Weight! Weight! Don’t Tell Me

How Healthcare Providers Can Help Prevent Childhood Obesity

Dr. Mok’s Notes May 2008

Some days in the office, I feel like I’m on the public radio weekly news quiz show. It seems like almost every child or family needs help finding the answer to the weight question. In fact, over a third of children have a body mass index at or over 85 percent, making them overweight, and almost one fifth are considered obese with a BMI at or over 95 percent.

This epidemic has made it necessary to measure height and weight at every visit and calculate the BMI. If you count smoke exposure as a vital sign, that means we are measuring eight or nine things on most patients on the way to the exam room. 

Since healthy eating and an active life style are essential anticipatory guidance issues for every child, it is now routine to include the following items in prevention information:

• Try to get five to seven servings of fruits and vegetables each day
• Limit time in front of a TV or computer screen to under two hours each day
• Choose water or lowfat milk as a beverage instead of sugared drinks
• Get at least an hour of vigorous activity in per day
• Encourage family meals at home instead of eating out or getting fast food
• Pay attention to portion sizes and use smaller plates to control calorie intake

The question always comes up about additional screening for other causes of obesity. The main endocrine problems are hypothyroidism, Cushing syndrome and growth hormone deficiency, all of which are associated with short stature.

Genetic syndromes such as Prader-Willi and Fragile X have developmental delay signs. Rare neurologic causes like craniopharingioma usually have other signs and symptoms. Some medications, especially steroids or psychotropics, can cause weight gain.

If these categories can be ruled out, then most likely the obesity is due to the complicated interplay of lifestyle and genetic inheritance.

For those patients over age two with a BMI over 85 percent, it is recommended that family history be assessed for diabetes and cardiovascular disease. This includes:

• First degree male relatives under age 55 or females under age 65 with CAD
• First degree relatives with LDL cholesterol over 250
• Siblings with LDL cholesterol over 130
• Diabetes
• Aortic valve stenosis or post Kawasaki disease
• A child at puberty with weight over 95 percent BMI
• A child at puberty with weight over 85 percent and two of the following:
  • Family history of type 2 diabetes
  • History of mother with gestational diabetes in that pregnancy
  • Presence of acanthosis nigricans
  • Polycystic ovary syndrome (see clinical FAQs)
  • Non-white ethnicity

These patients should be screened with fasting glucose and lipid profile and referred to weight management.

For all patients at puberty who have BMI over 95 percent, special attention should be paid to measuring blood pressure with the proper size cuff. They should have a fasting glucose and lipid profile measured along with an ALT looking for non-alcoholic steatohepatitis (see clinical FAQs). In addition, one has to be concerned about the following co-morbidities:

• Impaired glucose tolerance found on fasting glucose above 100-125 mg/dl or 2-hour glucose tolerance test over 140-200 mg/dl
• Hypertension
• Dyslipidemia with LDL over 130 or triglyceride over 150
• Non-alcoholic steatohepatitis
• Polycystic ovary syndrome
• Metabolic syndrome, which requires 3 of the following:
  • Triglyceride over 110 mg/dl
  • HDL cholesterol less than 40 mg/dl
  • Fasting glucose over 100
  • Waist circumference greater than the 90^th percentile
  • Blood pressure over the 90^th percentile
• Sleep apnea syndrome
• Slipped capital femoral epiphysis
• Pseudotumor cerebri

There is no doubt that much of our time and energy will now be spent helping children and families paying attention to energy intake and expenditure, as well as keeping them active for much of their day.

Even though the U.S. Preventive Services Task Force did not find convincing evidence that counseling and lifestyle intervention effectively prevent obesity, these approaches still seem to be the right thing to do. People do listen to their healthcare clinicians, and they heed our advice. 

The physical and emotional impacts of obesity are well documented. We need to be part of the weight problem solution.

Contact Dr. Mokrohisky at mokrohisky.stefan@tchden.org or (720) 777-6130.