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  1. Overweight and obesity are becoming increasingly significant problems in children and adolescents in the US - currently 1/3 of all children are overweight and obese.
  1. The diagnosis of overweight in children and adolescents requires a BMI >85th % and <95th%; and the diagnosis of obesity in children and adolescents requires a BMI > 95th %.
  1. Most obesity in childhood is primary (exogenous), but there are many secondary causes of obesity so a careful history and physical exam is needed in the evaluation of an overweight or obese child.
  1. There are many co-morbidities associated with obesity in children and adolescents including:
    1. Gallbladder disease
    2. Dyslipidemia
    3. Hypertension
    4. Diabetes mellitus
    5. Impaired glucose tolerance or insulin resistance
    6. PCOS
    7. Liver disease
    8. Obstructive sleep apnea
    9. Pseudotumor cerebri
    10. Orthopaedic problems
  1. The definition of metabolic syndrome includes abnormalities in the following:
    1. Increased waist circumference (or obesity as defined by BMI)
    2. Increased triglyceride levels
    3. Decreased HDL levels
    4. Abnormal fasting plasma glucose
    5. Elevated blood pressure
  1. Dyslipidemia is diagnosed when the total cholesterol level is >200 mg/dL or LDL > 130 mg/dL
  1. Dyslipidemia, overweight, obesity, smoking, hypertension, personal history of diabetes, and family history of premature CVD (<55 years of age for men and < 65 years of age for women) are all risk factors for cardiovascular disease in adulthood.
  1. The AAP recommends screening children and adolescents for dyslipidemia with a fasting lipid profile between the ages of 2-10 with one of the following criteria:
    1. Positive family history of dyslipidemia or premature CVD in a family member
    2. Unknown family history
    3. Patients with certain risk factors (overweight, obese, personal history of hypertension or diabetes mellitus, or cigarette smoking)
  1. Patients with normal fasting lipid panel should be rescreened every 3-5 years if risk factors remain.
  1. For patients with abnormal total cholesterol or LDL levels, the first step in treatment is low fat diet and repeat fasting lipid panel in 3-6 months.
  1. Low fat diets for obesity and dyslipidemia have been used in patients as young as 7 months of age without adverse effects in growth or development (including the use of low fat or skim milk in patients less than 2 years of age).
  1. Treatment with lipid lowering medication is considered in the following patients:
    1. LDL concentration persistently > 190 mg/dL despite diet therapy in a patient with no other CVD risk factors
    2. LDL concentration persistently > 160 mg/dL despite diet therapy in a patient with other risk factors including obesity, hypertension, cigarette smoking, or positive family history of premature CVD
    3. LDL concentration > 130 mg/dL in a patient with diabetes mellitus (after first abnormal screening test)
  1. Patients on lipid lower medication should also be followed by a subspecialist.
  1. The AAP and ADA recommend screening patients for diabetes at 10 years of age or the onset of puberty (whichever comes first) if they are overweight or obese and have two or more of the following risk factors:
    1. Type 2 diabetes in a first or second degree relative
    2. Member of a high risk ethnic group - Native American, non-Hispanic Black, Hispanic, or Asian American
    3. Signs of insulin resistance (hypertension, dyslipidemia, acanthosis nigricans or PCOS)