Sample Solution

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.

TABLE 7: Diagnostic evaluation for cause of obesity
Disease suspected Investigation
Hypothyroidism FT4, TSH
Cushing disease Urine free cortisol
S. cortisol: Morning & Evening
GH deficiency IGF1 & IGFBP3
GH stimulation test
Genetic syndromes DNA methylation: PWS
CNS disorder MRI brain
Monogenic obesity MC4R gene testing
Leptin levels

Fasting lipid profile, HBA1C, SGPT and Fasting plasma glucose should be checked in all over-weight and obese children after 3 years of age.
An Oral Glucose Tolerance Test (OGTT) should be performed in obese children with a family history of T2DM as per guidelines mentioned in above section and in grossly obese children.
Although obesity is associated with insulin resistance, diagnosis of insulin resistance by measuring plasma insulin concentration is no longer recommended, since the insulin assay is unreliable. ALT level greater than 25 and 22 in males and females respectively warrants ultrasonography of the liver followed by biopsy in those with a suspicion of cirrhosis.
TABLE 8
HISTORY
Mental retardation Genetic etiology
Short stature/ decreased height velocity Endocrine etiology
Medication history, eg. antipsychotics Medication etiology
Snoring, morning headaches Obstructive sleep apnea
Knee or hip pain Orthopedic morbidity
Polyuria, polydipsia Type 2 Diabetes
Hirsutism, irregular menses PCOS

PHYSICAL EXAMINATION