American Academy of Pediatrics (AAP): Practical Pediatrics

STEAMBOAT SPRINGS, COLO. – New-onset type 1 diabetes in an obese youth cannot reliably be distinguished from pediatric type 2 diabetes on clinical grounds in this era of epidemic obesity.

"The only way to distinguish obese type 1 diabetes from type 2 diabetes is to measure diabetes autoantibodies. And those autoantibody panels are commercially available now. Signs and symptoms, diabetic ketoacidosis, family history – they don’t really help you. We get an autoantibody panel routinely in obese kids above age 10 presenting with new-onset diabetes," said Dr. Charlotte M. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children’s Hospital in Providence, R.I.

Diabetic ketoacidosis is widely thought of as incompatible with type 2 diabetes. Not true. Close to 20% of youth with type 2 diabetes present with DKA. Similarly, while a history of recent weight loss is considered a classic presenting symptom of type 1 diabetes, it’s also present in about one-quarter of young people presenting with type 2 diabetes, Dr. Boney noted.

The presence of pancreatic autoantibodies spells type 1 diabetes metabolically, even if the patient appears phenotypically to have type 2 disease.

"Some pediatric endocrinologists call this ‘type one-and-a-half’ diabetes. No, no, no. Let’s not make things any weirder than they already are. They have autoimmune diabetes, which is clearly type 1 diabetes. It just happens to be a little more complicated in them because they also have the morbidity of obesity," she explained at the meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

The obesity epidemic has muddied the diagnostic waters, because now 20%-30% of patients with new-onset type 1 diabetes are obese, as is a similar proportion of the general pediatric population. At the same time, the obesity epidemic has led to an increase in type 2 diabetes.

But it’s important to bear in mind that most youths with new-onset diabetes still have type 1 disease, she said.

In the landmark prospective The SEARCH For Diabetes In Youth study, nearly all children who presented under age 10 years had type 1 diabetes. Among 10- to 19-year-olds, the proportion with type 2 disease was 15% among whites, but considerably greater among racial minorities: 58% among African Americans, 46% in Hispanics, 70% in Asian/Pacific Islanders, and 86% among Native Americans (JAMA 2007;297:2716-24).

In the ongoing, multicenter, National Institutes of Health–sponsored Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study, which enrolled 1,206 subjects with a presumptive diagnosis of type 2 diabetes, 9.8% proved to be positive for GAD-65and/or insulinoma-associated protein 2 autoantibodies. They had to be excluded from participation in the treatment phase (Diabetes Care 2010;33:1970-5).

As a practical approach to the initial therapy of young patients with new-onset diabetes, Dr. Boney urged that those with DKA and ketosis should be started on intravenous fluids and insulin, regardless of their age and body habitus. If they are over age 10 and obese, however, pancreatic autoimmunity should be ruled out before transitioning to long-term therapy. For autoantibody-negative patients whose clinical picture is consistent with type 2 diabetes, the treatment is metformin, the only Food and Drug Administration–approved therapy for children. Extensive experience shows that it’s a very safe drug, she said.

The TODAY trial is designed to determine whether the best treatment for type 2 diabetes in youth is metformin alone, metformin plus rosiglitazone, or metformin and an intensive lifestyle intervention aimed at achieving a 7%-10% weight loss.

The use of metformin to try to prevent diabetes in obese children with insulin resistance and the metabolic syndrome is the subject of large ongoing clinical trials. Until the results come in, Dr. Boney said she sees no role for off-label prescribing of metformin, given that weight loss and exercise are quite effective in improving insulin sensitivity.

Maturity Onset Diabetes of the Young, or MODY, is worth considering in white youth who are pancreatic autoantibody–negative and have a strong history of parental non–type 1 diabetes. MODY is a single-gene disorder that causes diabetes and is inherited from a parent.

"There are a lot of experts in the MODY field that think we’re grossly underdiagnosing monogenic diabetes," said Dr. Boney.

The treatment for MODY is not insulin or metformin, but rather oral sulfonylureas, although those agents are not FDA-approved for use in children, she observed.

Dr. Boney reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – New-onset type 1 diabetes in an obese youth cannot reliably be distinguished from pediatric type 2 diabetes on clinical grounds in this era of epidemic obesity.

"The only way to distinguish obese type 1 diabetes from type 2 diabetes is to measure diabetes autoantibodies. And those autoantibody panels are commercially available now. Signs and symptoms, diabetic ketoacidosis, family history – they don’t really help you. We get an autoantibody panel routinely in obese kids above age 10 presenting with new-onset diabetes," said Dr. Charlotte M. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children’s Hospital in Providence, R.I.

Diabetic ketoacidosis is widely thought of as incompatible with type 2 diabetes. Not true. Close to 20% of youth with type 2 diabetes present with DKA. Similarly, while a history of recent weight loss is considered a classic presenting symptom of type 1 diabetes, it’s also present in about one-quarter of young people presenting with type 2 diabetes, Dr. Boney noted.

The presence of pancreatic autoantibodies spells type 1 diabetes metabolically, even if the patient appears phenotypically to have type 2 disease.

"Some pediatric endocrinologists call this ‘type one-and-a-half’ diabetes. No, no, no. Let’s not make things any weirder than they already are. They have autoimmune diabetes, which is clearly type 1 diabetes. It just happens to be a little more complicated in them because they also have the morbidity of obesity," she explained at the meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

The obesity epidemic has muddied the diagnostic waters, because now 20%-30% of patients with new-onset type 1 diabetes are obese, as is a similar proportion of the general pediatric population. At the same time, the obesity epidemic has led to an increase in type 2 diabetes.

But it’s important to bear in mind that most youths with new-onset diabetes still have type 1 disease, she said.

In the landmark prospective The SEARCH For Diabetes In Youth study, nearly all children who presented under age 10 years had type 1 diabetes. Among 10- to 19-year-olds, the proportion with type 2 disease was 15% among whites, but considerably greater among racial minorities: 58% among African Americans, 46% in Hispanics, 70% in Asian/Pacific Islanders, and 86% among Native Americans (JAMA 2007;297:2716-24).

In the ongoing, multicenter, National Institutes of Health–sponsored Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study, which enrolled 1,206 subjects with a presumptive diagnosis of type 2 diabetes, 9.8% proved to be positive for GAD-65and/or insulinoma-associated protein 2 autoantibodies. They had to be excluded from participation in the treatment phase (Diabetes Care 2010;33:1970-5).

As a practical approach to the initial therapy of young patients with new-onset diabetes, Dr. Boney urged that those with DKA and ketosis should be started on intravenous fluids and insulin, regardless of their age and body habitus. If they are over age 10 and obese, however, pancreatic autoimmunity should be ruled out before transitioning to long-term therapy. For autoantibody-negative patients whose clinical picture is consistent with type 2 diabetes, the treatment is metformin, the only Food and Drug Administration–approved therapy for children. Extensive experience shows that it’s a very safe drug, she said.

The TODAY trial is designed to determine whether the best treatment for type 2 diabetes in youth is metformin alone, metformin plus rosiglitazone, or metformin and an intensive lifestyle intervention aimed at achieving a 7%-10% weight loss.

The use of metformin to try to prevent diabetes in obese children with insulin resistance and the metabolic syndrome is the subject of large ongoing clinical trials. Until the results come in, Dr. Boney said she sees no role for off-label prescribing of metformin, given that weight loss and exercise are quite effective in improving insulin sensitivity.

Maturity Onset Diabetes of the Young, or MODY, is worth considering in white youth who are pancreatic autoantibody–negative and have a strong history of parental non–type 1 diabetes. MODY is a single-gene disorder that causes diabetes and is inherited from a parent.

"There are a lot of experts in the MODY field that think we’re grossly underdiagnosing monogenic diabetes," said Dr. Boney.

The treatment for MODY is not insulin or metformin, but rather oral sulfonylureas, although those agents are not FDA-approved for use in children, she observed.

Dr. Boney reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – New-onset type 1 diabetes in an obese youth cannot reliably be distinguished from pediatric type 2 diabetes on clinical grounds in this era of epidemic obesity.

"The only way to distinguish obese type 1 diabetes from type 2 diabetes is to measure diabetes autoantibodies. And those autoantibody panels are commercially available now. Signs and symptoms, diabetic ketoacidosis, family history – they don’t really help you. We get an autoantibody panel routinely in obese kids above age 10 presenting with new-onset diabetes," said Dr. Charlotte M. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children’s Hospital in Providence, R.I.

Diabetic ketoacidosis is widely thought of as incompatible with type 2 diabetes. Not true. Close to 20% of youth with type 2 diabetes present with DKA. Similarly, while a history of recent weight loss is considered a classic presenting symptom of type 1 diabetes, it’s also present in about one-quarter of young people presenting with type 2 diabetes, Dr. Boney noted.

The presence of pancreatic autoantibodies spells type 1 diabetes metabolically, even if the patient appears phenotypically to have type 2 disease.

"Some pediatric endocrinologists call this ‘type one-and-a-half’ diabetes. No, no, no. Let’s not make things any weirder than they already are. They have autoimmune diabetes, which is clearly type 1 diabetes. It just happens to be a little more complicated in them because they also have the morbidity of obesity," she explained at the meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

The obesity epidemic has muddied the diagnostic waters, because now 20%-30% of patients with new-onset type 1 diabetes are obese, as is a similar proportion of the general pediatric population. At the same time, the obesity epidemic has led to an increase in type 2 diabetes.

But it’s important to bear in mind that most youths with new-onset diabetes still have type 1 disease, she said.

In the landmark prospective The SEARCH For Diabetes In Youth study, nearly all children who presented under age 10 years had type 1 diabetes. Among 10- to 19-year-olds, the proportion with type 2 disease was 15% among whites, but considerably greater among racial minorities: 58% among African Americans, 46% in Hispanics, 70% in Asian/Pacific Islanders, and 86% among Native Americans (JAMA 2007;297:2716-24).

In the ongoing, multicenter, National Institutes of Health–sponsored Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study, which enrolled 1,206 subjects with a presumptive diagnosis of type 2 diabetes, 9.8% proved to be positive for GAD-65and/or insulinoma-associated protein 2 autoantibodies. They had to be excluded from participation in the treatment phase (Diabetes Care 2010;33:1970-5).

As a practical approach to the initial therapy of young patients with new-onset diabetes, Dr. Boney urged that those with DKA and ketosis should be started on intravenous fluids and insulin, regardless of their age and body habitus. If they are over age 10 and obese, however, pancreatic autoimmunity should be ruled out before transitioning to long-term therapy. For autoantibody-negative patients whose clinical picture is consistent with type 2 diabetes, the treatment is metformin, the only Food and Drug Administration–approved therapy for children. Extensive experience shows that it’s a very safe drug, she said.

The TODAY trial is designed to determine whether the best treatment for type 2 diabetes in youth is metformin alone, metformin plus rosiglitazone, or metformin and an intensive lifestyle intervention aimed at achieving a 7%-10% weight loss.

The use of metformin to try to prevent diabetes in obese children with insulin resistance and the metabolic syndrome is the subject of large ongoing clinical trials. Until the results come in, Dr. Boney said she sees no role for off-label prescribing of metformin, given that weight loss and exercise are quite effective in improving insulin sensitivity.

Maturity Onset Diabetes of the Young, or MODY, is worth considering in white youth who are pancreatic autoantibody–negative and have a strong history of parental non–type 1 diabetes. MODY is a single-gene disorder that causes diabetes and is inherited from a parent.

"There are a lot of experts in the MODY field that think we’re grossly underdiagnosing monogenic diabetes," said Dr. Boney.

The treatment for MODY is not insulin or metformin, but rather oral sulfonylureas, although those agents are not FDA-approved for use in children, she observed.

Dr. Boney reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – The youth obesity crisis has a huge and underappreciated flip side: An epidemic of overuse injuries in heavy kids who’ve been told to start exercising without receiving any informed guidance.

"A lot of times we’re turning to sports and exercise in the battle against obesity, and it’s backfiring," according to Dr. Paul R. Stricker, a pediatric sports medicine specialist at the Scripps Clinic in San Diego.

"We hear about overweight all the time in the media, but overuse injuries are also an epidemic in my world. They are rampant. We’ve got millions of kids every year with overuse injuries from doing too much, too fast after a lifetime of inactivity," he said at the meeting.

"Obese youth are being told to ‘just start jogging,’ and a few weeks later they’re ending up in my sports medicine clinic. And they’re already defeated," said Dr. Stricker, a past president of the American Medical Society for Sports Medicine who served as a U.S. team physician at the Olympics.

"The experience of camaraderie and accomplishment of being on a team can absolutely do wonders for [obese] children."

The approach to exercise among previously sedentary overweight and obese youth needs to be quite different from that taken with active kids experienced in sports. The start is more gradual and cautious. The initial emphasis is placed upon stretching, strengthening, and conditioning in order to allow the body time to adapt to new demands.

Dr. Stricker likes to start these kids off with non-impact exercises, such as swimming, water aerobics, bicycling, and low-impact dance or walking. Supervised strength training is a particularly good way for these heavy kids to get on board the life-long exercise train.

"They can see real progress very quickly. It really gets them motivated, and the increased muscle mass is helpful because it brings an increased metabolic rate, which promotes weight loss," he explained.

If a heavy, sedentary kid wants to take up a team sport – be it wrestling, football, or a non-contact sport – the message from coaches and parents ought to be that the first season should be a learning experience in which the emphasis focuses on catching up in terms of sport skills. The new player might not see much game time this year, but next year could be different.

"The experience of camaraderie and accomplishment of being on a team can absolutely do wonders for these children," according to the pediatrician.

Overweight and obese kids face multiple challenges in taking up exercise. Not only do they have a lengthy history as couch potatoes, but their diet is typically quite poor. And while heavy kids look like they’re skeletally mature because of their size, in fact they’re often late bloomers. Their open growth plates predispose to fractures.

Among the most common overuse injuries Dr. Stricker encounters in overweight kids who’ve taken up exercise are:

• Patellar maltracking. Heavy children often have knock knees, shortened and inflexible hamstrings and quadriceps, and weak patella muscles, all of which promote patellar maltracking laterally. The extra weight being carried around increases the patellar load, further predisposing to kneecap pain and maltracking. Affected kids find running, jumping, and going up and down stairs particularly problematic.

• Foot overpronation. Overweight youth typically have flattened arches. This results in biomechanical problems, including tibial rotation with resultant excess forces being transmitted through the medial side of the lower leg. The faulty biomechanics, coupled with excess weight and a rapid increase in physical activity, results in tissue overload. Shin splints, foot pain, and patellar maltracking are common.

"It’s very important for us to evaluate below the knee, to look at the feet and say, ‘Hey, you might benefit from an insert,’ " Dr. Stricker said.

He virtually never refers these heavy kids with flattened arches to a podiatrist for a $400 pair of custom orthotics. It’s a waste of money. Over-the-counter inserts costing $30-$35 work as well or better. Avoid the soft, floppy, spongy variety in favor of inserts comprised of a thin layer of cushioning over hard molded plastic; Superfeet and Spenco make good-quality products, he said.

• Heat sickness. Kids in general are more vulnerable to heat injury than adults. They have a higher metabolic rate as well as a greater body surface to mass ratio. They have a poor thirst drive. Plus, sweat glands are typically immature and fewer in number in youth below ages 12-14 years. Their smaller blood volume makes it more difficult to dissipate heat.

All of these issues are accentuated in overweight kids. Moreover, since they are new to exercise and sports, their inefficiency of movement results in generation of extra heat, Dr. Stricker explained.

• Low back pain. This is very common when heavy kids take up exercise. Contributing factors include a lack of tone in the core abdominal and lower back muscles, coupled with hamstring and quadriceps inflexibility and excess weight being carried around the abdomen.

"These kids need to generate core strength through planks and other exercises that engage their core besides sit-ups, which for a lot of these kids are no fun and usually embarrassing," he continued.

• Slipped capital femoral epiphysis. This is the most common hip disorder in overweight 10- to 18-year-olds. Black males are at increased risk. The injury occurs when the proximal hip epiphysis slides off the growth plate.

"If a kid comes in with knee or thigh pain or a limp, always think ‘hip’ as well. Check for hip range of motion. If it’s not equal and symmetric or it brings on a lot of pain, you’ve got to get an x-ray and you’d better be thinking about [slipped capital femoral epiphysis]. It’s usually a surgical situation," according to Dr. Stricker.

He reported having no relevant financial disclosures.

STEAMBOAT SPRINGS, COLO. – The youth obesity crisis has a huge and underappreciated flip side: An epidemic of overuse injuries in heavy kids who’ve been told to start exercising without receiving any informed guidance.

"A lot of times we’re turning to sports and exercise in the battle against obesity, and it’s backfiring," according to Dr. Paul R. Stricker, a pediatric sports medicine specialist at the Scripps Clinic in San Diego.

"We hear about overweight all the time in the media, but overuse injuries are also an epidemic in my world. They are rampant. We’ve got millions of kids every year with overuse injuries from doing too much, too fast after a lifetime of inactivity," he said at the meeting.

"Obese youth are being told to ‘just start jogging,’ and a few weeks later they’re ending up in my sports medicine clinic. And they’re already defeated," said Dr. Stricker, a past president of the American Medical Society for Sports Medicine who served as a U.S. team physician at the Olympics.

"The experience of camaraderie and accomplishment of being on a team can absolutely do wonders for [obese] children."

The approach to exercise among previously sedentary overweight and obese youth needs to be quite different from that taken with active kids experienced in sports. The start is more gradual and cautious. The initial emphasis is placed upon stretching, strengthening, and conditioning in order to allow the body time to adapt to new demands.

Dr. Stricker likes to start these kids off with non-impact exercises, such as swimming, water aerobics, bicycling, and low-impact dance or walking. Supervised strength training is a particularly good way for these heavy kids to get on board the life-long exercise train.

"They can see real progress very quickly. It really gets them motivated, and the increased muscle mass is helpful because it brings an increased metabolic rate, which promotes weight loss," he explained.

If a heavy, sedentary kid wants to take up a team sport – be it wrestling, football, or a non-contact sport – the message from coaches and parents ought to be that the first season should be a learning experience in which the emphasis focuses on catching up in terms of sport skills. The new player might not see much game time this year, but next year could be different.

"The experience of camaraderie and accomplishment of being on a team can absolutely do wonders for these children," according to the pediatrician.

Overweight and obese kids face multiple challenges in taking up exercise. Not only do they have a lengthy history as couch potatoes, but their diet is typically quite poor. And while heavy kids look like they’re skeletally mature because of their size, in fact they’re often late bloomers. Their open growth plates predispose to fractures.

Among the most common overuse injuries Dr. Stricker encounters in overweight kids who’ve taken up exercise are:

• Patellar maltracking. Heavy children often have knock knees, shortened and inflexible hamstrings and quadriceps, and weak patella muscles, all of which promote patellar maltracking laterally. The extra weight being carried around increases the patellar load, further predisposing to kneecap pain and maltracking. Affected kids find running, jumping, and going up and down stairs particularly problematic.

• Foot overpronation. Overweight youth typically have flattened arches. This results in biomechanical problems, including tibial rotation with resultant excess forces being transmitted through the medial side of the lower leg. The faulty biomechanics, coupled with excess weight and a rapid increase in physical activity, results in tissue overload. Shin splints, foot pain, and patellar maltracking are common.

"It’s very important for us to evaluate below the knee, to look at the feet and say, ‘Hey, you might benefit from an insert,’ " Dr. Stricker said.

He virtually never refers these heavy kids with flattened arches to a podiatrist for a $400 pair of custom orthotics. It’s a waste of money. Over-the-counter inserts costing $30-$35 work as well or better. Avoid the soft, floppy, spongy variety in favor of inserts comprised of a thin layer of cushioning over hard molded plastic; Superfeet and Spenco make good-quality products, he said.

• Heat sickness. Kids in general are more vulnerable to heat injury than adults. They have a higher metabolic rate as well as a greater body surface to mass ratio. They have a poor thirst drive. Plus, sweat glands are typically immature and fewer in number in youth below ages 12-14 years. Their smaller blood volume makes it more difficult to dissipate heat.

All of these issues are accentuated in overweight kids. Moreover, since they are new to exercise and sports, their inefficiency of movement results in generation of extra heat, Dr. Stricker explained.

• Low back pain. This is very common when heavy kids take up exercise. Contributing factors include a lack of tone in the core abdominal and lower back muscles, coupled with hamstring and quadriceps inflexibility and excess weight being carried around the abdomen.

"These kids need to generate core strength through planks and other exercises that engage their core besides sit-ups, which for a lot of these kids are no fun and usually embarrassing," he continued.

• Slipped capital femoral epiphysis. This is the most common hip disorder in overweight 10- to 18-year-olds. Black males are at increased risk. The injury occurs when the proximal hip epiphysis slides off the growth plate.

"If a kid comes in with knee or thigh pain or a limp, always think ‘hip’ as well. Check for hip range of motion. If it’s not equal and symmetric or it brings on a lot of pain, you’ve got to get an x-ray and you’d better be thinking about [slipped capital femoral epiphysis]. It’s usually a surgical situation," according to Dr. Stricker.

He reported having no relevant financial disclosures.

STEAMBOAT SPRINGS, COLO. – The youth obesity crisis has a huge and underappreciated flip side: An epidemic of overuse injuries in heavy kids who’ve been told to start exercising without receiving any informed guidance.

"A lot of times we’re turning to sports and exercise in the battle against obesity, and it’s backfiring," according to Dr. Paul R. Stricker, a pediatric sports medicine specialist at the Scripps Clinic in San Diego.

"We hear about overweight all the time in the media, but overuse injuries are also an epidemic in my world. They are rampant. We’ve got millions of kids every year with overuse injuries from doing too much, too fast after a lifetime of inactivity," he said at the meeting.

"Obese youth are being told to ‘just start jogging,’ and a few weeks later they’re ending up in my sports medicine clinic. And they’re already defeated," said Dr. Stricker, a past president of the American Medical Society for Sports Medicine who served as a U.S. team physician at the Olympics.

"The experience of camaraderie and accomplishment of being on a team can absolutely do wonders for [obese] children."

The approach to exercise among previously sedentary overweight and obese youth needs to be quite different from that taken with active kids experienced in sports. The start is more gradual and cautious. The initial emphasis is placed upon stretching, strengthening, and conditioning in order to allow the body time to adapt to new demands.

Dr. Stricker likes to start these kids off with non-impact exercises, such as swimming, water aerobics, bicycling, and low-impact dance or walking. Supervised strength training is a particularly good way for these heavy kids to get on board the life-long exercise train.

"They can see real progress very quickly. It really gets them motivated, and the increased muscle mass is helpful because it brings an increased metabolic rate, which promotes weight loss," he explained.

If a heavy, sedentary kid wants to take up a team sport – be it wrestling, football, or a non-contact sport – the message from coaches and parents ought to be that the first season should be a learning experience in which the emphasis focuses on catching up in terms of sport skills. The new player might not see much game time this year, but next year could be different.

"The experience of camaraderie and accomplishment of being on a team can absolutely do wonders for these children," according to the pediatrician.

Overweight and obese kids face multiple challenges in taking up exercise. Not only do they have a lengthy history as couch potatoes, but their diet is typically quite poor. And while heavy kids look like they’re skeletally mature because of their size, in fact they’re often late bloomers. Their open growth plates predispose to fractures.

Among the most common overuse injuries Dr. Stricker encounters in overweight kids who’ve taken up exercise are:

• Patellar maltracking. Heavy children often have knock knees, shortened and inflexible hamstrings and quadriceps, and weak patella muscles, all of which promote patellar maltracking laterally. The extra weight being carried around increases the patellar load, further predisposing to kneecap pain and maltracking. Affected kids find running, jumping, and going up and down stairs particularly problematic.

• Foot overpronation. Overweight youth typically have flattened arches. This results in biomechanical problems, including tibial rotation with resultant excess forces being transmitted through the medial side of the lower leg. The faulty biomechanics, coupled with excess weight and a rapid increase in physical activity, results in tissue overload. Shin splints, foot pain, and patellar maltracking are common.

"It’s very important for us to evaluate below the knee, to look at the feet and say, ‘Hey, you might benefit from an insert,’ " Dr. Stricker said.

He virtually never refers these heavy kids with flattened arches to a podiatrist for a $400 pair of custom orthotics. It’s a waste of money. Over-the-counter inserts costing $30-$35 work as well or better. Avoid the soft, floppy, spongy variety in favor of inserts comprised of a thin layer of cushioning over hard molded plastic; Superfeet and Spenco make good-quality products, he said.

• Heat sickness. Kids in general are more vulnerable to heat injury than adults. They have a higher metabolic rate as well as a greater body surface to mass ratio. They have a poor thirst drive. Plus, sweat glands are typically immature and fewer in number in youth below ages 12-14 years. Their smaller blood volume makes it more difficult to dissipate heat.

All of these issues are accentuated in overweight kids. Moreover, since they are new to exercise and sports, their inefficiency of movement results in generation of extra heat, Dr. Stricker explained.

• Low back pain. This is very common when heavy kids take up exercise. Contributing factors include a lack of tone in the core abdominal and lower back muscles, coupled with hamstring and quadriceps inflexibility and excess weight being carried around the abdomen.

"These kids need to generate core strength through planks and other exercises that engage their core besides sit-ups, which for a lot of these kids are no fun and usually embarrassing," he continued.

• Slipped capital femoral epiphysis. This is the most common hip disorder in overweight 10- to 18-year-olds. Black males are at increased risk. The injury occurs when the proximal hip epiphysis slides off the growth plate.

"If a kid comes in with knee or thigh pain or a limp, always think ‘hip’ as well. Check for hip range of motion. If it’s not equal and symmetric or it brings on a lot of pain, you’ve got to get an x-ray and you’d better be thinking about [slipped capital femoral epiphysis]. It’s usually a surgical situation," according to Dr. Stricker.

He reported having no relevant financial disclosures.