Transcription:
Evaluating Pediatric Obesity

Andrew Wilner, MD (Host): Thanks for joining me for another episode of Pediatrics in Practice with Children's Mercy, Kansas City. I'm your host, Dr. Andrew Wilner, Associate Professor of Neurology at the University of Tennessee Health Science Center, Memphis, Tennessee. My guest today is Dr. Kelsee Halpin, a Pediatric Endocrinologist at Children's Mercy, Kansas City, and Assistant Professor of Pediatrics at the University of Missouri Kansas City School of Medicine. Today, Dr. Halpin is going to help us understand the problem of pediatric obesity, which affects one out of every five children. Welcome Dr. Halpin.

Kelsee Halpin, MD, MPH (Guest): Thanks Dr. Wilner for having me.

Host: Dr. Halpin, thanks for joining us. To get started, this may seem like a simple question, but how do you know if a child is obese or not?

Dr. Halpin: Yeah, and actually, it seems very simple, but it's kind of a complex thing. So, we absolutely rely on our pediatricians during their well-child visits and visits with children to calculate body mass index. And so that is getting an accurate height and weight and most electronic health records are gonna automate that for you and calculate that body mass index and assign a percentile. So, where that child's body mass index lies compared to other children of the same gender and the same age. The issue with body mass index is it doesn't necessarily differentiate between muscle mass and bone mass. And so there are limitations but that is a best practice that we have. And so we encourage our pediatricians to always obtain those, and be looking for those kids that are plotting at the 95th percentile or higher.

Host: Okay. Now I understand that there are actually three classes of obesity. Is that correct?

Dr. Halpin: Yeah. So, that has been a more recent classification set that has come about in the last few years. The reason being, as you said, in our introduction, right now, one out of every five children in the United States have a body mass index at the 95th percentile or higher. So, one in five are obese. And because of that, we needed better ways to quantify within that category, the severity of obesity.

And so now we have children that can be classified as class one obesity. And those are those who have a body mass index above the 95th percentile, but less than what we call 120% of the 95th percentile. So, it's kind of tricky, but you look at their BMI, you compare it to the BMI at the 95th percentile for their age and gender. And then you assign that a percent. So above 120% we call that class two obesity and above 140% of the 95th percentile is class three. And the more severe classes of obesity come with higher risk of those cardiovascular and metabolic diseases that we're concerned about. Thankfully those more severe classes, class two and three are much less common and present only in about two to 5% of children.

Host: Okay now just casual observations. We often see obese children as part of obese families with obese parents. And I don't know what the statistics are on that, but how much of obesity is genetic?

Dr. Halpin: A good portion. And as, as you kind of alluded to anecdotally, we see that a lot. And so particularly in your very young children, so children under five years of age, those children, often when they have a high body mass index, sometimes we kind of don't know, we downplay it because they're young. They have time to grow and lean out, but we know that children that young who are already obese, their risk of obesity as an adult is directly related to how many obese parents they have, whether it's one or two, increases that risk that they will be an obese adult. And so when you see those families and you see those young children, it certainly is an additional risk factor compared to an obese young child who had two lean parents.

So I, I don't know that there's an exact percentage to stick on it, but certainly having an obese parent is going to increase the likelihood of that kid having obesity that's gonna follow them along until adulthood.

Host: Can you dissect that a little bit? Because a lot of these obese parents, didn't have obese parents, right. There's been an explosion of obesity amongst adults. So, how much is really lifestyle of the family versus some gene that makes you overweight? Has anyone explored that?

Dr. Halpin: Yeah. I mean, it's so complicated to really tease that out within research, just because there's so many overlapping variables, but in general, when I'm seeing people in clinic, I explain to them that about half of your abnormal weight gain is due to lifestyle. Okay, then energy you're putting in, in the form of food and the energy that you're putting out, you know, as a result of your activity level.

And then the other half of it is things that are completely outside of people's control. Gene changes, but not just a single gene change, lots of different gene changes that add up to a cumulative risk that you gain weight easier. Hormonal changes, different things that we can't necessarily account for with lifestyle.

So to kind of ballpark it about half of it is related to lifestyle. And the other half is risk factors that we can't really modify, which is like so much attention is put on unhealthy lifestyle modification, but it's important to really recognize that for vast majority of these kids it is not just because they ate too much and were not active enough. I mean, there is something ingrained in them. And you sort of alluded to this, you know, these parents didn't necessarily have obese parents, but for these children, if your parent is obese, particularly your mother as she is pregnant with you, that does something to the genetic meetup that makes the children more likely to gain weight easily.

So it's sort of a generational thing. And I anticipate as we get into our next generation, we're going to see the consequences of this current obesity epidemic in our children as they have children. And so it's certainly a concern.

Host: Yes. Now if half is due to genetics and half is due to an environment, more food going in than energy going out where does a pediatric endocrinologist come in?

Dr. Halpin: Yeah. So there are some rare instances where that half that has nothing to do with lifestyle, so what we talked about genetics and hormones; there are some rare instances where there is actual hormonal pathology that can result in rapid weight gain. So, a lot of times that's where I come in, in children that have hormone abnormalities that will make them gain weight rapidly.

Those are things like hypothyroidism. So, low thyroid hormone definitely predisposes you to weight gain, having too much cortisol or that Cushing syndrome, Cushing disease, having high prolactin levels. So in a small percentage of these children who have rapid weight gain, there is an underlying hormonal abnormality that can be pinpointed. And then a lot of times they end up getting referred to us for evaluation of those issues. The other time I come in is when they're gaining weight quickly and their lab work kind of watching that shows signs of consequences of that weight gain, things like higher blood sugar.

Host: Okay. So if a child, a pediatrician sees a child and they're doing their routine growth curves, and all of a sudden the weight curve starts to surpass the height curve, or labs show new onset diabetes; those would be two indications for referral. Is that right?

Dr. Halpin: Well, it's a little tough. So normally if it's just the weight going up while the height is remains stable, a lot of those kids don't need us. Frankly, it's just they're so, like we said, one in five, right? One in five children are struggling with that particular growth pattern because there's not really the capacity for every referral for rapid weight gain to come through endocrinology. But the ones we absolutely want to see as if the weight percentiles are going up and the height percentiles are going down. So, when you have declining height percentile, that is growth failure, linear growth failure. And that in combination with rapid weight gain, is a concern for a hormonal issue every single time.

And so we definitely want to see those kids to do more of an endocrine workup for causes of rapid weight gain. And then as you mentioned, any child that has concerns for high blood sugar, that is obese, we would want to be involved in that child's care.

Host: Well, thanks for clarifying that. What about medications? Are they a cause of childhood obesity?

Dr. Halpin: Certainly. certainly there's certain classes of medications that contribute to rapid weight gain and obesity. And those are always what you want to sort of tease out in your history. So as you're seeing these kids, if there is a clear year starting point for when the weight percentiles started to increase; and usually that means body mass index percentiles starting to increase; you want to tease out what happened at that point in time, what was the difference? And when that child was gaining weight, normally versus it to become rapid and occasionally you will get the history of a child that was started on a medication that promotes weight gain.

So, some of the more common ones that we hear as they reach us are people that start on depoprovera for contraception or to suppress periods. People with mood disorders or behavior disorders that are started on atypical anti-psychotics, things like olanzapine, Risperdol and those types of mood medications often can contribute to rapid weight. Certain antidepressants SSRIs can contribute to that. So if you are getting a history of weight gain that occurs simultaneously with the start of a new medication, you really want to be looking into whether that is a potential side effect of that therapy.

Host: Thank you. You mentioned medications for mental health disorders. I was curious how often is there an overlap? Or are mental health disorders, more common in children who are obese versus children who are not obese. Let's put it that way.

Dr. Halpin: Yeah. And unfortunately they are in the sense that there's higher rates of depression, anxiety, bullying that occur in obese children. And so, it's usually more as thought to be as a consequence of the obesity. So, then you sort of have this complicating factor that there is higher rates of mental health illness in obese children, and then treatment of those mental health concerns may ultimately contribute more to weight gain. So it can kind of get into a cycle that way.

Host: Sure. So, can affect a child's self image for example. All right. Well, how many pediatric endocrinologists are on your team at Children's Mercy?

Dr. Halpin: Yeah. So, we've got a great group and a pretty large division. So, they're constantly hiring it seems, but I think last day you checked, we had 19 pediatric endocrinologists here, as well as a few nurse practitioners that are able to see children. And then we see children all across Missouri and Kansas. And so certainly a very big patient population base.

Host: Wow. Is there anything else you'd like to add before we wrap up?

Dr. Halpin: I've talked with a lot of pediatricians and I see a lot of obesity referrals, and I think the key here, is we cannot be afraid to talk about it at our checkups. And so there's always this sort of stigma and guilt that comes along with sort of pointing out high body mass index and labeling a child as obese.

And certainly we want to be sensitive to that, but I think sometimes we do a disservice by downplaying the importance of that. And so when you're seeing in families, I think you just, you have to point out the growth chart, show them how they are plotting and how the body mass index is rising. Explain why that is a concern, but also validate that you are not thinking they are just lazy and eating too much. That this is a very complicated disease. One that is very common. But that we have to address it early because the earlier we address it and focus on that healthy lifestyle modification, the higher likelihood of success there is at preventing that child from becoming an obese adult.

Host: Well, that's a great observation and great advice, Dr. Halpin. Thank you very much for an informative discussion on childhood obesity.

Dr. Halpin: Of course, thank you so much for having me.

Host: This has been Pediatrics in Practice with Children's Mercy, Kansas City. Please remember to subscribe, rate and review this podcast and all the other Children's Mercy podcasts. To learn more about developmental and behavioral health services at Children's Mercy, please visit children'smercy.org. I'm your host, Dr. Andrew Wilner. Thanks for listening.