Ace the Case: A 15-Year-Old Girl With Morbid Obesity

Clinical Review

Obesity during adolescence and childhood has become an increasingly widespread problem in the United States and around the world. Despite global recognition and attempts to remedy the situation, the prevalence of obesity in both children and adolescents has continued to increase.3 Although obesity rates are increasing among all age groups, the largest increase has been observed among adolescents.3 Currently, in the United States, more than 40% of 16 to 19 year olds are overweight and 34.5% meet criteria for obesity.3 Factors associated with higher rates of obesity include Black or Hispanic race, lower education level, lower socioeconomic status, and living in a non-metropolitan or rural area.3,4

Most cases of obesity are due to environmental factors, such as poor diet and sedentary lifestyle.1 Endocrine or genetic disorders are responsible for <1% of the obesity in young patients.1 These disorders, which include hypothyroidism, growth hormone deficiency, pseudohypoparathyroidism, Prader–Willi syndrome, Bardet-Biedl syndrome, and Kleinefelter syndrome, are almost always associated with additional symptoms such as short stature or slowed growth velocity.1 Because of the rarity of these conditions, the Endocrine Society recommends against routine screening for endocrine etiologies for childhood obesity unless the patient’s height or height velocity are attenuated.2 Most experts also discourage thyrotropin or cortisol testing because these are often elevated in overweight children in general.1 Genetic testing for obesity syndromes should be performed in cases of extreme obesity for children younger than age 5 years, for hyperphagia, or for those with a concerning family history.2

Although genetic and endocrine studies are typically unnecessary in the evaluation of the obese adolescent, additional testing is often indicated. Obese adolescents are likely to experience numerous medical comorbidities secondary to their excess weight, including asthma, obstructive sleep apnea, orthopedic problems, high blood pressure, insulin resistance, hyperlipidemia, and polycystic ovarian syndrome.5 Given these associations, all children who are obese should be screened with the following recommended tests:2

  • Blood pressure measurement
  • A1C
  • Fasting glucose
  • Fasting lipids
  • Liver enzymes
  • Free and total testosterone, steroid hormone binding globulin

Psychological issues, including depression and anxiety, are also common. Depending on history, patients may be referred to a psychologist or psychiatrist to manage mental health issues.2

Prevention and early treatment of childhood and adolescent obesity is important to prevent medical complications later in life. Research has shown that overweight 5 year olds are 4 times as likely as normal-weight children to become obese.6 Most children who are obese will become obese adults, experiencing obesity-related complications, such cardiovascular disease, diabetes mellitus, chronic kidney disease, musculoskeletal disorders, and cancers.7,8 In 2015 alone, obesity contributed to 4 million deaths globally, two-thirds of which included cardiovascular disease.8 Early intervention is key. A study of 664 children and adolescents who are obese revealed that a 1-year lifestyle intervention treatment was more successful in young children when compared to adolescents.1 In this study, despite higher BMI values at baseline, the 4 to 7 year olds achieved an average BMI reduction of 0.5 compared to just 0.27 for adolescents aged 13 to 16 years.9

All adolescents and children should be screened for obesity with the BMI annually.5 For children older than age 2 years, obesity is typically defined as a BMI score ≥95th percentile for a child’s sex and age. “Overweight” is typically defined as a BMI ≥85th percentile but <95th percentile. Endorsed by the United States Preventive Services Task Force, the American Academy of Pediatrics, and the Endocrine Society, the Centers for Disease Control’s growth charts are frequently used by clinicians to make this assessment. For children aged <2 years, the Endocrine Society defines obesity as a sex-specific weight for recumbent length ≥97.7th percentile on the World Health Organization charts.2

When diagnosed, treatment should be initiated immediately. The American Academy of Pediatrics published its recommendations in 2007, which include a staged approach to weight management.10,11 Patients should spend at least 3 to 6 months in each stage, only progressing to the next stage if necessary.10,11 Stage progression is indicated if the BMI is not decreasing and either comorbidities or parental obesity is present. The 4 stages include the following:10,11

  1. Prevention Plus: healthy lifestyle changes
  2. Structured Weight Management
  3. Comprehensive Multidisciplinary Management
  4. Tertiary Care Intervention

The first stage, Prevention Plus, should focus on healthy lifestyle changes, such as eating ≥5 servings of fruits and vegetables per day, limiting screen time to ≤2 hours per day, performing ≥1 hours of physical activity per day, and eliminating sugar-sweetened beverages.10,11 In the second stage, Structured Weight Management, adolescents should be referred to a registered dietitian to develop a structured eating plan.10,11 During this step, additional training for the child and parent should be implemented, including behavioral counseling, parenting skills, food planning, and physical activity counseling.10,11 In the third stage, Comprehensive Multidisciplinary Management, the American Academy of Pediatrics recommends a multidisciplinary team involvement, including a social worker or counselor, trained nurse practitioner, registered dietitian, and exercise specialist.10,11 A structured program should be implemented at this point, including food monitoring, goal setting, contingency management, and parent training.10,11 In the fourth stage, Tertiary Care Intervention, obesity medications, meal replacements, very-low energy diets, and surgical intervention are considered.10,11

Similarly, in 2017, the United States Preventive Services Task Force promoted behavioral interventions as the first-line treatment for adolescent obesity.5 These interventions should ideally include a multidisciplinary team comprised of pediatricians, physical therapists, registered dietitians, psychologists, and other behavioral specialists.5 According to the United States Preventive Services Task Force, comprehensive, intensive behavioral interventions, defined as at least 26 contact hours over 2 to 12 months, results in weight loss. Interventions that include at least 52 contact hours result in greater weight loss, as well as improvements in cardiovascular and metabolic risk factors.5 Sessions should include both the parent and child, either separately, together, or both, and should provide education on diet, exercise, reading food labels, stimulus control, goal setting, self-monitoring, contingent rewards, and problem solving.5

When behavioral methods are unsuccessful, medication can be considered. Only one FDA-approved medication exists for obese adolescents. Orlistat, which is FDA-approved for adolescents aged 12 years and older, has showed conflicting results.5 Small studies of obese adolescents have shown a moderate amount of weight loss using orlistat, but randomized controlled trials have failed to show a major effect.5 During a 6-month, double-blind placebo controlled trial, change in BMI did not differ significantly between the two groups.12

Additional medications have also been used in adolescents. Although successful in achieving weight loss, sibutramine, a norepinephrine and serotonin reuptake inhibitor, was taken off the market in 2009 secondary to cardiovascular safety concerns.13 Metformin has been used off-label for obesity but has been shown to have minimal effects on BMI (reductions <1).5 Although a pooled analyses of 8 different metformin trials showed lower BMI in treated patients when compared to placebo, the reduction was small.14 During all metformin trials, the average weight change with metformin ranged from a loss of 5 pounds to a gain of 5 pounds, whereas the placebo groups ranged from a loss of 2 pounds to a gain of 11 pounds.14

Surgical intervention, although once thought of as a last resort for obese adolescents, may be an acceptable early treatment for certain patients. In its 2018 revised bariatric surgery guidelines, the American Society for Metabolic and Bariatric Surgery stated that surgical intervention should be considered early for obese adolescents.15 The guidelines state that “metabolic and bariatric surgery is a proven, effective treatment for severe obesity disease in adolescents and should be considered standard of care. Pediatricians and primary care providers should recognize that children with severe obesity require tertiary care and refer early to a MBS center with advanced treatments and support.”15

Per the American Society for Metabolic and Bariatric Surgery, metabolic or bariatric surgery in adolescents, defined as ages 10 to 19 years, is indicated in the following patients:15

  • BMI ≥35 kg/m2 or 120% of the 95th percentile and clinically significant comorbid conditions. Acceptable comorbid conditions include the following:
    • Obstructive sleep apnea
    • Type 2 diabetes mellitus
    • Idiopathic intracranial hypertension
    • Nonalcoholic steatohepatitis
    • Blount’s disease
    • Slipped capital femoral epiphysis
    • Gastroesophageal reflux disease
    • Hypertension
  • BMI ≥40 kg/m2 or 140% of the 95th percentile

In addition to meeting the criteria, patients must also be motivated and able to adhere to recommended treatments, both pre- and postoperatively.15 The most commonly performed procedures include gastric banding, sleeve gastrectomy, and Roux-en-Y gastric bypass.15 Contraindications to bariatric surgery include a medically correctable cause of obesity, substance abuse problem, psychiatric or psychosocial condition that prevents treatment adherence, or a current or planned pregnancy within 12 to 18 months.15 Although not for everyone, surgical intervention can result in substantially more weight loss than diet and exercise alone, preventing many of the possible sequelae of adolescent obesity.

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Question
Which of the following tests is NOT indicated in the patient discussed above?
Please complete this question.
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Correct answer: C

Rationale: Obese adolescents are likely to experience numerous medical comorbidities secondary to their excess weight.5 A fasting lipid panel will screen for hyperlipidemia, liver enzymes will screen for fatty liver disease, and free and total testosterone will screen for hyperandrogenism associated with PCOS.2 In addition, Miss M should have a hemoglobin A1C and a fasting glucose drawn. Cortisol, a screening test for Cushing’s disease, is unnecessary in this patient. In addition to Cushing’s disease being rare, many experts discourage cortisol testing in these patients because it is often falsely elevated secondary to obesity alone.1

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