**5. Clinical assessment of obesity**

Obesity is more complicated to diagnose in children than in adults because children increase in height, weight and body fat naturally as they grow. The criteria for defining obesity in children are the fat mass assessment, the distribution of the body fat measure by age and sex and a centile cut off to define the point in the body fat measure distribution corresponding to obesity [33].

Initial assessments of these patients should include taking a careful history (investigating comorbidities, family history and potentially modifiable behaviors) and physical examination with BMI plotted on a BMI-for-age chart.

The careful history includes as follows: elements of perinatal life (gestational diabetes, maternal obesity, birth weight, infant feeding, medications—glucocorticoids, some antiepileptics, antipsychotics), weight history (onset of parental and child obesity, current eating behaviors, management interventions), complications (psychological, sleeping disorders, gastrointestinal and orthopedic complications, menstrual disturbances in girls), family history (ethnicity, history of obesity, type 2 diabetes, cardiovascular disease, dyslipidemia, obstructive sleep apnea, polycystic ovary syndrome, bariatric, surgery, eating disorders) and lifestyle history (detailed exploration of family eating, nutritional, and activity patterns, sleep) [34].

Physical examination should include the following: anthropometric data (weight, height, BMI, abdominal circumference), adiposity distribution (central versus generalized), assess blood pressure, markers of comorbidities and physical stigmata of a genetic syndrome, endocrine disorders, congenital or acquired hypothalamic alterations (fewer than 5% of cases) [4, 34].

The child's BMI must be plotted on nationally recommended BMI—for age charts. Children and adolescents with a BMI ≥99th percentile are even more likely to have comorbidities [4].

Abdominal circumference (AC) is also used for assessing excess fatty tissue is an indirect method for assessing abdominal fat tissue. Given the strong association between body fat distribution and risk of metabolic complications, it is helpful to calculate in all children with excess weight from the age of 5 years and upwards the relationship between waist circumference and height.

Other methods of measuring fat, such as bioelectrical impedance, and total body water measurement are used in research, but not in clinical evaluation [4].

Careful screening for hypertension using an appropriately sized blood pressure cuff is important (e.g., hypertension is diagnosed if systolic or diastolic blood pressure falls over 95th percentile for age, gender and height in at least three occasions) [35, 36].

the direct effect of obesity, insulin resistance in others, it is considered a predictor of hypertension, independent of BMI. Arterial hypertension in the pathogenesis of obesity and insulin resistance may play a role in which leptin resistance physiological actions of insulin that leptin central nervous system vessels and kidneys should be changed. Studies suggest the involvement of oxidative stress in the pathogenesis and hypertension by stimulating reac-

Obesity is more complicated to diagnose in children than in adults because children increase in height, weight and body fat naturally as they grow. The criteria for defining obesity in children are the fat mass assessment, the distribution of the body fat measure by age and sex and a centile cut off to define the point in the body fat measure distribution corresponding to

Initial assessments of these patients should include taking a careful history (investigating comorbidities, family history and potentially modifiable behaviors) and physical examination

The careful history includes as follows: elements of perinatal life (gestational diabetes, maternal obesity, birth weight, infant feeding, medications—glucocorticoids, some antiepileptics, antipsychotics), weight history (onset of parental and child obesity, current eating behaviors, management interventions), complications (psychological, sleeping disorders, gastrointestinal and orthopedic complications, menstrual disturbances in girls), family history (ethnicity, history of obesity, type 2 diabetes, cardiovascular disease, dyslipidemia, obstructive sleep apnea, polycystic ovary syndrome, bariatric, surgery, eating disorders) and lifestyle history

Physical examination should include the following: anthropometric data (weight, height, BMI, abdominal circumference), adiposity distribution (central versus generalized), assess blood pressure, markers of comorbidities and physical stigmata of a genetic syndrome, endocrine disorders, congenital or acquired hypothalamic alterations (fewer than 5% of cases) [4, 34].

The child's BMI must be plotted on nationally recommended BMI—for age charts. Children and adolescents with a BMI ≥99th percentile are even more likely to have comorbidities [4].

Abdominal circumference (AC) is also used for assessing excess fatty tissue is an indirect method for assessing abdominal fat tissue. Given the strong association between body fat distribution and risk of metabolic complications, it is helpful to calculate in all children with excess weight from the age of 5 years and upwards the relationship between waist circumfer-

Other methods of measuring fat, such as bioelectrical impedance, and total body water mea-

surement are used in research, but not in clinical evaluation [4].

(detailed exploration of family eating, nutritional, and activity patterns, sleep) [34].

tive oxygen species by the renin–angiotensin–aldosterone system [32].

**5. Clinical assessment of obesity**

104 Adiposity - Epidemiology and Treatment Modalities

with BMI plotted on a BMI-for-age chart.

obesity [33].

ence and height.

Endocrine problems must be considered carefully on signs suggesting hypothyroidism (goiter), insulin resistance (acanthosis nigricans), polycystic ovary syndrome (hirsutism, excessive acne) and Cushing syndrome (violaceous striae, moon face) [36].

Symptoms of polyuria, nocturia or polydipsia may be the result of type 2 diabetes mellitus. Depending on their durations, overweight and obesity are important potential risk factors for respiratory complications (asthma, sleep apnea), abdominal pain or hepatomegaly (gastroesophagial reflux, nonalcoholic fatty liver), musculoskeletal problems (hip or knee pain, genu valgum, slipped capital femoral epiphysis, Blount disease) and psychological disorders (depression, body dissatisfaction, bulimia nervosa impaired social relationships and decreased health-related quality of life depression) [4, 37–39].

Reproductive system and Tanner stage disturbance can reveal premature puberty, apparent micropenis (but normal penis may be hidden in fat), undescended testis/micropenis (Prader Willi syndrome) and must be evaluated [4].

The degree of investigation is dependent on the patient's age and severity of obesity, the findings on history and physical examination, and associated familial risk factors.

First-line investigations recommended in cases of childhood obesity include fasting plasma glucose, triglycerides, low-density lipoprotein and high-density lipoprotein cholesterol, liver function tests and, possibly, insulinemia [4, 34, 35].

The investigations for overweight children include the fasting lipid screening test. If this children present risk factors represented by hypertension, dyslipidemia and family history of diabetes, it is necessary to evaluated the serum levels of fasting glucose, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) to every 2 years (increased value of ALT and AST is associated with possible non-alcoholic fatty liver disease) [36].

In obese, children is necessary to evaluated serum levels of fasting lipids, glucose, ALT and AST every 2 years, and insulinemia [4, 34, 35].

Second-line investigations may include liver ultrasound, an oral glucose tolerance test, more detailed endocrine assessment and polysomnography [4, 34].

Patients with fasting blood glucose >100 mg/dL or overweight children (BMI 85th to 95th percentile) who have a family history of diabetes mellitus or signs of insulin resistance (acanthosis nigricans), polycystic ovary syndrome, or metabolic syndrome should also be evaluated with an oral glucose tolerance test [4, 34, 35]. If the result of oral glucose tolerance test is more than 126 mg/dL, counseling and repeating test is necessary because pediatric obesity can lead to impaired glucose tolerance. The value of HbA1c of 40 mmol/mol (5.8%) is an appropriate screening tool for diagnosing impaired glucose tolerance [40, 41].

Liver ultrasound is recommended for all obese children and adolescents. In children with confirmed ALT >40 IU/L or palpable liver, more thorough diagnostic tests are advisable with gamma-GT and differential diagnosis of hepatitis [41].

Other laboratory tests such as thyroid function tests (if there is a faster increase in weight than height), pelvic ultrasound and hormonal doses in cases of suspected polycystic ovary syndrome have been recommended [4, 41].

Psychological and psychiatric evaluations are essential to identify psychological disturbances including depression, loss-of-control eating, unhealthy and extreme weight control behaviors, and decreased health-related quality of life which are warning signs of bulimia nervosa and binge-eating disorder [39].

In patients with hypertension more diagnostic tests should be done: cardiac exam: ECG and echocardiogram, standard urinalysis, microalbuminuria, creatinine and potassium levels [4, 41].

We should realize screening for diagnosis of metabolic syndrome in the presence of at least three of the following situations: BMI indicate obesity or waist circumference/height ratio >0.5, systolic and/or diastolic blood pressure >95th percentile, fasting blood glucose >100 mg/dL, serum level of triglycerides >95th percentile, serum level of HDL cholesterol [4, 41].

According to International Diabetes Federation (IDF), the consensus definition of metabolic syndrome in children (older than 6 years) and adolescents are as follows:













Vitamin D deficiency is common in obese children and is associated with risk factors for type 2 diabetes in obese children, but they are not still recommended by national clinical practice guidelines as routine measures [43].
