Frequently Asked Questions -
Childhood Obesity in Minnesota Webinar, September 2010

I have a child who is greater than the 95th percentile for BMI.  What evaluation and labs should I do? 
Physical exam to confirm the diagnosis of obesity. ROS and FH to determine if he is at increased risk for co-morbid conditions. Diet and exercise history.

Recommendations for lab testing varies among providers. For obese children we would recommend:

• Fasting glucose and insulin (if patient is not fasting and unlikely to return, a random glucose can screen for diabetes; for morbidly obese children or children at increased risk for DM, a 2hr oral glucose tolerance test with insulin levels can be done)
• hgb A1C  
• fasting lipid profile (again, if child is not fasting as random lipid profile can screen for severe lipid abnormalities)
• ALT and AST
• vitamin D
• TSH Note that it is very unlikely that hypothyroidism will cause obesity, but many parents believe it to be a cause of obesity and will not face necessary lifestyle changes until this is done.
  

What is the recommended evaluation and management for suspected Polycystic Ovarian Syndrome (PCOS)?
For girls with symptoms and signs of PCOS (hirsutism, persistent, severe or worsening acne, pattern alopecia, anovlulation, premature pubarche, or polycystic ovaries), labs include:

• Testosterone
• free testosterone
• LH
• FSH
• 17-hydroxyprogesterone
• DHEA-S
• androstenedione
• We DO NOT recommend pelvic US, as pelvic US is not generally useful in young girls--they have such small cysts that it is usually negative and not necessary for the diagnosis.

If PCOS is strongly suspected, many pediatricians refer to Pediatric Endocrinology or Obstetrics/Gynecology. Treatment regimens vary, but usually include diet and exercise with/without either a combination oral contraception pill (OCP) for 3 month trial (most often an OCP with spironolactone to improve hirsutism) and/or metformin.

What are pharmacological treatment options/recommendations for obesity or hyperlipidemia?
Pharmacologic therapy for obesity is most successful in individuals who have already made substantial lifestyle changes and continue to receive counseling on lifestyle changes. Orlistat remains on the market. It is a medication that causes malabsorption of about 30% of ingested fat. It is approved for children >12 years old. Off-label use of some medications is also done for obesity.
Most patients would benefit from referral to a specialized obesity clinic prior to initiation of treatment with medications.

What does an exercise prescription look like for an obese child?  What does a diet prescription look like?
Recommendations should be age-specific and family dynamic-specific. Try to focus on one or two small changes at a time, to avoid overwhelming the family.

Many obese children do not exercise at all. We begin with one of 2 options: either a sports team or walking. We would ask a child to start with walking 2-3 days a week at a moderate pace (too fast to carry on a conversation, but not so fast that you cannot answer simple questions) for 10-15 minutes. We try to have families avoid purchasing devices for exercise (Wii, etc) EXCEPT for a high-quality treadmill. For families that can afford to purchase them, they are probably worth their cost, particularly in MN. Morbidly obese children with severe exercise limitations may be referred for rehabilitation therapy.

Diet prescription may be a defined, calorie specific diet (usually a series of defined choices for each meal) OR a defined change of eating at each visit (for example, on one visit child is asked to eliminate sweet beverages, on another, asked to eat a piece of fruit before dinner, etc). In general, discussing dietary changes with the parents, and making them responsible for the changes, is more effective than discussing them with the child.

Some web-based options include:

www.fueluptoplay60.com	www.cdc.gov/ obesity/childhood/	www.mypyramid.gov	www.kidnetic.com
A fitness and nutrition program that has been implemented in more than half the country's school. Schools and students can track their progress with an online nutrition and activity tracker and compete for prizes.	An excellent resource for health professionals and parents. Includes information on childhood obesity prevalance, contributing factors and recommendations for diet and excercise.	Includes data and statistics for health professionals. Includes excellent on childhood obesity prevalance, contributing factors, and tips for health professionals and parents.	A very cool, kid-friendly website that gets them off the chair with goofy challenges and educates them about healthy eating and activity.
www.letsgo.org	www.letsmove.gov	AAP Diet and Exercise Prescription Pad
Terrific information for parents who are interested in increasing healthy eating and activity for their kids as well as information for providers and community members.	A nationwide initiative backed by the First Lady to promote making healthy choices, improve food quality in schools and increase access to healthy, affordable food.

How do I treat hypercholesterolemia?
Treatment, except in very severe cases, starts with diet and exercise. Children with persistent LDL cholesterol elevation should be referred to pediatric hyperlipidemia specialists (usually pediatric cardiologists)