When Is Obesity Not Just Obesity?
by Shannon Patrick, ARNP, MSN, Janet Silverstein, MD
Jun 18, 2013
An Obese Teenage Girl: What Would You Do?
Ashley, a 14-year-old Latina girl, is seen in your office for a routine physical examination before starting high school in a few months. She is accompanied by her mother. Both deny any particular concerns at this time.
Review of systems. Ashley reports that she experiences nocturia, usually awakening 1-2 times a night. She denies voiding more frequently during the day and is unable to recall exactly when her nocturia began, but reports that it has been happening “for a long time.” She also reports that recently, she has been thirstier than usual. Her mother confirms that Ashley occasionally snores.
It has been approximately 3 years since Ashley’s first menses; she cannot recall the date of her most recent period but reports that they are irregular. She has not been losing weight. She also denies any problems with headaches, vision changes, vaginal yeast infections, or other symptoms.
Social history. Ashley lives with her mother and 2 younger siblings. She rarely sees her father. She will be starting 9th grade and does not participate in any extracurricular activities. She will have physical education class twice weekly when school starts but does not participate in any other physical activity. She enjoys texting her friends and watching television.
Diet history. Ashley usually skips breakfast and eats lunch at school, which typically consists of pizza or a chicken sandwich and a sports drink or juice. She eats a large snack when she gets home from school, often ramen noodles or sandwiches and potato chips. Her mother usually prepares dinner at home, which consists of a meat, a starch (potatoes, rice, or pasta), and a vegetable. They sometimes have dessert, and Ashley also often has a bedtime snack, usually cookies or cold cereal.
Although Ashley and her mother are not able to provide exact quantities of food eaten at meals, her mother feels that Ashley’s portions are “large.” The family eats at fast-food restaurants twice a week on nights that Ashley’s younger brother has soccer practice. She drinks juice, sugared soda, and water at home. She eats “some” cheese and consumes 2% milk only when she eats cereal for a bedtime snack.
Medical history. Ashley has a history of mild intermittent asthma, for which she uses a beta-agonist inhaler. Neither she nor her mother can recall when she last needed to use her inhaler and believe it has been at least 3 or 4 months. She has been at or above the 90% for weight on the growth charts since she was in kindergarten, with an increase in her rate of weight gain during the 3 years before her first menstrual cycle at age 11. Her body mass index (BMI) has been above the 97th percentile since age 6 years. Her mother asks whether Ashley could have “a thyroid problem.”
Family history. Ashley’s mother reports that she had gestational diabetes during her last pregnancy. Ashley’s maternal grandmother and grandfather have type 2 diabetes, hypertension, and hypercholesterolemia. A younger sister also has asthma. The mother’s sister was recently diagnosed with hypothyroidism. Ashley’s father is “overweight” but healthy, as far as the mother knows. She does not know much about his family history but thinks that his father may have had a heart attack when he was in his late 40s or early 50s.
Physical examination. Ashley was alert and oriented, in no acute distress, and obviously obese. On funduscopic examination, the optic discs were sharp, with visual fields normal to confrontation.
The thyroid gland was of normal size, shape, and texture. She had a nuchal fat pad. Her abdomen was soft and obese, with positive bowel sounds, no tenderness, and no hepatomegaly to palpation or percussion; the examination was limited somewhat by body habitus. Her liver was not enlarged to percussion or to scratch testing.
The patient had Tanner 5 breasts and pubic hair. Internal rotation of the hips was normal, and her gait was normal. Deep-tendon reflexes were normal. She had acanthosis nigricans on the back of her neck and in both axillae; excess hair growth on her lower abdomen; and light-colored striae on her hips, thighs, and breasts.
Measurements (Figures 1 and 2) were:
- Weight: 101.2 kg (223.1 lb);
- Height: 163.5 cm (64.4 in);
- BMI: 37.8 kg/m2 (>99th percentile for age and sex); and
- Blood pressure: 140/86 mm Hg.
Ashley’s height and weight chart.
Ashley’s BMI chart.
Urine dipstick testing was positive for glycosuria and proteinuria and negative for ketonuria. A nonfasting random blood glucose obtained during her visit was 206 mg/dL.
Ashley was cautioned to avoid sugared drinks and given a prescription for laboratory work to be done the next morning.
Initial laboratory evaluation:
- A1c: 7.6%
- Fasting glucose: 128 mg/dL
- BUN: 14 mg/dL
- Creatinine: 0.73 mg/dL
- AST: 34 IU/L
- ALT: 89 IU/L
- TSH: 1.810 µIU/mL
- Total cholesterol: 198 mg/dL
- HDL-C: 37 mg/dL
- LDL-C: 124 mg/dL
- Triglycerides: 234 mg/dL
- Microalbumin:Creatinine ratio: 18 mg/g creatinine
What is Ashley’s Diagnosis?
1. Type 1 diabetes
3. Type 2 diabetes mellitus (T2DM)
4. Maturity-onset diabetes of the young
3. Type 2 diabetes mellitus (T2DM)