deaths annually. From 1965-1980 obesity in children rose 54 percent for 6-11 year olds and 39 percent for 12-17 year olds.

These few statistics highlight the scope of the problem that we face. However, in the evaluation of the overweight child and adolescent it is vital to appreciate the true biological causes of overweight. The media has portrayed overweight children and adults as being lazy and that their lack of interest in caring for themselves, among other things, is the prime cause for their increased weight. This is blatantly false and has been disproved scientifically. Doctors like myself who care for overweight children and their families realize the strong biological factors that influence a person’s weight. Once everyone, including the child, appreciates the biological basis of overweight, then the evaluation can take place in a guilt-free and supportive environment.

A GENETIC COMPONENT TO OVERWEIGHT
"It’s not your fault," is my opening statement to the children and families that I see in our obesity clinics. I want the children and family members who accompany them to know that I understand the biological basis of their problem.

This disarming opening statement reassures them in the face of comments that they may have heard from their teachers, friends and even well meaning family members. We know that there are at least six different genes that determine an individual’s ability to be efficient (store calories easily as fat) or inefficient (burn calories easily).

To further highlight the genetic link, I point out that it is no accident that in 90- 95 percent of overweight children, there is at least one obese adult family member.

This helps them to understand that obesity is similar to other conditions, such as cancer and high blood pressure, which have a biological basis as well. Once these concepts are understood I complete the picture with an introduction of how our environment influences whether we will develop medical problems for which we have an underlying genetic risk. If an overweight individual lives in an environment where food is scarce and exercise is plentiful, having genes that make them efficient is clearly an advantage. However, this same individual living in an environment where exercise is not part of their lifestyle and unlimited high calorie-dense foods are available leads to overweight.

A DETAILED EVALUATION
The evaluation is comprehensive and pays attention to the growth of the child, including fetal and infancy growth patterns, diet and exercise patterns and nutritional and medical complications. Reviewing the child’s growth charts for height and weight are often helpful in tracking the periods of weight gain. Much greater concern needs to be shown for the child who demonstrates crossing of weight percentiles, as compared to the child who, although overweight, does not demonstrate continuing weight gain trends.

Hormonal causes of obesity, such as Cushing’s syndrome, growth hormone deficiency or an underactive thyroid gland, would be accompanied by a decline in growth, so a careful review of the growth chart can quickly rule out serious endocrine problems.

Overweight that is not due to any other hormonal cause is usually associated with tall stature and rapid growth. Small birth weight babies who are overweight as toddlers represent the highest risk group for future weight and weight-related medical problems in older childhood and adolescence. We do not fully understand this phenomenon, but it may have something to do with catch-up that occurs after birth in compensation for the relative starvation in fetal life. The family history is critical as it often is peppered with individuals who are overweight, have diabetes, abnormal cholesterol levels, gallbladder disease, heart attack or stroke under the age of 55. If any or all of these problems are seen in one family it increases the level of concern for a particular child.

A thorough physical examination is then performed focusing on skin signs, such as acanthosis nigricans (a darkening and furrowing of the skin related to high insulin levels), skin tags or other evidence of the very rare conditions associated with obesity. Less than 1 percent of all cases of obesity are attributable to these conditions. The important thing to keep in mind is that these rare conditions are all associated with short stature, whereas obesity without any underlying cause (aside from the genetic link) is associated with tall stature.

An expanded review of systems is then performed, which is aimed at identifying the medical complications of obesity. High blood pressure is very common, occurring in approximately 50 percent of our patients. The presence of frequent urination and thirst may be a sign that type two diabetes mellitus (non-insulin requiring) has already manifested itself.

Irregular periods in females with or without excessive body hair may be a sign of polycystic ovarian syndrome, a condition known to be associated with elevated insulin levels. The presence of mouth breathing or snoring may be an indication that the child is having difficulty exchanging air during normal breathing and may suffer from sleep apnea.

THE ROLE OF ENVIRONMENT
Previous weight loss attempts, especially in the older child, allow me to understand a little about the families and patients’ health expectations and experiences.

Often it is during this segment of the evaluation that unhealthy family-child issues become prominent. Namely the interaction between parents and child during the initial evaluation can be hostile and oppositional. It is critical never to frighten overweight children with the risks of their weight and caution should be advised in assigning any blame for overweight to them as well. It is common to hear parents demand that the health care team tell their child that they have to stop eating. They relate that they have been trying to get the child to do the same, "but he/she just won’t listen."

A nutritional history is always obtained and food diaries, although not necessarily accurate to estimate calorie intake, are extremely useful to identify high calorie-dense foods and excessive calories consumed with soda and fruit drinks. In my experience, the ability to successfully keep a food diary correlates well with short-term success in healthier lifestyle maintenance.

While appreciating the importance of genes in determining each person’s pre-determined weight set point, it is important to appreciate the role of environment and physical activity in overweight. Very frequently children and their parents report watching television and playing computer games for more than three hours per day. Clearly this inactivity is a contributing factor to the rise in overweight.

In summary, the evaluation of the obese child needs to be comprehensive, and must be conducted in a guilt-free environment. The team evaluating the child must understand the interplay between genetics and the environment and be especially sensitive to the child’s feelings.

For an appointment with the Division of Pediatric Endocrinology and Diabetes, please call (973) 322-7337.

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