Observation has always played a vital role in narrowing down probable causes of obesity that in turn guides further rational management. In this article, Dr YK Amdekar discusses cases elaborating the importance of observation to manage obesity.

Obese versus overweight

Being overweight and obese are not the same. An obese person has an excess of fat accumulated in the abdominal wall, around the waist and buttocks besides other areas such as arms, neck and cheeks. Whereas an overweight person appears muscular and shows no undue bulges around the abdomen or waist. Of course, being overweight may be the initial stage before obesity develops and the difference can be made out only on measurements of various parameters such as weight for height, waist/hip ratio and BMI.

Diagnostic facts to observe

1. Height- General rule is “short and obese” is endocrinal (congenital hypothyroidism or adrenal hyperplasia or tumour) / syndromic (Prader-Villi syndrome) and “tall/average height and obese” is exogenous (due to lifestyle issues) or familial. This is more important in children who have not completed their growth. However, constitutionally short adults may become obese due to changes in lifestyle and so may not be pathological. Such an adult would be short and thin in early life and then became obese, which may be either exogenous or endocrinal.
2. Mental status (cognition)- One can judge by observation whether an obese person looks mentally normal or subnormal. A mild abnormality may not be noticeable and may not be significant. A hypothyroid child would be mentally subnormal and so also one suffering from a syndromic disorder. (Syndromic disorder refers to a constellation of a few abnormal signs). However, an adult who has developed acquired hypothyroidism may be sluggish more and has subtle cognition defect that is not discernible.
3. Asymmetric growth- It may not be striking but can be made out if observed closely. The lower body segment (lower limbs) is short as compared to the upper segment of the body (spine growth - sitting height) in congenital hypothyroidism. The normal ratio of the upper segment to the lower segment of the body is 1.7 to 1 which reduces over time and in adults, it is nearly equal or 1 to 1.1.
4. Other facts- Typical facies (myxedematous face) is characteristic of hypothyroidism, besides lethargy (slowness), coarse dry skin, macroglossia (large tongue), umbilical hernia and pallor. Cherubic face with the fullness of cheeks (steroid facies) is typical of adrenal hyperplasia and such a patient may be breathless or look sick because of hypertension and headache. A syndromic child may have other features.

How observation may help to arrive at a probable diagnosis

Case 1

A two-year-old child presented with increasing weight. On observation, he looked overweight, short, slow in his activities, dull, had abdominal distension, umbilical hernia, hoarse voice and coarse facies. This is typical of congenital hypothyroidism.

Diagnosis: Severe deficiency can be suspected at birth with lethargy without sickness.

Case 2

A four years old child presented with obesity. Observation revealed central obesity with baggy cheeks and abdominal wall, sick and mildly breathless. This look is suggestive of steroid excess while sick and breathless denotes probable hypertension.

Diagnosis: Together, it is likely to be adrenal hyperplasia or tumour.

Case 3

A six-year-old child presented with obesity. Observation revealed central obesity and was short in height. The child looked mentally subnormal with abnormal behaviour and generalised hypotonia.

Diagnosis: This suggests syndromic obesity and was confirmed to be Prader-Willi syndrome. Such children are hyperphagic, which means eating excessively.

Case 4

An eight-year-old child presented with obesity. Observation revealed a tall child with an excess weight but otherwise happy looking and mentally active.

Diagnosis: Tall and obese is due to exogenous obesity and is due to an imbalance between intake and output of energy.

Case 5

A four-year-old child presented with increasing weight. Observation revealed besides an excess weight, severe cognitive delay, large head size, not moving left upper and lower limb and a visible tube in the neck and abdominal wall. This is typical of residual brain damage due to TB meningitis with hydrocephalus with ventriculoperitoneal (VP) shunt in place. Obesity in such a child may be either due to poor activity or hyperphagia due to brain damage. A developmentally delayed child may be overweight especially if the swallowing mechanism is intact.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.