Obesity

Pediatr. Rev. 2001;22;250

DOI: 10.1542/pir.22-7-250

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Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
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in brief

A PPD tuberculin skin test is indicated for patients who may have
been exposed to tuberculosis and ultrasonography should be performed
to seek adrenal calcifications. In most
cases of adrenal insufficiency, ultrasonography should be performed
to look for adrenal hemorrhage or
cysts.
This patient had persistently low
cortisol levels, both at baseline and
following ACTH stimulation. His
aldosterone level was undetectable,
explaining his salt craving. He had a
PPD placed, which was negative,
and abdominal ultrasonography results were normal. His antiadrenal
antibody titer was high, and his underlying disease process was judged
to be autoimmune. Currently he is
doing well on replacement therapy,
requiring higher doses at times of
illness.

Management
The emergent treatment of acute adrenal crisis involves fluid resuscitation
and correction of the associated hypoglycemia. At the same time, the
patient requires cortisol replacement
with hydrocortisone. Hydrocortisone is the agent of choice in the
acute treatment of adrenal insufficiency because it acts rapidly and has
both glucocorticoid and mineralocorticoid activity. Once the patient is
clinically stable, maintenance hormone replacement and a diagnostic
evaluation can be initiated.
The mineralocorticoid is replaced
with fludrocortisone, and the glucocorticoid is replaced by hydrocortisone. The dose of hydrocortisone
needs to be increased in times of
stress, such as illness, trauma, or surgery. Those patients found to have
antiadrenal antibodies are at in-

creased risk of developing other autoimmune disorders and, therefore,

require close monitoring.

Lessons for the Clinician

Adrenal crisis is one of a small number of endocrinologic emergencies.
The constellation of symptoms of
vomiting, fever, and lethargy easily
can be confused with the more common diagnosis of gastroenteritis.
This case highlights the need to look
for alternative causes if the vomiting
and lethargy progress. Obtaining
electrolyte measurements can provide the key diagnostic clue. Of
course, a history of extreme salt craving, as seen in this case, also can be
very helpful in pointing toward adrenal insufficiency. (Karen Brenner,
MD, John G. Frohna, MD, MPH, The
University of Michigan Health System, Ann Arbor, MI)

In Brief
Obesity
Overweight Prevalence and Trends for
Children and Adolescents. The National Health and Nutrition Examination Surveys, 1963 to 1991. Troiano RP, Flegal KM, Kuczmarshki RJ,
Campbell SM, Johnson CL. Arch Pediatr Adolesc Med. 1995;149:
10851091
Health Consequences of Obesity in
Youth: Childhood Predictors of
Adult Disease. Dietz WH. Pediatrics.
1998;101:518 525
Treatment of Pediatric Obesity. Epstein
LH, Myers MD, Raynor HA, Saelens
BE. Pediatrics. 1998;101:554 570
Promoting Healthy Eating and Physical
Activity in Adolescents. Story M,
Neumark-Sztainer D. Adolescent
Medicine State of the Art Reviews.
1999;10:109 123
250 Pediatrics in Review Vol.22 No.7 July 2001

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 Etiology and Treatment. SchonfieldWarden N, Warden CH. Pediatr Clin
North Am. 1997;44:339 361

Recent increases in the prevalence of

obesity in childhood and adolescence
have prompted much concern in the
United States. At least 11% to 19% of
adolescents are estimated to be obese,
defined as a body mass index greater
than the 85th to 95th percentiles, according to cycle II of the National
Health and Nutrition Examination Sur-

vey (1988 to 1991). This increase has

occurred in just the past 30 years.
Efforts to address this trend are underway, principally because of the associated morbidity that begins in adolescence but continues and intensifies in
adulthood. It is important to employ
effective weight loss treatments early
in childhood or adolescence because if
weight loss has not been achieved by
late adolescence, only 5% of obese
adolescents will lose weight successfully by adulthood. Unfortunately, finding effective and lasting treatments
has been difficult; research is underway
to evaluate how to have a greater
impact on preadolescent and adolescent obesity.

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in brief

Obesity in adolescence is commonly

defined by body mass index (BMI). It is
important to remember that obesity is a
function of increased fat mass, not just
an increase in weight. Although there is
no identifiable organic disease leading
to the excessive fat mass for most
obese adolescents, it is too simplistic to
state that it is a function of energy
expenditure and energy intake. Some
advances have been made in understanding the etiology of obesity, and it
is possible that endocrine pathways in
the adipose tissue may play a large part
in the development of obesity. The hormone leptin has been found to correlate positively with BMI and possibly
energy expenditure. Puberty has been
accompanied by shifts in the leptin
levels by gender. Additional research in
this area could have a profound effect
on the treatment and prevention of
obesity.
Many of the consequences of obesity occur in adulthood, but numerous
negative and devastating consequences
begin in childhood, such as lasting psychosocial difficulties, sleep apnea, abnormal glucose tolerance, hypertension,
hyperlipidemia, pseudotumor cerebri,
and Blount disease. This expands in
adulthood to include an increased risk

of cancer, cardiovascular disease,

diabetes mellitus, and orthopedic
problems.
Many efforts have been made to
decrease childhood and adolescent
obesity before it progresses to adult
obesity. The goals of treatment are
long-term weight maintenance and
adoption of healthy lifestyles. Interventions have included dietary, activity,
and behavior changes and medication.
These have been implemented on the
individual level as well as among families, peers, schools, and communities.
No one method of weight loss stands
out above the others. Additionally, very
few published studies have examined
differences in weight loss and maintenance within and between ethnic
groups. Most follow-up evaluations of
available programs have shown significant relapses among participants even
if initial weight loss has been successful. In general, the most successful
programs incorporate a multidisciplinary approach that addresses dietary
consumption, energy expenditure, and
the behavioral and psychosocial aspects
of obesity. It is encouraging that some
of the intensive programs involving
physicians, counselors, social workers,
and dietetics professionals have had

some positive effects. Positive effects

include a reduction in weight, blood
pressure, serum lipids, and insulin resistance and increased self-concept. Research is ongoing to ascertain if earlier
treatment of obesity in the preadolescent years will provide more lasting
benefits.
L. Walker, MD
Department of Pediatrics
Section of Adolescent Medicine
Georgetown University Medical Center
Washington, DC
Comment: Obesity is considered the
most prevalent nutritional disease of
youth in the United States. The relationship between prenatal, childhood,
or adolescent obesity and adult obesity remains unclear. Obese adolescents are more likely to be obese
adults. However, among obese adults,
only 15% to 30% were obese in
childhood or adolescence. We must
focus on those who have become
obese, but also on the behaviors and
habits learned early that may lead to
adult obesity.
Tina L. Cheng, MD, MPH
Associate Editor, In Brief

Pediatrics in Review Vol.22 No.7 July 2001 251

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

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& Services

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