Overview/Definition
Definition:
• Adolescent obesity is BMI ≥95th percentile for age and gender, representing serious health condition affecting 20-25% of Indian teenagers
Pharmacologic intervention considered when lifestyle modifications fail and BMI remains ≥95th percentile with comorbidities or BMI ≥120% of 95th percentile without comorbidities.
Epidemiology:
• Prevalence of adolescent obesity in India: 15-25% in urban areas, 5-10% in rural areas, increasing rapidly
Associated comorbidities present in 60-80% obese adolescents: type 2 diabetes, hypertension, dyslipidemia, sleep apnea
Higher prevalence in higher socioeconomic groups, private school children.
Age Distribution:
• Early adolescence (12-14 years): Rapid weight gain during puberty, body image concerns emerge
Mid-adolescence (15-17 years): Peer pressure peaks, risky behaviors increase
Late adolescence (17-18 years): Adult-like patterns, transition to adult care
Gender differences: Girls show higher rates of body dissatisfaction.
Clinical Significance:
• Important topic for DNB Pediatrics and NEET SS examinations covering comprehensive obesity management, pharmacotherapy indications, lifestyle interventions, comorbidity screening
Understanding multidisciplinary approach, family involvement, psychological aspects crucial
Long-term health implications and prevention strategies essential.
Age-Specific Considerations
Newborn:
• Neonates (0-28 days): Early life factors affecting future obesity risk - high birth weight, maternal obesity, gestational diabetes
Rapid weight gain in first months associated with later obesity
Breastfeeding protective against childhood obesity
Early nutritional programming important.
Infant:
• Infants (1-24 months): Rapid weight gain (>75th percentile weight-for-length) predicts later obesity
Introduction of solid foods timing and composition important
Screen for food allergies affecting dietary diversity
Avoid fruit juices, early introduction of sugary foods.
Child:
• Children (2-12 years): Establishment of eating patterns, physical activity habits
Family lifestyle interventions most effective
Screen for early comorbidities: insulin resistance, dyslipidemia
School-based interventions important
Avoid pharmacological interventions in this age group.
Adolescent:
• Adolescents (12-18 years): Peak age for obesity intervention, body image concerns prominent
Pharmacological options become available
Independence in food choices increases
Risk for eating disorders
Transition planning to adult obesity care
Reproductive health considerations.
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Clinical Presentation
Symptoms:
• Physical symptoms: Exercise intolerance, joint pain, sleep disturbances, frequent respiratory infections
Psychological symptoms: Low self-esteem, depression, anxiety, social withdrawal
Gastrointestinal: Gastroesophageal reflux, constipation
Reproductive: Menstrual irregularities in girls, early puberty.
Physical Signs:
• Anthropometric: BMI ≥95th percentile, increased waist circumference, neck circumference >35 cm
Skin changes: Acanthosis nigricans (insulin resistance), striae, intertrigo
Cardiovascular: Hypertension, tachycardia
Respiratory: Sleep apnea signs, reduced exercise capacity.
Severity Assessment:
• Mild obesity: BMI 95th-99th percentile, minimal comorbidities
Moderate obesity: BMI >99th percentile or 120% of 95th percentile, some comorbidities present
Severe obesity: BMI >120% of 95th percentile with multiple comorbidities, significant functional impairment.
Differential Diagnosis:
• Endocrine causes: Hypothyroidism, Cushing syndrome, growth hormone deficiency, PCOS
Genetic syndromes: Prader-Willi syndrome, Bardet-Biedl syndrome
Medication-induced: Corticosteroids, antipsychotics, anticonvulsants
Hypothalamic disorders: Craniopharyngioma, trauma.
Diagnostic Approach
History Taking:
• Weight history: Age of onset, family history of obesity, previous weight loss attempts
Dietary assessment: 24-hour recall, eating patterns, portion sizes, frequency of meals
Physical activity: Screen time, organized sports, sedentary behaviors
Psychological: Mood, body image, eating disorders.
Investigations:
• Metabolic screening: Fasting glucose, HbA1c, lipid profile, liver enzymes, uric acid
Hormonal evaluation: TSH, free T4, cortisol if indicated
Inflammatory markers: CRP, ESR
Imaging: Abdominal ultrasound for fatty liver, sleep study if sleep apnea suspected.
Normal Values:
• BMI percentiles: Normal <85th percentile, overweight 85th-94th percentile, obese ≥95th percentile
Metabolic parameters: Fasting glucose <100 mg/dL, HbA1c <5.7%, total cholesterol <170 mg/dL, triglycerides <90 mg/dL (12-15 years), <130 mg/dL (16-19 years).
Interpretation:
• BMI Z-score calculation for severity assessment
Waist circumference >90th percentile indicates central obesity
Metabolic syndrome criteria: ≥3 of 5 criteria (central obesity, high triglycerides, low HDL, hypertension, glucose intolerance)
HOMA-IR >3.16 suggests insulin resistance.
Management/Treatment
Acute Management:
• Comprehensive evaluation: Medical history, physical examination, laboratory screening
Comorbidity assessment: Screen for diabetes, hypertension, dyslipidemia, sleep apnea
Psychological evaluation: Depression, anxiety, eating disorders
Family assessment: Readiness for lifestyle changes.
Chronic Management:
• Multidisciplinary approach: Pediatrician, dietitian, exercise physiologist, psychologist
Lifestyle intervention: Dietary modification, physical activity increase, behavior modification
Pharmacotherapy: Consider if lifestyle fails after 6 months, specific criteria met
Bariatric surgery: Reserved for severe cases, specific criteria.
Lifestyle Modifications:
• Dietary changes: Reduce caloric intake by 250-500 kcal/day, increase fruits/vegetables, limit sugar-sweetened beverages
Physical activity: 60 minutes moderate-vigorous activity daily, limit screen time <2 hours
Behavioral: Goal setting, self-monitoring, family involvement.
Follow Up:
• Intensive monitoring: Monthly visits initially, then every 2-3 months
Weight management: Target 5-10% weight loss or BMI reduction
Laboratory monitoring: Every 6-12 months for metabolic parameters
Long-term: Annual comprehensive assessment, transition planning.
Age-Specific Dosing
Medications:
• Orlistat (≥12 years): 120 mg three times daily with meals containing fat
Liraglutide (≥12 years, FDA approved): Start 0.6 mg daily, increase weekly by 0.6 mg to maximum 3.0 mg daily
Phentermine (≥16 years): 15-37.5 mg daily, short-term use only.
Formulations:
• Orlistat: 120 mg capsules, take with each main meal containing fat
Liraglutide: Pre-filled pen injections 0.6, 1.2, 1.8, 2.4, 3.0 mg
Phentermine: Capsules 15, 30 mg, tablets 37.5 mg
Take with or without food except orlistat.
Safety Considerations:
• Orlistat side effects: Gastrointestinal (fatty stools, urgency, incontinence), fat-soluble vitamin deficiency
Liraglutide: Nausea, vomiting, diarrhea, pancreatitis risk, thyroid cancer concern (boxed warning)
Phentermine: Increased heart rate, blood pressure, insomnia, dependency potential.
Monitoring:
• Efficacy: Weight loss ≥5% at 12 weeks, BMI reduction, waist circumference
Safety: Liver enzymes, lipid profile, blood pressure, heart rate
Orlistat: Fat-soluble vitamins (A, D, E, K)
Liraglutide: Lipase, signs of pancreatitis, thyroid monitoring.
Prevention & Follow-up
Prevention Strategies:
• Primary prevention: Promote healthy lifestyle from early childhood, family-based interventions
School-based programs: Nutrition education, physical activity promotion
Community interventions: Safe spaces for physical activity, healthy food access
Policy approaches: Sugar-sweetened beverage taxes.
Vaccination Considerations:
• Standard immunization schedule maintained
Consider hepatitis A/B vaccination if fatty liver disease present
Annual influenza vaccination
COVID-19 vaccination important as obesity increases severe disease risk
Monitor injection sites for local reactions.
Follow Up Schedule:
• Initial phase: Monthly visits for first 3-6 months
Maintenance phase: Every 2-3 months for medication monitoring
Annual comprehensive assessment: Growth, development, comorbidity screening
Transition: Adult obesity medicine or endocrinology by age 18-21.
Monitoring Parameters:
• Anthropometric: Weight, BMI, waist circumference, body composition if available
Metabolic: Glucose, lipids, liver enzymes, blood pressure
Psychological: Depression screening, body image, eating behaviors
Quality of life: School performance, peer relationships, physical functioning.
Complications
Acute Complications:
• Medication side effects: Severe gastrointestinal symptoms with orlistat, pancreatitis with liraglutide
Gallbladder disease: Rapid weight loss may precipitate gallstones
Eating disorders: Restrictive eating, binge-purge behaviors
Psychological: Depression worsening, suicidal ideation.
Chronic Complications:
• Metabolic: Type 2 diabetes, metabolic syndrome, fatty liver disease
Cardiovascular: Hypertension, dyslipidemia, atherosclerosis
Reproductive: PCOS, infertility, pregnancy complications
Psychological: Persistent body image issues, depression, social impairment.
Warning Signs:
• Severe abdominal pain (pancreatitis concern with liraglutide)
Signs of eating disorder: Severe food restriction, binge-purge behaviors
Depression symptoms: Mood changes, social withdrawal, academic decline
Rapid weight loss: >2-3 pounds per week may indicate unsafe practices.
Emergency Referral:
• Immediate referral for: Severe abdominal pain, signs of pancreatitis, suicidal ideation
Eating disorder specialist: Restrictive eating, binge-purge behaviors
Bariatric surgery center: BMI >40 with major comorbidities or BMI >35 with significant comorbidities after failed medical management.
Parent Education Points
Counseling Points:
• Obesity is medical condition requiring comprehensive treatment approach
Family involvement crucial for success
Weight loss medications are tools, not magic solutions
Lifestyle changes must be maintained long-term
Realistic expectations: 5-10% weight loss significant health benefit.
Home Care:
• Family meal planning: Involve teenager in food preparation, regular family meals
Physical activity: Find enjoyable activities, limit screen time
Medication adherence: Consistent timing, take with appropriate meals
Environmental changes: Remove tempting foods, stock healthy options.
Medication Administration:
• Orlistat: Take with each fat-containing meal, skip if no fat in meal
Liraglutide: Subcutaneous injection same time daily, rotate injection sites
Multivitamin: Take 2 hours apart from orlistat
Storage: Liraglutide requires refrigeration, orlistat room temperature.
When To Seek Help:
• Contact healthcare provider for: Severe side effects, poor weight loss response after 12 weeks, signs of depression or eating disorder
Emergency care for: Severe abdominal pain, persistent vomiting, signs of dehydration, thoughts of self-harm.