Clinical Evaluation of The Obese Child and Adolescent (UptoDate Mai 013)

Clinical evaluation of the obese child and adolescent Page 1 of 59
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Clinical evaluation of the obese child and adolescent
Author Section Editors Deputy Editor

William J Klish, MD Kathleen J Motil, MD, PhD Alison G Hoppin, MD
Mitchell Geffner, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2013. | This topic last updated: Mai 20, 2013.
INTRODUCTION — Obesity has become one of the most important public health problems in the
United States (figure 1) [1-3]. As the prevalence of obesity increases, so does the prevalence of the
comorbidities associated with obesity [4]. For this reason, it is imperative that health care providers
identify overweight and obese children so that counseling and treatment can be provided.
Recommendations, guidelines, and consensus statements for the evaluation and treatment of obese
children and adolescents have been published by the North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition (NASPGHAN) [5], an Expert Committee convened by the
Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration
(HRSA) [6,7], the American Heart Association [8], the United States Preventive Services Task Force
(USPSTF) [9] an international Obesity Consensus Working Group [10], and the National Association
of Children’s Hospitals and Related Institutions (NACHRI) [11].
The clinical evaluation of the overweight child and adolescent will be presented here. Other aspects of
clinical management of obesity in children are discussed in separate topic reviews:
■ (See "Management of childhood obesity in the primary care setting".)
■ (See "Definition; epidemiology; and etiology of obesity in children and adolescents".)
■ (See "Comorbidities and complications of obesity in children and adolescents".)
DIAGNOSIS — Calculation of body mass index (BMI) is a clinically practical tool for the assessment
of overweight and obesity in children. BMI is equal to the body weight (in kilograms) divided by the
height (in meters) squared (table 1). It correlates with adiposity [12-14] and complications of childhood
overweight [15-18]. Because BMI does not directly measure body fat, it may overestimate adiposity in
a child with increased muscle mass (eg, an athlete), and underestimate adiposity in a child with
reduced muscle mass (eg, a sedentary child). (See "Measurement of body composition in children",
section on 'Estimates of adiposity'.)
All children older than two years should have their BMI calculated at least annually from measured
height and weight [6,7,19,20]. The results should be plotted on an appropriate growth curve (figure 2A
-B). Health care providers typically underestimate weight status on casual examination, so it is
important to use measured heights and weights to determine and track obesity status [21]. (See "The
pediatric physical examination: General principles and standard measurements", section on 'Standard
measurements'.)
The BMI percentile and trend of percentile for age and sex determines whether the child is
underweight (<5th percentile), of normal weight (between 5th and 85th percentile), overweight (BMI
≥85th percentile and <95th percentile), or obese (≥95th percentile). BMI percentiles also can be
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determined using a calculator for boys (calculator 1) and for girls (calculator 2). Management
strategies vary accordingly (algorithm 1). (See "Definition; epidemiology; and etiology of obesity in
children and adolescents".)
■ Increasing BMI trend – If the BMI is below the 85th percentile but has increased more than three
to four units (kg/m2) per year and begins to cross percentile lines, particularly if the child is older
than four years, the family should be warned that the child is at risk of becoming overweight
and be provided with simple tips for maintaining a healthy weight [6,20,22]. The tables give
examples of tips to help families improve nutrition and reduce caloric intake (table 2A-B and
table 3A-C), increase physical activity (table 4), and adopt parenting strategies to support these
goals (table 5).
■ Overweight – If the BMI is ≥85th percentile but less than the 95th percentile, the child is
overweight by definition. He or she should be screened for comorbidities of obesity (see
'Evaluation' below), and given counseling to optimize lifestyle habits with a goal of slowing the
rate of weight gain [6]. These families should be provided with information about healthy
lifestyle such as the tips outlined in the tables above. They also may benefit from direct
counseling from the clinician or from a dietitian to address their specific challenges (table 6).
■ Obese – If the BMI is ≥95th percentile, the child is obese by definition. He or she has a
significant likelihood of obesity in adulthood [23-26]. He or she should be carefully evaluated for
comorbidities of obesity, be provided with direct counseling from the clinician or allied health
care provider, and have regular follow-up to monitor progress [6]. (See 'Evaluation' below and
"Comorbidities and complications of obesity in children and adolescents".)
The age of the child and growth patterns of the family must be taken into consideration when
evaluating trends in BMI percentile [4]. The influence of maternal nutrition and intrauterine
environment are reflected primarily in the growth parameters at the time of birth, whereas genetic
factors have a later influence. Thus, the weight percentile of some children whose birthweight
percentile is less than what would be expected based upon family growth patterns may increase over
time. However, less than 5 percent of children cross two major percentiles lines upward on the growth
charts of the CDC after four years of age [27], and children who do so are at risk of overweight [4].
(See "Normal growth patterns in infants and prepubertal children", section on 'Determinants of normal
growth'.)
EVALUATION — The evaluation of the overweight or obese child should identify treatable causes
and comorbidities [4,7]. The evaluation should include a complete history and physical examination.
Laboratory and radiologic studies also may be obtained as indicated by the history and examination.
History — The history should include the age of onset of overweight and information about the child's
eating and exercise habits. The age of onset is helpful in distinguishing overfeeding from genetic
causes of overweight since syndromic obesity often has onset before two years of age (table 7A-B).
Information from the dietary and activity history may identify potential areas for intervention [4].
The dietary history should include the following factors, as summarized in the table (table 8) [4,28]:
■ Identification of the caretakers who feed the child
■ Identification of foods high in calories and low in nutritional value that can be reduced,
eliminated, or replaced (eg, juice, soda)
■ Assessment of eating patterns (eg, timing, content, and location of meals and snacks); a child
or adolescent who feels unable to control consumption of large amounts of food may have an
eating disorder [29] (see "Eating disorders: Epidemiology, pathogenesis, clinical features, and
course of illness"). Children who eat less frequent meals (eg, those who skip meals) are more
likely to be obese than those who eat more frequently [30], but this association may not be
causal.
The activity history should include the following factors, as summarized in the table (table 9) [4]:
■ Identification of barriers to walking or riding a bike to school
■ Evaluation of time spent in play
■ Evaluation of school recess and physical education (frequency, duration, and intensity)
■ Assessment of after-school and weekend activities
■ Assessment of screen-time (television, videotapes and DVDs, and video games)
The medical history should include review of all medications, particularly those that are known to be
weight-promoting (eg, certain psychoactive drugs such as risperidone, antiepileptic drugs, and
glucocorticoids) (table 10). (See "Definition; epidemiology; and etiology of obesity in children and
adolescents", section on 'Medications'.)
Review of systems — The review of systems should probe for evidence of comorbidities or
underlying etiologies (table 11) [4,7]. An abrupt onset of obesity with rapid weight gain should prompt
investigation of medication-induced weight gain, a major psychosocial trigger, endocrine causes of
obesity (eg, Cushing disease, hypothalamic tumor), or some obesity syndromes (Prader-Willi
syndrome, or rapid-onset obesity with hypothalamic dysfunction, hypoventilation, autonomic
dysregulation, and neural crest tumor [ROHHADNET syndrome]) [31]. (See "Definition; epidemiology;
and etiology of obesity in children and adolescents", section on 'Endocrine disease'.)
Family history — The risk of comorbidities of obesity is strongly influenced by the family history of
such morbidities, whether or not the affected family member is overweight [32]. Obesity in one or both
parents is an important predictor for whether a child's obesity will persist into adulthood [33-36]. Thus,
the family history should include information about obesity in first-degree relatives (parents and
siblings) [4]. It also should include information about common comorbidities of obesity, such as
cardiovascular disease, hypertension, diabetes, liver or gall bladder disease, and respiratory
insufficiency in first- and second-degree relatives (grandparents, uncles, aunts, half-siblings, nephews
and nieces).
Psychosocial history — The psychosocial history should include information related to:
■ Depression (eg, sleep disturbance, hopelessness, sadness, appetite changes) (see

"Depression in adolescents: Epidemiology, clinical manifestations, and diagnosis")
■ Information about school and social issues (eg, does the child have friends? Is he or she a
target for teasing?)
■ Tobacco use, since cigarette smoking increases the long-term cardiovascular risk [7,37-
40] (see "Comorbidities and complications of obesity in children and adolescents")
Examination — As with the history, the examination of the overweight child or adolescent should
evaluate the presence of comorbidities and underlying etiologies. Key findings to note are shown in
the table (table 12).
General appearance — Important aspects of assessment of general appearance include

assessment for dysmorphic features, which may suggest a genetic syndrome (table 7A-B),
assessment of affect, and assessment of fat distribution [4,7].
The distribution of the excess fat may help to distinguish the etiology of obesity. The excess fat in
obesity from overeating or overfeeding usually is distributed in the trunk and periphery. In contrast, the
"buffalo type" distribution of body fat (concentrated in the interscapular area, face, neck, and trunk) is
suggestive of Cushing syndrome. (See "Definition; epidemiology; and etiology of obesity in children
and adolescents", section on 'Endocrine disease' and "Epidemiology and clinical manifestations of
Cushing's syndrome".)
Abdominal obesity (also called central, visceral, android, or male-type obesity) is associated with
certain comorbidities, including the metabolic syndrome, polycystic ovary syndrome, and insulin
resistance. Measurement of the waist circumference, in conjunction with calculation of the body mass
index (BMI), may help to identify patients at risk for these comorbidities. Abdominal obesity and
measurement of the waist circumference are discussed separately. (See "Measurement of body
composition in children", section on 'Fat distribution' and "Comorbidities and complications of obesity
in children and adolescents", section on 'Metabolic syndrome' and "Clinical features and diagnosis of
polycystic ovary syndrome in adolescents".)
Blood pressure — A careful blood pressure should be obtained with a proper sized cuff. The
bladder of the cuff should cover at least 80 percent of the arm circumference (the width of the bladder
will be about 40 percent of the arm circumference) (figure 3) [41]. In many children and adolescents
with obesity, this will require use of "adult" or "large adult" sized cuffs. Hypertension increases the long
-term cardiovascular risk in overweight or obese children [7]. In addition, hypertension may be a sign
of Cushing syndrome [4]. (See "Epidemiology and clinical manifestations of Cushing's syndrome".)
Hypertension is defined as a blood pressure greater than the 95th percentile for gender, age and
height on three separate occasions (table 13 and table 14). Age- and height-specific blood pressure
percentiles also may be determined using calculators for boys (calculator 3) or for girls (calculator 4).
(See "Definition and diagnosis of hypertension in children and adolescents".)
Stature — Assessment of stature and height velocity is useful in distinguishing exogenous obesity
from obesity that is secondary to genetic or endocrine abnormalities, including hypothalamic-pituitary
lesions [42,43]. Exogenous obesity drives linear height, so most obese children are tall for their age.
By contrast, most endocrine and genetic causes of obesity are associated with short stature (figure 4).
Growth velocity may be slowed in children with endocrine causes of obesity, and children with Prader-
Willi syndrome are often short for their genetic potential and/or fail to have a pubertal growth spurt.
(See "Clinical features, diagnosis, and treatment of Prader-Willi syndrome".)
Head, eyes, throat — Examination of the head, eyes, and throat may provide clues to the etiology
of obesity and/or comorbidities [7].
■ Microcephaly is a feature of Cohen syndrome.
■ Blurred disc margins (picture 1) may indicate pseudotumor cerebri, an unexplained but not
uncommon association with obesity [44]. (See "Idiopathic intracranial hypertension
(pseudotumor cerebri): Clinical features and diagnosis".)
■ Nystagmus or visual complaints raise the possibility of a hypothalamic-pituitary lesion [43].

Other findings that support this possibility are rapid onset of obesity or hyperphagia, decrease
in growth velocity, precocious puberty, or neurologic symptoms [43]. (See "Clinical
manifestations and diagnosis of central nervous system tumors in children".)
■ Clumps of pigment in the peripheral retina may indicate retinitis pigmentosa, which occurs in
Bardet-Biedl syndrome.
■ Enlarged tonsils may indicate obstructive sleep apnea. (See "Evaluation of suspected
obstructive sleep apnea in children".)
■ Erosion of the tooth enamel may indicate self-induced vomiting in patients with an eating
disorder. (See "Eating disorders: Epidemiology, pathogenesis, clinical features, and course of
illness".)
Skin and hair — Examination of the skin and hair is particularly useful in evaluating signs of
endocrine etiologies or complications [7]:
■ Dry, coarse, or brittle hair may be present in hypothyroidism. (See "Clinical manifestations of
hypothyroidism".)
■ Striae and ecchymoses are manifestations of Cushing syndrome; however, striae are much
more likely to be the result of rapid accumulation of subcutaneous fat.
■ Acanthosis nigricans (picture 2A-B) may signify type 2 diabetes or insulin resistance [45-47].
■ Hirsutism may be present in polycystic ovarian syndrome (PCOS) and Cushing syndrome.
Abdomen — Abdominal tenderness may be a sign of gallbladder disease [7]. Hepatomegaly may
be a clue to nonalcoholic fatty liver disease [7].
Musculoskeletal — The musculoskeletal examination may provide evidence of underlying

etiology or comorbidity of childhood overweight:
■ Nonpitting edema may indicate hypothyroidism. (See "Clinical manifestations of

hypothyroidism".)
■ Postaxial polydactyly (an extra digit next to the fifth digit) may be present in Bardet-Biedl
syndrome [48], and small hands and feet may be present in Prader-Willi syndrome (table 7A-
B) [4]. (See "Clinical features, diagnosis, and treatment of Prader-Willi syndrome".)
■ The musculoskeletal examination may provide evidence of slipped capital femoral epiphysis
(limited range of motion at the hip, gait abnormality) or Blount disease (bowing of the lower
legs). (See "Slipped capital femoral epiphysis (SCFE)" and "Comorbidities and complications of
obesity in children and adolescents", section on 'Tibia vara (Blount disease)'.)
■ Dorsal finger callousness may be a clue to self-induced vomiting in patients with an eating
disorder [4]. (See "Eating disorders: Epidemiology, pathogenesis, clinical features, and course
of illness".)
Genitourinary — The genitourinary examination and evaluation of pubertal stage may provide
evidence of genetic or endocrine causes of obesity [4]. Evaluation of pubertal stage is discussed
separately. (See "Normal puberty", section on 'Sexual maturity rating (Tanner stages)' and "Clinical
features, diagnosis, and treatment of Prader-Willi syndrome", section on 'Hypogonadism'.)
■ Undescended testicles, small penis, and scrotal hypoplasia may indicate Prader-Willi
syndrome.
■ Small testes may suggest Prader-Willi or Bardet-Biedl syndrome [48].
■ Delayed or absent puberty may occur in the presence of hypothalamic-pituitary tumors, Prader-
Willi syndrome, Bardet-Biedl syndrome, leptin deficiency, or leptin receptor deficiency.
■ Precocious puberty occasionally is a presenting symptom of a hypothalamic-pituitary lesion

[43]. (See "Clinical manifestations and diagnosis of central nervous system tumors in children"
and "Definition, etiology, and evaluation of precocious puberty".)
Development — Most of the syndromic causes of overweight in children are associated with
cognitive or developmental delay (table 7A-B). Prader-Willi syndrome is also associated with marked
hypotonia during infancy and delayed development of gross motor skills. (See "Clinical features,
diagnosis, and treatment of Prader-Willi syndrome", section on 'Behavior characteristics'.)
Laboratory studies
Suggested tests — The laboratory evaluation for overweight and obesity in children is not fully
standardized. Most experts suggest routine screening for type 2 diabetes mellitus, dyslipidemia,
hypertension, and fatty liver disease in children with BMI ≥85th or ≥95th percentile, using a basic panel
of tests (ie, fasting glucose, serum alanine aminotransferase [ALT], and lipid panel [total cholesterol,
triglycerides, LDL-cholesterol and HDL-cholesterol], and serum ALT) [7,8,10,42]. Some providers also
measure a fasting insulin level (for purposes of counseling rather than screening), as discussed
below. The recommended threshold for performing this screening varies slightly; an expert panel from
the United States National Heart, Lung, and Blood Institute (NHLBI) recommends initial lipid screening
for children between two and eight years of age with a BMI ≥95th percentile (or other risk factors for
cardiovascular disease), and for older children with a BMI ≥85th percentile [49]. Abnormal laboratory
tests can be an added stimulus for weight loss. The rationale for these laboratory tests is discussed in
detail separately. (See "Definition and screening for dyslipidemia in children" and "Comorbidities and
complications of obesity in children and adolescents".)
Assessment for other comorbidities including type 2 diabetes, sleep apnea, and polycystic ovary
syndrome, depends on the presence of risk factors or symptoms, as outlined in the table (table 15).
■ Screening for diabetes should be performed in children over 10 years of age who are
overweight or obese AND have two or more additional risk factors, which include a family
history of type 2 diabetes in a first- or second-degree relative, high-risk ethnicity, acanthosis
nigricans, or PCOS (table 16). For these patients, screening should consist of fasting plasma
glucose (FPG) or an oral glucose tolerance test (OGTT). Hemoglobin A1C (A1C) can be used
as an alternative to fasting glucose for patients who are not fasting. Patients with intermediate
or conflicting results for any of these tests should undergo repeat testing and be monitored for
future development of diabetes. Definitive diagnosis of diabetes mellitus requires meeting
diagnostic criteria on at least two separate occasions. (See "Epidemiology, presentation, and
diagnosis of type 2 diabetes mellitus in children and adolescents", section on 'Screening'.)
■ Vitamin D deficiency appears to be common among children and adolescents with obesity
either because of generalized vitamin and mineral deficiencies secondary to poor eating habits,
and/or due to sequestration in excess adipose tissue. In studies from Spain, Texas and New
York, Vitamin D deficiency was present in about half of children and adults with severe obesity,
and was associated with higher BMI and features of the metabolic syndrome [50-53]. However,
there is currently inadequate evidence to determine whether the risk of vitamin D deficiency is
sufficiently high in all populations of children with obesity to justify routine screening. Vitamin D
levels depend on several factors, including sunlight exposure, skin color, the use of sun screen,
and diet quality. (See "Vitamin D insufficiency and deficiency in children and adolescents",
section on 'Causes of vitamin D deficiency'.)
Interpretation of results
■ A fasting glucose of 100 to 125 mg/dL (5.55 to 6.94 mmol/L) is considered to be prediabetic,
and a level of ≥126 mg per dL (7.0 mmol/L) (on two occasions) is consistent with the diagnosis
of diabetes. Children with an elevated fasting glucose should have a confirmatory oral glucose
tolerance test (OGTT) or be referred to an endocrinologist for further evaluation. (See
"Epidemiology, presentation, and diagnosis of type 2 diabetes mellitus in children and

adolescents", section on 'Screening'.)
■ Measurement of hemoglobin A1C (A1C) is a useful marker of the average blood glucose
concentration over the preceding 8 to 12 weeks. Because of improved assay standardization
and validation against other diagnostic methods, it can now be used for screening or to make a
diagnosis of diabetes mellitus, provided that an assay that is certified by the National
Glycohemoglobin Standardization Program (NGSP) is used. Patients with A1C 5.7-6.4 percent
are considered prediabetic (impaired glucose tolerance), and those with A1C ≥6.5 percent
probably have diabetes. Both groups of patients should have a confirmatory OGTT or be
referred to an endocrinologist for further evaluation. (See "Epidemiology, presentation, and
diagnosis of type 2 diabetes mellitus in children and adolescents", section on 'Hemoglobin
A1C'.)
■ Some providers measure fasting insulin because abnormal results can be helpful in explaining
clinical risks to patients and families. Other providers use the finding of acanthosis nigricans as
a basis for the same discussion. In either case, the provider can explain that there is a
significant likelihood that type 2 diabetes mellitus will eventually develop if weight loss is not
achieved (see "Pathogenesis of type 2 diabetes mellitus", section on 'Impaired insulin secretion
and insulin resistance'). Of note, the fasting insulin level should not be used as a clinical
screening tool for type 2 diabetes. It is an unreliable measure of insulin sensitivity, because it is
poorly correlated with whole body insulin sensitivity as measured by the euglycemic
hyperinsulinemic clamp. Moreover, currently there is no FDA-approved pharmacologic
treatment for isolated insulin resistance.
■ Fasting total cholesterol of >200 mg/dL (5.18 mmol/L) or a LDL cholesterol of >130 mg/dL (3.38
mmol/L) is consistent with hyperlipidemia (table 17). Obese children with hyperlipidemia should
be monitored and perhaps treated, since hyperlipidemia increases the risk of atherosclerosis as
the obese child grows older. Fasting serum triglycerides of >150 mg/dL (1.70 mmol/L) in
adolescents with obesity are considered to be elevated and an early sign of the "metabolic
syndrome". Non-fasting measurement of total cholesterol and non-HDL-cholesterol is an
acceptable alternative in children with low risk for cardiovascular disease, but fasting lipid
profiles are preferred for children with obesity. (See "Definition and screening for dyslipidemia
in children" and "Management of pediatric dyslipidemia".)
■ Liver function tests should be obtained because nonalcoholic fatty liver disease (NAFLD) is
typically asymptomatic [5]. Obese children with an elevation of ALT greater than two times the
norm that persists for greater than three months should be evaluated for the presence of
NAFLD and other chronic liver diseases (eg, viral hepatitis, autoimmune hepatitis, Wilson
disease, alpha-1 antitrypsin deficiency) [5]. (See "Comorbidities and complications of obesity in
children and adolescents", section on 'Nonalcoholic fatty liver disease'.)
■ If screening for vitamin D deficiency is undertaken, levels are measured as serum 25(OH)
vitamin D. The reference range varies by region, but levels <20 ng/mL are generally considered
deficient. In populations of children with obesity, vitamin D deficiency was not generally
associated with overt clinical symptoms [50,51]. However, if deficiency is found, vitamin D
supplementation should be initiated to avoid long-term consequences. (See "Treatment of
vitamin D deficiency in adults".)
Additional testing may be necessary if there are findings consistent with hypothyroidism, PCOS,
Cushing syndrome, and sleep apnea [5,8,10,54]. Syndromic obesity should be evaluated in children
with developmental delay or dysmorphic features (table 7A). Endocrine causes of obesity are unlikely
if the growth velocity is normal during childhood or early adolescence [42] (see 'Stature' above). Thus,
laboratory screening for hypothyroidism is rarely indicated in a child with normal growth velocity. Of
note, mildly elevated levels of thyroid stimulating hormone (TSH) are more often found in obese
children as compared to normal-weight children, but this is a consequence rather than a cause of the
obesity [55]. Moreover, most of the weight gain in hypothyroid individuals is due to accumulation of
salt and water, so hypothyroidism rarely causes substantial weight gain.
Radiographic evaluation — The radiographic evaluation of overweight or obese children is directed

by findings on the history and physical examination.
■ Plain radiographs of the lower extremities should be obtained if there are clinical findings
consistent with slipped capital femoral epiphysis (hip or knee pain, limited range of motion,
abnormal gait) or Blount disease (bowed tibia). (See "Slipped capital femoral epiphysis
(SCFE)".)
■ Abdominal ultrasonography may be indicated in children with findings consistent with gallstones
(eg, abdominal pain, abnormal transaminases) [7].
■ Abdominal ultrasonography also may be used to confirm the presence of fatty liver. However,
the severity of liver involvement does not correlate with radiographic findings. (See
"Comorbidities and complications of obesity in children and adolescents", section on
'Nonalcoholic fatty liver disease'.)
INDICATIONS FOR REFERRAL — Children who have comorbidities of obesity that require rapid
weight loss warrant referral to pediatric obesity centers for appropriate dietary, pharmacologic, and/or
surgical therapy [7,11]. These comorbidities include:
■ Type 2 diabetes, strong evidence of increased diabetes risk, or polycystic ovary syndrome
(PCOS) (should also be referred to a pediatric endocrinologist) (see "Epidemiology,
presentation, and diagnosis of type 2 diabetes mellitus in children and adolescents" and
"Clinical features and diagnosis of polycystic ovary syndrome in adolescents")
■ Pseudotumor cerebri (should also be referred to a pediatric neurologist) (see "Idiopathic

intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis")
■ Sleep apnea (should also be referred to a pediatric sleep medicine specialist or pulmonologist)
(see "Evaluation of suspected obstructive sleep apnea in children")
■ Obesity hypoventilation syndrome (should also be referred to a pediatric sleep medicine

specialist or pulmonologist) (see "Clinical manifestations and diagnosis of obesity
hypoventilation syndrome")
■ Slipped capital femoral epiphysis or tibia vara (Blount disease) (should also be referred to a
pediatric orthopedist) (see "Slipped capital femoral epiphysis (SCFE)")
Other children who may merit referral to a pediatric obesity center include severely obese children
younger than two years, and children with severe obesity (eg, BMI ≥40 kg/m2, or ≥120 percent of the
95th percentile), even if they have no comorbidities [6]. Severely overweight children may benefit from
referral to a pediatric obesity specialist for more intensive therapy than can usually be provided by the
primary care provider.
Finally, certain overweight or obese children require referral to mental health specialists. These
include:
■ Overweight children who are depressed should be referred for psychologic evaluation and
treatment, since weight loss therapy may be ineffective without concurrent psychologic care [6].
■ Overweight children with findings suggestive of an eating disorder (eg, inability to control
consumption of large amounts of food, self-induced vomiting or laxative use to avoid weight
gain, dorsal finger lesions) should be evaluated by a therapist with experience in eating
disorders; such children require psychologic treatment and should not participate in weight
control programs without the concurrence of a therapist [6].
RESOURCES — Resources related to overweight in children and adolescents for health care
providers and families include:
■ The Maternal and Child Health Library Knowledge Path

(mchlibrary.info/KnowledgePaths/kp_overweight.html)
■ The American Academy of Pediatrics (aap.org/obesity)
■ The Centers for Disease Control and Prevention (cdc.gov/nccdphp/dnpa/obesity)
■ Produce for Better Health Foundation (5aday.com)
■ The Child Care Nutrition Resource System (nal.usda.gov/childcare/)
■ Weight Control Information Network (win.niddk.nih.gov/index.htm)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The
Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at
the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview and who
prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and
are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-
mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on “patient info” and the keyword(s) of interest.)
■ Basics topic (see "Patient information: My child is overweight (The Basics)")
SUMMARY AND RECOMMENDATIONS
■ Obesity has become one of the most important public health problems in the United States
(figure 1) (see "Definition; epidemiology; and etiology of obesity in children and adolescents",
section on 'Epidemiology').
■ The body mass index (BMI) is the accepted standard measure of obesity and overweight in
children. It is equal to the body weight (in kilograms) divided by the height (in meters) squared
(table 1). "Obesity" is defined by a body mass index (BMI) ≥95th percentile for age and sex
(figure 2A-B), and "overweight" is defined by a BMI between the 85th and 94th percentile for age
and sex (figure 2A-B). (See 'Diagnosis' above.)
■ Height and weight should be measured and BMI calculated at least yearly in children older than
two years. Those who are overweight or obese should undergo evaluation to identify treatable
causes and comorbidities. (See "Definition; epidemiology; and etiology of obesity in children
and adolescents", section on 'Etiology' and "Comorbidities and complications of obesity in
children and adolescents".)
■ The evaluation should include a complete history and physical examination, with particular
attention to the signs and symptoms of comorbidities and genetic and endocrinologic causes of
overweight. (See 'History' above and 'Examination' above.)
■ Overweight or obese children and adolescents should undergo basic screening for dyslipidemia
and nonalcoholic fatty liver disease, with a fasting lipid panel and measurement of alanine
aminotransferase. The clinical utility of routine screening for insulin resistance or vitamin D
deficiency in this population has not been established. Overweight or obese children greater
than 10 years of age who have two or more risk factors including a family history of type 2
diabetes, high-risk ethnicity, acanthosis nigricans, or polycystic ovarian syndrome (PCOS)
should be screened for type 2 diabetes, using a fasting blood glucose and/or hemoglobin A1C
(table 16). Evaluation for other comorbidities should be performed as indicated by the history
and physical examination. (See 'Laboratory studies' above and 'Radiographic evaluation'
above.)
■ Overweight and obese children and adolescents with diabetes mellitus, PCOS, pseudotumor
cerebri, sleep apnea, obesity hypoventilation syndrome, fatty liver disease, slipped capital
femoral epiphysis, and tibia vara (Blount disease) should be referred to a pediatric obesity
specialist for weight control. We also recommend referral for obese children younger than two
years. (See 'Indications for referral' above.)
■ Overweight and obese children and adolescents with symptoms and signs of depression
should be referred for psychologic evaluation and treatment. (See "Depression in adolescents:
Epidemiology, clinical manifestations, and diagnosis".)
■ Overweight and obese children and adolescents with symptoms and signs of an eating disorder
should be evaluated by a therapist with experience in eating disorders. We recommend that
such patients should not participate in weight control programs without the concurrence of their
therapist. (See "Eating disorders: Epidemiology, pathogenesis, clinical features, and course of
illness" and "Eating disorders: Overview of treatment".)
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REFERENCES
1. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US
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Topic 5861 Version 20.0
GRAPHICS
Prevalence of obesity* among children and teenagers, by age group and

selected period--United States, 1963-2010
* Children with body mass index (BMI) values at or above the 95th percentile of the sex-specific body mass
index (BMI) growth charts released by the Centers for Disease Control (CDC) in 2000.
National Health and Nutrition Examination Surveys. Additional information is available at:
http://www.cdc.gov/nchs/fastats/overwt.htm.
Calculation of body mass index (BMI)
English formula for BMI:

703 x Weight in pounds ÷ (Height in inches)2
Metric formula for BMI:

Weight in Kilograms ÷ (Height in meters)2
Body mass index-for-age percentiles, boys, 2 to 20 years, CDC

growth charts: United States
Developed by the National Center for Health Statistics in collaboration with the National Center
for Chronic Disease Prevention and Health Promotion (2000).
Body mass index-for-age percentiles, girls, 2 to 20 years, CDC

growth charts: United States
Developed by the National Center for Health Statistics in collaboration with the National Center
for Chronic Disease Prevention and Health Promotion (2000).
Child weight assessment algorithm
This algorithm reflects the author's approach to management of childhood

overweight and obesity in a primary care setting.
ALT: alanine aminotransferase.
* May be performed by nurse.
• Some providers also measure a fasting insulin level, for the purposes of counseling, rather
than for screening.
Courtesy of Dr. William Klish
Tips for maintaining a healthy weight: Nutrition
Phase I
Choose sugar-free beverages or low-fat milk only
Choose sugar-free beverages, water or low-fat (skim, one-half percent, and 1
percent) milk.
Limit milk to 16 to 24 ounces per day. Avoid flavored milks, including fat-free
versions.
Have fast food no more than once a week, and try the following healthier
options:
Choose plain hamburger kid's meal with water, diet soda, or skim milk.
Try a grilled chicken sandwich ordered without mayonnaise with a piece of fruit
from home.
Try a 6-inch, low-fat Subway sandwich (ordered without mayonnaise, cheese, or

oils), with baked chips or pretzels.
Avoid burgers with double meat, cheese, bacon, mayonnaise, and super-sized
french fries.
Choose three meals with one snack per day
Healthy breakfast ideas: two pieces whole wheat toast with a glass of skim milk;
small bowl of cereal such as bran flakes, Cheerios or old-fashioned oat meal with
skim milk; or a fat-free yogurt and a piece of fresh fruit.
Healthy snacks include fresh fruit, fat-free yogurt, or low-fat popcorn.
Limit snacks to one serving size.
Try the Plate Method at dinner. Design a dinner plate with one-half a plate of
vegetables, one-quarter plate of lean meat, and one-quarter plate of starch or
starchy vegetables (potatoes, corn, or peas) (see www.choosemyplate.gov). Avoid
second helpings.
Courtesy of Texas Children's Hospital.
Tips for maintaining a healthy weight: nutrition
Phase II
Eat a variety of foods.
Eat fruits, vegetables, whole grain breads, cereals, rice, and pastas; low-fat and fat
-free dairy products; lean chicken, turkey, fish, and legumes; and healthy fats. Use
a small amount of added fats and sugars. Avoid fried foods. See the Low-fat, Low-
Sugar Eating Guidelines for a list of food choices and sample menus.
Eat proper portion sizes.
Young children and inactive girls should choose the lower number of servings from
each food group. Most active school-aged children and teen girls, as well as
inactive teen boys should choose the middle number of servings. Active teen boys
and some very active teen girls should choose the higher number of servings from
each food group.
Number of
Group servings per Serving size
day
Bread, cereal, rice, 6 to 11 1 slice whole wheat bread; 1/2 cup cooked
pasta and starchy whole-grain cereal, brown rice, or whole
vegetable wheat pasta
Fruit 2 to 4 1 small piece fruit or 1/2 banana; 1 cup fresh

fruit such as melon or berries; 1/2 cup
canned fruit; four ounces juice; two
tablespoons dried fruit
Vegetable 3 to 5 1/2 cup cooked vegetables or vegetable

juice; 1 cup raw vegetables
Milk, yogurt, and 2 to 4 1 cup skim or 1 percent milk; 1 cup fat-free

cheese or low-fat yogurt; 1 ounce fat-free or
reduced fat cheese
Meat, poultry, fish, 2 to 3 2 to 3 ounces of skinless chicken, turkey, or

dry beans, eggs fish; 1/2 cup beans or tofu; 1/4 cup nuts; 2
and nuts tablespoons nut butter; 1/4 cup egg whites
or egg substitute
Fats, oils, sweets Use a small 1 teaspoon butter, margarine, mayonnaise,

amount oil, or sugar; 1 tablespoon salad dressing
Stock your house with healthful food choices.
Eliminate unhealthful food choices from your house including low-fat cookies, cakes
and ice cream as these foods are often enriched with sugar. Instead, stock your
house with fresh fruit, cut up vegetables and fat-free or low-fat yogurt. Children
can choose between an apple or yogurt for a snack, not an apple or potato chips.
Limit restaurant eating to 1 time per week.

Restaurants provide large food portions. Split entrees or plan to take half home. If
time is an issue, choose low-fat frozen dinners with bagged salad and/or a side of
frozen vegetables.
Take your lunch to school.

Pack a lunch with 2 ounces of lean meat or 1 ounce low-fat or fat-free cheese on
whole grain bread with one serving of fruit, vegetables and fat-free milk or yogurt.
Avoid eating breakfast at school. Instead, choose a bowl of whole grain cereal at
home.
Tips for maintaining a healthy weight: Low-fat, low-sugar eating

guidelines
Food Food to choose more

Food to limit
group often
Breads, Barley, bulgur, buckwheat Biscuits; store brought muffins,
cereals, (kasha); whole grain breads, croissants, sweet rolls, Danish,
starches and bagels, English muffins, and donuts; sugar coated
starchy hamburger buns, rolls, tortillas, cereals, crackers made with
vegetables crackers, cereals, pancakes, and saturated fats; pasta and rice
waffles; brown rice, whole dishes prepared in a butter
wheat pasta, whole wheat cream sauce; baked, fried,
couscous, unflavored oatmeal, mashed or scalloped potatoes
winter squash, sweet potatoes,
corn, corn tortillas
Vegetables Any fresh or frozen vegetable Any vegetables prepared in

such as artichoke and artichoke butter, cream, or cheese sauce;
hearts, asparagus, beans fried vegetables
(green, wax, Italian), bean
sprouts, beets, broccoli, brussel
sprouts, cabbage, carrots,
cauliflower, celery, cucumber,
eggplant, green onions, greens
(collard, kale, mustard, turnip),
mushrooms, okra, onions, pea
pods, peppers, radishes, salad
greens (endive, escarole,
lettuce, romaine, spinach),
sauerkraut, spinach, summer
squash, tomatoes and tomato
sauce, vegetable juices, water
chestnuts, watercress, zucchini
Fruits Whole fresh and frozen fruits Canned fruit, fruit juices, dried
such as apple, banana, fruit and fried fruits
blueberries, cantaloupe,
cherries, grapefruit, grapes,
honeydew melon, kiwi, mango,
orange, peach, pear, pineapple,
plums, and strawberries
Meat, poultry, Fish, shellfish, skinned white- Regular beef, pork, lamb, veal,
fish, dried meat chicken and turkey, and luncheon meats; fried
beans, eggs beans, peas, lentils, egg chicken and fish, eggs, sausage,
substitutes, egg whites, hot dogs
soybeans, and tofu
Milk, yogurt Skim and 1 percent milk, plain 2 percent and whole milk, 1
and cheese nonfat yogurt, nonfat yogurt percent and whole chocolate
sweetened with aspartame or milk, goat's milk, kefir, low-fat
nonnutritive sweetener; fat-free yogurt (plain or fruit flavored),
or low-fat cheese and cottage custard-style yogurt, regular
cheese cheese and cottage cheese
Tips for maintaining a healthy weight: Low-fat, low-sugar eating

guidelines
Food Food to choose more

Food to limit
group often
Fats Almonds, avocado, canola oil; Bacon, butter, chitterlings,
fat-free or reduced-fat coconut; cream (half and half,
margarine, mayonnaise and whipped cream), cream cheese,
salad dressings; olives, olive oil, saturated fats such as coconut,
peanut butter, peanuts, palm and palm kernel oils;
sunflower seeds, walnuts shortening or lard, sour cream
Sweets Sugar substitutes such as Equal, Candy, sugar, syrup, honey,

Sweet 'n Low, or Splenda; light jam, jelly, gelatin, Popsicles and
or sugar-free syrups, light or fruit juice bars, fruit snacks and
low-sugar jams and jellies; fruit leather
sugar-free gelatin; sugar-free
Popsicles
Beverages Water, diet sodas, sugar-free Regular sodas, fruit juices,

drink mixes, sugar-free flavored sports drinks, drink mixes,
water, unsweetened iced tea, sweet tea, and flavored coffee
coffee beverages
Miscellaneous Catsup, mustard, pickles, salsa,

spices, lemon juice
Snacks (in Low-fat popcorn, pretzels, Chips, buttered popcorn; store

very limited baked or low-fat chips, rice bought cakes, cookies and pies;
amounts) cakes, graham crackers, granola chocolate, sherbet, ice cream,
bars, fat-free and low-fat frozen pudding
yogurt, fat-free fudge bars,
homemade fruit smoothies
Low-fat, low-sugar eating guidelines sample menus*
Breakfast Breakfast Breakfast

2 slices whole-grain Breakfast taco (small whole- 1 cup old-fashioned
bread or frozen waffles wheat flour tortilla, 1/2 cup oatmeal
egg substitute, 1 ounce
2 teaspoons almond reduced-fat cheese, 2 1 cup skim milk
butter tablespoons salsa)
1 small pear
1 cup skim milk or 1 small orange
yogurt Lunch
Lunch
1 small banana Peanut butter
2 ounces water-packed tuna sandwich on whole
Lunch mixed with 1 tablespoon light wheat bread
mayonnaise, chopped celery
Turkey sandwich (2 Apple
ounces turkey breast 10 whole grain crackers
on a whole- grain bread 1 cup carrot and
or roll) 1 small apple celery sticks
1 cup green grapes 1 cup skim milk or fat-free, 2 tablespoons light

ranch dressing
1 cup baby carrots, reduced-calorie yogurt
jicama and bell pepper 1 cup skim milk or
strips Water or diet soda fat-free, reduced-
calorie yogurt
2 tablespoons fat-free Dinner
ranch dressing Water or diet soda
1 cup vegetable soup (carrots,
1 cup skim milk or fat- celery, onions, tomato) Dinner
free, reduced-calorie
yogurt 2-3 ounces grilled chicken 3-4 ounces baked
breast (skinless) barbeque chicken
Bottled water or diet breast (skinless)
soda 1/2 cup black beans
1/2 cup mashed
Dinner 1/2 cup steamed/boiled brown sweet potato
rice
3-4 ounces grilled 1/2 cup steamed
salmon 2 corn tortillas cabbage
2/3 cup steamed/boiled 1 cup lettuce and tomato salad 1/2 cup steamed
brown rice with 1/8 avocado slice turnip greens
2 cups mixed salad Water or unsweetened iced tea 1 small whole grain
greens roll with 1
Snack tablespoon light
1 tablespoon balsamic margarine
vinegar with 2 1/2 mango
teaspoons olive oil Water or
1 cup fat-free, reduced-calorie unsweetened iced
1/2 cup steamed green yogurt with 1 ounce almond tea
beans slivers
Snack
Water with lemon
6 cups low-fat
Snack popcorn
Fruit smoothie Diet soda or sugar-

free Kool-Aid
(1 cup skim milk, 1 cup
frozen fruit such as
peaches or mixed
berries)
3 cups low-fat popcorn
1 ounce peanuts
* All meals are prepared without added fat.

Tips for maintaining a healthy weight: exercise
Exercise Phase I
Begin decreasing time spent in sedentary activities.
Identify how many hours per day your family spends in sedentary activities such as
watching TV, playing video games, and surfing the internet and make efforts to
decrease this time every day this week. Explore ways to be physically active on a
daily basis.
Exercise Phase II
Decrease sedentary time
Limit television, video games and computer time to no more than 1 hour per day.
Limiting sedentary time will encourage children to choose other activities, most of
which will generate increased physical activity. Buy active toys rather than
computer games or videotapes. Define indoor areas for physical play such as "Nerf"
balls, bouncy balls or scooter toys.
Incorporate physical activity into daily routines.

Walk or ride bike to school. Play outdoors, in the gym or on the playground for 30
minutes before homework every day. Walk with friends instead of talking to them
on the telephone.
Accumulate 1 hour of physical activity during the day.

Both children and adults should be active for 1 hour every day. This activity can be
accumulated throughout the day. Consider purchasing a pedometer ($10 - $15)
and join the 10,000 steps a day program.
Be physically active as a family.

Plan family activities for the weekend such as bike riding, hiking; trips to the zoo,
museum or library; and house or yard projects. Take family walks.
Consider participating in organized sports or physical activities.

Get involved in team sports or marching band at school. Take classes in activities
that you enjoy such as dance, martial arts, swimming or tennis; or buy an aerobics
tape and exercise at home.
Tips for maintaining a healthy weight: tips for parents
Be a good role model.

Children learn by example. Eat a variety of healthful foods and be physically active
every day so that your children will learn healthful habits.
Offer structured meals and snacks.

Most children need food every 4 - 5 hours. Three meals and one snack time is
appropriate for most school-aged children. Discourage between meal "grazing." Plan
meals and snacks ahead of time.
Disband the "clean plate" club.

Children are born with an innate sense of when they have had enough to eat.
Encouraging them to eat past the point of fullness will result in weight gain.
Never use food as a reward or punishment.

Food is for nourishing and fueling bodies. Instead, use non-food rewards such as
special time spent together.
Remember the rules.

Parents should be responsible for offering healthy foods and structured meals and
snacks. Children should decide how much they eat. Be consistent.
Choosing a weight maintenance program.

The program should:
Be staffed with a variety of health professionals. The best programs include
pediatric dietitians, exercise physiologists, physicians, and psychiatrists or
psychologists.
Perform in depth medical assessment and medical monitoring.
Focus on the whole family, and not just the overweight child.
Be adapted to the specific age and capabilities of the child.
Focus on behavior changes including appropriate diet and physical activity.
Include a maintenance program or other support and referral resources to deal

with underlying issues that contributed to being overweight.
Tips for dietary counseling in children
Challenge Possible solutions

Family has little or no structure Encourage family to eat meals together.
to dietary patterns (few family
meals, meals are not eaten at Emphasize scheduling of meals and snacks.
the table, television on during
meals, etc...) Avoid skipping meals.
Limit meal-time distractions (eg, television).
Child is motivated by sports Emphasize physical activity as primary goal; frame

and activity, but has little dietary recommendations as tools to be stronger
interest in making dietary and improve athletic performance.
changes
Discuss energy in versus energy out; emphasize
the importance of achieving proper balance
between nutrition and activity.
Family frequently eats meals Identify barriers that prevent families from eating
away from home at home more often.
Provide meal-planning resources, initially using

recipes that are familiar to them; begin the process
of cooking more at home using these recipes.
Assess the type of restaurant, usual selections, and

discuss alternatives.
Large portion sizes Emphasize structured (pre-planned and timed)

meals and snacks.
Provide tools and education to help child learn to

pay attention to bodily cues for hunger and
fullness.
Fast eating pace Emphasize that eating slowly is important in

recognizing fullness.
Provide family with strategies to slow down eating

pace.
Discuss "mindful eating" and encourage all family

members to practice slow, mindful eating.
Poor dietary quality (lack of Provide education about food groups, discussing
fruits/vegetables and whole the importance of each food group as part of the
grains, consumption of whole daily diet.
milk, etc...)
One approach is to discuss the concept of a
"balanced plate," focusing on supplying ample
vegetables, fruits and fiber (approximately 1/4
plate each for vegetables, grains, fruits, and
protein). Guidance available at
www.choosemyplate.gov.
Lacks nutritional knowledge Assess family's level of nutritional knowledge, and

(no label reading, does not start by helping them set small goals, such as
make shopping list, etc...) balancing their plates or providing a variety of
foods.
When the family is ready, increase goals gradually

by discussing which foods should be eaten most
often, which foods should be eaten sparingly, and
teaching the family how to read food labels.
Excessive refined grains (white Emphasize the importance of including fiber in the
bread) and simple diet as a means of decreasing hunger and feeling
carbohydrates (sugars) full after eating.
Explain that whole grains are digested and

absorbed at a slower rate than refined gains and
sugars, resulting in a more stable blood sugar
which reduces hunger and is healthier.
High-fat dairy intake Compare nutritional information in high fat dairy

products to low fat dairy products.
Discuss types of fat: which fats are healthier, and

which fats should be avoided (ie, trans fats and
saturated fats).
Skipping meals Emphasize the importance of eating three regularly

-scheduled meals a day to have a healthy weight
and metabolism.
Explain that meal-skipping can lead to increased

hunger and excessive eating later.
Start by establishing a small goal to eat just one

food group at the time that they would usually skip
a meal.
Increase goal gradually by introducing other food

groups as the child is ready; encouraging them to
achieve a balanced meal.
Excessive snacking Set a snack schedule between meals to encourage

less grazing.
Outline several choices for healthy snacks.
Emphasize the importance of eating a single

portion of food from two different food groups to
encourage fullness until the next meal.
High intake of sugar- Discuss empty calories from sugar-containing

sweetened beverages beverages (which include 100 percent fruit juice).
Estimate the number of calories that the child is

currently taking from beverages.
Suggest low-sugar alternatives for family to try.
Low fruit and vegetable intake Provide education regarding serving sizes of
vegetables and fruits.
Discuss the importance of fiber from vegetables

and fruits.
Have the family try new vegetables and fruits to

increase variety.
Provide quick and easy recipes or products.
Picky eating Introduce child to new foods gradually.
Provide the same foods for each family member;

no "special orders."
Eat meals and snacks together as a family.
Structure meals and snacks.
Encourage, but do not pressure child to eat a

specific food. Continue to offer the same food on
multiple occasions.
Selected genetic syndromes associated with obesity
Obesity
Clinical
Syndrome Locus Gene onset
features
(type)
Albright hereditary 20q13.2 GNAS1 Early Short stature,
osteodystrophy (generalized) short
(Pseudohypoparathyroidism metacarpals and
type 1a) (MIM #103580) metatarsals,
round facies,
delayed
dentition, +/−
hypocalcemia
and/or
subcutaneous
calcium or bone
deposition
(osteoma cutis),
precocious
puberty, mild
cognitive deficit
Alström (MIM #203800) 2p13 ALMS1 Age 2-5 yrs Blindness,

(central) deafness,
acanthosis
nigricans, chronic
nephropathy,
type 2 diabetes,
cirrhosis, primary
hypogonadims in
males only,
normal cognition
Bardet-Biedl (MIM 11q13 BBS1 Age 1-2 yrs Mental

#209900) (central) retardation,
16q21 BBS2 hypotonia,
retinitis
3p12-q13 BBS3 pigmentosa,
(ARL6) polydactyly,
hypogonadism
15q22.3- BBS4 +/− glucose
q23 intolerance,
deafness, renal
2q31 BBS5
disease
20p12 BBS6
(MKKS)
4q27 BBS7
14q32 BBS8
(TTC8)
7p14 BBS9
12q BBS10
9q33.1 BBS11
(TRIM32)
4q27 BBS12
17q23 BBS13
(MKS1)
12q21.3 BBS14
(CEP290)
2p15 BBS15
(C2ORF86)
Beckwith-Wiedemann (MIM 11p15.5 in multiple − Hyperinsulinemia,

#130650) most cases; hypoglycemia,
deregulation hemihypertrophy,
of imprinted intolerance of
genes fasting
including
IGF2
Carpenter (MIM #201000) 6p11 RAB23 (central) Mental

retardation, short
stature,
brachycephaly,
polydactyly,
syndactyly of
feet,
cryptorchidism,
umbilical hernia,
high-arched
palate,
hypogonadism in
males only
Cohen (MIM #216550) 8q22 COH1 Mid- Mental

childhood retardation,
(central) microcephaly,
small hands and
feet,
cryptorchidism,
hypotonia and
failure to thrive in
infancy,
prominent central
incisors, long,
thin fingers and
toes
Prader-Willi (MIM 15q Age 1-3 yrs Microcephaly,

#176270) (generalized) short stature,
hypotonia,
almond- shaped
eyes, high-arched
palate, narrow
hands and feet,
delayed puberty,
early failure to
thrive with
hyperphagia and
increased weight
gain by 2-3
years, mild to
moderate
cognitive deficit
Adapted from:
1. Pediatric Obesity. In: Pediatric Nutrition Handbook, 6th ed, Kleinman R (Ed), American
Academy of Pediatrics, Elk Grove Village, IL, 2009. p.751
2. Hoppin AG. Obesity. In: Pediatric Gastrointestinal Disease: Pathopsychology, Diagnosis,
Management, 4th ed, Walker WA, Goulet O, Kleinman, RE, et al (Eds), BC Decker,
Ontario, 2004. p.311.
3. Leibel RL, Chua SC, Rosenbaum M. Obesity. In: The Metabolic and Molecular Bases of
Inherited Disease, 8th ed, Scriver CR, Beaudet AL, Sly WS, Valle D (Eds), McGraw-Hill,
New York, 2001. p.3965.
Single gene defects associated with obesity
Single gene
Chromosome Clinical features
disorder
Leptin deficiency (LEP) 7q31.3 Severe, early onset obesity,
hypometabolic rate, hyperphagia,
pubertal delay, impaired glucose
tolerance, hypothalamic
hypogonadism
Pro-opiomelanocortin 2p23.3 Severe, early onset obesity, red

deficiency (POMC) hair, hyperphagia, adrenal
insufficiency, hyperpigmentation
Proprotein convertase 1 5q15-q21 Early onset obesity, abnormal

(PCSK1, also known as glucose homeostasis,
prohormone convertase hypogonadotropic hypogonadism,
1) hypocortisolism, elevated plasma
proinsulin and POMC
Melanocortin receptor 4 18q21.3-q22 Early onset, moderate-severe

haploinsufficiency (MC4R) obesity, early onset hyperphagia,
increased bone density
Leptin receptor deficiency 1p31-p22 Severe, early onset obesity,

(LEPR) hypometabolic rate, hyperphagia,
pubertal delay, hypothalamic
hypogonadism
Adapted from:
1. Hoppin AG. Obesity. In: Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis
and Management, 4th ed, Walker WA, Goulet O, Kleinman RE, et al (Eds), BC Decker,
Ontario, 2004. p.311
2. Leibel RL, Chua SC, Rosenbaum M. Obesity. In: The Metabolic and Molecular Bases of
Inherited Disease, 8th ed, Scriver CR, Beaudet AL, Sly WS, Valle D (Eds), McGraw-Hill,
New York, 2001. p.3965.
Assessment of nutritional factors related to childhood obesity
Examples of
Nutritional Contribution to weight
questions for clinical
factor gain
assessment
Restaurants Meals eaten away from home "How many times a week
and fast food increase portion size and total does your family get
energy intake, and are of poorer takeout food?"
[1-6]
nutrient quality . Increased
frequency of eating meals away "How many meals a week
from home is associated with does your family eat at a
[7,8] restaurant or eat fast food?"
increased BMI .
Sweetened High intake of sugar-sweetened "How many times a day, or

beverages beverages is linked to increased how many ounces, does
[9- your child drink the
prevalence of obesity in children
11]
, but causality has not been following: juice, soda,
flavored milk, sports drinks,
established[12]. Fruit juice also
or sweetened tea?"
should be considered a sweetened
beverage.
Portion sizes Larger portions lead to increased "Are seconds or large

[13-15] portions a challenge for
energy intake .
your child?"
"How many baseball-size

servings of pasta, rice, or
cereal does your child eat at
a meal?"
"How many decks of cards

of meat or protein does
your child eat at a meal?"
Energy-dense An association between energy "How often does your child

foods dense foods and obesity has been eat fried foods?"
established in adults, but not yet in
children [15]. "What does your child
typically eat for snacks?"
"What type of milk, cheese,

cereal, and protein do you
have at home?"
Fruits and Eating fruits and vegetables may "What fruits and vegetables
vegetables displace more energy dense foods do you currently have in
and increase satiety. There is some your home?"
evidence that low consumption of
these foods is associated with "How often does your child
obesity [16-18]. eat vegetables at lunch or
dinner?"
"At which meals or snacks

does your child eat fruit?"
Breakfast Skipping breakfast associated with "When is the first time your
increasing obesity in children child typically
despite perceived decrease in daily has something to eat or
[19-23] drink after waking up?"
caloric intake , and has
adverse effects on school
[24-26] "Does your child eat
performance .
breakfast at home or at
school?"
"How often does your child

skip breakfast?"
Meal Snacking tends to result in "When does your child eat

frequency and increased energy intake and poorer meals and snacks at
snacking diet quality; a direct association home?"
between snacking and obesity in
children has not been established. "Where does your child eat
their snacks?"
"How long after a meal does

your child eat a snack?"
"How many snacks does

your child eat on the
weekends?"
References:
1. Whitlock EP, O'Connor EA, Williams SB, Beil TL, Lutz KW. Effectiveness of Weight
Management Interventions in Children: A Targeted Systematic Review for the USPSTF.
Pediatrics 2010.
2. Paeratakul S, Ferdinand DP, Champagne CM, Ryan DH, Bray GA. Fast-food consumption
among US adults and children: dietary and nutrient intake profile. J Am Diet Assoc 2003;
103:1332-8.
3. Diliberti N, Bordi PL, Conklin MT, Roe LS, Rolls BJ. Increased portion size leads to
increased energy intake in a restaurant meal. Obes Res 2004; 12:562-8.
4. Bowman SA, Gortmaker SL, Ebbeling CB, Pereira MA, Ludwig DS. Effects of fast-food
consumption on energy intake and diet quality among children in a national household
survey. Pediatrics 2004; 113:112-8.
5. French SA, Story M, Neumark-Sztainer D, Fulkerson JA, Hannan P. Fast food restaurant
use among adolescents: associations with nutrient intake, food choices and behavioral
and psychosocial variables. Int J Obes Relat Metab Disord 2001; 25:1823-33.
6. Nielsen SJ, Siega-Riz AM, Popkin BM. Trends in food locations and sources among
adolescents and young adults. Prev Med 2002; 35:107-13.
7. Schmidt M, Affenito SG, Striegel-Moore R, Khoury PR, Barton B, Crawford P, Kronsberg S,
Schreiber G, Obarzanek E, Daniels S. Fast-food intake and diet quality in black and white
girls: the National Heart, Lung, and Blood Institute Growth and Health Study. Arch Pediatr
Adolesc Med 2005; 159:626-31.
8. Thompson OM, Ballew C, Resnicow K, Must A, Bandini LG, Cyr H, Dietz WH. Food
purchased away from home as a predictor of change in BMI z-score among girls. Int J
Obes Relat Metab Disord 2004; 28:282-9.
9. Pereira MA, Kartashov AI, Ebbeling CB, Van Horn L, Slattery ML, Jacobs DR Jr, Ludwig DS.
Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year
prospective analysis. Lancet 2005; 365:36-42.
10. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-
sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet
2001; 357:505-8.
11. Harnack L, Stang J, Story M. Soft drink consumption among US children and adolescents:
nutritional consequences. J Am Diet Assoc 1999; 99:436-41.
12. Tordoff MG, Alleva AM. Effect of drinking soda sweetened with aspartame or high-fructose
corn syrup on food intake and body weight. Am J Clin Nutr 1990; 51:963-9.
13. Lewis CJ, Park YK, Dexter PB, Yetley EA. Nutrient intakes and body weights of persons
consuming high and moderate levels of added sugars. J Am Diet Assoc 1992; 92:708-13.
Rolls BJ, Engell D, Birch LL. Serving portion size influences 5-year-old but not 3-year-old
children's food intakes. J Am Diet Assoc 2000; 100:232-4.
14. Krebs NF, Himes JH, Jacobson D, Nicklas TA, Guilday P, Styne D. Assessment of child and
adolescent overweight and obesity. Pediatrics 2007; 120 Suppl 4:S193-228.
15. Orlet Fisher J, Rolls BJ, Birch LL. Children's bite size and intake of an entree are greater
with large portions than with age-appropriate or self-selected portions. Am J Clin Nutr
2003; 77:1164-70.
16. McCrory MA, Fuss PJ, Hays NP, Vinken AG, Greenberg AS, Roberts SB. Overeating in
America: association between restaurant food consumption and body fatness in healthy
adult men and women ages 19 to 80. Obes Res 1999; 7:564-71.
17. Bazzano LA, He J, Ogden LG, Loria CM, Vupputuri S, Myers L, Whelton PK. Fruit and
vegetable intake and risk of cardiovascular disease in US adults: the first National Health
and Nutrition Examination Survey Epidemiologic Follow-up Study. Am J Clin Nutr 2002;
76:93-9.
18. Maskarinec G, Novotny R, Tasaki K. Dietary patterns are associated with body mass index
in multiethnic women. J Nutr 2000; 130:3068-72.
19. Wolfe WS, Campbell CC, Frongillo EA Jr, Haas JD, Melnik TA. Overweight schoolchildren in
New York State: prevalence and characteristics. Am J Public Health 1994; 84:807-13.
20. Gibson SA, O'Sullivan KR. Breakfast cereal consumption patterns and nutrient intakes of
British schoolchildren. J R Soc Health 1995; 115:366-70.
21. Ortega RM, Requejo AM, Lopez-Sobaler AM, Quintas ME, Andres P, Redondo MR, Navia B,
Lopez-Bonilla MD, Rivas T. Difference in the breakfast habits of overweight/obese and
normal weight schoolchildren. Int J Vitam Nutr Res 1998; 68:125-32.
22. Pastore DR, Fisher M, Friedman SB. Abnormalities in weight status, eating attitudes, and
eating behaviors among urban high school students: correlations with self-esteem and
anxiety. J Adolesc Health 1996; 18:312-9.
23. Summerbell CD, Moody RC, Shanks J, Stock MJ, Geissler C. Relationship between feeding
pattern and body mass index in 220 free-living people in four age groups. Eur J Clin Nutr
1996; 50:513-9.
24. Wyatt HR, Grunwald GK, Mosca CL, Klem ML, Wing RR, Hill JO. Long-term weight loss and
breakfast in subjects in the National Weight Control Registry. Obes Res 2002; 10:78-82.
25. Murphy JM, Pagano ME, Nachmani J, Sperling P, Kane S, Kleinman RE. The relationship of
school breakfast to psychosocial and academic functioning: cross-sectional and
longitudinal observations in an inner-city school sample. Arch Pediatr Adolesc Med 1998;
152:899-907.
26. Ross MM, Kolbash S, Cohen GM, Skelton JA. Multidisciplinary treatment of pediatric
obesity: nutrition evaluation and management. Nutr Clin Pract 2010; 25:327-34.
Data from:
Krebs NF, et al. Pediatrics 2007; 120:S193.
Ross MM, et al. Nutr Clin Pract 2010; 25:327.
Assessment of physical activity in children
Sedentary behaviors
Hours spent watching television, including videos or movies
Hours spent playing video games (hand-held, internet or on-line, or television/video-

based)
Hours spent on computer or in internet-based activities, aside from school work
Hours spent talking on telephone or texting
Hours spent doing productive sedentary behaviors, such as homework, reading, and
computer-based learning
Physical activity behaviors

Type, frequency, duration, and intensity of structured physical activity (organized
physical activity, such as sports)
Time spent in unstructured play (eg, outside play, and routine activity such as
walking to school)
Example of questions to ask for a brief semi-quantitative assessment of physical

activity in children. Evaluating activity in each of these areas provides an
estimate of the child's overall activity level, and helps identify areas for potential
improvement.
Based on recommendations in: Krebs NF, Himes JH, Jacobson D, Nicklas TA, Guilday P, Styne
D. Assessment of child and adolescent overweight and obesity. Pediatrics 2007; 120 Suppl
4:S193-228.
Drugs that cause weight gain and some alternatives
Drugs that cause weight Possible

Category
gain alternatives
Antipsychotics
Conventional Thioridazine Haloperidol
Atypical Olanzapine, Clozapine, Quetiapine, Ziprasodone, Aripiprazole

Risperidone
Lithium Lithium carbonate
Anti-depressants
Tricyclics Amitriptyline, Clomipramine, Doxepin, Protriptyline
Imipramine, Nortriptyline
Selective serotonin Paroxetine Other SSRIs

reuptake inhibitors
Other Mirtazapine Bupropion, Nefazadone
Anticonvulsant drugs Valproate, Carbamazepine, Topiramate,

Gabapentin Lamotrigine,
Zonisamide
Antidiabetic drugs Insulin, Sulfonylureas, Metiglinide, Metformin, Alpha-

Thiazolidinediones glucosidase inhibitors
Serotonin and Pizotifen

histamine antagonist
Antihistamines Cyproheptidine
Beta-adrenergic Propranolol, Atenolol, Metoprolol

blockers
Steroid hormones Glucocorticoids
Progestins: Megestrol acetate,

Medroxyprogesterone acetate
Copyright ©2001 George A Bray, MD. Reproduced with permission.
Important aspects of the review of systems in overweight or

obese children
Additional studies or
Symptom Potential significance
referral
Delayed Genetic syndrome Pediatric geneticist and/or
development neurologist
Short stature or Genetic syndrome Pediatric geneticist

reduced height
velocity Endocrinologic etiology (eg, 24 hour urine collection for free
Cushing syndrome, cortisol, thyroid function tests;
hypothyroidism, ROHHADNET pediatric endocrinologist
syndrome [rapid onset obesity
with hypothalamic dysfunction,
hypoventilation, autonomic
dysregulation, and neural crest
tumor])
Headaches Pseudotumor cerebri Pediatric neurologist
Snoring Sleep apnea, obesity Polysomnogram (sleep study)

hypoventilation syndrome and/or referral to a pediatric
sleep medicine or ENT specialist
Daytime Sleep apnea, obesity Polysomnogram (sleep study),

sleepiness hypoventilation syndrome possibly blood gasses; and/or
referral to a pediatric sleep
medicine, pulmonologist, or
ENT specialist
Abdominal pain Gall bladder disease Liver function tests, abdominal

ultrasonography
Nonalcoholic fatty liver disease Liver function tests; pediatric

gastroenterologist
Hip pain, knee Slipped capital femoral Radiographs; pediatric

pain, limp epiphysis (SCFE) or Blount orthopedist
disease (tibia vara)
Oligomenorrhea Polycystic ovary syndrome Pediatric endocrinologist or

or amenorrhea (PCOS) adolescent specialist
Prader-Willi syndrome Pediatric geneticist
Urinary Type 2 diabetes Urinalysis, fasting blood

frequency, glucose, hemoglobin A1c,
nocturia, glucose tolerance test; pediatric
polydipsia, endocrinologist
polyuria
Binge eating or Eating disorder Specialist in eating disorders

purging
Insomnia Depression Pediatric psychologist or

psychiatrist
Anhedonia Depression Pediatric psychologist or

psychiatrist
ENT: ear/nose/throat.
Adapted from: Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee
recommendations. The Maternal and Child Health Bureau, Health Resources and Services
Administration and the Department of Health and Human Services. Pediatrics 1998; 102:E29
and Dietz WH, Robinson TN. Clinical practice. Overweight children and adolescents. N Engl J
Med 2005; 352:2100.
Findings of note on physical examination in children with obesity
Exam
Definition Clinical concern raised
finding
Endocrine or genetic condition
Short stature Height <50th percentile with (eg, Cushing syndrome)
weight >95th percentile* (if not
OR explained by familial short
unexplained stature)
decrease in
height velocity Growth velocity <5 cm/year in a
prepubertal child, or declining
across over two or more height
percentile curves on a standard
chart (eg, decreasing from the
90th to the 50th percentile)
Hypertension Hypertension if systolic or Essential hypertension, renal

diastolic blood pressure >95th disease, or Cushing syndrome
percentile for age, gender, and
height on ≥3 occasions
Acanthosis Hyperpigmented, thickened, Increased risk of insulin

nigricans velvety skin in body folds and resistance
creases, particularly neck
Excessive Hirsutism: excessive growth of Polycystic ovary syndrome

acne, hair in atypical areas, such as (PCOS)
hirsutism face and neck
Violaceous Linear lesions, red, pink, or Cushing syndrome

striae purple in color, particularly on
abdomen
Papilledema, Optic disc swelling on Pseudotumor cerebri (idiopathic

cranial nerve funduscopic exam, caused by intracranial hypertension)
VI paralysis increased intracranial pressure
Tonsillar Tonsils occupy more than 50 Obstructive sleep apnea

hypertrophy percent of the lateral dimension
of oropharynx
Goiter Enlarged or swollen thyroid Hypothyroidism

gland
Wheezing High-pitched whistling on Asthma

auscultation
Hepatomegaly, Increased liver span Non-alcoholic fatty liver disease,

right upper or gallstones
quadrant
tenderness
Micropenis Unusually small penis In most cases the small-

appearing penis is actually
normal size; the length is buried
under suprapubic fat
Undescended Testicle not palpable in scrotum Prader-Willi syndrome

testes
Abnormal gait, Slipped capital femoral

limp, pain in epiphysis (SCFE)
hip or groin,
limited range
of motion in
hip
Bowing of tibia Lower leg angles inward, Blount disease

causing a bowleg appearance
Small hands Genetic condition (eg, Prader-

and feet, or Willi syndrome or Bardet-Biedl
polydactyly syndrome)
* Most children with obesity who have not completed linear growth are relatively tall for their
age. Therefore, height <50th percentile is unusual.
Determining appropriate blood pressure cuff size in children
The width of the bladder of the blood pressure cuff should be approximately 40
percent of the circumference of the upper arm midway between the olecranon
and the acromion. The length of the bladder of the cuff should encircle 80 to 100
percent of the circumference of the upper arm at the same position.
Blood pressure levels for boys by age and height percentile
Systolic BP (mmHg) Diastolic BP (mmHg)

Age BP
Percentile of height Percentile of
(year) (percentile)
th th th th th th th th th th th
5 10 25 50 75 90 95 5 10 25 50
1 th 80 81 83 85 87 88 89 34 35 36 37
50
90th 94 95 97 99 100 102 103 49 50 51 52
th 98 99 101 103 104 106 106 54 54 55 56

95
99th 105 106 108 110 112 113 114 61 62 63 64
2 th 84 85 87 88 90 92 92 39 40 41 42
50
th 97 99 100 102 104 105 106 54 55 56 57
90
95th 101 102 104 106 108 109 110 59 59 60 61
th 109 110 111 113 115 117 117 66 67 68 69

99
3 th 86 87 89 91 93 94 95 44 44 45 46
50
th 100 101 103 105 107 108 109 59 59 60 61
90
th 104 105 107 109 110 112 113 63 63 64 65
95
99th 111 112 114 116 118 119 120 71 71 72 73
4 th 88 89 91 93 95 96 97 47 48 49 50
50
th 102 103 105 107 109 110 111 62 63 64 65
90
th 106 107 109 111 112 114 115 66 67 68 69
95
th 113 114 116 118 120 121 122 74 75 76 77
99
5 50th 90 91 93 95 96 98 98 50 51 52 53
th 104 105 106 108 110 111 112 65 66 67 68

90
95th 108 109 110 112 114 115 116 69 70 71 72
th 115 116 118 120 121 123 123 77 78 79 80

99
6 th 91 92 94 96 98 99 100 53 53 54 55
50
90th 105 106 108 110 111 113 113 68 68 69 70
th 109 110 112 114 115 117 117 72 72 73 74

95
99th 116 117 119 121 123 124 125 80 80 81 82
7 50th 92 94 95 97 99 100 101 55 55 56 57
th 106 107 109 111 113 114 115 70 70 71 72

90
95th 110 111 113 115 117 118 119 74 74 75 76
th 117 118 120 122 124 125 126 82 82 83 84

99
8 th 94 95 97 99 100 102 102 56 57 58 59

50
90th 107 109 110 112 114 115 116 71 72 72 73
th 111 112 114 116 118 119 120 75 76 77 78

95
99th 119 120 122 123 125 127 127 83 84 85 86
9 50th 95 96 98 100 102 103 104 57 58 59 60
th 109 110 112 114 115 117 118 72 73 74 75

90
95th 113 114 116 118 119 121 121 76 77 78 79
th 120 121 123 125 127 128 129 84 85 86 87

99
10 th 97 98 100 102 103 105 106 58 59 60 61

50
90th 111 112 114 115 117 119 119 73 73 74 75
th 115 116 117 119 121 122 123 77 78 79 80

95
99th 122 123 125 127 128 130 130 85 86 86 88
11 th 99 100 102 104 105 107 107 59 59 60 61

50
th 113 114 115 117 119 120 121 74 74 75 76
90
th 117 118 119 121 123 124 125 78 78 79 80
95
th 124 125 127 129 130 132 132 86 86 87 88
99
12 50th 101 102 104 106 108 109 110 59 60 61 62
th 115 116 118 120 121 123 123 74 75 75 76

90
th 119 120 122 123 125 127 127 78 79 80 81
95
th 126 127 129 131 133 134 135 86 87 88 89
99
13 th 104 105 106 108 110 111 111 60 60 61 62

50
90th 117 118 120 122 124 125 126 75 75 76 77
th 121 122 124 126 128 129 130 79 79 80 81

95
th 128 130 131 133 135 136 137 87 87 88 89
99
14 50th 106 107 109 111 113 114 115 60 61 62 63
th 120 121 123 125 126 128 128 75 76 77 78

90
95th 124 125 127 128 130 132 132 80 80 81 82
th 131 132 134 136 138 139 140 87 88 89 90

99
15 th 109 110 112 113 115 117 117 61 62 63 64

50
90th 122 124 125 127 129 130 131 76 77 78 79
th 126 127 129 131 133 134 135 81 81 82 83

95
99th 134 135 136 138 140 142 142 88 89 90 91
16 th 111 112 114 116 118 119 120 63 63 64 65

50
90th 125 126 128 130 131 133 134 78 78 79 80
th 129 130 132 134 135 137 137 82 83 83 84

95
99th 136 137 139 141 143 144 145 90 90 91 92
17 50th 114 115 116 118 120 121 122 65 66 66 67
th 127 128 130 132 134 135 136 80 80 81 82

90
95th 131 132 134 136 138 139 140 84 85 86 87
th 139 140 141 143 145 146 147 92 93 93 94

99
th th
The 90 percentile is 1.28 standard deviation, 95 percentile is 1.645 standard
th
deviation, and the 99 percentile is 2.326 over the mean.
BP: blood pressure.
From: the Fourth report on the diagnosis, evaluation, and treatment of high blood pressure in
children and adolescents. National Heart, Lung and Blood Institute. National Institutes of
Health. May 2004.
Blood pressure levels for girls by age and height percentile
Systolic BP (mmHg) Diastolic BP (mmHg)

Age BP
Percentile of height Percentile of
(year) (percentile)
th th th th th th th th th th th
5 10 25 50 75 90 95 5 10 25 50
1 th 83 84 85 86 88 89 90 38 39 39 40
50
90th 97 97 98 100 101 102 103 52 53 53 54
th 100 101 102 104 105 106 107 56 57 57 58

95
99th 108 108 109 111 112 113 114 64 64 65 65
2 th 85 85 87 88 89 91 91 43 44 44 45
50
th 98 99 100 101 103 104 105 57 58 58 59
90
95th 102 103 104 105 107 108 109 61 62 62 63
th 109 110 111 112 114 115 116 69 69 70 70

99
3 th 86 87 88 89 91 92 93 47 48 48 49
50
th 100 100 102 103 104 106 106 61 62 62 63
90
th 104 104 105 107 108 109 110 65 66 66 67
95
99th 111 111 113 114 115 116 117 73 73 74 74
4 th 88 88 90 91 92 94 94 50 50 51 52
50
th 101 102 103 104 106 107 108 64 64 65 66
90
th 105 106 107 108 110 111 112 68 68 69 70
95
th 112 113 114 115 117 118 119 76 76 76 77
99
5 50th 89 90 91 93 94 95 96 52 53 53 54
th 103 103 105 106 107 109 109 66 67 67 68

90
95th 107 107 108 110 111 112 113 70 71 71 72
th 114 114 116 117 118 120 120 78 78 79 79

99
6 th 91 92 93 94 96 97 98 54 54 55 56
50
90th 104 105 106 108 109 110 111 68 68 69 70
th 108 109 110 111 113 114 115 72 72 73 74

95
99th 115 116 117 119 120 121 122 80 80 80 81
7 50th 93 93 95 96 97 99 99 55 56 56 57
th 106 107 108 109 111 112 113 69 70 70 71

90
95th 110 111 112 113 115 116 116 73 74 74 75
th 117 118 119 120 122 123 124 81 81 82 82

99
8 th 95 95 96 98 99 100 101 57 57 57 58
50
90th 108 109 110 111 113 114 114 71 71 71 72
th 112 112 114 115 116 118 118 75 75 75 76

95
99th 119 120 121 122 123 125 125 82 82 83 83
9 50th 96 97 98 100 101 102 103 58 58 58 59
th 110 110 112 113 114 116 116 72 72 72 73

90
95th 114 114 115 117 118 119 120 76 76 76 77
th 121 121 123 124 125 127 127 83 83 84 84

99
10 th 98 99 100 102 103 104 105 59 59 59 60

50
90th 112 112 114 115 116 118 118 73 73 73 74
th 116 116 117 119 120 121 122 77 77 77 78

95
99th 123 123 125 126 127 129 129 84 84 85 86
11 th 100 101 102 103 105 106 107 60 60 60 61

50
th 114 114 116 117 118 119 120 74 74 74 75
90
th 118 118 119 121 122 123 124 78 78 78 79
95
th 125 125 126 128 129 130 131 85 85 86 87
99
12 50th 102 103 104 105 107 108 109 61 61 61 62
th 116 116 117 119 120 121 122 75 75 75 76

90
th 119 120 121 123 124 125 126 79 79 79 80
95
th 127 127 128 130 131 132 133 86 86 87 88
99
13 th 104 105 106 107 109 110 110 62 62 62 63

50
90th 117 118 119 121 122 123 124 76 76 76 77
th 121 122 123 124 126 127 128 80 80 80 81

95
th 128 129 130 132 133 134 135 87 87 88 89
99
14 50th 106 106 107 109 110 111 112 63 63 63 64
th 119 120 121 122 124 125 125 77 77 77 78

90
95th 123 123 125 126 127 129 129 81 81 81 82
th 130 131 132 133 135 136 136 88 88 89 90

99
15 th 107 108 109 110 111 113 113 64 64 64 65

50
90th 120 121 122 123 125 126 127 78 78 78 79
th 124 125 126 127 129 130 131 82 82 82 83

95
99th 131 132 133 134 136 137 138 89 89 90 91
16 th 108 108 110 111 112 114 114 64 64 65 66

50
90th 121 122 123 124 126 127 128 78 78 79 80
th 125 126 127 128 130 131 132 82 82 83 84

95
99th 132 133 134 135 137 138 139 90 90 90 91
17 50th 108 109 110 111 113 114 115 64 65 65 66
th 122 122 123 125 126 127 128 78 79 79 80

90
95th 125 126 127 129 130 131 132 82 83 83 84
th 133 133 134 136 137 138 139 90 90 91 91

99
th th
The 90 percentile is 1.28 standard deviation, 95 percentile is 1.645 standard
th
deviation, and the 99 percentile is 2.326 over the mean.
BP: blood pressure.
From: the Fourth report on the diagnosis, evaluation, and treatment of high blood pressure in
children and adolescents. National Heart, Lung and Blood Institute. National Institutes of
Health. May 2004.
Abnormal growth in a child with Cushing's disease
Growth chart of a girl diagnosed with Cushing's disease at age 11.25 years. The patient
had poor height velocity since age 9.6 years in conjunction with a 2.25-year delayed bone
age (leftward arrow from height point at actual age 11.25 years), and excessive weight
gain over the same time period. An ACTH-producing pituitary adenoma was discovered and
removed by trans-sphenoidal surgery at age 11.5 years. The patient subsequently had full
biochemical recovery, initially followed by a significant improvement in height velocity and
a significant reduction in weight (loss of 16 pounds over 6 months). With progressive
puberty, the patient's bone age delay decreased (1.25 years at actual age 12.25 years,
and 0.5 years at actual age 14 years) in association with physiological height plateauing.
The progressive acceleration in bone age was likely due to the effects of pubertal estrogen.
The bracket at the far right of the height curve represents the mid-parental target height
range (±1 SD). As is typical in patients with childhood Cushing's disease, the mid-parental
[1]
target height was not achieved.
ACTH: adrenocorticotropic hormone; GnRH: gonadotropin hormone releasing hormone; SD: standard
deviation; %: percent.
Reference:
1. Chan LF, Storr HL, Grossman AB, Savage MO. Pediatric Cushing's syndrome: Clinical features,
diagnosis, and treatment. Arq Bras Endocrinol Metabol 2007; 51:1261-1271.
Courtesy of Mitchell Geffner, MD.
Papilledema
Papilledema, characterized by blurring of the optic disc margins,

loss of physiologic cupping, hyperemia, and fullness of the veins, in
a 5-year-old girl with intracranial hypertension due to vitamin A
intoxication.
Courtesy of Gerald Striph, MD.
Acanthosis nigricans
Classic hyperpigmented axillary lesion in acanthosis nigricans.

Courtesy of Jeffrey Flier, MD.
Acanthosis nigricans
A velvety, slightly verrucous plaque is present on the neck.
Additional assessment for weight-related comorbidities to be

considered for selected children with obesity
Condition Tests Reason Note

Cardiac disease Lipid profile Hyperlipidemia, Fasting sample
hypertriglyceridemia, preferred
cardiovascular
disease risk
Hypertension Repeat BP Required to diagnose Use

measurements on or exclude appropriately
several occasions hypertension sized cuffs and
age-appropriate
norms
24-hour ambulatory Evaluate for Suggested if the

BP monitoring "masked" diagnosis is
hypertension; rule unclear from
out "white coat" random office
hypertension measurements
CBC, metabolic Exclude other causes Suggested if

panel, renin assay, of hypertension hypertension is
urinalysis, renal confirmed
ultrasound
Fatty liver Liver ultrasound; α-1 Determine cause of Persistent

disease -antitrypsin, elevated elevation of AST,
ceruloplasmin, ANA, transaminases ALT for >6
hepatitis antibodies months warrants
further
investigation
Liver biopsy Determine cause of Imaging cannot

elevated accurately
transaminases, determine
assess degree of inflammation
hepatitis and fibrosis
Type 2 diabetes Fasting glucose, oral Assess for insulin Fasting glucose
mellitus or glucose tolerance resistance, renal ≥126 mg/dL or
impaired glucose test, HbA1c, urinary involvement HbA1c ≥6.5
tolerance microalbumin percent indicates
diabetes. Fasting
glucose 100-125
mg/dL or HbA1c
5.7-6.4 percent
considered pre-
diabetes.
Sleep apnea Polysomnogram Evaluate sleep Polysomnogram

(sleep study) related breathing also may detect
disorders disordered sleep
pattern
Orthopedic Hip x-rays Evaluate for SCFE Use frog-leg

disease positioning for
radiograph
Knee x-rays Evaluate for Blount

disease
Polycystic ovary 17- To confirm whether

syndrome hydroxyprogesterone, hyperandrogenemia
DHEAS, is present, and
androstenedione, free exclude other causes

testosterone (or total of
testosterone and hyperandrogenemia
SHBG), LH, FSH,
possibly pelvic
ultrasound
Precocious LH, FSH, testosterone Early onset of Physical exam

puberty or estradiol, DHEAS obesity often is sufficient
to evaluate
Pseudotumor Fundoscopic exam, Increased

cerebri lumbar puncture intracranial pressure
suggested by
papilledema, and
confirmed by lumbar
puncture
BP: blood pressure; CBC: complete blood count; AST: aspartate aminotransferase; ALT: alanine
aminotransferase; ANA: antinuclear antibodies; HbA1c: hemoglobin A1c; SCFE: slipped capital
femoral epiphysis; DHEAS: dehydroepiandrosterone sulfate; SHBG: sex hormone binding
globulin; LH: luteinizing hormone; FSH: follicle-stimulating hormone.
Adapted from:
1. Barlow SE. Expert committee recommendations regarding the prevention, assessment,
and treatment of child and adolescent overweight and obesity: summary report.
Pediatrics. 2007 Dec; 120 Suppl 4:S164-92.
2. Krebs NF, et al. Assessment of child and adolescent overweight and obesity. Pediatrics.
2007 Dec; 120 Suppl 4:S193-228.
Screening recommendations for type 2 diabetes mellitus in

children and adolescents
Overweight status
Body mass index ≥85th percentile for age and gender
Weight for height ≥85th percentile
Weight ≥120 percent of ideal for height
Plus any two of the following risk factors:

Family history of type 2 diabetes mellitus in a 1st or 2nd degree relative
High-risk race/ethnicity (Native American, African-American, Latino, Asian

American, Pacific Islander)
Signs of insulin resistance on physical examination or conditions associated with

insulin resistance (Acanthosis nigricans, hypertension, dyslipidemia, polycystic
ovary syndrome, or small-for-gestational age birthweight)
Maternal history of diabetes or gestational diabetes mellitus during the child's

gestation
Screening frequency
Begin screening at age 10 years, or at onset of puberty if this occurs less than 10
years old
Repeat screening every three years
American Diabetes Association. Standards of medical care in diabetes--2013. Diabetes Care

2013; 36 Suppl 1:S11.
Definition of lipid levels in children from the 2011 Expert Panel

Integrated Guidelines for Cardiovascular Health and Risk
reduction in Children and Adolescents*
Acceptable Borderline ∆
Category High
mg/dL (mmol/L) mg/dL (mmol/L)
TC <170 (4.4) 170-199 (4.4-5.2) ≥200 (5.2)
LDL-C <110 (2.8) 110-129 (2.8-3.3) ≥130 (3.4)
Non-HDL-C <120 (3.1) 120-144 (3.1-3.7) ≥145 (3.8)
ApoB <90 (2.3) 90-109 (2.3-2.8) ≥110 (2.8)
TG
• 0-9 years <75 (0.8) 75-99 (0.8-1.1) ≥100 (1.1)
• 10-19 years <90 (1 mmol/L) 90-129 (1-1.5) ≥130 (1.5)
∆
Category Acceptable Borderline Low
HDL-C >45 (1.2) 40-45 (1-1.2) <40 (1.0)
ApoA-1 >120 (3.1) 115-120 (3-3.1) <115 (3.0)
* Values for plasma lipid and lipoprotein levels are from the National Cholesterol Education
Program (NCEP) Expert Panel on Cholesterol Levels in Children. Non-HDL-C values from the
Bogalusa Heart Study are equivalent to the NCEP Pediatric Panel cut points for LDL-C. Values
for plasma apoB and apoA-1 are from the National Health and Nutrition Examination Survey III.
∆ The threshold points for high and borderline-high values represent approximately the 95th
and 75th percentiles, respectively. Low threshold points for HDL-C and apoA-1 represent
approximately the 10th percentile.
TC: triglycerides, LDL-C: low-density lipoprotein cholesterol, HDL-C: high-density lipoprotein,

ApoB: apolipoprotein B, ApoA-1: apolipoprotein A-1
Reproduced from: Daniels SR, Benuck I, Christakis DA, et al. Expert panel on integrated
guidelines for cardiovascular health and risk reduction in children and adolescents: Full report,
2011. National Heart Lung and Blood Institute. Available at:
http://www.nhlbi.nih.gov/guidelines/cvd_ped/peds_guidelines_full.pdf.

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Clinical evaluation of the obese child and adolescent Page 1 of 59

Clinical evaluation of the obese child and adolescent

Author Section Editors Deputy Editor

■ (See "Management of childhood obesity in the primary care setting".)

■ (See "Definition; epidemiology; and etiology of obesity in children and adolescents".)

■ (See "Comorbidities and complications of obesity in children and adolescents".)

■ Identification of the caretakers who feed the child

■ Identification of barriers to walking or riding a bike to school

■ Evaluation of time spent in play

■ Assessment of after-school and weekend activities

■ Assessment of screen-time (television, videotapes and DVDs, and video games)

■ Depression (eg, sleep disturbance, hopelessness, sadness, appetite changes) (see

General appearance — Important aspects of assessment of general appearance include

■ Microcephaly is a feature of Cohen syndrome.

■ Nystagmus or visual complaints raise the possibility of a hypothalamic-pituitary lesion [43].

Musculoskeletal — The musculoskeletal examination may provide evidence of underlying

■ Nonpitting edema may indicate hypothyroidism. (See "Clinical manifestations of

■ Small testes may suggest Prader-Willi or Bardet-Biedl syndrome [48].

■ Precocious puberty occasionally is a presenting symptom of a hypothalamic-pituitary lesion

"Epidemiology, presentation, and diagnosis of type 2 diabetes mellitus in children and

Radiographic evaluation — The radiographic evaluation of overweight or obese children is directed

■ Pseudotumor cerebri (should also be referred to a pediatric neurologist) (see "Idiopathic

■ Obesity hypoventilation syndrome (should also be referred to a pediatric sleep medicine

■ The Maternal and Child Health Library Knowledge Path

■ The American Academy of Pediatrics (aap.org/obesity)

■ The Centers for Disease Control and Prevention (cdc.gov/nccdphp/dnpa/obesity)

■ Produce for Better Health Foundation (5aday.com)

■ The Child Care Nutrition Resource System (nal.usda.gov/childcare/)

■ Weight Control Information Network (win.niddk.nih.gov/index.htm)

■ Basics topic (see "Patient information: My child is overweight (The Basics)")

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 5861 Version 20.0

Prevalence of obesity* among children and teenagers, by age group and

Calculation of body mass index (BMI)

English formula for BMI:

Metric formula for BMI:

Body mass index-for-age percentiles, boys, 2 to 20 years, CDC

Body mass index-for-age percentiles, girls, 2 to 20 years, CDC

Child weight assessment algorithm

This algorithm reflects the author's approach to management of childhood

Tips for maintaining a healthy weight: Nutrition

Try a 6-inch, low-fat Subway sandwich (ordered without mayonnaise, cheese, or

Choose three meals with one snack per day

Healthy snacks include fresh fruit, fat-free yogurt, or low-fat popcorn.

Limit snacks to one serving size.

Courtesy of Texas Children's Hospital.

Tips for maintaining a healthy weight: nutrition

Eat proper portion sizes.

Fruit 2 to 4 1 small piece fruit or 1/2 banana; 1 cup fresh

Vegetable 3 to 5 1/2 cup cooked vegetables or vegetable

Milk, yogurt, and 2 to 4 1 cup skim or 1 percent milk; 1 cup fat-free

Meat, poultry, fish, 2 to 3 2 to 3 ounces of skinless chicken, turkey, or

Fats, oils, sweets Use a small 1 teaspoon butter, margarine, mayonnaise,

Stock your house with healthful food choices.

Limit restaurant eating to 1 time per week.

Take your lunch to school.

Courtesy of Texas Children's Hospital.

Tips for maintaining a healthy weight: Low-fat, low-sugar eating

Food Food to choose more

Vegetables Any fresh or frozen vegetable Any vegetables prepared in

Courtesy of Texas Children's Hospital.

Tips for maintaining a healthy weight: Low-fat, low-sugar eating