Sample Solution

rmal.
Waist Circumference (WC) is a good indicator of central adiposity and is a better predictor of metabolic syndrome (24,25), cardiovascular disease risk factors (26) and insulin resistance in children than BMI.
A cut-off of 70th WC percentile is suggested to screen children for risk of MS in our population. WC is measured with the child standing using a non-stretchable tape applied horizontally just above the upper lateral border of the right ileum(27). Measurement is made at the end of a normal expiration and recorded to the nearest 0.1cm. Age- and sex-specific reference curves for WC for 2-18 year old Indian children are available by Khadilkar et al (18).

3) Clinical Examination:
This includes assessment of vital signs especially measurement of Blood pressure with an appropriate size cuff.
Look for dysmorphic features that would suggest a genetic syndrome. Cushingoid facies, hyperpigmented stretch striae and hypertension suggest cushing’s or exogenous steroid exposure. A hump on the back of neck and stretch striae may also be present in children with simple obesity. Dry skin or enlarged thyroid gland may suggest hypothyroidism and presence of acanthosis nigricans is an indicator of insulin resistance. Acne and hirsutism in girls could be due to PCOD. Shortening of 4th and 5th metacarpal should raise the suspicion of pseudohypoparathyroidism.
Look for gynecomastia in males. Genital examination for Tanner staging & evaluation of early puberty should be done. Undescended testes in males could be associated with syndromic obesity.

4) Laboratory Investigations:
Initial investigations include evaluation for cause and consequences of obesity. Specific testing for the endocrine disorders is done only if there is strong clinical suspicion. These are mentioned in Table 3. Genetic testing should be considered in children with early onset severe obesity, voracious appetites, family history of severe obesity and in those where a clinical suspicion of genetic obesity syndromes is present. Lab investigations currently available in India for monogenic obesity are; MC4R, Leptin and FTO gene. Leptin deficiency is rare and resistance is more common. TSH levels are often mildly elevated in obese children and are a major cause for referral.