The School - Aged Child
Case 4.4 Obesity
106 The School-Aged Child
TV. She likes to read. She denies ever using tobacco products, drugs, or alcohol. She admits to feeling sad and lonely at times but denies ever wanting to injure herself. She likes her parents but says they don ’ t always understand her or have time to talk to her.
Tara lives with both parents in a 2 - bedroom, third fl oor apartment near to her school. Her father is employed as a laborer, and her mother works for a cleaning service 5 evenings a week. The family has a stable income. She has 3 older siblings, ages 17, 19, and 21, living out of the home. Her maternal grandmother lives nearby, and Tara often goes to her home after school. Both parents were smokers previously but stopped 5 years ago. They moved to this area from Puerto Rico 20 years ago. Both speak fl uent English.
OBJECTIVE
General: Tara is a 12 - year - old, Hispanic female who is neatly dressed and cooperative.
Vital s igns: She is 5 feet tall and weighs 174 pounds. Her blood pressure is 116/70, pulse is 74, and respirations are 16 breaths/minute. Temperature is normal.
HEENT : PERRLA; EOMs intact. Oral pharynx is positive for 3 + /4 tonsils, without lesions or exudate.
No dental caries are noted.
Neck: Supple with full range of motion. No lymphadenopathy is present.
Respiratory: Her lungs are clear bilaterally with no wheezes, rales, or rhonchi.
Cardiac: Normal sinus rhythm with no murmur or irregular beats.
Chest: Breast buds are present bilaterally, with no tenderness or discharge.
Abdomen: Soft but protuberant with no masses or hepatosplenomegaly. Normal bowel sounds are heard in all 4 quadrants.
Neuromuscular: Back is straight with no curvature noted on forward bend. She has full range of motion in all extremities. Refl exes are normal.
Skin: Clear except for darkly pigmented areas on her neck.
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___BMI
___ Oral glucose tolerance test ( OGGT ) ___Insulin resistance
___Cholesterol screen ___Sleep study
___Psychosocial evaluation
What is the most likely differential diagnosis and why?
___Sleep apnea ___Obesity
___Insulin resistance ___Type 2 diabetes ___Exercise intolerance ___Psychosocial issues
Are any referrals needed at this time?
Obesity 107
Can the school be of assistance?
What community resources are available to this family?
What type of nutrition support may aid this family?
Are there standardized guidelines to assess and treat the problem of childhood obesity?
RESOLUTION
Diagnostic t ests: Lipid profi le, oral glucose tolerance test, and insulin levels would provide a basis to determine if she currently has risk factors for hypercholesterolemia, insulin resistance, or type 2 diabetes. Sleep apnea should also be considered due to the history of snoring; however, it is a less common complication in obese children accounting for approximately 7% of cases (Mallory et al., 1989 ). A sleep study should therefore be considered.
BMI: Body mass index is a surrogate for adiposity. It is a number calculated from a person ’ s weight in kilograms to the square height in meters. It provides an indicator of adiposity and is used to screen for weight categories that may lead to health problems.
Oral glucose tolerance test (OGGT): This is a standard laboratory method to determine how the body metabolizes sugar. It is used to diagnose impaired glucose tolerance, a frequent precursor to type 2 diabetes.
Insulin Resistance: Insulin, made in the pancreas helps the body use glucose for energy. In insulin resistance, muscle, fat, and liver cells do not respond properly to insulin; and, as a result, the body requires more insulin to help glucose enter the cells. The pancreas eventually fails to keep up leading to elevated blood glucose levels and type 2 diabetes.
Cholesterol Screen: Cardiovascular disease risk factors are fairly common among obese children.
These include elevated cholesterol levels, high blood pressure, and type 2 diabetes. In a population study of obese children, it was found that obese children are more likely to have risk factors associ- ated with cardiovascular disease than other children (Freedman, Mei, Srinivasan, Berenson, & Dietz, 2007 ).
Sleep Study: Sleep apnea is a less common complication of obesity in children. It is associated with loud snoring and labored breathing and occurs in only a small percentage of obese children.
Psychosocial Evaluation: Psychosocial issues are a fairly common consequence of childhood obesity.
Obese children are frequent targets of social discrimination and stigmatization. This may be a cause of low self - esteem that may hinder academic and social functioning over time.
What is the most likely differential diagnosis and why?
Exercise intolerance due to asthma associated with obesity:
The patient is a 12 - year - old, Hispanic female with a primary complaint of shortness of breath with exertion. She denies any other symptoms and is taking no medications. Her physical exam is remark- able only for an elevated BMI of 34, which places her in the obese range at greater than the 95 th percentile for her age group, and darkly pigmented areas around her neck called acanthosis nigricans, a known risk factor for insulin resistance. Studies have shown an association between obesity and asthma (Luder et al., 1998 ). In asthma, the airways become narrow and partially obstructed causing breathing diffi culty. Cardiovascular disease risk would be another major consideration in Tara ’ s health assessment. In addition to physical concerns, it is important for the provider to also monitor social and emotional development.
Are any referrals needed at this time?
Referral to a dietitian may be helpful. Referral to an ear, nose, and throat specialist would rule out any mechanical breathing diffi culties due to enlarged tonsils or adenoids.
Can the school be of assistance?
A referral to the school nurse to counsel and support Tara between offi ce visits may be benefi cial.
108 The School-Aged Child
What community resources are available to this family?
Tara would likely benefi t from participation in an after - school activity. Helping her to research pro- grams at her school, her local Boys and Girls Clubs, or her YMCA may assist her on the way to a more active lifestyle. Use of Internet resources like Let ’ s Move may provide ideas to fi nd ways to be more active at home as well.
What type of nutrition support may aid this family?
Involving the entire family in discussing ways to improve eating habits and activity will likely provide much needed guidance. Calorie and fat content lists from local fast - food restaurants will offer guidance in making better food choices.
Are there standardized guidelines to assess and treat the problem of childhood obesity?
The American Academy of Pediatrics released a policy statement in 2003 by the Committee on Nutrition called Prevention of Pediatric Overweight and Obesity . It proposes strategies for early identi- fi cation with the use of BMI and offers options for dietary and physical activity interventions during regular health care visits (American Academy of Pediatrics, Policy Statement, Committee on Nutrition, 2003 ). The National Association of Pediatric Nurse Practitioners provides guidelines for assessment of physical and mental health concerns in their Health Eating and Activity Together ( HEAT ) program.
Pediatric obesity is a multi - faceted problem that requires a many - pronged approach. It is a complex health issue involving metabolism, genes, behavior, culture, environment, and socioeconomic status.
Research has shown that there are long - term, midlife, and socioeconomic consequences to being persistently overweight, especially among women and those in a lower socioeconomic class. These include chronic health problems, no further education beyond high school, and higher odds of receiv- ing welfare or unemployment compensation at age 40 (Clarke, O ’ Malley, Schulenberg, & Johnston, 2010 ).
In 2011, the tide appears to be turning; early signs of success in the prevention and control of obesity are now emerging. There has been no signifi cant increase in obesity prevalence since 2003.
This encouraging sign is attributed to innovative policies and environmental changes in communities, work sites, and schools.
REFERENCES AND RESOURCES
American Academy of Pediatrics, Policy Statement, Committee on Nutrition ( 2003 ). Prevention of pediatric overweight and obesity . Retrieved on August 11, 2010. http://aappolicy.aappublications.org/cgi/reprint/
pediatrics;112/2/424.pdf
Centers for Disease Control and Prevention . Childhood overweight and obesity . Retrieved on August 11, 2010, http://www.cdc.gov/obesity/childhood/index.html
Clarke , P. J. , O ’ Malley , P. M. , Schulenberg , J. E. , & Johnston , L. D. (July 7, 2010 ). Midlife health and socioeconomic consequences of persistent overweight across early adulthood: Findings from a national survey of American adults (1986 – 2008) American Journal of Epidemiology Advanced access published online . Retrieved from http://aje.oxfordjournals.org/cgi/content/abstract/kwq156v1
Committee on Environmental Health, Policy Statement ( 2009 ). The built environment: Designing communities to promote physical activity in children . Pediatrics , 123 ( 6 ), 1591 – 1598 .
Freedman , D. S. , Mei , Z. , Srinivasan , S. R. , Berenson , G. S. , & Dietz , W. H. ( 2007 ). Cardiovascular risk factors and excess adiposity among overweight children and adolescents: The Bogalusa Heart Study . Journal of Pediatrics , Jan: 150 ( 1 ), 12 – 17 .
Let ’ s move: America ’ s move to raise a generation of healthier kids . Retrieved from http://www.letsmove.gov/
Luder , E. , Melnik , T. , & DiMaio , M. ( 1998 ). Association of being overweight with greater asthma symptoms in inner city black and Hispanic children . Journal of Pediatrics , 132 ( 4 ), 699 – 703 .
Mallory , G. B. , Fiser , D. H. , & Jackson , R. ( 1989 ). Sleep - associated breathing disorders in morbidly obese children and adolescents . Journal of Pediatrics , 115 ( 6 ), 892 – 897 .
McConnell , P. ( 2010 ). Solving the childhood obesity problem, how schools can be part of the solution, practice roundtable . ICAN Infant, Child and Adolescent Nutrition , 2 ( 4 ), 232 – 236 .
National Diabetes Information Clearinghouse . Insulin resistance and pre - diabetes . Retrieved on August 11, 2010.
http://diabetes.niddk.nih.gov/dm/pubs/insulinresistance/