Obesity

Referrals pathways for Regional Paediatric model

Index:

Diagnosis

Practice points

Management

Referral pathways

Obesity is classified as a BMI >95th percentile for age- and sex-matched BMI.

Overweight is classified as a BMI >85th percentile for age- and sex-matched BMI.

Obesity and overweight are very common problems in Australia, with rates increasing rapidly. Increasing data suggests that overweight infants and toddlers are more commonly overweight adults.

Diagnosis

Overweight and obesity is determined by calculating and plotting body mass index (BMI). Abdominal (waist) circumference is also used. Once diagnosed, monitoring for complications remains very important (see management below).

Note that it is uncommon for a medical diagnosis or syndrome to be the cause of overweight or obesity, however it must be considered in any workup (particularly in those with short stature, developmental delay or dysmorphism).

The diagnosis of metabolic syndrome (in adults) requires at least three of:

• waist circumference > 102 cm (male) or > 88 cm (female)
• triglycerides > 150 mg/dL
• HDL < 40 mg/dL (male) or < 50 mg/dL (female)
• BP > 130/85 mmHg
• fasting BSL > 5.5mmol/L

Practice points

 

 

• Obesity is classified as a BMI >95th percentile for BMI. Overweight is classified as a BMI >85th percentile for BMI.
• Note that it is uncommon for a medical diagnosis or syndrome to be the cause of overweight or obesity, however it must be considered in any workup, particularly in those with short stature, developmental delay or dysmorphism.
• management of obesity requires exclusion of medical causes, monitoring for complications and management strategies.

Management

Management of obesity requires three main steps:

• exclusion of medical causes
  • it is uncommon for children to have an underlying medical cause for weight problems, although does become more likely in those with short stature, developmental delay or dysmorphism.
  • hypothyroidism
• monitoring for complications
  • examination: weight & height, BMI, waist circumference, BP and pulse, acanthosis nigricans, hepatomegaly, striae
  • investigations: LFT, fasting lipids (incl LDL/HDL) & cholesterol, fasting glucose, fasting insulin (debatable use), PCOS screen (if clinically indicated), liver ultrasound.
• management strategies
  • lifestyle modification - diet and exercise form the key components to the management of overweight & obesity
  • medication - consider in certain circumstances
    • antihypertensives
    • metformin (insulin resistance, weight)
    • statins, bile-acid binding resins & cholesterol-absorption inhibitors

Referral pathways

• Paediatrician
  • Most cases of overweight and obesity can be adequately managed in the general practice setting. Referral to paediatric outpatient services can be considered in the management of overweight and obesity when:
    • underlying medical cause suspected (see above)
    • complications present (insulin resistance/T2DM, hypertension, lipid/cholesterol abnormalities, OSA, NAFLD, PCOS, SUFE, etc.)
    • failure of management strategies in the primary care setting with escalating weight.
• Dietitian
  • Dietetic services are invaluable assisting with management of overweight and obesity.
• Psychologist/counsellor
  • Mental health services can be useful in more difficult situations of overweight and obesity.
• Lifestyle programs
  • Better Health Company on line obesity program based on the MEND program (please see link to registration form for health professionals here).
• Other resources
  • BMI charts
  • WHO growth charts
  • NH&MRC management guidelines
  • Eat for Health - Australian dietary guidelines
  • Australian Government Dept of Health physical activity guidelines
  • Better Health Channel - obesity guidelines
  • Bariatric surgery recommendations - RACP position statement 2010