Obesity Prevention and Management — Comorbidity Assessment and Evaluation — Clinical Pathway: Outpatient Specialty Care and Primary Care

Comorbidity Assessment and Evaluation

NOTE: For most co-morbidities, the primary care provider can refer the patient to Healthy Weight Clinic alone where additional sub-specialty referrals can then be made, if necessary. If primary care provider feels more expedited sub-specialty evaluation is needed or if patient is unable to be seen at Healthy Weight Clinic, referral to appropriate sub-specialists can be made.

Co-morbidities
Co-morbidities History Physical Exam Additional Evaluation to Consider
(if not previously performed)
Pre-diabetes and diabetes Family history Acanthosis nigricans
  • Labs: Fasting glucose and HbA1c1 within the past 3 months
  • Referral(s) to:
  • Note: Patients with diabetes can be referred to Healthy Weight Clinic but should continue receiving care from an Endocrinologist for diabetes.
Hypertension Family history Accurately measured BP percentile
  • If BP elevated (≥ 95th percentile) on 3 different encounters, then consider a referral to:
Dyslipidemia Family history Xanthomas
  • Labs:
    • Fasting lipid profile
    • If unable to obtain a fasting lipid profile, use non-HDL cholesterol and HDL levels to determine cardiovascular risk.
  • Referral(s) to:
  • Note: Recommend urgent referral to Lipid Heart provider in Healthy Weight or Lipid Heart Clinic if triglycerides > 400 or LDL Cholesterol > 190
Sleep Apnea Sleep Apnea Verbal Screen
Snoring
Labored breathing
Observed pauses in breathing
Fatigue/Daytime sleepiness
Learning/Behavior problems
Bedwetting (Nocturnal Enuresis)
Family History of OSA
Enlarged tonsils
Loud nasal breathing/frequent mouth breathing
  • Procedure: Sleep Study
  • Referral(s) to:
    • Healthy Weight Clinic or Adolescent Bariatrics Program
    • Sleep Clinic (along with sleep study)
    • Otolaryngology if concern for tonsillar/adenoidal hypertrophy
NAFLD/NASH Mostly Asymptomatic; RUQ abdominal pain Hepatomegaly
RUQ tenderness to palpation
Slipped Cap Femoral Epiphysis (SCFE) and Juvenile Osteochondritis (aka Blount's Disease)
  • Hip pain
    Knee pain
    Shin pain
    Limp
  • Abnormal hip range of motion
    Leg-length discrepancy
    Leg-bowing
    Limp
  • Imaging:
    • If suspicion for SCFE with stable hips, obtain AP and frog lateral of bilateral hips on pelvic film
    • If suspicion for SCFE with unstable hips, obtain AP and true lateral of bilateral hips on pelvic film
    • If suspicion for osteochondritis/Blount’s disease, obtain 2 X-rays:
      1. AP film (standing) of bilateral LE from hips to floor with patellas facing forward
      2. Lateral film of involved tibia/fibula/femur with patella facing forward and maximal knee extension
  • Referral(s) to: Orthopedics
Polycystic Ovarian Syndrome (PCOS) PCOS verbal screen Hirsutism
Acne
Acanthosis
Nigricans
  • Labs: Total and free testosterone, sex-hormone binding globulin, DHEA-S, 17-OH progesterone, androstenedione, TSH, LH, FSH, prolactin, urine Hcg
  • Imaging:
    • Ultrasound to rule out other causes of hyperandrogenism (NOT required for diagnosis of PCOS)
  • Referral(s) to:
Pseudotumor Cerebri Syndrome (PTCS) PTCS verbal screen Papilledema
  • Urgent referral to the emergency room if papilledema present and/or high level of suspicion
  • Referral(s) to:
Psychosocial
  • Depression screen
  • Ask about bullying, teasing, and/or eating disorders
 
  • Referral to behavioral health or counseling
Vitamin D Deficiency Family history
Nutritional intake
 
  • Labs: Vitamin D 25-OH
    • Obtain calcium, phosphorous, alkaline phosphatase, and intact PTH If concern for severe vitamin D deficiency or nutritional rickets
  • Imaging:
    • DXA scan if history of frequent or low-impact fractures
  • Therapy:
    • Initiation of Vitamin D3 (cholecalciferol) supplementation if history suggests insufficient intake
  • Referral(s) to:
    • Bone Health Clinic if high concern for nutritional rickets or frequent or low-impact fractures
    • Endocrinology if unable to be seen at Bone Health Clinic

 

Other Conditions to Consider that can Cause Overweight/Obesity
Other conditions to consider that can cause overweight/obesity History Physical Exam Additional Evaluation to Consider
(if not previously performed)
Hypothyroidism
  • Family History
  • Poor linear growth
  • Abnormal puberty
  • Fatigue
  • Constipation
  • Cold intolerance
  • Dry skin/nails
Enlarged thyroid gland (may or may not be present)
  • Labs: TSH, T4 panel with T3 uptake
  • Referral(s) to: Endocrinology
Cushing's Disease Family History
  • Violaceous striae
  • Weakness
  • Moon facies
Referral(s) to: Endocrinology
Genetic Disorders
  • Developmental Delay
  • Short Stature
  • Syndromic features
  • Short Stature
  • Referral(s) to:
    • Healthy Weight Program
    • Genetics
Medications that can cause weight gain:
  • Antipsychotics – i.e. Abilify, Risperdal, Seroquel, Thorazine, Clozaril
  • Mood stabilizer – i.e. Tegretol, Depakote, Lithium
  • Antidepressants – i.e. Paxil (SSRI), Lexapro, Tofranil, Remeron
  • Steroids
  • Other – i.e. Depo-Provera, other OCPs