This document discusses the evaluation and management of childhood obesity. It defines obesity as a BMI greater than the 95th percentile. It describes evaluating a child's weight history, family history, physical exam findings, and recommended medical tests. The management of obesity involves lifestyle modifications like diet and exercise changes, as well as potential pharmacotherapy or surgery in severe cases. The goal is gradual weight loss to reduce BMI SDS by 5% over 6 months.

1. Childhood
Obesity
Moderators -
Dr Pradeep
Dr Prashanth

2. 13 year old male
child brought with
complains of excessive
weight gain since
3years.

3. On examination, Weight is 50kg and height 138cm with
BMI 26.2 kg/m2. How will you evaluate?

5. What is obesity?

6. BMI
● 85th to 95th centile - overweight
● >95th centile - obese
● Weight for height (weight for length): Till 2 years of
age (>97.7th percentile suggest obesity).

8. Majority (~98%) do not have a pathological cause (exogenous
or constitutional obesity).
● Exogenous obesity: Normal growth, development, and
puberty are suggestive.
● Monogenic obesity: Early-onset obesity (before 5 years of
age) with extreme hyperphagia (food-seeking behavior-
stealing food, eating food leftover by others; impaired
satiety).
● Obesity syndromes:Distinct features (abnormal facies,
digits, vision) and systemic involvement, with hyperphagia.

12. ● Hypothalamic obesity: Neurological features (headache,
irritability, seizures) and/or neuro-logical insult with rapid
weight gain, hyperphagia. Neuroimaging is essential to
identify a hypothalamic lesion.
● Drug-induced obesity: Associated with glucocorticoids,
antipsychotics (risperidone and olanzapine), and antiepileptic
drugs (valproate and carbamazepine).
● Endocrine causes (hypothyroidism, Cushing syndrome,
pseudohypoparathyroidism). Associated short stature is the
hallmark of underlying endocrine cause.

13. History -

16. A family history of any of the following is an indication to
screen for dyslipidemia.
• Either parent, grandparent, aunt, uncle or sibling aged < 55
years (males) and < 65 years (females) having any of these:
myocardial infarction, stroke, angina, coronary artery by-pass,
stent, angioplasty or sudden cardiac death
• Parents with total cholesterol > 240 mg/dL or known lipid
abnormalities in parents.

17. Antenatal and perinatal history.
● High preconcetional weight
● Maternal smoking
● IUGR
● What is thrifty gene hypothesis?

18. Diet history
● 24h dietary recall
Special attention to intake of fruits,
vegetables and water, as well as high
caloric food and high carbohydrate beverages.

19. General physical examination-
Vitals
● Blood pressure
Anthropometry
● Weight for age
● Height for age
● BMI

20. Hypertension in obesity is multifactorial
● altered renal sodium handling
● increased systemic vascular resistance
● activation of the sympathetic nervous system

21. Body mass index-
It is an age independent index.
● Erroneous diagnosis of obesity in
short stature.
● It cannot locate the site of fat.
● It cannot differentiate between obese and muscular.
● Lower reliability in pubertal age.

25. Skin fold thickness
● It measures body fat %.
Disadvantages
● Significant inter and intra
observer variation.
● Affected by gender and
ethnicity.
● No Indian reference data.
● No significant advantage
over BMI

26. Waist circumference
● Highly sensitive and specific for
central obesity.
● Cutoff - 102cm for adult males
88cm for adult females
71cm for prepubertal
children
● No Indian data.

27. It must be measured with a stretch resistant tape, applied
horizontally just above the upper lateral border of right ileum at
the end of normal expiration and recorded to the nearest 0.1 cm.

28. Waist - Hip ratio
● >0.95 in males and >0.8 in females shows significant
health risk.

30. Head to toe examination
One must examine the adolescent for features of
complications of obesity like insulin resistance
● acanthosis nigricans
● skin tags and
● furunculosis

31. ● tonsillar enlargement and typical facies of obstructive sleep
apnea syndrome (OSAS)
● hepatomegaly (fatty liver in non-alcoholic fatty
liver disease - NAFLD)
● abnormal gait (slipped capital femoral epiphyses)
papilledema and VI cranial nerve palsy (pseudotumor cerebri).
● Tanner staging and Examine all adolescents for pubertal
gynecomastia (resulting from increased estrogen levels from
aromatase in adipose tissue).

32. ● One must look for features of an underlying endocrinopathy
like goitre and delayed relaxation of reflexes (hypothyroidism)
● abdominal striae and truncal obesity (Cushing's disease)
● midline defects and cherubic facies (GH deficiency)
● short 3rd and 4th metacarpals (pseudohypoparathyroidism).
● optic fundus features of retinitis pigmentosa and polydactyly
(Bardet Biedl syndrome).

35. Investigations
Step-1:
The endocrine society recommends endocrine work-up of
obesity, only, if the height velocity is attenuated with respect to
the family or pubertal status OR child has markers of specific
endocrine dysfunction.

36. Commonly recommended screening tests include
● a fasting thyroid profile (Free T4 and TSH)
● overnight dexamethasone suppression test (ONDST)
(Cushing's disease screen).

37. Step-2:
● All overweight and obese adolescents must have their
fasting blood sugar, liver function test and fasting lipid
profile estimated.

38. A practical definition of adolescent metabolic syndrome is
the presence of three out of the following five criteria:
1. Abdominal obesity (waist circumference >90th percentile)
2. Hyper-triglyceridemia ≥ 110 mg/dL
3. High density lipoprotein (HDL) cholesterol ≤ 40 mg/dL
4. Blood pressure ≥ 90th percentile according to age, gender
and height

40. Step-3:
Adolescents, classified to have metabolic syndrome, or, with
even one of the five criteria positive or clinical features of insulin
resistance, need to undergo a detailed evaluation of the
metabolic profile

46. Management
● Behaviour changes
● Appropriate calorie intake

47. Prevention
● Exclusive breastfeeding till 6 months of age.
● Regular meal timings, including breakfast.
● At-least 7–8 hours of sleep daily at night.
● Lifestyle intervention should precede and should be
maintained during pharmacotherapy.

49. Obesity prevention guidelines from American Academy of
Pediatrics recommend Fight Childhood Obesity by ‘5-2-1-0’ rule .
Accordingly, children can consume above 5 servings of fruits and
vegetables, screen time below 2 hours, participate in one hour of
physical activity, and consume 0 sugar-sweetened beverages
daily.

50. Targets
● Gradual and sustained loss.
● Body mass index (BMI) SD score (SDS) reduction of 5%
roughly translating to 7–10% weight loss over 6 months.
● Avoid loss over 1.5 kg per month.

51. ● Pharmacotherapy
1. Phentermine
1. Orlistat
1. Locaserin
1. Liraglutide

52. Metformin:
Approved in Type 2 DM after 8 years of age. May consider in
causes related to antipsychotic medication, polycystic ovarian
disease, and steatohepatitis.

53. Surgery -
● Should be discouraged as it carries more significant
complications than adults.
● Indicated only with severe obesity (BMI >40 kg/m2 or >35
kg/m2 with complications) and only after completion of
linear growth.
● A multidisciplinary obesity team with long-term follow-up is
essential to maintain compliance with nutritional
recommendations.
● Extreme motivation, strict diet, and activity schedule must
be maintained after surgery.

54. Complications
● Malabsorption
● Vitamin deficiency
● Mineral deficiency