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  • What are the factors that contribute to pathological weight gain resulting in severe obesity?

  • How does the health care provider help decrease the blame and guilt felt by many adolescents who have severe obesity?

  • What aspects of the family history will help provide insight on barriers to treatment?

  • Which patients are appropriate candidates for bariatric surgery?

This chapter will address the following American College of Graduate Medical Education competencies: patient care, medical knowledge, and interpersonal and communication skills.

Patient Care: Understanding the development of severe obesity is critical to helping families implement appropriate and effective obesity treatment plans.

Medical Knowledge: Understanding and being able to accurately assess obesity and obesity-related comorbidities in an adolescent with severe obesity is critical to individualizing treatment, including bariatric surgery.

Interpersonal and Communication Skills: Excellent interpersonal and communication skills are critical in partnering with the adolescent with severe obesity through treatment while at the same time fostering family support and patient autonomy.

Approximately 2% to 3% of the US adolescent population has a body mass index (BMI) over 40 kg/m2, with an estimate of 45,000 adolescents with a BMI greater than 50 kg/m2.1 A BMI of 40 kg/m2 translates into being about 100 lb over ideal body weight, and a BMI of 50 kg/m2 is equivalent to being about 200% of ideal body weight. Most children who reach a BMI over 40 kg/m2 have experienced years of pathological weight gain. A normal-weight 4-year-old child who gains 10 extra pounds per year will have a BMI of 40 kg/m2 at the age of 14 years. In a genetically susceptible person, this may equate to having a positive caloric imbalance of 100 calories per day. Children may experience even more pathological weight gain of up to 40 to 60 extra pounds per year during puberty or during times of individual and family psychosocial stress. The vicious cycle of abnormal weight gain can often result in an adolescent who feels hopeless about his or her ability to manage obesity and leaves the adolescent with an extraordinary amount of weight to lose. Despite this hopelessness and frustration, it is very important for the patient and their medical provider to understand the factors that have contributed to a patient’s pathological weight gain.

Factors contributing to pathological weight gain can be divided in 3 major categories. The first are genetic and medical factors contributing to weight gain. Adolescents with severe obesity who present with short stature, developmental/cognitive delay, or abnormal pubertal development may have an underlying genetic syndrome contributing to their severe obesity which may have not been previously diagnosed. In addition to obesity syndromes, severe obesity often runs in families. A history of obesity and obesity comorbidity in first- and second-degree relatives will give the pediatric health care provider some insight into the potential ...

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