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Screening by BMI
Screening consists of height and weight measurement and calculation of Body Mass Index (Wt/Ht2).
| BMI | Diagnosis | Treatment Guidelines |
|---|---|---|
| BMI >95 percentile | OVERWEIGHT | In depth medical Assessment & treatment |
| BMI 85-95th percentile | At Risk of Overweight | Start dietary & activity intervention Follow in 6 months |
| BMI < 85th percentile | Normal | Preventive strategies Monitor BMI at all visits |
Medical Assessment
Medical History
- Severe Headache
- Blurring of Vision
- Snoring During Sleep
- Oligomenorrehea/amenorrehea
- Hip or Knee Pain
- Chest Pain, Exertional Dyspnea
- Syncope
Family History (age < 55 years)
- Diabetes
- Obesity
- Hypertension
- Heart Attack
- Stroke
- Dyslipidemias
Dietary History
- Intake of liquid calories, juice, soda, sweetened beverages
- Examples of breakfast, lunch, dinner and snacks (daily eating habits and dietary details)
Activity History
- Sedentary activity time, time for TV, computer/video games, homework
- Physical activity, gym, outdoor activity, special activities
Examination
- Height(cm), Weight(kg), BMI, B.P.(Average of 3 B.P.)
- Waist circumference(cm)
- Hip circumference(cm)
- Cardiac examination
- Fundus examination ( if headaches)
- Acanthosis nigricans
- Hirsuitism
- Enlarged tonsils, adenoids
- General physical examination
Known Complications of Obesity
Acute Complications
- Obstructive sleep apnea
- Psuedotumor cereberi
- Slipped Capital Femoral Epiphysis
Chronic Complications
- Dyslipedemia: (look for age related values)
increased triglycerides
inecreased LDL
decreased HDL - Hyperinsulinemia >15miu/ml
- Hypertension (systolic or diastolic BP>90th percentile for age)
- Glucose intolerance or Type 2 diabetes
- Poly Cystic Ovarian Syndrome
- Metabolic Syndrome
Management
Anthropometric & Metabolic Assessment
- BMI, BMI Z scores, waist & hip circumference, BP (average of 3 readings)
- Fasting lipid profile, fasting glucose and insulin, LFT’s, CRP, HbA1C, Urine for microalbuminurea
- PFTs if indicated or symptoms
- Evaluation for sleep apnea if symptoms with lateral neck X-ray and sleep studies
- Evaluation for pseudotumor cerebri if associated with headaches
- Baseline EKG; Echo if morbidly obese, abnormal EKG or associated risk factors such as hypertension, strong (+) family history, symptoms, etc.
Identification of Complications
- Treat urgent/care complication if any
- Identify chronic complications
- Assess for the presence of Metabolic Syndrome -
3 or more of the following risk factors :- Elevated BP>90th Percentile for age
- TG>90th percentile for age
- HDL< 40mg/dl
- Waist circumference >90th percentile for age & race specific
- Waist circumference >90th percentile for age & race specific
Interventions
- Start early interventions
- Promote breast feeding
- No fruit juice till 6 mths of age
- Stop all sweetened bevarges
- Based on new food pyramid and low glycemic index foods, limit starch to whole grain products, only 1 per meal.
- No white bread, ready to eat cereals , potatoes, cakes and cookies.
- Low fat milk products 3-4/day.
- 3-5 servings of fruits and vegetables.
- Olive oil/canola oil and handful or nuts.
- Drink 6-8 glasses of water daily.
Activity
- Limit TV watching time to less than 2 hours per day.
- Prescription for regular physical activity at home – stationary bike, Jump rope, exercise video tape.
- Join a recreation center or Gym.
Behavior Therapy
- Family involvement and understanding.
- Desire to make a change.
- Small permanent changes at a time.
- Continued reinforcement – not limited to few weeks.
Weight Goals
BMI: 85th – 95th Percentile
- Weight Maintenance
- Change of lifestyle
BMI > 95th Percentile
- No Complications
- Weight Maintenance
- Long term to achieve Weight loss
- Complications
- Weight Loss of half a pound per week
Prevention Strategies
- Promote breast feeding
- No fruit juice until 6 months of age
- Not more than 1 cup of juice in daily diet
- Avoid sweetened beverages at all times
- Cut down refined starch, baked products, breads, ready to eat cereals
- Limit TV watching/computer games etc. to less than 2 hrs/daily
- 1 hour of daily physical exercise or activity
- Never use food as reward
- Parental involvement, and to be role models
- Offer only healthy options
- Constant reinforcement of these behaviors at school and home
Lifestyle guidelines
- Eat 3 meals a day, if desired 2 snacks & 6-8 glasses of water.
- Limit fruit juice to no more than 1 cup per day. Limit caffeine containing beverages.
Eliminate sugar laden beverages. - Limit starch to 1 serving per meal, limit starch that converts to sugar easily.
- Select 2-4 servings of fresh fruits a day, limit dried fruit.
- Select 3-5 servings of vegetables a day.
- Select lean sources of proteins, 2-3 servings per day.include more fish and tuna.
- Select skim or 1% low fat milk, 2-3 cups a day. Lite or non fat yogurt. Low fat hard cheese.
- Select olive or canola oil, eliminate saturated, hydrogenated or partially hydrogenated oils.
- Limit fast food to once a week, skip the fries, coke, shakes etc.
- Do 1 hour of physical activity a day.
- Get a scale and check your weight once every other week.
Medical Complications
The Metabolic Syndrome: Historical Perspective
The clustering of cardiovascular risk factors including obesity, hypertension
and dyslipidemia have been noted since 1970. However, Professor Reaven
at Stanford in his Banting lecture in 1988 made the important observation
that this cluster of risk factors may be linked to insulin resistance.
Professor Reaven called this entity “Syndrome X” but it is more commonly
called the metabolic syndrome, or the insulin resistance syndrome. Note
that Professor Reaven listed glucose intolerance rather than diabetes
since subjects who developed type 2 diabetes need a second deficit which
is impaired insulin secretion. As a result many or most individuals with
insulin resistance will not actually have type 2 diabetes. In his 1988
Banting lecture, Professor Reaven attempted to show that people can have
the insulin resistance syndrome even without obesity. However, other
investigators such as Despres have noted that insulin resistance occurs
most often in combination with increases in visceral fat. Not all of
the components described in the 1988 Banting lecture are equally strongly
related to insulin resistance. A number of techniques including factor
analysis have been used to suggest that hypertension has no or only a
very weak relationship to insulin resistance.
References:
Reaven GM. Banting lecture 1988: Role of insulin resistance in human
disease. Diabetes. 1988;37:1595-1607.
Pouliot MC, Després JP, Lemieux S, et al. Waist circumference and abdominal
sagittal diameter: best simple anthropometric indexes of abdominal adipose
tissue accumulation and related cardiovascular risk in men and women.
Am J Cardiol. 1994;73:460-468.
Hanley AJG, Festa A, D’Agostino RB Jr, Wagenknecht LE, Savage PJ, Tracy
RP, Saad MF, and Haffner SM. Metabolic and inflammation variable clusters
and prediction of type 2 diabetes: Factor analysis using directly measured
insulin sensitivity. Diabetes, 53:1773-1781, 2004.
Modified NCEP Criteria
3 or more of the following:
- Fasting plasma glucose >100mg/dl
- Hypertriglyceridemia: >90th percentile for age
- Low HDL cholesterol <40 mg/dl
- Hypertension: BP >90th percentile for age
- Central adiposity: waist circumference >90th percentile for age sex and race
Management of Metabolic Syndrome
- Low carbohydrate diet - Limit consumption of sweetened beverages.
- Glucose Intolerance or Type 2 - Consider OGT & Metform in therapy after consultation with obesity experts.
- Daily physical activity with target weight loss of 5-10 % in 6 months to 1 year period.
- Persistent lifestyle changes.
Toolkit for Physicians
Nutritional Handbook