A 16-year-old Mexican American girl presents to her pediatrician for her annual checkup. She emigrated to the United States from Mexico with her family 5 years ago. The girl is the oldest of four children, all of whom are obese. Both parents are in their early 40s and also have obesity.

Despite numerous attempts by the pediatrician and staff to provide nutritional counseling and recommendations for exercise, the girl remains unable to adopt a healthy lifestyle. Her mother has said that the foods they eat at home are high in starch. The patient also turns to processed foods to snack on between meals, especially after school. She is largely sedentary except for gym class at school twice per week. She spends most of her free time taking care of her three younger siblings and helping around the house until her parents return from work in the evening.

The patient is 5 ft 4 in, weighs 200 lb, and has a body mass index of 34.3. Blood pressure and temperature are normal. She has polycystic ovary syndrome and has had three vaginal yeast infections in the last year. She has chubby cheeks, a thick neck, and hirsutism.