History and Physical Exam

Social History

• Assessment of eating behaviors and physical activity patterns.

• Self-efficacy and readiness to change:
• Identification of the following specific dietary practices, which may be targets for change

•  Frequency of eating outside the home at restaurants or fast food establishments
•  Excessive consumption of sweetened beverages
•  Consumption of excessive portion sizes for age

•  Additional practices to be considered for evaluation during the qualitative dietary assessment include:

• Excessive consumption of 100% fruit juice
• Breakfast consumption (frequency and quality)
• Excessive consumption of foods that are high in energy density
• Low consumption of fruits and vegetables
• Meal frequency and snacking patterns (including quality)

• Assessment of Physical Activity Patterns

• Self-efficacy and readiness to change
• Environment and social support and barriers to physical activity
• Whether the child is meeting recommendations of 60 minutes of at least moderate physical activity per day.
• Level of sedentary behavior, which should include hours of behavior such as television and/or DVD watching, playing video games.

Family History

• Obesity
• Cardiac events
• Diabetes
• High blood pressure
• Hypercholesterolemia.
• Pregnancy history – ask if there were maternal gestational diabetes or other complications of pregnancy (hypertension, impaired intrauterine growth, birth weight (with focus on identifying those born small or large for gestational age).

Review of Systems

• Sleep patterns (snoring, nocturnal binge eating, nocturia, duration)
• Physical limitations due to orthopedic problems
• Mood assessment
• Eating patterns (focus in history of dieting and on binging).
• In female adolescents, the regularity of periods and the presence of hyperandrogenism (acne, hirtuism)
• Abdominal pain

Physical Exam

• Vital Signs: Blood pressure reading and pulse
• Possible physical findings: Developmental delay, short stature, dysmorphism, hypogonadism, and purple abdominal striae. Acanthosis nigricans or manifestations of hyperandrogenism in females.
• Musculoskeletal exam focusing on skeletal deformities and limitation of motion.
• Abdominal exam to assess for liver size and presence of right upper quadrant pain, masses of stool.
• Skin exam to assess for acanthosis nigricans, acne, hirsutism, striae (pink/white striae can indicate rapid weight gain; whereas a child with no striae has gained weight slowly and progressively)
• GU exam Tanner staging, pubertal status, hypogonadism, buried/hidden penis
• Breast exam (boys and girls) -- pubertal status, pseudogynecomastia vs true gynecomastia

Lab Testing

Suggested lab tests to perform include: CBC, CMP, TSH, free T4, HgA1c (Nowicka et al., 2011), fasting insulin  sensitivity, and a fasting lipid panel.

Genetics

“Genetic syndromes associated with pediatric obesity include, Prader-Willi syndrome, Turner Syndrome, or Laurence-Moon-Bardet-Biedle. Findings such as developmental delay, short stature/delayed growth, dysmorphic features, abnormal or absent genitalia, and digital anomalies should raise suspicion of an underlying genetic anomaly and consideration of definitive testing. If any of these conditions is suspected, referral to a geneticist or other relevant subspecialties, is recommended” (Sothern, Gordon, & Alman 2006).

Differential Diagnosis

• Cushing’s Syndrome
• Hypothyroidsm
• Polycystic Ovarian Syndrome
• Metabolic Syndrome (Syndrome X, diabetes, HTN, and hyperlipidemia)
• Insulinoma
• Growth Hormone Deficiency
• Hypothalmic Disorders
• Congenital Leptin Deficiency (morbid obesity)
• Defects in MSH receptors (morbid obesity)
• Genetic Causes:

• Prader Willi (hypotonia, hypogonadism)
• Cohens syndrome (microcephaly, hypotonia, short stature, ocular anomolies, neutropenia)
• Laurence-Moon Bardet-Bied (polydactyly, renal anomalies, retinitis pigmentosia)
• Biemond syndrome (diabetes mellitus, polydactyly, coloboma, facial abnormalities, hypogonadism)

(McGraw Hill Diagnosaurus, 2011)