Overview
Definition:
Pediatric obesity is defined as a body mass index (BMI) at or above the 95th percentile for children and teens of the same age and sex
It is a complex chronic disease characterized by excessive adipose tissue accumulation, significantly increasing the risk of numerous health problems.
Epidemiology:
Childhood obesity is a global public health crisis
In India, prevalence rates are rising rapidly, particularly in urban areas, affecting a significant proportion of children and adolescents
Factors include genetic predisposition, dietary shifts, reduced physical activity, and socioeconomic determinants.
Clinical Significance:
Pediatric obesity is associated with a higher risk of developing chronic conditions such as type 2 diabetes mellitus, hypertension, dyslipidemia, obstructive sleep apnea, non-alcoholic fatty liver disease, and orthopedic issues
It also impacts psychological well-being, affecting self-esteem and contributing to social stigma, with long-term implications for adult health.
Clinical Presentation
Symptoms:
Often asymptomatic
May present with physical findings of excess weight
Associated symptoms can include fatigue, reduced physical stamina, joint pain, snoring, and symptoms related to comorbidities like polyuria and polydipsia (diabetes) or difficulty breathing during sleep (sleep apnea).
Signs:
Elevated BMI percentile (≥95th) for age and sex
Increased waist circumference
Acanthosis nigricans, particularly in neck and axillae, suggesting insulin resistance
Signs of comorbidities such as hypertension, precocious puberty, or orthopedic deformities (e.g., Blount's disease, slipped capital femoral epiphysis).
Diagnostic Criteria:
Diagnosis is based on BMI percentile for age and sex, as per WHO or Indian Academy of Pediatrics (IAP) guidelines
Obesity is defined as BMI ≥ 95th percentile
Overweight is defined as BMI between 85th and 95th percentile
Waist circumference measurement can provide additional information about central adiposity.
Diagnostic Approach
History Taking:
Detailed dietary history (type, frequency, portion sizes of food)
Physical activity assessment (duration, intensity, types of activity)
Family history of obesity and related comorbidities
Psychosocial history, including self-esteem, bullying, and family support
Review of growth charts from infancy
Assess for any underlying endocrine or genetic causes (rare).
Physical Examination:
Accurate measurement of height and weight to calculate BMI
Plot BMI on age and sex-specific growth charts
Assess for acanthosis nigricans
Examine skin for striae
Evaluate for signs of associated comorbidities: blood pressure, cardiovascular examination, respiratory assessment for sleep apnea, musculoskeletal assessment.
Investigations:
Routine screening for comorbidities: Lipid profile (total cholesterol, LDL, HDL, triglycerides)
Fasting blood glucose and HbA1c
Liver function tests (LFTs) and ultrasound abdomen to screen for NAFLD
Thyroid function tests (TSH, free T4)
Consider screening for vitamin D deficiency
Hormonal evaluation may be indicated if endocrine cause is suspected.
Differential Diagnosis:
Other causes of increased weight such as Cushing's syndrome, hypothyroidism, Prader-Willi syndrome, pseudohypoparathyroidism
It is crucial to differentiate simple obesity from these rare endocrine or genetic conditions through appropriate history, physical examination, and investigations.
Management
Initial Management:
The cornerstone of management is a staged approach involving lifestyle modifications
This includes dietary changes, increased physical activity, and behavioral counseling
Management should be individualized and family-centered.
Staged Approach:
Level 1 (Prevention and Universal Education): General advice on healthy eating and physical activity for all children and families
Level 2 (Lifestyle Modification): Structured program focusing on diet, physical activity, and behavior change, guided by healthcare professionals, for children identified as overweight or obese
Level 3 (Multidisciplinary Weight Management): For children with severe obesity or significant comorbidities, involving a team of specialists (pediatrician, dietitian, psychologist, exercise physiologist)
Level 4 (Specialized Medical and Surgical Care): For adolescents with severe, life-threatening obesity or comorbidities unresponsive to other treatments, considering pharmacotherapy or bariatric surgery.
Lifestyle Modifications:
Diet: Emphasis on a balanced diet with reduced intake of processed foods, sugary drinks, and unhealthy fats
Increase intake of fruits, vegetables, and whole grains
Portion control is crucial
Physical Activity: Aim for at least 60 minutes of moderate-to-vigorous physical activity daily
Reduce sedentary time
Behavior Change: Address eating habits, emotional eating, and sleep patterns
Encourage family involvement and support
Setting realistic goals
Regular monitoring of weight and BMI is essential.
Pharmacological Management:
Reserved for select cases, typically in adolescents with BMI ≥ 35 kg/m² or BMI ≥ 30 kg/m² with comorbidities, after failure of intensive lifestyle interventions
Medications like Orlistat (reduces fat absorption) or Liraglutide (GLP-1 receptor agonist) may be considered, with close monitoring for side effects
These require specialist supervision and adherence to strict protocols.
Bariatric Surgery:
Considered in carefully selected adolescents with severe obesity (BMI ≥ 40 kg/m², or BMI ≥ 35 kg/m² with serious comorbidities) who have failed to achieve sustainable weight loss through lifestyle interventions and pharmacotherapy
Requires a comprehensive multidisciplinary team evaluation and post-operative support.
Complications
Early Complications:
Psychological issues such as low self-esteem, depression, anxiety, and social isolation
Physical complications can include obstructive sleep apnea, orthopedic problems (e.g., pain, gait disturbances), and early signs of metabolic syndrome.
Late Complications:
Long-term sequelae include type 2 diabetes mellitus, hypertension, dyslipidemia, cardiovascular disease, non-alcoholic fatty liver disease, polycystic ovary syndrome (in girls), premature puberty, and an increased risk of obesity in adulthood
Certain cancers are also linked to obesity.
Prevention Strategies:
Primary prevention involves promoting healthy lifestyle habits from infancy
This includes breastfeeding, introduction of age-appropriate solid foods, encouraging physical activity, limiting screen time, and avoiding the marketing of unhealthy foods to children
Early identification and intervention for overweight children are crucial.
Prognosis
Factors Affecting Prognosis:
The prognosis depends on the severity of obesity, presence and severity of comorbidities, adherence to treatment, family support, and early initiation of interventions
Early and sustained lifestyle changes offer the best prognosis.
Outcomes:
Successful management can lead to improved metabolic parameters, reduced risk of chronic diseases, enhanced physical function, and better psychological well-being
However, childhood obesity can be a lifelong challenge, and long-term remission may be difficult to achieve without continuous effort.
Follow Up:
Regular follow-up is essential, typically every 3-6 months for monitoring weight, BMI, and comorbidities
This includes nutritional assessment, behavioral support, and adjustment of treatment plans as needed
Long-term follow-up into adulthood is recommended to maintain weight management and prevent recurrence of obesity and its complications.
Key Points
Exam Focus:
Understand the staged approach to pediatric obesity management
Know the BMI percentile cutoffs for overweight and obesity
Be familiar with the common comorbidities and their screening methods
Recognize indications for pharmacotherapy and bariatric surgery in adolescents.
Clinical Pearls:
Always involve the family in management plans
Emphasize gradual, sustainable lifestyle changes rather than crash diets
Use motivational interviewing techniques
Screen for psychological impact of obesity
Refer to specialized multidisciplinary teams when indicated.
Common Mistakes:
Underestimating the complexity of obesity as a chronic disease
Focusing solely on weight rather than health behaviors
Neglecting psychological aspects
Inadequate follow-up and support
Not considering comorbidities or their screening
Relying on single interventions instead of a comprehensive, staged approach.