Childhood obesity: Difference between revisions

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{{CMG}} {{AE}}


{{SK}} Obesity in Kids, Obesity in Children, Childhood Obesity, Pediatric obesity
{{CMG}} {{AE}}  {{I.D}}


{{SK}} obesity in kids, obesity in children, pediatric obesity




==Overview==
==Overview==
'''Childhood obesity'''  is a [[medical condition]] that affects [[Childhood|children]]. Overweight and obesity are defined by the World Health Organization (WHO) as "abnormal or excessive fat accumulation that may impair health"<ref>https://www.who.int/westernpacific/health-topics/obesity</ref> Childhood Obesity is a Body Mass Index (BMI) at or above the 95th percentile for children of the same gender and age.<ref>https://www.cdc.gov/obesity/childhood/defining.html</ref> Childhood and adolescent obesity is an epidemic in the United States.<ref name="pmid31832491">{{cite journal| author=Sanyaolu A, Okorie C, Qi X, Locke J, Rehman S| title=Childhood and Adolescent Obesity in the United States: A Public Health Concern. | journal=Glob Pediatr Health | year= 2019 | volume= 6 | issue=  | pages= 2333794X19891305 | pmid=31832491 | doi=10.1177/2333794X19891305 | pmc=6887808 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31832491  }} </ref> About 13.7 million (18.5 %) of American children and adolescents are currently considered obese.<ref>https://www.cdc.gov/obesity/data/childhood.html#Prevalence</ref>
[[Childhood obesity]] is a Body Mass Index (BMI) at or above the 95th percentile for children of the same gender and age. It is a serious health problem that can result in health complications. [[Childhood obesity]] can be caused by dietary factors, lifestyle factors, underlying medical conditions, genetic causes or certain medications. Obesity may present with high blood pressure, shortness of breath, sleep apnea, gastroesophageal reflux, constipation, insulin resistance, constipation, or irregular menstruation. The presence of polyuria and polydipsia suggests possible diabetes, excess facial hair, insulin resistance and irregular menstruation in adolescent girls may be due to [[polycystic ovary syndrome (PCOS)]] and dry skin, constipation and intolerance to cold suggest [[hypothyroidism]]. laboratory tests indicated depend on the clinical presentation. Management of obesity includes the treatment of any underlying medical conditions and lifestyle modification.


==Historical Perspective==
==Historical Perspective==
*The word obesity is a Latin word which was first used in [1611] by Randle Cotgrade.<ref>http://histowiki.com/history/health/2375/the-history-of-obesity-timeline/#:~:text=The%20Greeks%20were%20the%20first%20to%20recognize%20obesity,obesity%20as%20the%20result%20of%20a%20character%20flaw.</ref>


*In [450 B.C.], it was first recognized as a medical disorder by the ancient Greeks. Hippocrates quoted "''Corpulence is not only a disease itself, but the harbinger of others''”.<ref>http://histowiki.com/history/health/2375/the-history-of-obesity-timeline/#:~:text=The%20Greeks%20were%20the%20first%20to%20recognize%20obesity,obesity%20as%20the%20result%20of%20a%20character%20flaw.</ref>
*[[Obesity]] was first recognized as a medical disorder by [[Hippocrates]], an [[ancient Greek physician]], in [450 B.C] <ref name="Carmichael1999">{{cite journal|last1=Carmichael|first1=A R|title=Current concepts: Treatment for morbid obesity|journal=Postgraduate Medical Journal|volume=75|issue=879|year=1999|pages=7–12|issn=0032-5473|doi=10.1136/pgmj.75.879.7}}</ref>
*In [[circa 11th century]], the complications of obesity including narrowed blood vessels, stroke, and difficulty breathing were described by Avicenna in his book [[Cannon of Medicine]].<ref name="Carmichael1999" />


*In [550 B.C.], obesity was linked to heart disease and diabetes by the Indian surgeon Shushruta.<ref>http://histowiki.com/history/health/2375/the-history-of-obesity-timeline/#:~:text=The%20Greeks%20were%20the%20first%20to%20recognize%20obesity,obesity%20as%20the%20result%20of%20a%20character%20flaw.</ref>
==Classification==


==Classification==
*[[Childhood obesity]] may be classified according to age- and gender- adjusted BMI into two groups:<ref name="pmid28359099">{{cite journal| author=Styne DM, Arslanian SA, Connor EL, Farooqi IS, Murad MH, Silverstein JH | display-authors=etal| title=Pediatric Obesity-Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline. | journal=J Clin Endocrinol Metab | year= 2017 | volume= 102 | issue= 3 | pages= 709-757 | pmid=28359099 | doi=10.1210/jc.2016-2573 | pmc=6283429 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28359099  }} </ref>
* Child weight may be classified according to [BMI-for-age growth chart] into:
 
:*[[Overweight]] BMI between 85th and 94th percentiles
:*[[Obesity]]: BMI is ≥95th percentile
:*[[Obesity]] BMI 95th percentile or above
:*[[Severe obesity]]: BMI ≥120% of the 95th percentile or BMI ≥35 kg/m2.
:*[[Severe obesity]] 99th percentile or higher


==Pathophysiology==
==Pathophysiology==
* The pathogenesis of [[childhood obesity]] is characterized by [[energy imbalance]]
 
* This energy imbalance is the result of excess energy intake and/ or decreased energy expenditure.
*The pathogenesis of [[childhood obesity]] is characterized by [[fat accumulation]] due to an [[energy imbalance]].<ref>https://www.who.int/dietphysicalactivity/childhood_why/en/</ref>
* It has been suggested that a dysfunction in the Ghrelin/Leptin hormonal pathway may contribute to abnormal appetite control and increased energy intake.
*This energy imbalance is the result of excess calories intake and/ or decreased calories expenditure.<ref>https://www.who.int/dietphysicalactivity/childhood_why/en/</ref>
*It has been suggested that a dysfunction in the ghrelin/leptin hormonal pathway may contribute to abnormal appetite control and energy balance.<ref name="pmid17212793">{{cite journal| author=Klok MD, Jakobsdottir S, Drent ML| title=The role of leptin and ghrelin in the regulation of food intake and body weight in humans: a review. | journal=Obes Rev | year= 2007 | volume= 8 | issue= 1 | pages= 21-34 | pmid=17212793 | doi=10.1111/j.1467-789X.2006.00270.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17212793  }} </ref>
*Gene mutations in single genes including [[Leptin (LEP)]], [[Leptin Receptor (LEPR)]], [[Pro-opio melanocortin (POMC)]] has been associated with the development of some cases of [[childhood obesity]]. <ref name="pmid30416642">{{cite journal| author=Thaker VV| title=GENETIC AND EPIGENETIC CAUSES OF OBESITY. | journal=Adolesc Med State Art Rev | year= 2017 | volume= 28 | issue= 2 | pages= 379-405 | pmid=30416642 | doi= | pmc=6226269 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30416642  }} </ref>


==Causes==
==Causes==
[[Childhood obesity]] may be caused by [[poor eating habits]], [[lack of physical activity]], [[genetic causes]], [[an underlying medical condition]] or [[medications]].
[[Childhood obesity]] may be caused by [[unhealthy dietary intake]]<ref>https://www.nhs.uk/conditions/obesity/causes/</ref>, [[unhealthy lifestyle]] <ref name="pmid27759894">{{cite journal| author=Ren H, Zhou Z, Liu WK, Wang X, Yin Z| title=Excessive homework, inadequate sleep, physical inactivity and screen viewing time are major contributors to high paediatric obesity.<nowiki><ref name="pmid27759894"></nowiki>{{cite journal |vauthors=Ren H, Zhou Z, Liu WK, Wang X, Yin Z |title=Excessive homework, inadequate sleep, physical inactivity and screen viewing time are major contributors to high paediatric obesity |journal=Acta Paediatr |volume=106 |issue=1 |pages=120–127 |date=January 2017 |pmid=27759894 |pmc=6680318 |doi=10.1111/apa.13640 |url=}}</ref>, [[environmental factors]]<ref>https://www.cdc.gov/obesity/childhood/causes.html#:~:text=Childhood%20Obesity%20Causes%20&%20Consequences%201%20Behavior.%20Behaviors,Community%20Environment.%20...%203%20Consequences%20of%20Obesity.</ref>, [[psychological stress]] <ref name="pmid31877943">{{cite journal| author=Ruiz LD, Zuelch ML, Dimitratos SM, Scherr RE| title=Adolescent Obesity: Diet Quality, Psychosocial Health, and Cardiometabolic Risk Factors. | journal=Nutrients | year= 2019 | volume= 12 | issue= 1 | pages=  | pmid=31877943 | doi=10.3390/nu12010043 | pmc=7020092 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31877943  }} </ref>, [[genetic causes]] <ref name="pmid32384097">{{cite journal| author=Kleinendorst L, Abawi O, van der Voorn B, Jongejan MHTM, Brandsma AE, Visser JA | display-authors=etal| title=Identifying underlying medical causes of pediatric obesity: Results of a systematic diagnostic approach in a pediatric obesity center. | journal=PLoS One | year= 2020 | volume= 15 | issue= 5 | pages= e0232990 | pmid=32384097 | doi=10.1371/journal.pone.0232990 | pmc=7209105 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32384097  }} </ref>, [[medication-induced]] <ref name="pmid32384097">{{cite journal| author=Kleinendorst L, Abawi O, van der Voorn B, Jongejan MHTM, Brandsma AE, Visser JA | display-authors=etal| title=Identifying underlying medical causes of pediatric obesity: Results of a systematic diagnostic approach in a pediatric obesity center. | journal=PLoS One | year= 2020 | volume= 15 | issue= 5 | pages= e0232990 | pmid=32384097 | doi=10.1371/journal.pone.0232990 | pmc=7209105 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32384097  }} </ref> or [[cerebral injury]].<ref name="pmid32384097">{{cite journal| author=Kleinendorst L, Abawi O, van der Voorn B, Jongejan MHTM, Brandsma AE, Visser JA | display-authors=etal| title=Identifying underlying medical causes of pediatric obesity: Results of a systematic diagnostic approach in a pediatric obesity center. | journal=PLoS One | year= 2020 | volume= 15 | issue= 5 | pages= e0232990 | pmid=32384097 | doi=10.1371/journal.pone.0232990 | pmc=7209105 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32384097  }} </ref>


===Lifestyle and dietary intake===
===Dietary factors===
Children and adolescents are consuming low nutrient high-calorie foods and beverages at home, school and other places. They are consuming more fast food which is low in nutrients and high in calories, fat and sodium. CDC reports that children and adolescents in the U.S. consumed an average of 13.8% of their daily calories from fast food during 2015-2018. <ref>https://www.cdc.gov/nchs/products/databriefs/db375.htm</ref> In addition, they are consuming large amounts of sugar-sweetened beverages which has been directly associated with obesity in multiple reviews.<ref name="pmid26258560">{{cite journal| author=Keller A, Bucher Della Torre S| title=Sugar-Sweetened Beverages and Obesity among Children and Adolescents: A Review of Systematic Literature Reviews. | journal=Child Obes | year= 2015 | volume= 11 | issue= 4 | pages= 338-46 | pmid=26258560 | doi=10.1089/chi.2014.0117 | pmc=4529053 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26258560  }} </ref> <ref name="pmid20138901">{{cite journal| author=Hu FB, Malik VS| title=Sugar-sweetened beverages and risk of obesity and type 2 diabetes: epidemiologic evidence. | journal=Physiol Behav | year= 2010 | volume= 100 | issue= 1 | pages= 47-54 | pmid=20138901 | doi=10.1016/j.physbeh.2010.01.036 | pmc=2862460 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20138901  }} </ref> Physical inactivity, excess use of screen time and inadequate sleep also contribute to the obesity epidemic.<ref name="pmid27759894">{{cite journal| author=Ren H, Zhou Z, Liu WK, Wang X, Yin Z| title=Excessive homework, inadequate sleep, physical inactivity and screen viewing time are major contributors to high paediatric obesity. | journal=Acta Paediatr | year= 2017 | volume= 106 | issue= 1 | pages= 120-127 | pmid=27759894 | doi=10.1111/apa.13640 | pmc=6680318 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27759894  }} </ref> <ref name="pmid31137502">{{cite journal| author=Morrissey B, Allender S, Strugnell C| title=Dietary and Activity Factors Influence Poor Sleep and the Sleep-Obesity Nexus among Children. | journal=Int J Environ Res Public Health | year= 2019 | volume= 16 | issue= 10 | pages=  | pmid=31137502 | doi=10.3390/ijerph16101778 | pmc=6571639 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31137502  }} </ref>
Children and adolescents are consuming low nutrient high-calorie foods and beverages at home, school and other places. They are consuming more fast food which is low in nutrients and high in calories, fat and sodium. CDC reports that children and adolescents in the U.S. consumed an average of 13.8% of their daily calories from fast food during 2015-2018.<ref>https://www.cdc.gov/nchs/products/databriefs/db375.htm</ref> In addition, they are consuming large amounts of sugar-sweetened beverages which has been directly associated with obesity in multiple reviews.<ref name="pmid26258560">{{cite journal| author=Keller A, Bucher Della Torre S| title=Sugar-Sweetened Beverages and Obesity among Children and Adolescents: A Review of Systematic Literature Reviews. | journal=Child Obes | year= 2015 | volume= 11 | issue= 4 | pages= 338-46 | pmid=26258560 | doi=10.1089/chi.2014.0117 | pmc=4529053 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26258560  }} </ref> <ref name="pmid20138901">{{cite journal| author=Hu FB, Malik VS| title=Sugar-sweetened beverages and risk of obesity and type 2 diabetes: epidemiologic evidence. | journal=Physiol Behav | year= 2010 | volume= 100 | issue= 1 | pages= 47-54 | pmid=20138901 | doi=10.1016/j.physbeh.2010.01.036 | pmc=2862460 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20138901  }} </ref>
 
===Lifestyle factors===
Physical inactivity, excess use of screen time and inadequate sleep also contribute to the obesity epidemic.<ref name="pmid27759894"><nowiki>{{cite journal| author=Ren H, Zhou Z, Liu WK, Wang X, Yin Z| title=Excessive homework, inadequate sleep, physical inactivity and screen viewing time are major contributors to high paediatric obesity.</nowiki><nowiki><ref name="pmid27759894"></nowiki>{{cite journal |vauthors=Ren H, Zhou Z, Liu WK, Wang X, Yin Z |title=Excessive homework, inadequate sleep, physical inactivity and screen viewing time are major contributors to high paediatric obesity |journal=Acta Paediatr |volume=106 |issue=1 |pages=120–127 |date=January 2017 |pmid=27759894 |pmc=6680318 |doi=10.1111/apa.13640 |url=}}</ref> <ref name="pmid31137502">{{cite journal| author=Morrissey B, Allender S, Strugnell C| title=Dietary and Activity Factors Influence Poor Sleep and the Sleep-Obesity Nexus among Children. | journal=Int J Environ Res Public Health | year= 2019 | volume= 16 | issue= 10 | pages=  | pmid=31137502 | doi=10.3390/ijerph16101778 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31137502  }} </ref>  


===Environmental factors===
===Environmental factors===
Eating habits of the child are also affected by demographics, lunch policies at schools and work demands on parents.<ref name="pmid25949965">{{cite journal| author=Sahoo K, Sahoo B, Choudhury AK, Sofi NY, Kumar R, Bhadoria AS| title=Childhood obesity: causes and consequences. | journal=J Family Med Prim Care | year= 2015 | volume= 4 | issue= 2 | pages= 187-92 | pmid=25949965 | doi=10.4103/2249-4863.154628 | pmc=4408699 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25949965  }} </ref>
Eating habits of the child are affected by demographics, lunch policies at schools and work demands on parents.<ref name="pmid25949965">{{cite journal| author=Sahoo K, Sahoo B, Choudhury AK, Sofi NY, Kumar R, Bhadoria AS| title=Childhood obesity: causes and consequences. | journal=J Family Med Prim Care | year= 2015 | volume= 4 | issue= 2 | pages= 187-92 | pmid=25949965 | doi=10.4103/2249-4863.154628 | pmc=4408699 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25949965  }} </ref>


===Psychological factors===
===Psychological stress===
These factors influence a child's eating habits and many children eat in response to stress and or negative emotions such as boredom, anger, sadness, anxiety or depression.
Chronic stress increases the risk of obesity, diabetes, heart disease, metabolic syndrome and mental health problems.<ref name="pmid31877943">{{cite journal| author=Ruiz LD, Zuelch ML, Dimitratos SM, Scherr RE| title=Adolescent Obesity: Diet Quality, Psychosocial Health, and Cardiometabolic Risk Factors. | journal=Nutrients | year= 2019 | volume= 12 | issue= 1 | pages=  | pmid=31877943 | doi=10.3390/nu12010043 | pmc=7020092 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31877943  }} </ref>


===Genetic factors===
===Endocrine causes===
Often, a child whose parents are overweight or obese will also be overweight or obese. Although this is often caused by shared unhealthy eating habits in the household, it has been suggested that there may be a genetic (inherited) predisposition toward being obese, although this is as yet unproven and research is ongoing.
There are hormonal disorders that may be associated with weight gain and obesity in children including: [[hypothyroidism]]<ref name="pmid18690306">{{cite journal| author=Verma A, Jayaraman M, Kumar HK, Modi KD| title=Hypothyroidism and obesity. Cause or effect? | journal=Saudi Med J | year= 2008 | volume= 29 | issue= 8 | pages= 1135-8 | pmid=18690306 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18690306  }} </ref>, [[cushing's syndrome]]<ref name="pmid27241967">{{cite journal| author=Stratakis CA| title=Diagnosis and Clinical Genetics of Cushing Syndrome in Pediatrics. | journal=Endocrinol Metab Clin North Am | year= 2016 | volume= 45 | issue= 2 | pages= 311-28 | pmid=27241967 | doi=10.1016/j.ecl.2016.01.006 | pmc=4889872 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27241967  }} </ref>, [[polycystic ovary syndrome (PCOS)]]<ref name="pmid29184806">{{cite journal| author=Kamboj MK, Bonny AE| title=Polycystic ovary syndrome in adolescence: diagnostic and therapeutic strategies. | journal=Transl Pediatr | year= 2017 | volume= 6 | issue= 4 | pages= 248-255 | pmid=29184806 | doi=10.21037/tp.2017.09.11 | pmc=5682369 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29184806  }} </ref>, [[precocious puberty]]<ref name="pmid28400459">{{cite journal| author=Chen C, Zhang Y, Sun W, Chen Y, Jiang Y, Song Y | display-authors=etal| title=Investigating the relationship between precocious puberty and obesity: a cross-sectional study in Shanghai, China. | journal=BMJ Open | year= 2017 | volume= 7 | issue= 4 | pages= e014004 | pmid=28400459 | doi=10.1136/bmjopen-2016-014004 | pmc=5566589 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28400459  }} </ref>, and [[pseudohypoparthyroidism]].<ref name="pmid27875418">{{cite journal| author=Shoemaker AH, Jüppner H| title=Nonclassic features of pseudohypoparathyroidism type 1A. | journal=Curr Opin Endocrinol Diabetes Obes | year= 2017 | volume= 24 | issue= 1 | pages= 33-38 | pmid=27875418 | doi=10.1097/MED.0000000000000306 | pmc=5484400 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27875418  }} </ref>


===Medical conditions===
===Genetic causes===
There are genetic syndromes and hormonal disorders that maybe associated with weight gain and obesity in children including: hypothyroidism, Cushing syndrome, growth hormone deficiency, growth hormone resistance, leptin deficiency or resistance to leptin action, polycystic ovary syndrome (PCOS), precocious puberty, prolactin-secreting tumors, Turner syndrome, Down syndrome, Cohen syndrome, Prader-Willi syndrome, Pseudohypoparthyroidism and laurence-Moon-Biedl syndrome.<ref>https://emedicine.medscape.com/article/985333-overview#a5</ref>
Often, a child whose parents are overweight or obese will also be overweight or obese. Although this is often caused by shared unhealthy eating habits in the household, several [[genetic]] causes have been identified as a cause of obesity.<ref name="pmid30416642">{{cite journal| author=Thaker VV| title=GENETIC AND EPIGENETIC CAUSES OF OBESITY. | journal=Adolesc Med State Art Rev | year= 2017 | volume= 28 | issue= 2 | pages= 379-405 | pmid=30416642 | doi= | pmc=6226269 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30416642  }} </ref> These can be divides into [[monogenic causes]], [[syndromic obesity]] and [[polygenic obesity]].<ref name="pmid30416642">{{cite journal| author=Thaker VV| title=GENETIC AND EPIGENETIC CAUSES OF OBESITY. | journal=Adolesc Med State Art Rev | year= 2017 | volume= 28 | issue= 2 | pages= 379-405 | pmid=30416642 | doi= | pmc=6226269 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30416642  }} </ref> Monogenic obesity is caused of a mutation to a single gene including Leptin (LEP) mutations, Leptin Receptor (LEPR) mutations, Pro-opio melanocortin (POMC) mutations, MC4R deficiency, Proconvertase (PC1/2) deficiency, SIM1 deficiency, NTRK2/BDNF mutations and SH2B1 mutations.<ref name="pmid30416642">{{cite journal| author=Thaker VV| title=GENETIC AND EPIGENETIC CAUSES OF OBESITY. | journal=Adolesc Med State Art Rev | year= 2017 | volume= 28 | issue= 2 | pages= 379-405 | pmid=30416642 | doi= | pmc=6226269 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30416642  }} </ref> Syndromic obesity include [[Prader Willi Syndrome (PWS)]], [[Cohen syndrome]]<ref name="pmid30416642">{{cite journal| author=Thaker VV| title=GENETIC AND EPIGENETIC CAUSES OF OBESITY. | journal=Adolesc Med State Art Rev | year= 2017 | volume= 28 | issue= 2 | pages= 379-405 | pmid=30416642 | doi= | pmc=6226269 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30416642  }} </ref>, [[Turner syndrome]]<ref name="pmid29479339">{{cite journal| author=Lebenthal Y, Levy S, Sofrin-Drucker E, Nagelberg N, Weintrob N, Shalitin S | display-authors=etal| title=The Natural History of Metabolic Comorbidities in Turner Syndrome from Childhood to Early Adulthood: Comparison between 45,X Monosomy and Other Karyotypes. | journal=Front Endocrinol (Lausanne) | year= 2018 | volume= 9 | issue=  | pages= 27 | pmid=29479339 | doi=10.3389/fendo.2018.00027 | pmc=5811462 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29479339  }} </ref>, [[down syndrome]], and [[Laurence-Moon-Bardet-Biedl syndrome]].<ref name="pmid33304690">{{cite journal| author=Kumar A, Husain A, Saleem A, Khawaja UA, Virani S| title=Laurence-Moon-Bardet-Biedl Syndrome: A Rare Case With a Literature Review. | journal=Cureus | year= 2020 | volume= 12 | issue= 11 | pages= e11355 | pmid=33304690 | doi=10.7759/cureus.11355 | pmc=7720918 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33304690  }} </ref>


===Medications===
===Medication-induced===
Medications that may cause weight gain in children include cortisol and other glucocorticoids, tricyclic antidepressants, sulfonylureas, monoamine oxidase inhibitors, risperidone, clozapine, oral contraceptives, insulin (in excessive doses) and thiazolidinediones. <ref>https://emedicine.medscape.com/article/985333-overview#a5</ref>
Medications that may cause weight gain in children include second-generation antipsychotics<ref name="pmid31215494">{{cite journal| author=Bretler T, Weisberg H, Koren O, Neuman H| title=The effects of antipsychotic medications on microbiome and weight gain in children and adolescents. | journal=BMC Med | year= 2019 | volume= 17 | issue= 1 | pages= 112 | pmid=31215494 | doi=10.1186/s12916-019-1346-1 | pmc=6582584 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31215494  }} </ref>, glucocorticoids<ref name="pmid31958298">{{cite journal| author=Tosur M, Viau-Colindres J, Astudillo M, Redondo MJ, Lyons SK| title=Medication-induced hyperglycemia: pediatric perspective. | journal=BMJ Open Diabetes Res Care | year= 2020 | volume= 8 | issue= 1 | pages=  | pmid=31958298 | doi=10.1136/bmjdrc-2019-000801 | pmc=6954773 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31958298  }} </ref>, risperidone<ref name="pmid33240086">{{cite journal| author=Vanwong N, Ngamsamut N, Nuntamool N, Hongkaew Y, Sukprasong R, Puangpetch A | display-authors=etal| title=Risperidone-Induced Obesity in Children and Adolescents With Autism Spectrum Disorder: Genetic and Clinical Risk Factors. | journal=Front Pharmacol | year= 2020 | volume= 11 | issue=  | pages= 565074 | pmid=33240086 | doi=10.3389/fphar.2020.565074 | pmc=7677569 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33240086  }} </ref>, clozapine<ref name="pmid27681143">{{cite journal| author=Vasudev K, Choi YH, Norman R, Kim RB, Schwarz UI| title=Genetic Determinants of Clozapine-Induced Metabolic Side Effects. | journal=Can J Psychiatry | year= 2017 | volume= 62 | issue= 2 | pages= 138-149 | pmid=27681143 | doi=10.1177/0706743716670128 | pmc=5298525 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27681143  }} </ref>, and tricyclic antidepressants<ref name="pmid20456284">{{cite journal| author=van Reedt Dortland AK, Giltay EJ, van Veen T, Zitman FG, Penninx BW| title=Metabolic syndrome abnormalities are associated with severity of anxiety and depression and with tricyclic antidepressant use. | journal=Acta Psychiatr Scand | year= 2010 | volume= 122 | issue= 1 | pages= 30-9 | pmid=20456284 | doi=10.1111/j.1600-0447.2010.01565.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20456284  }} </ref>.


===Hypothalamic obesity===
===Cerebral injury===
Weight gain may occur after acquired hypothalamic lesions following surgery, cranial radiation or diencepahlic tumors. It can also be a result of cranial trauma or inflammation of the hypothalamus. <ref>https://www.mayoclinicproceedings.org/action/showPdf?pii=S0025-6196%2816%2930595-X</ref>
Obesity can occur after acquired hypothalamic lesions following surgery, meningitis or ischemic injury.<ref name="pmid32384097">{{cite journal| author=Kleinendorst L, Abawi O, van der Voorn B, Jongejan MHTM, Brandsma AE, Visser JA | display-authors=etal| title=Identifying underlying medical causes of pediatric obesity: Results of a systematic diagnostic approach in a pediatric obesity center. | journal=PLoS One | year= 2020 | volume= 15 | issue= 5 | pages= e0232990 | pmid=32384097 | doi=10.1371/journal.pone.0232990 | pmc=7209105 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32384097  }} </ref>


==Complications==
==Differentiating [[childhood obesity]] due to lifestyle factors from other Diseases==
Without a change in diet or exercise patterns, childhood obesity can lead to medical conditions including Type 2 diabetes, high blood pressure, high cholesterol, heart disease, asthma, obstructive sleep apnea, fatty liver disease, gall stones, glucose intolerance, insulin resistance and other disorders.<ref>https://www.cdc.gov/obesity/childhood/causes.html</ref> <ref name="pmid25949965">{{cite journal| author=Sahoo K, Sahoo B, Choudhury AK, Sofi NY, Kumar R, Bhadoria AS| title=Childhood obesity: causes and consequences. | journal=J Family Med Prim Care | year= 2015 | volume= 4 | issue= 2 | pages= 187-92 | pmid=25949965 | doi=10.4103/2249-4863.154628 | pmc=4408699 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25949965  }} </ref> Studies have shown that obese children are more likely to grow up to be obese adults.<ref>https://www.cdc.gov/vitalsigns/pdf/2013-08-vitalsigns.pdf</ref>
Obese children often suffer from weight stigma, teasing and bullying amongst their peers.<ref name="pmid31988872">{{cite journal| author=Kang NR, Kwack YS| title=An Update on Mental Health Problems and Cognitive Behavioral Therapy in Pediatric Obesity. | journal=Pediatr Gastroenterol Hepatol Nutr | year= 2020 | volume= 23 | issue= 1 | pages= 15-25 | pmid=31988872 | doi=10.5223/pghn.2020.23.1.15 | pmc=6966224 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31988872  }} </ref> They experience descrimination in the society. These children are more likely to suffer from low self esteem, anxiety and depression.<ref name="pmid31760948">{{cite journal| author=Di Cesare M, Sorić M, Bovet P, Miranda JJ, Bhutta Z, Stevens GA | display-authors=etal| title=The epidemiological burden of obesity in childhood: a worldwide epidemic requiring urgent action. | journal=BMC Med | year= 2019 | volume= 17 | issue= 1 | pages= 212 | pmid=31760948 | doi=10.1186/s12916-019-1449-8 | pmc=6876113 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31760948  }} </ref>


==Differentiating [Obesity due to lifestyle factors] from other diseases==
*[[Childhood obesity]] due to lifestyle factors must be differentiated from other diseases that cause [[obesity]], [[high blood pressure]], and [[insulin resistance]] such as:
*[Childhood obesity] due to lifestyle factors must be differentiated from other diseases that cause [overweight], [high blood pressure], and [insulin resistance] such as:
 
:*[Hypothyroidism]
:*[[Hypothyroidism]]
:*[Cushing syndrome]
:*[[Cushing's syndrome]]
:*[[Polycystic ovary syndrome (PCOS)]]


==Epidemiology and demographics==
==Epidemiology and demographics==
*The prevalence of children who are overweight or obese worldwide is approximately 38 million in children under the age of 5 in 2019 and more than 340 million between 5 and 19 years old in 2016.<ref>https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight</ref>
*The prevalence of children who are overweight or obese worldwide is approximately 38 million in children under the age of 5 in 2019 and more than 340 million between 5 and 19 years old in 2016.<ref>https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight</ref>


*In 2015-2016, the prevalence of [Childhood Obesity] among children aged 2-19 years was estimated to be 13.7 million cases (18.5%) in USA.<ref>https://www.cdc.gov/obesity/data/childhood.html</ref>
*In 2015-2016, the prevalence of [[Childhood Obesity]] in USA was estimated to be 13.9% among children aged 2 to 5 years, 18.4% among children aged 6 to 11 and 20.6% among adolescents aged 12 to 19 years.<ref>https://www.cdc.gov/nchs/products/databriefs/db288.htm#:~:text=The%20prevalence%20of%20obesity%20was%2039.8%%20among%20adults,20%E2%80%9339%20overall%20and%20in%20both%20men%20and%20women.</ref>


===Age===
===Age===
*Children of all age groups may develop [Childhood Obesity].
 
*[Childhood Obesity] is more commonly observed among children aged 12 to 19 years old in the USA. This is followed by children aged 6 to 11 years old and then children aged 2 to 5 years of age.
*Children of all age groups may develop [[Childhood Obesity]].
*[[Childhood Obesity]] is more commonly observed among children aged 12 to 19 years old in the USA. This is followed by children aged 6 to 11 years old and then children aged 2 to 5 years of age.


===Gender===
===Gender===
*[Childhood Obesity] prevalence by gender is different depending on the region.  
 
*[Males] are more commonly affected than [females] age 5 to 19 years in most high and upper middle-income countries.<ref name="pmid28850992">{{cite journal| author=Ernst A, Schlattmann P, Waldfahrer F, Westhofen M| title= | journal=Laryngorhinootologie | year= 2017 | volume= 96 | issue= 8 | pages= 519-521 | pmid=28850992 | doi=10.1055/s-0043-113690 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28850992  }} </ref>
*[[Childhood Obesity]] prevalence by gender is different depending on the region.
*[Females] are more commonly affected than males in some middle-income countries.<ref name="pmid29017226">{{cite journal| author=Hesse G, Schaaf H| title= | journal=Laryngorhinootologie | year= 2017 | volume= 96 | issue= 10 | pages= 674 | pmid=29017226 | doi=10.1055/s-0043-119253 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29017226  }} </ref>
*[[Males]] are more commonly affected than [[females]] 5 to 19 years of age in most high and upper middle-income countries.<ref>https://nutrition.bmj.com/content/bmjnph/early/2020/09/07/bmjnph-2020-000074.full.pdf</ref>


===Race===
===Race===
*There are racial differences for [obesity in children].
 
*There are racial differences for [[obesity in children]].


*Obesity prevalence was higher among Hispanics and non-Hispanic blacks than non-Hispanic whites and non-Hispanic Asians.<ref>https://www.cdc.gov/nchs/data/databriefs/db288.pdf </ref>
*Obesity prevalence was higher among Hispanics and non-Hispanic blacks than non-Hispanic whites and non-Hispanic Asians.<ref>https://www.cdc.gov/nchs/data/databriefs/db288.pdf </ref>


==Risk Factors==
==Risk Factors==
*Common risk factors in the development of [Childhood obesity] are [high calorie diet], [lack of physical activity], children who have [family members who are obese], [stress] and [low-income households].
 
*Common risk factors in the development of [[Childhood obesity]] are [[high calorie diet]], [[lack of physical activity]], children who have obese family members, [[stress]] and [[low-income households]].


==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==


 
*If left untreated, patients with [[childhood obesity]] may progress to develop [[glucose intolerance]], [[type 2 diabetes]], [[high blood pressure]], [[high cholesterol]], [[asthma]], [[obstructive sleep apnea]], [[non-alcoholic fatty liver]], [[gall stones]],[[joint pain]] and [[depression]].
*Common complications of [[childhood obesity]] include the progression to [[adult obesity]] and increased risk of [[heart disease]], [[diabetes]] and [[cancer risk]].<ref>https://www.cdc.gov/obesity/childhood/causes.html</ref>
*Obese children often suffer from weight stigma, teasing and bullying amongst their peers.<ref name="pmid31988872">{{cite journal| author=Kang NR, Kwack YS| title=An Update on Mental Health Problems and Cognitive Behavioral Therapy in Pediatric Obesity. | journal=Pediatr Gastroenterol Hepatol Nutr | year= 2020 | volume= 23 | issue= 1 | pages= 15-25 | pmid=31988872 | doi=10.5223/pghn.2020.23.1.15 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31988872  }} </ref> They experience descrimination in the society. They are more likely to suffer from low self esteem, anxiety and depression.<ref name="pmid31760948">{{cite journal| author=Di Cesare M, Sorić M, Bovet P, Miranda JJ, Bhutta Z, Stevens GA | display-authors=etal| title=The epidemiological burden of obesity in childhood: a worldwide epidemic requiring urgent action. | journal=BMC Med | year= 2019 | volume= 17 | issue= 1 | pages= 212 | pmid=31760948 | doi=10.1186/s12916-019-1449-8 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31760948  }} </ref>


==Diagnosis==
==Diagnosis==


==='''Diagnostic Criteria'''===  
==='''Diagnostic Criteria'''===


:*The diagnosis of [[childhood obesity]] for children age 2 and older is made when the Body Mass Index (BMI) is at or above the 95th percentile on the BMI-for-age growth chart.<ref>https://www.nichd.nih.gov/health/topics/obesity/conditioninfo/diagnosed</ref>


==='''History and Symptoms'''===


*Symptoms of [[childhood obesity]] may include the following:


:*[[Shortness of breath]]
:*[[Sleep apnea]]
:*[[Constipation]]
:*[[Gastroesophageal reflux]]
:*[[Irregular menstruation]]


==='''History and Symptoms'''===
===Physical Examination===
*Symptoms of [childhood obesity] may include the following:
:*[hypertension]
:*[irregular menstruation]
:*[facial hair]
:*[polyuria] and [polydipsia] may suggest [diabetes].
:*[dry skin], [constipation], and [intolerance to cold] may suggest [hypothyroidism].
:*[irregular periods], [excess facial hair] and [acne] may suggest [polycystic ovarian syndrome] or [excess cortisol].


=== Physical Examination ===
*Physical examination may be remarkable for:
*Physical examination may be remarkable for:
:*[dry skin] and [fatigability] may be signs of hypothyroidism.<ref>https://emedicine.medscape.com/article/985333-overview#a5</ref>
:*[purple striae] and [accumulation of fat in the neck and trunk] may suggest cortisol excess.<ref>https://emedicine.medscape.com/article/985333-overview#a5</ref>
:*[signs of early sexual development] may be a sign of precocious puberty.<ref>https://emedicine.medscape.com/article/985333-overview#a5</ref>
:*[acne] and [excess facial hair] may suggest cortisol excess or polycystic ovary syndrome. <ref>https://emedicine.medscape.com/article/985333-overview#a5</ref>


==='''Laboratory Findings'''===
:*[[Stretch marks on hips and abdomen]]
*Children with BMI 85 or more require [fasting blood glucose], [fasting lipid panel], [ALT], [AST] and [serum hemoglobin A1C] or [2-hour glucose tolerance test]. <ref>https://ihcw.aap.org/Documents/Assessment%20%20and%20Management%20of%20Childhood%20Obesity%20Algorithm_FINAL.pdf</ref>
:*[[Acanthosis nigricans]]
*The following tests may be indicated for children with obesity depending on the clinical presentation:<ref>https://emedicine.medscape.com/article/985333-overview</ref>
:*[[Dry skin]], [[constipation]], and [[fatigability]] may be signs of hypothyroidism.<ref name="pmid28336049">{{cite journal| author=Chaker L, Bianco AC, Jonklaas J, Peeters RP| title=Hypothyroidism. | journal=Lancet | year= 2017 | volume= 390 | issue= 10101 | pages= 1550-1562 | pmid=28336049 | doi=10.1016/S0140-6736(17)30703-1 | pmc=6619426 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28336049  }} </ref>
:*[Thyroid function tests]
:*[[Accumulation of fat in the neck and trunk]], [[moon facies]], [[facial plethora]], [[acanthosis nigricans]], [[acne]], and [[hirsutism]] may suggest [[cushing syndrome]].<ref name="pmid29754644">{{cite journal| author=Lodish MB, Keil MF, Stratakis CA| title=Cushing's Syndrome in Pediatrics: An Update. | journal=Endocrinol Metab Clin North Am | year= 2018 | volume= 47 | issue= 2 | pages= 451-462 | pmid=29754644 | doi=10.1016/j.ecl.2018.02.008 | pmc=5962291 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29754644  }} </ref>
:*[Adrenal function tests]
:*[[Signs of early sexual development]] may be a sign of precocious puberty.<ref name="pmid29094880">{{cite journal| author=Klein DA, Emerick JE, Sylvester JE, Vogt KS| title=Disorders of Puberty: An Approach to Diagnosis and Management. | journal=Am Fam Physician | year= 2017 | volume= 96 | issue= 9 | pages= 590-599 | pmid=29094880 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29094880  }} </ref>
:*[Liver function tests]
:*[[Acne]], [[hirsutism]], and [[acanthosis nigricans]] in an adolescent girl may suggest [[polycystic ovary syndrome]].<ref name="pmid29184806">{{cite journal| author=Kamboj MK, Bonny AE| title=Polycystic ovary syndrome in adolescence: diagnostic and therapeutic strategies. | journal=Transl Pediatr | year= 2017 | volume= 6 | issue= 4 | pages= 248-255 | pmid=29184806 | doi=10.21037/tp.2017.09.11 | pmc=5682369 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29184806  }} </ref>
:*[Serum leptin]
 
:*[Serum calcium], [phosphorus] and [parathyroid hormone]
==='''Laboratory Findins'''===
:*[Growth hormone]
 
:*[Reproductive hormones]
*Overweight and obese Children require screening tests:[[hemoglobin A1C]], [[fasting plasma glucose]], [[2-hour plasma glucose]], and [[fasting lipids]].<ref name="StyneArslanian2017">{{cite journal|last1=Styne|first1=Dennis M.|last2=Arslanian|first2=Silva A.|last3=Connor|first3=Ellen L.|last4=Farooqi|first4=Ismaa Sadaf|last5=Murad|first5=M. Hassan|last6=Silverstein|first6=Janet H.|last7=Yanovski|first7=Jack A.|title=Pediatric Obesity—Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline|journal=The Journal of Clinical Endocrinology & Metabolism|volume=102|issue=3|year=2017|pages=709–757|issn=0021-972X|doi=10.1210/jc.2016-2573}}</ref>
*The following tests may be indicated for children with obesity depending on the clinical presentation:
 
:*[[TSH]], [[T4]], [[T3]], and [[free T4]]<ref>https://www.thyroid.org/pediatric-thyroid-function/</ref>
:*[[Adrenal function tests]]
:*[[Liver function tests]]
:*[[Serum leptin]]
:*[[Serum calcium]], [[phosphorus]] and [[parathyroid hormone]]
:*[[Gonadotropin-releasing hormone agonist]] stimulation test <ref name="pmidhttps://doi.org/10.1542/peds.2006-2402">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1542/peds.2006-2402 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }} </ref>
:*[[Free testosterone]], [[total Testosterone]], [[LH]], [[FSH]], and [[dehydroepiandrosterone sulfate]].<ref name="pmidhttps://doi.org/10.1542/peds.2019-2056J">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1542/peds.2019-2056J | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }} </ref>


==Treatment==  
==Treatment==  


==='''Medical therapy'''===
==='''Medical therapy'''===
*Management of [obesity in children] focuses on reducing BMI of the child safely, preventing and managing complications.  
 
*The mainstay of therapy for [obesity in children] is [diet] and [exercise].
*Management of [[obesity in children]] focuses on safely reducing the BMI of the child, preventing and managing complications.
*[Setmelanotide], a melanocortin-4-receptor agonist was approved by the U.S. Food and Drug Administration (FDA) for children age 6 and older with obesity caused by rare genetic disorders.
*The mainstay of therapy for [[obesity in children]] is [[lifestyle modification]] through [[diet]], [[exercise]] and [[behavioral modification]].<ref name="pmid28359099">{{cite journal| author=Styne DM, Arslanian SA, Connor EL, Farooqi IS, Murad MH, Silverstein JH | display-authors=etal| title=Pediatric Obesity-Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline. | journal=J Clin Endocrinol Metab | year= 2017 | volume= 102 | issue= 3 | pages= 709-757 | pmid=28359099 | doi=10.1210/jc.2016-2573 | pmc=6283429 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28359099  }} </ref>
*[[Setmelanotide]], a melanocortin-4-receptor agonist was approved by the U.S. Food and Drug Administration (FDA) for children age 6 and older with obesity caused by three rare genetic disorders.<ref>https://www.fda.gov/drugs/drug-safety-and-availability/fda-approves-first-treatment-weight-management-people-certain-rare-genetic-conditions</ref>


==='''Surgery'''===
==='''Surgery'''===
*Bariatric surgery are performed in some adolescents with severe obesity.
 
*Bariatric surgery are performed in some adolescents with severe obesity.<ref name="pmid28174231">{{cite journal| author=Beamish AJ, Reinehr T| title=Should bariatric surgery be performed in adolescents? | journal=Eur J Endocrinol | year= 2017 | volume= 176 | issue= 4 | pages= D1-D15 | pmid=28174231 | doi=10.1530/EJE-16-0906 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28174231  }} </ref>


==='''Prevention'''===
==='''Prevention'''===
*There are multiple preventive measures available for [childhood obesity]
 
*Effective measures for the primary prevention of [childhood obesity] include [consumption of fruits and vegetables], [drinking water], [restriction of sweetened drinks and sugary snacks], [regular physical activity], [limiting screen time], [reducing stress], and [providing a healthy sleep routine].
*There are multiple preventive measures available for [[childhood obesity]]
*Effective measures for the primary prevention of [[childhood obesity]] include exclusive [[breast feeding]] for the first 6 months of life<ref name="pmid31030194">{{cite journal| author=Rito AI, Buoncristiano M, Spinelli A, Salanave B, Kunešová M, Hejgaard T | display-authors=etal| title=Association between Characteristics at Birth, Breastfeeding and Obesity in 22 Countries: The WHO European Childhood Obesity Surveillance Initiative - COSI 2015/2017. | journal=Obes Facts | year= 2019 | volume= 12 | issue= 2 | pages= 226-243 | pmid=31030194 | doi=10.1159/000500425 | pmc=6547266 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31030194  }} </ref>, [[consumption of fruits and vegetables]], [[drinking water]], [[restriction of sweetened drinks and sugary snacks]], [[regular physical activity]], [[limiting screen time]], [[reducing stress]], and [[providing a healthy sleep routine]].


==See also==
==See also==
*[[Hereditary factors in childhood obesity]]
*[[Hereditary factors in childhood obesity]]


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==External links==
==External links==
*[http://www.commonsensemedia.org/resources/childhood_obesity.php Common Sense Media Resources]
 
*[http://www.commercialalert.org/issues/health/childhood-obesity Commercial Alert's web page on childhood obesity]
*[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16870015&query_hl=7&itool=pubmed_docsum Study of Breakfast Eating and Income Levels in Preschoolers]
* [[Mindless Eating|Mindless eating]] Cornell University [[Food and Brand Lab]] [http://www.mindlesaseating.org/]
*[http://www.mayoclinic.com/health/childhood-obesity/FL00058 Mayo clinic article on preventing childhood obesity]
*[http://www.mayoclinic.com/health/childhood-obesity/FL00058 Mayo clinic article on preventing childhood obesity]
*{{cite web|url=http://www.sirc.org/articles/fattened_statistics.shtml |title=Fattened statistics |accessdate=2007-04-21 |last=March |first=Peter |work=Social Issues Research Center }}
*{{cite web|url=http://www.ericdigests.org/pre-9218/obesity.htm|title=Childhood Obesity|accessdate=2007-08-04 |last=Summerfield |first=Liane M. |work=[[Education Resources Information Center]] Clearinghouse on Teacher Education, [[Washington, DC]]}}


[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Primary care]]
[[Category:Obesity]]
[[Category:Obesity]]


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Latest revision as of 05:10, 7 March 2021


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Iman Djarraya, BMedSci, MBChB, MPH[2]

Synonyms and keywords: obesity in kids, obesity in children, pediatric obesity


Overview

Childhood obesity is a Body Mass Index (BMI) at or above the 95th percentile for children of the same gender and age. It is a serious health problem that can result in health complications. Childhood obesity can be caused by dietary factors, lifestyle factors, underlying medical conditions, genetic causes or certain medications. Obesity may present with high blood pressure, shortness of breath, sleep apnea, gastroesophageal reflux, constipation, insulin resistance, constipation, or irregular menstruation. The presence of polyuria and polydipsia suggests possible diabetes, excess facial hair, insulin resistance and irregular menstruation in adolescent girls may be due to polycystic ovary syndrome (PCOS) and dry skin, constipation and intolerance to cold suggest hypothyroidism. laboratory tests indicated depend on the clinical presentation. Management of obesity includes the treatment of any underlying medical conditions and lifestyle modification.

Historical Perspective

Classification

  • Obesity: BMI is ≥95th percentile
  • Severe obesity: BMI ≥120% of the 95th percentile or BMI ≥35 kg/m2.

Pathophysiology

Causes

Childhood obesity may be caused by unhealthy dietary intake[7], unhealthy lifestyle [8], environmental factors[9], psychological stress [10], genetic causes [11], medication-induced [11] or cerebral injury.[11]

Dietary factors

Children and adolescents are consuming low nutrient high-calorie foods and beverages at home, school and other places. They are consuming more fast food which is low in nutrients and high in calories, fat and sodium. CDC reports that children and adolescents in the U.S. consumed an average of 13.8% of their daily calories from fast food during 2015-2018.[12] In addition, they are consuming large amounts of sugar-sweetened beverages which has been directly associated with obesity in multiple reviews.[13] [14]

Lifestyle factors

Physical inactivity, excess use of screen time and inadequate sleep also contribute to the obesity epidemic.[8] [15]

Environmental factors

Eating habits of the child are affected by demographics, lunch policies at schools and work demands on parents.[16]

Psychological stress

Chronic stress increases the risk of obesity, diabetes, heart disease, metabolic syndrome and mental health problems.[10]

Endocrine causes

There are hormonal disorders that may be associated with weight gain and obesity in children including: hypothyroidism[17], cushing's syndrome[18], polycystic ovary syndrome (PCOS)[19], precocious puberty[20], and pseudohypoparthyroidism.[21]

Genetic causes

Often, a child whose parents are overweight or obese will also be overweight or obese. Although this is often caused by shared unhealthy eating habits in the household, several genetic causes have been identified as a cause of obesity.[6] These can be divides into monogenic causes, syndromic obesity and polygenic obesity.[6] Monogenic obesity is caused of a mutation to a single gene including Leptin (LEP) mutations, Leptin Receptor (LEPR) mutations, Pro-opio melanocortin (POMC) mutations, MC4R deficiency, Proconvertase (PC1/2) deficiency, SIM1 deficiency, NTRK2/BDNF mutations and SH2B1 mutations.[6] Syndromic obesity include Prader Willi Syndrome (PWS), Cohen syndrome[6], Turner syndrome[22], down syndrome, and Laurence-Moon-Bardet-Biedl syndrome.[23]

Medication-induced

Medications that may cause weight gain in children include second-generation antipsychotics[24], glucocorticoids[25], risperidone[26], clozapine[27], and tricyclic antidepressants[28].

Cerebral injury

Obesity can occur after acquired hypothalamic lesions following surgery, meningitis or ischemic injury.[11]

Differentiating childhood obesity due to lifestyle factors from other Diseases

Epidemiology and demographics

  • The prevalence of children who are overweight or obese worldwide is approximately 38 million in children under the age of 5 in 2019 and more than 340 million between 5 and 19 years old in 2016.[29]
  • In 2015-2016, the prevalence of Childhood Obesity in USA was estimated to be 13.9% among children aged 2 to 5 years, 18.4% among children aged 6 to 11 and 20.6% among adolescents aged 12 to 19 years.[30]

Age

  • Children of all age groups may develop Childhood Obesity.
  • Childhood Obesity is more commonly observed among children aged 12 to 19 years old in the USA. This is followed by children aged 6 to 11 years old and then children aged 2 to 5 years of age.

Gender

  • Childhood Obesity prevalence by gender is different depending on the region.
  • Males are more commonly affected than females 5 to 19 years of age in most high and upper middle-income countries.[31]

Race

  • Obesity prevalence was higher among Hispanics and non-Hispanic blacks than non-Hispanic whites and non-Hispanic Asians.[32]

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

  • The diagnosis of childhood obesity for children age 2 and older is made when the Body Mass Index (BMI) is at or above the 95th percentile on the BMI-for-age growth chart.[36]

History and Symptoms

Physical Examination

  • Physical examination may be remarkable for:

Laboratory Findins

Treatment

Medical therapy

Surgery

  • Bariatric surgery are performed in some adolescents with severe obesity.[45]

Prevention

See also

References

  1. ↑ 1.0 1.1 Carmichael, A R (1999). "Current concepts: Treatment for morbid obesity". Postgraduate Medical Journal. 75 (879): 7–12. doi:10.1136/pgmj.75.879.7. ISSN 0032-5473.
  2. ↑ 2.0 2.1 Styne DM, Arslanian SA, Connor EL, Farooqi IS, Murad MH, Silverstein JH; et al. (2017). "Pediatric Obesity-Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab. 102 (3): 709–757. doi:10.1210/jc.2016-2573. PMC 6283429. PMID 28359099.
  3. ↑ https://www.who.int/dietphysicalactivity/childhood_why/en/
  4. ↑ https://www.who.int/dietphysicalactivity/childhood_why/en/
  5. ↑ Klok MD, Jakobsdottir S, Drent ML (2007). "The role of leptin and ghrelin in the regulation of food intake and body weight in humans: a review". Obes Rev. 8 (1): 21–34. doi:10.1111/j.1467-789X.2006.00270.x. PMID 17212793.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Thaker VV (2017). "GENETIC AND EPIGENETIC CAUSES OF OBESITY". Adolesc Med State Art Rev. 28 (2): 379–405. PMC 6226269. PMID 30416642.
  7. ↑ https://www.nhs.uk/conditions/obesity/causes/
  8. ↑ 8.0 8.1 {{cite journal| author=Ren H, Zhou Z, Liu WK, Wang X, Yin Z| title=Excessive homework, inadequate sleep, physical inactivity and screen viewing time are major contributors to high paediatric obesity.<ref name="pmid27759894">Ren H, Zhou Z, Liu WK, Wang X, Yin Z (January 2017). "Excessive homework, inadequate sleep, physical inactivity and screen viewing time are major contributors to high paediatric obesity". Acta Paediatr. 106 (1): 120–127. doi:10.1111/apa.13640. PMC 6680318 Check |pmc= value (help). PMID 27759894.
  9. ↑ https://www.cdc.gov/obesity/childhood/causes.html#:~:text=Childhood%20Obesity%20Causes%20&%20Consequences%201%20Behavior.%20Behaviors,Community%20Environment.%20...%203%20Consequences%20of%20Obesity.
  10. ↑ 10.0 10.1 Ruiz LD, Zuelch ML, Dimitratos SM, Scherr RE (2019). "Adolescent Obesity: Diet Quality, Psychosocial Health, and Cardiometabolic Risk Factors". Nutrients. 12 (1). doi:10.3390/nu12010043. PMC 7020092 Check |pmc= value (help). PMID 31877943.
  11. ↑ 11.0 11.1 11.2 11.3 Kleinendorst L, Abawi O, van der Voorn B, Jongejan MHTM, Brandsma AE, Visser JA; et al. (2020). "Identifying underlying medical causes of pediatric obesity: Results of a systematic diagnostic approach in a pediatric obesity center". PLoS One. 15 (5): e0232990. doi:10.1371/journal.pone.0232990. PMC 7209105 Check |pmc= value (help). PMID 32384097 Check |pmid= value (help).
  12. ↑ https://www.cdc.gov/nchs/products/databriefs/db375.htm
  13. ↑ Keller A, Bucher Della Torre S (2015). "Sugar-Sweetened Beverages and Obesity among Children and Adolescents: A Review of Systematic Literature Reviews". Child Obes. 11 (4): 338–46. doi:10.1089/chi.2014.0117. PMC 4529053. PMID 26258560.
  14. ↑ Hu FB, Malik VS (2010). "Sugar-sweetened beverages and risk of obesity and type 2 diabetes: epidemiologic evidence". Physiol Behav. 100 (1): 47–54. doi:10.1016/j.physbeh.2010.01.036. PMC 2862460. PMID 20138901.
  15. ↑ Morrissey B, Allender S, Strugnell C (2019). "Dietary and Activity Factors Influence Poor Sleep and the Sleep-Obesity Nexus among Children". Int J Environ Res Public Health. 16 (10). doi:10.3390/ijerph16101778. PMID 31137502.
  16. ↑ Sahoo K, Sahoo B, Choudhury AK, Sofi NY, Kumar R, Bhadoria AS (2015). "Childhood obesity: causes and consequences". J Family Med Prim Care. 4 (2): 187–92. doi:10.4103/2249-4863.154628. PMC 4408699. PMID 25949965.
  17. ↑ Verma A, Jayaraman M, Kumar HK, Modi KD (2008). "Hypothyroidism and obesity. Cause or effect?". Saudi Med J. 29 (8): 1135–8. PMID 18690306.
  18. ↑ Stratakis CA (2016). "Diagnosis and Clinical Genetics of Cushing Syndrome in Pediatrics". Endocrinol Metab Clin North Am. 45 (2): 311–28. doi:10.1016/j.ecl.2016.01.006. PMC 4889872. PMID 27241967.
  19. ↑ 19.0 19.1 Kamboj MK, Bonny AE (2017). "Polycystic ovary syndrome in adolescence: diagnostic and therapeutic strategies". Transl Pediatr. 6 (4): 248–255. doi:10.21037/tp.2017.09.11. PMC 5682369. PMID 29184806.
  20. ↑ Chen C, Zhang Y, Sun W, Chen Y, Jiang Y, Song Y; et al. (2017). "Investigating the relationship between precocious puberty and obesity: a cross-sectional study in Shanghai, China". BMJ Open. 7 (4): e014004. doi:10.1136/bmjopen-2016-014004. PMC 5566589. PMID 28400459.
  21. ↑ Shoemaker AH, Jüppner H (2017). "Nonclassic features of pseudohypoparathyroidism type 1A". Curr Opin Endocrinol Diabetes Obes. 24 (1): 33–38. doi:10.1097/MED.0000000000000306. PMC 5484400. PMID 27875418.
  22. ↑ Lebenthal Y, Levy S, Sofrin-Drucker E, Nagelberg N, Weintrob N, Shalitin S; et al. (2018). "The Natural History of Metabolic Comorbidities in Turner Syndrome from Childhood to Early Adulthood: Comparison between 45,X Monosomy and Other Karyotypes". Front Endocrinol (Lausanne). 9: 27. doi:10.3389/fendo.2018.00027. PMC 5811462. PMID 29479339.
  23. ↑ Kumar A, Husain A, Saleem A, Khawaja UA, Virani S (2020). "Laurence-Moon-Bardet-Biedl Syndrome: A Rare Case With a Literature Review". Cureus. 12 (11): e11355. doi:10.7759/cureus.11355. PMC 7720918 Check |pmc= value (help). PMID 33304690 Check |pmid= value (help).
  24. ↑ Bretler T, Weisberg H, Koren O, Neuman H (2019). "The effects of antipsychotic medications on microbiome and weight gain in children and adolescents". BMC Med. 17 (1): 112. doi:10.1186/s12916-019-1346-1. PMC 6582584 Check |pmc= value (help). PMID 31215494.
  25. ↑ Tosur M, Viau-Colindres J, Astudillo M, Redondo MJ, Lyons SK (2020). "Medication-induced hyperglycemia: pediatric perspective". BMJ Open Diabetes Res Care. 8 (1). doi:10.1136/bmjdrc-2019-000801. PMC 6954773 Check |pmc= value (help). PMID 31958298.
  26. ↑ Vanwong N, Ngamsamut N, Nuntamool N, Hongkaew Y, Sukprasong R, Puangpetch A; et al. (2020). "Risperidone-Induced Obesity in Children and Adolescents With Autism Spectrum Disorder: Genetic and Clinical Risk Factors". Front Pharmacol. 11: 565074. doi:10.3389/fphar.2020.565074. PMC 7677569 Check |pmc= value (help). PMID 33240086 Check |pmid= value (help).
  27. ↑ Vasudev K, Choi YH, Norman R, Kim RB, Schwarz UI (2017). "Genetic Determinants of Clozapine-Induced Metabolic Side Effects". Can J Psychiatry. 62 (2): 138–149. doi:10.1177/0706743716670128. PMC 5298525. PMID 27681143.
  28. ↑ van Reedt Dortland AK, Giltay EJ, van Veen T, Zitman FG, Penninx BW (2010). "Metabolic syndrome abnormalities are associated with severity of anxiety and depression and with tricyclic antidepressant use". Acta Psychiatr Scand. 122 (1): 30–9. doi:10.1111/j.1600-0447.2010.01565.x. PMID 20456284.
  29. ↑ https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
  30. ↑ https://www.cdc.gov/nchs/products/databriefs/db288.htm#:~:text=The%20prevalence%20of%20obesity%20was%2039.8%%20among%20adults,20%E2%80%9339%20overall%20and%20in%20both%20men%20and%20women.
  31. ↑ https://nutrition.bmj.com/content/bmjnph/early/2020/09/07/bmjnph-2020-000074.full.pdf
  32. ↑ https://www.cdc.gov/nchs/data/databriefs/db288.pdf
  33. ↑ https://www.cdc.gov/obesity/childhood/causes.html
  34. ↑ Kang NR, Kwack YS (2020). "An Update on Mental Health Problems and Cognitive Behavioral Therapy in Pediatric Obesity". Pediatr Gastroenterol Hepatol Nutr. 23 (1): 15–25. doi:10.5223/pghn.2020.23.1.15. PMID 31988872.
  35. ↑ Di Cesare M, Sorić M, Bovet P, Miranda JJ, Bhutta Z, Stevens GA; et al. (2019). "The epidemiological burden of obesity in childhood: a worldwide epidemic requiring urgent action". BMC Med. 17 (1): 212. doi:10.1186/s12916-019-1449-8. PMID 31760948.
  36. ↑ https://www.nichd.nih.gov/health/topics/obesity/conditioninfo/diagnosed
  37. ↑ Chaker L, Bianco AC, Jonklaas J, Peeters RP (2017). "Hypothyroidism". Lancet. 390 (10101): 1550–1562. doi:10.1016/S0140-6736(17)30703-1. PMC 6619426 Check |pmc= value (help). PMID 28336049.
  38. ↑ Lodish MB, Keil MF, Stratakis CA (2018). "Cushing's Syndrome in Pediatrics: An Update". Endocrinol Metab Clin North Am. 47 (2): 451–462. doi:10.1016/j.ecl.2018.02.008. PMC 5962291. PMID 29754644.
  39. ↑ Klein DA, Emerick JE, Sylvester JE, Vogt KS (2017). "Disorders of Puberty: An Approach to Diagnosis and Management". Am Fam Physician. 96 (9): 590–599. PMID 29094880.
  40. ↑ Styne, Dennis M.; Arslanian, Silva A.; Connor, Ellen L.; Farooqi, Ismaa Sadaf; Murad, M. Hassan; Silverstein, Janet H.; Yanovski, Jack A. (2017). "Pediatric Obesity—Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline". The Journal of Clinical Endocrinology & Metabolism. 102 (3): 709–757. doi:10.1210/jc.2016-2573. ISSN 0021-972X.
  41. ↑ https://www.thyroid.org/pediatric-thyroid-function/
  42. ↑ Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1542/peds.2006-2402 Check |pmid= value (help).
  43. ↑ Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1542/peds.2019-2056J Check |pmid= value (help).
  44. ↑ https://www.fda.gov/drugs/drug-safety-and-availability/fda-approves-first-treatment-weight-management-people-certain-rare-genetic-conditions
  45. ↑ Beamish AJ, Reinehr T (2017). "Should bariatric surgery be performed in adolescents?". Eur J Endocrinol. 176 (4): D1–D15. doi:10.1530/EJE-16-0906. PMID 28174231.
  46. ↑ Rito AI, Buoncristiano M, Spinelli A, Salanave B, Kunešová M, Hejgaard T; et al. (2019). "Association between Characteristics at Birth, Breastfeeding and Obesity in 22 Countries: The WHO European Childhood Obesity Surveillance Initiative - COSI 2015/2017". Obes Facts. 12 (2): 226–243. doi:10.1159/000500425. PMC 6547266 Check |pmc= value (help). PMID 31030194.

External links


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