AMERICAN
ACADEMY
OF
PEDIATRICS
PROCEEDINGSOBESITY
A
Panel
Discussion
Harry H. Gordon, M.D., Moderator
Department of Pediatrics, Sinai Hospital of Baltimore,
(10(1 the Johns Hopkins Medical School
OBESITY
IN PEDIATRIC
PRACTICE
By Lee Forrest Hill, M.D.
Blank Memorial HOsJ)it(1l, Des Moines, Iowa
i!ediutrics
VOLUME 20 SEPTEMBER 1957 NUMBER 3
O
BESITY may be encountered at any agein pediatric practice. In infancy it
seldom causes concern either to parents or
the physician. Parents, in fact, are inclined
to view with approval and no little pride
the overweight infant who eagerly
con-sumes barge quantities of food. Such
ac-complishments are looked upon as
indica-tions of health at its best.
The physician’s lack of concern stems
from his knowledge that the obesity of the
first year of life is almost certainly
transi-tory and will diminish with the increased
activity and lessened appetite which can
confidently be expected during the second
and preschool years. Stuart’ feels that the
chief significance of obesity in the young
infant with an excessive appetite appears to
be the indication that the infant readily
responds to a positive caloric balance by
storing fat. “This,” he states, “may be a
Presented at the Annual Meeting, October 8, 1956.
ADDRESS: 3200 University Avenue, Des Moines, Iowa.
540
portent of obesity to follow in adolescent
or adult life, if the habit of overeating is
developed and maintained.” It would seem,
therefore, that an indication clearly exists
for the institution of parental education in
the basic principle of good nutrition even
at this early age.
Obesity in the preschool years is
rela-tively uncommon. Thinness rather than
obesity is the characteristic of this age
period. During the early school years
sus-ceptible children, rather insidiously at first,
begin to show the trend for excessive fat
deposition. Its peak incidence occurs
roughly between the years of 8 and 14.
Many of these children will, during the
next few years, gradually lose their obesity
and emerge as young adults with quite
ac-ceptabbe figures (Fig. 1). Whether this
comes about as a voluntary reduction in
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ment in physiology of the body is not quite
clear.
Obese children are referred to the
pedia-trician by other physicians or they are
brought by worried parents, frequently
with the observation that there must be
something wrong with the child’s glands;
excessive deposition of fat may also be
noted as a gradually developing
phenome-non in a child being cared for by the
pedia-trician in his own practice.
Frankly obese children, such as are
re-ferred by another physician or are brought
by their parents usually pose no diagnostic
problem. Their adiposity is apparent at a
glance. In some children, however, clinical
differentiation between fatness on the one
hand and stoutness or stockiness on the
other may present certain difficulties.
Over-weightness cannot always be interpreted
correctly as being synonymous with obesity.
When this point was under discussion at a
Colloquy on Obesity at Iowa State College
a few years ago, one of the speakers of
national repute and an authority in the field
recommended “pinching” in an appropriate
site as a diagnostic technic of considerable
merit. In the discussion that followed it was
pointed out that such a maneuver in adult
patients, particularly of the female sex,
ran the risk of misinterpretation unless the
purposes of the examiner were carefully
cx-plained in advance. Pediatricians who
con-fine their practices to the generally
ac-cepted age group should be relatively free
from such misunderstanding, and hence
may use “pinching” for whatever it is worth
as a means of differentiating between
sub-cutaneous fat and muscle.
Properly taken roentgenograms and
measurements with skin calipers have been
employed to estimate the thickness of the
fat layer, but these technics would appear
to be more useful as research tools than
as practical procedures in the office.
For the detection of obesity in its early
stages of development, the use of standard
growth charts is advantageous. Being from
Iowa it is but natural that I should use the
Iowa growth charts. I am quite willing to
concede, however, that there are other
types equably good. A single set of
meas-urements is not likely to be very rewarding,
since it fails to reveal what has gone on
before, but a series of recorded periodic
measurements of height and weight
per-mits comparison of expected increment
in-creases regardless of body build, and hence
permits early recognition of a trend,
whether up or down. Excess storage of
fat is suggested when the weight curve
con-tinues to rise unaccompanied by a
cor-responding rise in the height curve (Fig.
2). In my experience growth charts kept in
this way have been a most effective visual
means of calling the attention of both parent
and child to an undesirable trend, and it
has been relatively easy to enlist their
in-terest in simple preventive measures at
this early stage.
Having reached the conclusion that his
patient merits the designation “obese,” the
physician’s next task is to determine if
possible the reason for the obesity. In
spite of repeated assertions to the contrary
the belief persists strongly among lay
people, less so among physicians, that
endo-crine dysfunction is a frequent cause of
obesity. All of us here undoubtedly have
had the experience repeatedly of parents’
bringing
their fat children to us with thecomplaint of “gland” trouble. Even children
referred by physicians not infrequently
have had a trial on thyroid medication.
There are, of course, endocrine and
hypo-thalamic disturbances which include obesity
among their manifestations, but they are
extremely rare and account for only a small
percentage of the total cases. Moreover,
their symptomatology and physical signs
differ so markedly from simple obesity that
differentiation on clinical grounds alone is
usually possible.
Among the endocrinopathies,
hypothy-roidism is most often suspected. Yet the
clinical appearance of the hypothyroid child
as contrasted with the usual obese child is
tall for his age, his complexion is ruddy,
and he is alert mentally. Fat deposits are
iiiost marked over breasts, hips, abdomen
and pubic area where the genitals,
al-though of normal size, may be nearly
hid-den. Many obese children stand in a
posi-tion of genu valgum. Basal metabolic rates
are normal or above normal if appropriate
standards are used. Blood pressure
read-ings are usually at the upper margin of
normal or are moderately elevated although
normal values may be attained if
appro-priate width cuffs are used. Concentrations
of cholesterol in the serum are normal and
bone-age is normal or slightly advanced.
In contrast, the hypothyroid child may be
overweight but this is due to myxedema,
not fat. His skin is pale and cold and he
is sluggish mentally. Appetites are usually
small. Talbot2 states that older hypothyroid
children may rarely have positive caloric
balances and storage of fat because their
appetites may not diminish in proportion
to the diminution in energy metabolism.
Wilkins3 says he has seen only two obese
children in over 200 with definite
hypo-thyroidism.
Some years back is was common practice
to label obese juvenile boys with hidden
genitals as examples of “Froehlich’s
syn-drome.’ This came about as the result of
a paper published in 1901 by Froehlich4 in
which he described a fat boy with
hypo-genitalism. His patient, however, had a
craniopharyngioma involving the
hypo-thalamus. In addition to the obesity and
delayed sexual maturation, other
manifesta-tions of this type of lesion were also present,
such as impaired vision, headache,
vomit-ing and distortion of the dorsum sella
turcica. The term “Froehlich’s syndrome”
should not be applied to children with
simple dietary obesity, but should be
re-served for children who exhibit the signs
and symptoms originally described by
Froehlich.
Gushing’s disease is an endocrinopathy
in which adiposity, especially about the
face and neck, is one of the cardinal
mani-festations. As everyone here has become
thoroughly familiar with the characteristics
of this disease through its iatrogenic
pro-duction from steroid therapy, it need not
be discussed further. Talbot2 states that
only 18 authenticated spontaneously
ac-quired pediatric cases have been recorded
in the last 25 years.
Another disorder associated with obesity
is the Laurence-Moon-Biedi syndrome.
However, these rare cases classically have
such other manifestations as retinitis
pig-mentosa, mental deficiency and
polydac-tybism and should therefore cause little
trouble in being differentiated from simple
dietary obesity. While hypothalamic
dis-orders and endocrine dysfunctions of the
type just discussed are admittedly rare,
nevertheless they do occur and should be
carefully considered by the clinician in
evaluation of the obese patient.
Now let us turn our attention back to the
group of adolescent children who are
physically normal with the exception of
obesity. Before the clinician can set up a
rational therapeutic approach it is essential
that he determine, if possible, the cause or
causes which have led to the obesity. In
the broad sense, it may be said that obesity
from any cause must be the result of
exces-sive caloric intake or to decreased
expen-diture of energy. Excessive intake,
hyper-phagia or just plain overeating, may have
several explanations. Earlier, I mentioned
Stuart’s idea that habit having its inception
in infancy may carry on into later childhood
and even into adult years. Ghildren may
ac-quire the habit of overeating in later years
or the excess calories may have their source
in the eating habits of the family. “Mrs.
J
ones sets a good table” may mean theserving of an overabundance of high calorie
foods both for her own and her family’s
enjoyment. Even where there is a vehement
denial that the obese child eats excessively
at the table, it is usually possible to elicit
an admission of a craving for sweets,
fre-quent raids on the refrigerator for snacks,
drug-store for ice cream sodas. Whatever the circumstances responsible for
establishing
the habit of overeating, it becomes
progres-sively more fixed and increasingly more
difficult to correct. Bruch5 states that
ap-proximately 50% of obese children eat
exces-sively because of psychogenic disturbances.
Food is resorted to as a relief from anxiety
states. She feels that the gain in weight
sometimes seen after tonsillectomy is on this
basis. It is this group who are most resistant
to therapeutic management. Little hope of
success can
be entertained
until theunder-lying emotional problem is uncovered and
resolved.
Decreased expenditure of energy results
from insufficient exercise either voluntary or because of illness. Most obese children
have sedentary habits. They are clumsy and
awkward and lack the coordination of the
athlete. They are not sought after by their
contemporaries for participation in athletic
pursuits, hence they resort to other interests
of a sedentary nature such as reading or
music where they are not at a disadvantage.
Some undoubtedly seek satisfaction in
eating as a compensation for backs in other
directions. To entice these children into
forms of exercise which will permit greater
expenditure of energy is sometimes a
diffi-cult task. The situation isn’t helped any by
the critical attitude of fathers, disillusioned
of their earlier visions of a star athlete in
the family.
Illnesses, such as rheumatic fever, which
require long periods of rest in bed, and
various muscular abnormalities which
im-pose
inactivity may result in obesitybe-cause of less expenditure of energy than
intake. Wilkins6 cites the case of a
6-year-old boy with amyotonia congenita who
weighed 53 kg and whose body “was largely
a lump of fat.”
In addition to excessive calorie intake
and decreased expenditure of energy as a
cause for obesity, the clinician must
evalu-ate the etiologic role of the genetic or
con-stitutional factor. I do not have any accurate
data from my own practice, but my
impres-sion is that the tendency to stoutness and
obesity represents a strong familial trait.
Obesity in one or both parents or in a close
relative is, I should say, the rule rather than
the exception. I am sure all of us have been
intrigued by the observation that one
person can consume what appears to be a
huge quantity of food and remain thin
while another eats the same amount or less
and stores fat. What the genetic or
physio-logic
factors may be, and how they operateto permit these differences is not clear.
Occasionally one encounters an obese child
where the parents’ denial of excessive
eating seems to be subtantiated. An
illus-tration is a 4-year-old boy whom I saw
recently. He weighed 26 kg and was
ob-viously obese. His mother was sure that he
ate no more than other children of his age,
and that his activity was similar to theirs.
After a reasonably careful work-up it was
concluded that he fell in the classification
of dietary obesity. A suitable diet for his
age and ideal weight was arranged by the
hospital dietitian. At the return visit a
couple of weeks later the mother
com-plained that the diet contained too much
food-she had been unable to persuade him
to eat all of it. So far as I know no evidence
has been advanced to show that there is
an inherent difference in the metabolism
of fat between obese and nonobese
in-dividuals.
Finally, I should like to say a few words
about the treatment of obese children. It
would be a simple matter indeed if all that
was required was the prescribing of a low
calorie diet. But unfortunately we are
deal-ing with a child who is obese rather than
with obesity in a child. Regulation of the
diet meets with success in the infant
be-cause he can’t help himself, but the
situ-ation is quite different with the young
adolescent who is far more interested in
the immediate satisfaction of his craving
for food than he is in attaining the remote
advantages of a slim figure at some future
date or of avoiding the theoretic dangers
of
slipped
epiphysis.
Attempts to enforce alow caloric diet upon an unco-operative
AMERICAN ACADEMY OF PEDIATRICS PROCEEDINGS
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Surreptitious stealing of food may be
re-sorted to, or money may be stolen to
pur-chase food at the store, or the child may
seek hand-outs at the neighbors. Even if
co-operation can be secured, it usually is
only temporary, and the child within a few
weeks reverts back to former eating habits
(Fig. 3).
There is a further objection to severely
restricted diets in the prepubescent and
pubescent years. These are years of rapid
growth when nutritional needs, especially
for protein and minerals, such as calcium,
are great. Any diet which deprives the
child of these essentials during this period
does more harm than good.
Eventually, there comes a time when
most adolescent children of their own free
will want to reduce (Fig. 4). This is the age
when dating, clothes, and appearance all
become important. It is the age, too, when
the rate of growth has begun to decelerate.
A proper reducing diet at this age will have
more chance of success and, of even more
importance, it will be nutritionally safe. For
the younger adolescent it seems to me the
therapeutic approach of choice should be
to attempt to prevent excessive gains rather
than to reduce weight. A diet can be
pre-scribed which will be reasonably satisfying
to the child while at the same time the
nutritional needs of rapid growth are
safe-guarded. The essentials of such a diet are
skimmed milk, meat, cheese, eggs, green
and yellow vegetables, and fruits. High
caloric foods of little nutritional value
should be avoided. These include cream,
gravies, oily salad dressings, butter,
pota-toes, spaghetti and macaroni, cakes, cookies,
breadstuffs and sweets.
Anorexigenic drugs, such as
dextro-amphetamine sulfate, have been of little
value in my experience. However, I have
prescribed them only rarely for I have felt
that the child should not be led to believe
that a pill three times a day before meals
was the answer to his or her obesity
problem.
In summing up the clinical aspects of
obesity in children, the following points
seem most pertinent: The trend toward
obesity should be recognized as early as
possible. The keeping of growth charts is
most useful for this purpose. Relatively
simple corrections in the eating habits of
the child and family established early may
prevent a difficult or impossible task later
on. The causes of obesity vary with the
in-dividual child. Overeating either because
of habit or an emotional disturbance, lack
of physical exercise, and a constitutional or
genetic tendency to store fat would seem to
be the major causes. Endocrine and
hypo-thalamic disorders are rare causes but do
occur and should be kept in mind. Diets
low in calories designed to reduce weight
are usually not successful in the young
ado-lescent and may be nutritionally harmful
in the period of rapid growth during
pubescence. Lack of co-operation may lead
to stealing and deceit. Go-operation is
usu-ally forthcoming in later adolescence when
the rewards of personal attractiveness are
more meaningful and desired. When
obe-sity is on a disturbed emotional basis,
psy-chiatric help may be necessary.
REFERENCES
1. Stuart, H. C. : Obesity in childhood. Quart.
Rev. Pediat., 10:131, 1955.
2. Talbot, N. B., Sobel, E. H., McArthur,
J.
W.,and Crawford,
J.
D. : FunctionalEn-docrinobogy From Birth Through
Ado-lescence. Cambridge, Harvard, 1952.
3. Wilkins, L. : Fat Metabolism. Report of
the Eleventh M & R Pediatric
Con-ference. Columbus, M & R Laboratories,
1954.
4. Bruch, H. : Froehlich syndrome: Report of
otignal case. Am.
J.
Dis. Child., 58: 1282, 1939.5. Bruch, H. : Psychiatric aspects of obesity
in children. Am.
J.
Psychiat., 99:752,1943.
6. Wilkins, L. : The Diagnosis and Treatment
of Endocrine Disorders in Childhood
and Adolescence, 1st Ed. Springfield,
