Pediatric Primary Care Case Studies (25 page)

You ask whether Mrs. Smith remembers being shown Maria’s growth grids or given information about her height and weight during her prior health supervision visits. She said, “Yes, Maria has been over the 95th percentile in height and weight since she was 6 months old. But our families are big people.”

Here is some information about the problem of obesity in children that you need to consider as you continue your data collection.

Obesity in Children

Epidemiology of Obesity

The rapidly increasing prevalence of childhood obesity has become an escalating problem and is considered a major public health issue in the United States. The National Health and Nutrition Examination Survey (NHANES) reported that 14% of children ages 2–5 years were overweight (National Center for Health Statistics, 2007), and in 2006 17% of children ages 6 to 17 in the United States were overweight (Federal Interagency Forum, 2008). A national study of 3-year-olds reported that 35% of the children in this study were overweight and that Hispanic children were twice as likely as black or white children to be overweight or obese (Kimbro, Brooks-Gunn, & McLanahan, 2007).

Etiology

Simply stated, obesity results when energy intake from food exceeds energy expenditure. Factors that cause this imbalance are numerous and influence both the prevalence and severity of overweight in an individual (Anderson & Butcher, 2006). Genetic inheritance factors are estimated to account for anywhere from 16% to 85% of body mass index (BMI) and from 35% to 63% of body fat percentage (Yang, Kelly, & He, 2007); however, the exact mechanism of how genes contribute to the prevalence and severity of obesity is unknown. All ethnic minorities in the United States are at higher risk for overweight than whites regardless of socioeconomic status (Freedman et al., 2008). Gene regulation involved in energy homeostasis, thermogenesis, adipogenesis, leptin, insulin levels, or a combination of these factors is thought to contribute to obesity (Lagou et al., 2008; Yang et al., 2007).

Genes interact with diet via digestion and absorption of nutrients to regulate energy metabolism and cellular growth. Genes also affect expenditure of energy through physical activity by regulating cellular maximal oxygen uptake and skeletal muscle metabolism. Thus, some individuals perform better in their athletic activities because of their genetic inheritance. However, the impetus to become involved in physical activity and the level of involvement largely occur through positive rewards for performance, which is a significant factor. In contrast, engaging in sedentary activities (watching television, excessive screen time activities) is associated with energy conservation with low metabolic demands. Television or screen time activities combined with food intake are particularly problematic. This hypothesis is now supported by studies demonstrating that excessive energy consumption with television viewing may be a greater problem than the lack of activity per se (Epstein et al., 2008; Matheson, Killen, Wang, Varady, & Robinson, 2004).

Intrauterine environment is now viewed as one of the most potent factors in determining risk for future overweight and obesity based on studies with large and small for gestational weight infants (Gillman, Rifas-Shiman, Berkey, Field, & Colditz, 2003; Simmons, 2004). An overly nutrient-rich intrauterine environment appears to impact fetal metabolism, which puts the child at risk for later overweight by creating demand for excessive energy intake after birth (Rasmussen & Kjolhede, 2008). Hence, maternal preconception overweight and excessive weight gain during pregnancy are issues associated with childhood overweight. The converse to this is the small for gestational age infant who is now thought to be programmed by a nutrient-poor environment to function with a “thrifty gene” that may forever alter the child’s level of nutrient needs. Overfeeding such a child is also problematic.

Certain environmental and lifestyle changes are directly linked to the increasing prevalence of childhood obesity in almost every part of the world; these result in children being raised in an obesogenic environment. When meals are not prepared at home and fast food is the meal of choice, there is a significantly greater risk for childhood overweight (Larson et al., 2008; Pereira et al., 2005). Likewise, the lack of neighborhood safety for outdoor play, increased sedentary screen time activities (> 2 hours per day) as part of a child’s everyday life events, and the reduction of physical education in schools are factors that reduce the opportunities of children to perform physical activities. Larger proportions of food servings, increased consumption of foods higher in total fat and saturated fats, decreased consumption of fruits and vegetables, and increased sweetened beverage intake are related to unhealthful food choices and eating patterns that are now more often the norm than not.

Parents provide both the genetic and environmental factors which are important to the weight of their children. Strong predictors of childhood overweight that continues throughout childhood are having either one or both parents overweight and low income status (Danielzik, 2004; Dorosty, Emmett,
Reilly, & ALSPAC, 2000; Gahagan, 2004; Sothern & Gordon, 2003; Whitaker, Wright, Pepe, Seidel, & Dierz, 1997).

Diagnostic Criteria for Childhood Obesity

The American Academy of Pediatrics (AAP) Expert Committee (Barlow & Expert Committee, 2007) and the Centers for Disease Control and Prevention (CDC) use body mass index (BMI) percentile classification based on age and gender to define childhood overweight and obesity. BMI measurements are used beginning at age 2 years. If a child’s BMI is equal to or greater than the 95th percentile for age and gender, the child is considered obese. A child is termed overweight if the BMI is at the 85th to less than the 95th percentile. The AAP and CDC recommend the use of weight-for-length in children younger than 2 years, with values above the 95th percentile indicating overweight. Although the BMI is not a perfect measure, it is currently considered the measurement of choice to determine overweight in children (Krebs et al., 2007; Kuczmarski et al., 2002).

Comorbidities Linked to Childhood Obesity

The problems associated with childhood obesity are numerous and include hypertension; lipid profile abnormalities; polycystic ovary syndrome; fatty plaque development within the arterial intima; type 2 diabetes mellitus (Libman & Arslanian, 2007), which occurs more commonly after 10 years of age; asthma (Glazebrook et al., 2006); more fractures and musculoskeletal conditions (Taylor et al., 2006); nonalcoholic fatty liver disease (Riley, Bass, Rosenthal, & Merriman, 2005); sleep-disordered breathing and obstructive sleep apnea (Muzumdar & Rao, 2006); and academic performance and social/emotional well-being issues (Gable, Britt-Rankin, & Krull, 2008). The pathophysiologic consequences of childhood obesity related to the comorbid conditions just identified are linked to such underlying processes as metabolic overwork due to insulin resistance, hyperglycemia, excessive adipose tissues, stress on bones, and negative self-esteem.

From the above review, what additional questions should you ask?

What other areas do you want to explore in the history which might be related to the obesity problem?

History

Pregnancy, Labor, and Delivery

Mrs. Smith reports that she had high blood pressure during her last 4 months of pregnancy with both of her children and was on insulin for gestational diabetes. She was induced at 38 weeks with Maria because of her hypertension and diabetes. Maria
weighed 8 pounds 15 ounces at birth, had no problems, and went home with mom on day 2.

Family Medical History

You ask about the weight status of other family members, cardiovascular risk factors (heart attacks before the age of 50 years, hypertension, hyperlipidemia), and diabetes.

Mrs. Smith tells you that Maria’s maternal and paternal grandmothers have type 2 diabetes and her paternal grandfather had a heart attack at age 52. Mrs. Smith relates that both sets of grandparents are very overweight with blood pressure and cholesterol problems. She tries to watch her own weight and considers herself to be a little overweight, wearing “large women” clothes. She ends by saying, “I come from big boned people.” Mrs. Smith said that her blood sugars have gone back to normal after both of her pregnancies. She says, “I don’t want to get diabetes like my mom and dad.” She reports that her husband has maintained his army weight since his discharge 3 months ago because he exercises a lot.

Additional Nutrition Questions

You start out by saying, “Let’s talk about what Maria ate yesterday for her meals and snacks.”

Mrs. Smith relates that Maria had a large bowl of sugar puffs for breakfast with milk and a piece of toast and fruit juice (6 ounces). For lunch, she ate at the fast food restaurant where mom works and had a kid’s meal—cheeseburger, fries, a yogurt, and a regular soda as a treat (because she was a good girl). Grandma cooked cheese enchiladas for the family dinner, and Maria had one, and a scoop of ice cream for dessert. She thinks Maria had her usual glass of whole milk (about 8 ounces) but doesn’t know for sure because her mom fed the kids because she had to work until 8 p.m. Her snacks were apple slices around 10 a.m. and a chocolate chip cookie before bed with 8 ounces of whole milk.

   You note to yourself that her diet is high in carbohydrates and Maria’s portion sizes are excessive.

Past Medical Problems and Review of Systems

   
Illnesses:
Maria has been healthy but was diagnosed with “low iron” anemia at age 15 months. She was treated with iron and was told to limit her milk intake. Maria has never been hospitalized or taken to the emergency room for illnesses or injuries and has no known allergies to foods or medications.

   
Sleep:
A review of systems is positive for loud snoring at night and some restlessness with sleep. However, Maria does not seem sleepy during the day and takes an occasional 20- to 30-minute nap. She sleeps about 10 to 11 hours a night.