Refer to Endocrinology

The epidemic of childhood obesity is well known to all pediatric healthcare providers. Referrals to endocrinology for childhood obesity are overwhelming our practice and making it very difficult to see patients with true endocrinologic disorders in a timely fashion. Obesity is rarely ever due to an endocrinologic disorder.

Endocrinology is not a weight loss service. Endocrinology does not have special access to dietitians unless the child has diabetes. We, as endocrinologists, are not dietitians and do not manage nutrition. An endocrinologist is not a substitute for a dietitian consultation. If assistance in managing nutrition is needed, then referral to the Healthy You program would be more appropriate. In addition, the Healthy You program is also familiar with managing medication, when appropriate, for weight loss and diabetes prevention.

Although there are true endocrine disorders that cause obesity, these are exceptionally rare and can typically be detected by review of the child’s growth curve. If referred, we are happy to exclude the rare endocrinologic disorders that cause obesity in children.

The child should be seen by an endocrinologist for obesity if:

1. The child is unusually short and obese. This combination is more typical of syndromic and endocrine forms of obesity.
2. Growth failure is present despite rapid weight gain. Typical of endocrine causes of obesity (i.e. Cushing’s Disease/Syndrome).
3. The child’s obesity started an an unusually eary age (i.e. before 2 years old). This could represent a rare syndromic/genetic form of obesity syndrome.
4. Fasting glucose >110 mg/dL.
5. Random glucose >200 mg/dL (diabetes).
6. HgbA1C > 6.2%.

We want to encourage and empower primary care providers to follow their patients with mildly abnormal HgbA1C and/or fasting glucose levels over a minimum 6-month period while implementing dietary and lifestyle modifications. Failure to stabilize or improve the values despite these efforts may warrant a visit with an endocrinologist. Referrals for mild abnormalities in HgbA1C are overwhelming our practice and making it difficult for us to see children with true endocrinologic disorders in a timely fashion. Not all children with “pre-diabetes” require referral to see an endocrinologist. Pre-diabetes just means the child is at higher risk for developing diabetes

Please consider the following points if you are referring a patient due to concern for an abnormal Hemoglobin A1C (HgbA1C) test:

⇒ We strongly recommend measuring both fasting glucose and HgbA1C to screen for diabetes (and pre-diabetes).

⇒ Although Insulin levels are commonly measured, they are rarely useful and do not impact treatment decisions. Please do not measure insulin levels in children when screening for diabetes.

⇒ Diabetes is present in the patient if they have the following results:

• Fasting blood glucose >= 126mg/dL
• Oral glucose tolerance test documenting glucose > 200 mg/dL at 2-hours
• Random blood glucose >= 200 mg/dL

⇒ The child should be seen by an endocrinologist if they have the following results:

• Fasting blood glucose >110 mg/dL
• Hemoglobin A1C values above 6.2%
• Combination of abnormal results such as HgbA1C >6% AND fasting glucose above 100 mg/dL
• Documentation of a concerning trend in HgbA1C and/or fasting glucose over a 6-month period despite dietary and lifestyle modification