Take a comprehensive approach to obesity control and prevention

Sandra G. Hassink, MD; William J. Klish, MD; Thomas N. Robinson, MD, MPH; and Marian Freedman

Dr. Hassink is director of the weight management program at Alfred I. DuPont Hospital for Children, Wilmington, Del.

Dr. Klish is chief of the Gastroenterology, Hepatology, and Nutrition Service and head of the Department of Medicine, Texas Children's Hospital, Houston; and professor of pediatrics and head of pediatric gastroenterology, Baylor College of Medicine, Houston.

Ms. Freedman is a contributing editor of Contemporary Pediatrics.

Drs. Hassink, Klish, and Robinson and Ms. Freedman have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

More Americans are becoming overweight or obese at earlier ages.¹ As the number of young people carrying excess weight increases, so do the rates of type 2 diabetes, hypertension, hypercholesterolemia, hypertriglyceridemia, and sleep disorders, as well as the risk of heart disease in adulthood. Yet many primary care physicians are reluctant to manage overweight in children and adolescents because doing so is time-consuming, frequently ineffective, and data about the efficacy of intervention are scarce.

How can you prevent and control obesity in your patients? At a minimum, you can provide basic advice to all families about healthful eating and activity habits and identify children who are either overweight or at risk. Helping families overcome barriers to these healthful habits increases the likelihood for successful intervention. But even more important than individual management, perhaps, is to advocate for change in your community that will foster healthful lifestyles.

Making the evaluation

Determining the child's body mass index (BMI) is the first step in assessing a child's weight. Divide the child's weight in kilograms by his height in meters squared; alternatively, divide the child's weight in pounds by height in inches squared and multiply by 703. Or use the calculator provided by the CDC at http:// http://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm.

Because children's body fat changes as they grow and differs between boys and girls, BMI should be plotted on a gender-specific growth chart, which uses percentiles to show how the child's BMI compares with children of the same gender and age. According to the CDC, a child with a BMI-for-age from the 85th to 95th percentile is at risk of overweight and a child at the 95th percentile or higher is overweight.²

A physical examination and history allow you to assess health risks and to identify complications and comorbidities of overweight. It also makes it possible to identify those few children whose overweight may be related to one of the rare metabolic or genetic causes of obesity, such as hypothyroidism, Cushing, Prader-Willi, Laurence-Moon-Biedl, Alstrom, or Cohen syndromes. Any overweight child with short stature and/or poor growth, dysmorphic features, hypogonadism, or developmental delay or mental retardation requires evaluation for these and similar conditions and should be referred to a pediatric obesity specialty clinic or a pediatric endocrinologist.

The history should include a review of the patient's growth pattern-weight-for-height before the age of 2 years and BMI after the age of 2 years. Moving up across percentiles is a red flag for a developing weight problem. Another danger signal is a family history of obesity and its comorbidities, especially cardiovascular disease, hyperlipidemia, hypertension, or type 2 diabetes. Assess the patient for these comorbidities, keeping in mind that acanthosis nigricans in young people is often a clue to insulin resistance and type 2 diabetes.

Other possible comorbidities, depending on the child's age and gender, include the metabolic syndrome that may lead to premature atherosclerosis, obstructive sleep apnea, pseudotumor cerebri, cholelithiasis, eating disorders, and polycystic ovary disease. Check for social morbidities, including low self-esteem, teasing, and depression-especially in adolescents.