DOI: 10.1542/pir.22-7-250 2001;22;250 Pediatr. Rev.

Obesity

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A PPD tuberculin skin test is in-dicated for patients who may havebeen exposed to tuberculosis and ul-trasonography should be performedto seek adrenal calcifications. In mostcases of adrenal insufficiency, ultra-sonography should be performedto look for adrenal hemorrhage orcysts.

This patient had persistently lowcortisol levels, both at baseline andfollowing ACTH stimulation. Hisaldosterone level was undetectable,explaining his salt craving. He had aPPD placed, which was negative,and abdominal ultrasonography re-sults were normal. His antiadrenalantibody titer was high, and his un-derlying disease process was judgedto be autoimmune. Currently he isdoing well on replacement therapy,requiring higher doses at times ofillness.

ManagementThe emergent treatment of acute ad-renal crisis involves fluid resuscitationand correction of the associated hy-poglycemia. At the same time, thepatient requires cortisol replacementwith hydrocortisone. Hydrocorti-sone is the agent of choice in theacute treatment of adrenal insuffi-ciency because it acts rapidly and hasboth glucocorticoid and mineralo-corticoid activity. Once the patient isclinically stable, maintenance hor-mone replacement and a diagnosticevaluation can be initiated.

The mineralocorticoid is replacedwith fludrocortisone, and the glu-cocorticoid is replaced by hydrocor-tisone. The dose of hydrocortisoneneeds to be increased in times ofstress, such as illness, trauma, or sur-gery. Those patients found to haveantiadrenal antibodies are at in-

creased risk of developing other au-toimmune disorders and, therefore,require close monitoring.

Lessons for the ClinicianAdrenal crisis is one of a small num-ber of endocrinologic emergencies.The constellation of symptoms ofvomiting, fever, and lethargy easilycan be confused with the more com-mon diagnosis of gastroenteritis.This case highlights the need to lookfor alternative causes if the vomitingand lethargy progress. Obtainingelectrolyte measurements can pro-vide the key diagnostic clue. Ofcourse, a history of extreme salt crav-ing, as seen in this case, also can bevery helpful in pointing toward adre-nal insufficiency. (Karen Brenner,MD, John G. Frohna, MD, MPH, TheUniversity of Michigan Health Sys-tem, Ann Arbor, MI)

In BriefObesityOverweight Prevalence and Trends for

Children and Adolescents. The Na-tional Health and Nutrition Exami-nation Surveys, 1963 to 1991. Troi-ano RP, Flegal KM, Kuczmarshki RJ,Campbell SM, Johnson CL. Arch Pedi-atr Adolesc Med. 1995;149:1085–1091

Health Consequences of Obesity inYouth: Childhood Predictors ofAdult Disease. Dietz WH. Pediatrics.1998;101:518–525

Treatment of Pediatric Obesity. EpsteinLH, Myers MD, Raynor HA, SaelensBE. Pediatrics. 1998;101:554–570

Promoting Healthy Eating and PhysicalActivity in Adolescents. Story M,Neumark-Sztainer D. AdolescentMedicine State of the Art Reviews.1999;10:109–123

Obesity. Arden MR. In: McAnarney ER,Kriepe RE, Orr DP, Comerci GD, eds.Textbook of Adolescent Medicine.Philadelphia, Pa: WB Saunders Co;1992:546–553

Pediatric Obesity: An Overview of Eti-ology and Treatment. Schonfield-Warden N, Warden CH. Pediatr ClinNorth Am. 1997;44:339–361

Recent increases in the prevalence ofobesity in childhood and adolescencehave prompted much concern in theUnited States. At least 11% to 19% ofadolescents are estimated to be obese,defined as a body mass index greaterthan the 85th to 95th percentiles, ac-cording to cycle II of the NationalHealth and Nutrition Examination Sur-

vey (1988 to 1991). This increase hasoccurred in just the past 30 years.Efforts to address this trend are under-way, principally because of the associ-ated morbidity that begins in adoles-cence but continues and intensifies inadulthood. It is important to employeffective weight loss treatments earlyin childhood or adolescence because ifweight loss has not been achieved bylate adolescence, only 5% of obeseadolescents will lose weight success-fully by adulthood. Unfortunately, find-ing effective and lasting treatmentshas been difficult; research is underwayto evaluate how to have a greaterimpact on preadolescent and adoles-cent obesity.

in brief

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Obesity in adolescence is commonlydefined by body mass index (BMI). It isimportant to remember that obesity is afunction of increased fat mass, not justan increase in weight. Although there isno identifiable organic disease leadingto the excessive fat mass for mostobese adolescents, it is too simplistic tostate that it is a function of energyexpenditure and energy intake. Someadvances have been made in under-standing the etiology of obesity, and itis possible that endocrine pathways inthe adipose tissue may play a large partin the development of obesity. The hor-mone leptin has been found to corre-late positively with BMI and possiblyenergy expenditure. Puberty has beenaccompanied by shifts in the leptinlevels by gender. Additional research inthis area could have a profound effecton the treatment and prevention ofobesity.

Many of the consequences of obe-sity occur in adulthood, but numerousnegative and devastating consequencesbegin in childhood, such as lasting psy-chosocial difficulties, sleep apnea, ab-normal glucose tolerance, hypertension,hyperlipidemia, pseudotumor cerebri,and Blount disease. This expands inadulthood to include an increased risk

of cancer, cardiovascular disease,diabetes mellitus, and orthopedicproblems.

Many efforts have been made todecrease childhood and adolescentobesity before it progresses to adultobesity. The goals of treatment arelong-term weight maintenance andadoption of healthy lifestyles. Interven-tions have included dietary, activity,and behavior changes and medication.These have been implemented on theindividual level as well as among fam-ilies, peers, schools, and communities.No one method of weight loss standsout above the others. Additionally, veryfew published studies have examineddifferences in weight loss and mainte-nance within and between ethnicgroups. Most follow-up evaluations ofavailable programs have shown signif-icant relapses among participants evenif initial weight loss has been success-ful. In general, the most successfulprograms incorporate a multidisci-plinary approach that addresses dietaryconsumption, energy expenditure, andthe behavioral and psychosocial aspectsof obesity. It is encouraging that someof the intensive programs involvingphysicians, counselors, social workers,and dietetics professionals have had

some positive effects. Positive effectsinclude a reduction in weight, bloodpressure, serum lipids, and insulin resis-tance and increased self-concept. Re-search is ongoing to ascertain if earliertreatment of obesity in the preadoles-cent years will provide more lastingbenefits.

L. Walker, MDDepartment of PediatricsSection of Adolescent MedicineGeorgetown University Medical CenterWashington, DC

Comment: Obesity is considered themost prevalent nutritional disease ofyouth in the United States. The rela-tionship between prenatal, childhood,or adolescent obesity and adult obe-sity remains unclear. Obese adoles-cents are more likely to be obeseadults. However, among obese adults,only 15% to 30% were obese inchildhood or adolescence. We mustfocus on those who have becomeobese, but also on the behaviors andhabits learned early that may lead toadult obesity.

Tina L. Cheng, MD, MPHAssociate Editor, In Brief

in brief

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DOI: 10.1542/pir.22-7-250 2001;22;250 Pediatr. Rev.

Obesity

 

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