Breast-feeding and risk for childhood obesity: does maternal diabetes or obesity status matter?

national survey on the pattern of breastfeeding in Iranian infants: The IrMIDHS study

Background: Breastfeeding has been recognized to have a great deal of benefits for both the mothers and infants. Moreover, the importance of exclusive breastfeeding in the first six months of life has been greatly acknowledged. Therefore, this study aimed to determine the prevalence of starting breastfeeding in the first hour after delivery and the exclusive breast milk feeding as well as the age at which complimentary foods are provided to the child and duration of breastfeeding in Iran. Methods: This nationwide cross-sectional study was conducted in the frame of a national survey, Iran Multiple Indicator Demographic and Health Survey (IrMIDHS), in 31 provinces of Iran. Participants were selected by multistage cluster sampling. The target sample was 3,096 clusters consisting of 2,187 urban and 909 rural families. Data were collected using a questionnaire through face-to-face interviews. Results: The rate of exclusive breastfeeding was 53.13% with higher prevalence in rural (67.76%) than in urban areas (47.79%) (P = 0.04), and among girls (56.35%) compared to boys (50.60%). The prevalence of breastfeeding as the main diet of Iranian infants under six months old was 70.72% and the prevalence of initiation of breastfeeding (up to the first hour after delivery) was 68.70%. The probability of breastfeeding continuance among twelve to fifteen months children was 84.22%; the corresponding figure was 51% among twenty to twenty three months old babies (p=0.03). Conclusion: Exclusive breastfeeding should be encouraged; and strategies that are more effective should be designed to protect, train and support young mothers to breastfeed their infants. The importance of early beginning of breastfeeding and its continuation should be underscored.

Impact of Maternal Glucose and Gestational Weight Gain on Child Obesity over the First Decade of Life in Normal Birth Weight Infants

Objective To determine, among children with normal birth weight, if maternal hyperglycemia and weight gain independently increase childhood obesity risk in a very large diverse population. Methods Study population was 24,141 individuals (mothers and their normal birth weight offspring, born 1995-2003) among a diverse population with universal GDM screening [50-g glucose-challenge test (GCT); 3 h. 100 g oral glucose tolerance test (OGTT) if GCT+]. Among the 13,037 full-term offspring with normal birth weight (2500-4000 g), annual measured height/weight was ascertained between ages 2 and 10 years to calculate gender-specific BMI-for-age percentiles using USA norms (1960-1995 standard). Results Among children who began life with normal birth weight, we found a significant trend for developing both childhood overweight (>85 %ile) and obesity (>95 %ile) during the first decade of life with both maternal hyperglycemia (normal GCT, GCT+ but no GDM, GDM) and excessive gestational weight gain [>40 pounds (18.1 kg)]; p < 0.0001 for both trends. These maternal glucose and/or weight gain effects to imprint for childhood obesity in the first decade remained after adjustment for potential confounders including maternal age, parity, as well as pre-pregnancy BMI. The attributable risk (%) for childhood obesity was 28.5 % (95 % CI 15.9-41.1) for GDM and 16.4 % (95 % CI 9.4-23.2) for excessive gestational weight gain. Conclusions for Practice Both maternal hyperglycemia and excessive weight gain have independent effects to increase childhood obesity risk. Future research should focus on prevention efforts during pregnancy as a potential window of opportunity to reduce childhood obesity.

When Breast Milk Alone Is Not Enough: Barriers to Breastfeeding Continuation among Overweight and Obese Mothers

BACKGROUND

Maternal overweight and obesity are associated with decreased breastfeeding duration.

OBJECTIVE

This study aimed to identify barriers to breastfeeding continuation among overweight and obese mothers.

METHODS

A retrospective cohort study examining breastfeeding continuation barriers was conducted using results of the Centers for Disease Control and Prevention Pregnancy Risk Assessment Monitoring System survey from Illinois, Maine, and Vermont from 2004 to 2008. SAS Complex Survey version 9.3 was used for analysis.

RESULTS

Of 19,145 mothers surveyed, 3717 (19%) were obese and 4367 (23%) were overweight. Overall, 14,731 women initiated breastfeeding, and 6467 discontinued breastfeeding prior to survey completion, around 4 months postpartum. The most common reasons that mothers reported for discontinuing breastfeeding were insufficient milk supply, infant not satisfied with breast milk alone, and breastfeeding difficulty. Overweight and obese women, compared with women of normal weight, had higher odds of discontinuing breastfeeding because their babies were not satisfied by breast milk alone (overweight: odds ratio [OR] = 1.39, 95% confidence interval [CI], 1.16-1.68; obese: OR = 1.26, 95% CI, 1.03-1.54). Obese mothers, compared with normal weight mothers, had lower odds of discontinuing breastfeeding because it felt like the right time (OR = 0.64, 95% CI, 0.47-0.88) and higher odds of discontinuing due to breastfeeding difficulties (OR = 1.29, 95% CI, 1.05-1.58) and infant jaundice (OR = 1.81, 95% CI, 1.26-2.60).

CONCLUSION

Obese and overweight mothers were significantly more likely to discontinue breastfeeding due to infant dissatisfaction with breast milk alone. Obese mothers had higher odds than normal weight mothers of discontinuing breastfeeding due to breastfeeding difficulties and infant jaundice. Breastfeeding education and support should be enhanced for this at-risk population.

Differences in breastfeeding initiation by maternal diabetes status and race, Ohio 2006-2011

To examine breastfeeding trends at hospital discharge from 2006 to 2011 by diabetes status and to determine associations between diabetes status and breastfeeding. Ohio Vital Statistics birth certificate data from 2006 to 2011, including all singleton births to Ohio resident mothers of reproductive age (16-44 years), were used to analyze trends in breastfeeding by diabetes status [prepregnancy diabetes (PDM), gestational diabetes (GDM)]. Logistic regression was used to evaluate the relationship between breastfeeding at discharge and diabetes type. Because a significant interaction between diabetes status and race existed, the model was stratified by race. This study includes 803,222 Ohio births from 2006 to 2011. A significant, increasing trend of breastfeeding (P < .0001) existed among women with GDM (63-70 %) and no DM (62-69 %). GDM breastfeeding rates were frequently the highest, while women with PDM often had the lowest breastfeeding initiation rates, regardless of sample characteristic. In models stratified by race, Black women were often the least likely to breastfeed, but overweight or obese and diabetes were not associated with a decreased likelihood of breastfeeding as they were among White women. While breastfeeding rates have increased in Ohio, they have still not reached the Healthy People 2020 goals. Our study shows that breastfeeding initiation rates vary by diabetes status and race. This study can aid in tailoring breastfeeding intervention and counseling efforts to women least likely to initiate breastfeeding, such as women with pregnancy diabetes, to improve the health of both infants and mothers.

Associations of infant milk feed type on early postnatal growth of offspring exposed and unexposed to gestational diabetes in utero

Purpose

Infants on prolonged breastfeeding are known to grow slower during the first year of life. It is still unclear if such effects are similar in offspring exposed to gestational diabetes (GDM) in utero. We examined the associations of infant milk feeding on postnatal growth from birth till 36 months of age in offspring exposed and unexposed to GDM.

Methods

Pregnant mothers undertook 75 g 2-h oral glucose tolerance tests at 26–28 weeks of gestation for GDM diagnosis. Up to 9 measurements of offspring weight and length were collected from birth till 36 months, and interviewer-administered questionnaires were used to ascertain the duration of breastfeeding.

Results

There was a statistically significant interaction between GDM status and breastmilk intake by any (p_interaction = 0.038) or exclusive/predominant breastfeeding (p_interaction = 0.035) for the outcome of conditional weight gain. In offspring of non-GDM mothers (n = 835), greater breastmilk intake (BF ≥ 4 milk months) was associated with lower conditional gains in weight [B (95 % CI) −0.48 (−0.58, −0.28); p < 0.001] within the first year of life, as well as decreasing weight SDS velocity [−0.01 (−0.02, −0.005); p < 0.001] and BMI SDS velocity [−0.008 (0.01, −0.002); p = 0.008] across age in the first 36 months. In offspring of GDM mothers (n = 181), however, greater breastmilk intake was associated with increased conditional gains in weight [0.72 (0.23, 1.20); p = 0.029] and BMI SDS [0.49 (0.04, 0.95); p = 0.04] in the first 6 months and did not demonstrate the decreasing weight and BMI SDS velocity observed in offspring of non-GDM mothers.

Conclusions

The reduced weight gain in the first year of life conferred by greater breastmilk intake in non-GDM children was not observed in GDM children.

Clinical trial registration

This study is registered under the Clinical Trials identifier NCT01174875; http://www.clinicaltrials.gov/ct2/show/NCT01174875?term=GUSTO&rank=2.

Electronic supplementary material

The online version of this article (doi:10.1007/s00394-015-1057-0) contains supplementary material, which is available to authorized users.

Risk factors of overweight and obesity among preschool children with different ethnic background

In this study, we evaluated the risk factors associated with overweight and obesity in 2,640 preschool children in Italy taking into account the ethnic background of the parents. Height and weight were measured and BMI was calculated. Personal and lifestyle data for the children (birth weight, type of breastfeeding, sleep duration, skipping breakfast, snacking, physical activity) and parents (ethnicity, educational level, occupation, weight, height) were collected by means of a questionnaire. Italian and Other European children generally showed the highest percentage of normal weight, while the other ethnic groups presented a greater imbalance. Overweight and obesity were high in African males, who also presented high birth weight. Breastfeeding was most common, although formula feeding was significantly higher in Italians than in immigrants. Immigrants, particularly males, tended to skip breakfast more than Italians. Physical activity was significantly higher in Italians than in immigrants. In the parents, underweight was particularly high in Italian and Other mothers. African parents had high rates of overweight and obesity and a low educational level. The most common profession was worker for the fathers and housewife for the mothers, with the exception of Italians in which clerical work prevailed. Multiple linear regression analysis showed that the BMI of children was closely related to the BMI of the parents and the birth weight. Hence, these are the most informative parameters in preventing obesity.

Association between Breastfeeding and Childhood Obesity: Analysis of a Linked Longitudinal Study of Rural Appalachian Fifth-Grade Children

INTRODUCTION

Although breastfeeding is associated with improving numerous health outcomes for the child, its role in reducing childhood obesity is contested. Despite this controversy, both the CDC and the US Department of Health and Human Services promote breastfeeding as one of the strategies for reducing childhood obesity. Rural Appalachia has one of the highest rates of childhood obesity and low rates of breastfeeding, compared to rest of the nation. The aim of this study was to examine the association between breastfeeding and childhood obesity at 11 years in the rural Appalachian state of West Virginia (WV).

METHODS

The study used linked data from two cross-sectional data sets to examine this relationship longitudinally in fifth-grade WV children. The main outcome variable was BMI adjusted percent (BMI%) and the main exposure was defined as occurrence of breastfeeding. Mean BMI% of children who were not breastfed was significantly higher, compared to children who were breastfed.

RESULTS

The result of the multiple regression analysis showed that breastfeeding significantly predicted BMI% of children after controlling for maternal education, health insurance, family history of hypercholesterolemia and diabetes, child's asthma status, and birth weight of the infant.

CONCLUSIONS

Our results are consistent with other studies that have shown a significant, but small, inverse association between breastfeeding and childhood obesity. Findings from this study suggest the need to improve breastfeeding rates in the rural Appalachian state of WV as one of the potential strategies to prevent obesity during childhood and adolescence.

The study of women, infant feeding and type 2 diabetes after GDM pregnancy and growth of their offspring (SWIFT Offspring study): prospective design, methodology and baseline characteristics

BACKGROUND

Breastfeeding is associated with reduced risk of becoming overweight or obese later in life. Breastfed babies grow more slowly during infancy than formula-fed babies. Among offspring exposed in utero to maternal glucose intolerance, prospective data on growth during infancy have been unavailable. Thus, scientific evidence is insufficient to conclude that breastfeeding reduces the risk of obesity among the offspring of diabetic mothers (ODM). To address this gap, we devised the Study of Women, Infant Feeding and Type 2 Diabetes after GDM Pregnancy and Growth of their Offspring, also known as the SWIFT Offspring Study. This prospective, longitudinal study recruited mother-infant pairs from the SWIFT Study, a prospective study of women with recent gestational diabetes mellitus (GDM). The goal of the SWIFT Offspring Study is to determine whether breastfeeding intensity and duration, compared with formula feeding, are related to slower growth of GDM offspring during the first year life. This article details the study design, participant eligibility, data collection, and methodologies. We also describe the baseline characteristics of the GDM mother-infant pairs.

METHODS

The study enrolled 466 mother-infant pairs among GDM deliveries in northern California from 2009-2011. Participants attended three in-person study exams at 6-9 weeks, 6 months and 12 months after delivery for infant anthropometry (head circumference, body weight, length, abdominal circumference and skinfold thicknesses), as well as maternal anthropometry (body weight, waist circumference and percent body fat). Mothers also completed questionnaires on health and lifestyle behaviors, including infant diet, sleep and temperament. Breastfeeding intensity and duration were assessed via several sources (diaries, telephone interviews, monthly mailings and in-person exams) from birth through the first year of life. Pregnancy course, clinical perinatal and newborn outcomes were obtained from health plan electronic medical records. Infant saliva samples were collected and stored for genetics studies.

DISCUSSION

This large, racially and ethnically diverse cohort of GDM offspring will enable evaluation of the relationship of infant feeding to growth during infancy independent of perinatal characteristics, sociodemographics and other risk factors. The longitudinal design provides the first quantitative measures of breastfeeding intensity and duration among GDM offspring during early life.

Protective effect of breastfeeding against overweight can be detected as early as the second year of life: a study of children from one of the most socially-deprived areas of Brazil

Millions of children live in Brazil's semi-arid region, one of the most socially-deprived areas of the country, where undernutrition co-exists with obesity as a consequence of the nutrition transition. There is evidence that childhood obesity predisposes adult obesity and, thus, that obesity should be prevented as early as possible. Some studies have shown that breastfeeding is a protective factor against overweight and obesity while other studies have not found this association. There have been few studies on this association in developing countries and of children below two years of age. The present study aimed to investigate whether children exposed to exclusive breastfeeding for ≥ 6 months showed a lower prevalence of overweight in the second year of life, based on a probability sample of 2,209 children (aged 12 to 24 months). The dependent variable was overweight, defined as weight-for-length z-scores of >2, based on the WHO 2006 standard while the independent variable was exclusive breastfeeding (≥ 6 months). The prevalence ratio (PR) and its 95% CI were estimated using Poisson regression with robust adjustment of variance. After adjusting for potential confounding factors (socioeconomic, demographic and health-related variables), children on exclusive breastfeeding for ≥ 6 months showed a lower prevalence of overweight (5.7% vs 9.1%, PR 0.62, 95% CI 0.45-0.89). It was found that exclusive breastfeeding for six months or more is a protective factor against overweight in children in the second year of life living in the Brazilian semi-arid region.

Gestational diabetes mellitus, maternal obesity, and adiposity in offspring

OBJECTIVE

To determine the effects of maternal gestational diabetes mellitus (GDM) on offspring adiposity in a well-characterized cohort of Mexican American mother-child pairs.

STUDY DESIGN

This study included 62 Mexican American mothers and their index offspring. Maternal GDM and normal glucose status during index pregnancy were documented, and mothers were previously matched by age, body mass index (BMI), and parity. Mother-child pairs were recruited when offspring were between the ages of 5 and 16 years. A medical history was collected, and anthropometrics were measured. Main outcome measures were offspring BMI, BMI z-scores, BMI percentiles, and hip and waist circumferences.

RESULTS

GDM-exposed offspring (n = 37) had greater measures of BMI (all P ≤ .02) and greater waist and hip circumferences (both P = .002) compared with 25 offspring of non-GDM mothers. Adjustment for offspring age, sex, Tanner stage, birth weight, months of breastfeeding, maternal prepregnancy BMI, and pregnancy weight gain attenuated the differences, but BMI z-score and BMI percentile remained significantly greater in the GDM-exposed group (P < .05).

CONCLUSION

Intrauterine exposure to GDM is associated with greater adiposity in Mexican American children, and this relationship is not mediated by maternal obesity. In contrast to previous reports, this study included only Mexican Americans; thus, ethnic variations may influence the contributions of maternal GDM and maternal obesity to offspring adiposity.

Breastfeeding: an overview of oral and general health benefits

BACKGROUND

Breastfeeding is the reference against which alternative infant feeding models must be measured with regard to growth, development and other health outcomes. Although not a systematic review, this report provides an update for dental professionals, including an overview of general and oral health-related benefits associated with breastfeeding.

TYPES OF STUDIES REVIEWED

The authors examined the literature regarding general health protections that breastfeeding confers to infants and mothers and explored associations between breastfeeding, occlusion in the primary dentition and early childhood caries. To accomplish these goals, they reviewed systematic reviews when available and supplemented them with comparative studies and with statements and reports from major nongovernmental and governmental organizations.

RESULTS

When compared with health outcomes among formula-fed children, the health advantages associated with breastfeeding include a lower risk of acute otitis media, gastroenteritis and diarrhea, severe lower respiratory infections, asthma, sudden infant death syndrome, obesity and other childhood diseases and conditions. Evidence also suggests that breastfed children may develop a more favorable occlusion in the primary dentition. The results of a systematic review in which researchers examined the relationship between breastfeeding and early childhood caries were inconclusive.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The American Academy of Pediatric Dentistry, Chicago, suggests that parents gently clean infants' gums and teeth after breastfeeding. The American Academy of Pediatrics, Elk Grove Village, Ill., recommends that breastfeeding should be exclusive for about the first six months of life and should continue, with the introduction of appropriate complementary foods, to at least age 12 months or beyond, as desired by mother and child. Dentists and staff members can take steps to ensure they are familiar with the evidence and guidelines pertaining to breastfeeding and to oral health. They are encouraged to follow the surgeon general's recommendations to promote and support optimal breastfeeding and oral health practices among their patients.

Diabetes and pregnancy: an endocrine society clinical practice guideline

OBJECTIVE

Our objective was to formulate a clinical practice guideline for the management of the pregnant woman with diabetes.

PARTICIPANTS

The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee of The Endocrine Society, 5 additional experts, a methodologist, and a medical writer.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence.

CONSENSUS PROCESS

One group meeting, several conference calls, and innumerable e-mail communications enabled consensus for all recommendations save one with a majority decision being employed for this single exception.

CONCLUSIONS

Using an evidence-based approach, this Diabetes and Pregnancy Clinical Practice Guideline addresses important clinical issues in the contemporary management of women with type 1 or type 2 diabetes preconceptionally, during pregnancy, and in the postpartum setting and in the diagnosis and management of women with gestational diabetes during and after pregnancy.

Breastfeeding in women with diabetes: lower rates despite greater rewards. A population-based study

AIMS

To explore intention to breastfeed and breastfeeding rates in hospital and on discharge across women with pre-gestational or gestational diabetes mellitus, or no diabetes.

METHODS

A retrospective cohort analysis was conducted using data from four Ontario hospitals. Women who delivered a viable infant between 1 April 2008 and 31 March 2010 were included in the study. Unadjusted and adjusted odds ratios were calculated for each outcome measure and were used to compare the breastfeeding rates among women with and without diabetes.

RESULTS

After controlling for potential confounders, women with insulin-treated diabetes were less likely to intend to breastfeed, when compared with women without diabetes (adjusted odds ratio 0.49, 95% CI 0.27-0.89). In hospital, women with insulin-treated diabetes were least likely to breastfeed (odds ratio 0.42, 95% CI 0.26-0.67), followed by women with non-insulin-treated diabetes (odds ratio 0.50, 95% CI 0.26-0.96) and women with gestational diabetes (odds ratio 0.77, 95% CI 0.68-0.87) when compared with women without diabetes. On discharge, women with insulin-treated diabetes were least likely to breastfeed (odds ratio 0.38, 95% CI 0.24-0.60), followed by women with gestational diabetes (odds ratio 0.75, 95% CI 0.66-0.85); rates of breastfeeding among women with non-insulin-treated diabetes were comparable on discharge with those of women without diabetes. Women seeking care from an antenatal provider other than a physician were 2-3 times more likely to breastfeed in hospital and on discharge.

CONCLUSIONS

Women with insulin-treated diabetes had the poorest outcomes with respect to breastfeeding rates. Gestational and non-insulin-treated diabetes were associated with lower rates of breastfeeding in hospital, while gestational diabetes was additionally associated with lower breastfeeding rates on discharge.

Cardiovascular disease in childhood: the role of obesity

In recent years, childhood obesity is becoming an epidemic health problem. It is now evident from many studies that childhood obesity is correlated with adult excess weight status and the development of risk factors for cardiovascular diseases in adulthood, including hypertension, type 2 diabetes mellitus, dyslipidemia, and metabolic syndrome. The exposure to obesity and to the above risk factors during childhood subsequently lead to atherosclerotic development, such as altered vascular structure and function, although the mechanisms are still unclear. Several non-invasive, and thus easy-to-obtain measures of arterial structure and function, have been shown to be clinically useful in providing information about vasculature early in the course of atherosclerosis, including measurement of endothelial function, carotid intima media thickness, and arterial stiffness. The early detection of cardiovascular abnormalities is essential because the control of the atherogenic process is more effective during its early stages. The present review focuses on the cardiovascular consequences of obesity, on the mechanisms and the methods of measurement of endothelial dysfunction in obese children and adolescents, and on the ways of intervention for the improvement of vascular health.

Early life opportunities for prevention of diabetes in low and middle income countries

BACKGROUND

The global burden of diabetes and other non-communicable diseases is rising dramatically worldwide and is causing a double poor health burden in low- and middle-income countries. Early life influences play an important part in this scenario because maternal lifestyle and conditions such as gestational diabetes and obesity affect the risk of diabetes in the next generation. This indicates important periods during the lifecourse when interventions could have powerful affects in reducing incidence of non-communicable diseases. However, interventions to promote diet and lifestyle in prospective parents before conception have not received sufficient attention, especially in low- and middle-income countries undergoing socio-economic transition.

DISCUSSION

Interventions to produce weight loss in adults or to reduce weight gain in pregnancy have had limited success and might be too late to produce the largest effects on the health of the child and his/her later risk of non-communicable diseases. A very important factor in the prevention of the developmental component of diabetes risk is the physiological state in which the parents enter pregnancy. We argue that the most promising strategy to improve prospective parents' body composition and lifestyle is the promotion of health literacy in adolescents. Multiple but integrated forms of community-based interventions that focus on nutrition, physical activity, family planning, breastfeeding and infant feeding practices are needed. They need to address the wider social economic context in which adolescents live and to be linked with existing public health programmes in sexual and reproductive health and maternal and child health initiatives.

SUMMARY

Interventions aimed at ensuring a healthy body composition, diet and lifestyle before pregnancy offer a most effective solution in many settings, especially in low- and middle-income countries undergoing socio-economic transition. Preparing a mother, her partner and her future child for "the 1000 days", whether from planned or unplanned conception would break the cycle of risk and demonstrate benefit in the shortest possible time. Such interventions will be particularly important in adolescents and young women in disadvantaged groups and can improve the physiological status of the fetus as well as reduce the prevalence of pregnancy conditions such as gestational diabetes mellitus which both predispose to non-communicables diseases in both the mother and her child. Pre-conception interventions require equipping prospective parents with the necessary knowledge and skills to make healthy lifestyle choices for themselves and their children. Addressing the promotion of such health literacy in parents-to-be in low- and middle-income countries requires a wider social perspective. It requires a range of multisectoral agencies to work together and could be linked to the issues of women's empowerment, to reproductive health, to communicable disease prevention and to the Millennium Development Goals 4 and 5.

Early postnatal life as a critical time window for determination of long-term metabolic health

Epidemiological studies demonstrated a clear phenomenological association between low birth weight and increased cardiometabolic risk later in life, very similar to that in high birth weight subjects. Pre- and/or neonatal overfeeding appears to be an etiological clue. In animal studies, irrespective of birth weight neonatal over-nutrition leads to later overweight, impaired glucose tolerance and cardiometabolic alterations. Probably, perinatally acquired alterations of DNA methylation patterns of gene promoters of central nervous regulators of body weight and metabolism play a key role in mediating these relationships. In humans, the long-term impact of neonatal nutrition is conclusively demonstrated by studies on the consequences of breastfeeding vs. formula-feeding. Taken together, the quantity and quality of nutrition during neonatal life plays a critical role, beyond prenatal development, in the long-term programming of health and disease. This opens a variety of opportunities and challenges to primarily prevent chronic diseases, e.g. the metabolic syndrome.

Biological determinants linking infant weight gain and child obesity: current knowledge and future directions

Childhood obesity rates have reached epidemic proportions. Excessive weight gain in infancy is associated with persistence of elevated weight status and later obesity. In this review, we make the case that weight gain in the first 6 mo is especially predictive of later obesity risk due to the metabolic programming that can occur early postpartum. The current state of knowledge regarding the biological determinants of excess infant weight gain is reviewed, with particular focus on infant feeding choice. Potential mechanisms by which different feeding approaches may program the metabolic profile of the infant, causing the link between early weight gain and later obesity are proposed. These mechanisms are likely highly complex and involve synergistic interactions between endocrine effects and factors that alter the inflammatory and oxidative stress status of the infant. Gaps in current knowledge are highlighted. These include a lack of data describing 1) what type of infant body fat distribution may impart risk and 2) how maternal metabolic dysfunction (obesity and/or diabetes) may affect milk composition and exert downstream effects on infant metabolism. Improved understanding and management of these early postnatal determinants of childhood obesity may have great impact on reducing its prevalence.

Relationship between breastfeeding and obesity in childhood

A cross-sectional study was conducted to investigate the weight status and the relationship of infant-feeding variables, birthweight and birth order with BMI in a group of Iranian children. Five hundred and eleven students of both sexes at the first grade in elementary schools (aged 7 years) were recruited randomly from all 19 educational districts of Tehran. Weights and heights of children and their mothers were measured. Data on breastfeeding (BF), formula-feeding, the timing of introduction of complementary foods (CF), birthweight, and birth order were collected from the mothers. The 2007 WHO reference value was used for determining child's weight status. Regression analysis in single and a 2-level linear regression models was used for examining the independent relationships of infant-feeding variables, birthweight and birth order with childhood BMI. The prevalence of underweight and overweight in this group of children was 7.6% and 19.7%, respectively. Total time of BF and duration of exclusive BF were not associated with childhood BMI. The timing of introduction of CF was inversely related to childhood BMI after controlling for other variables (beta:-0.34; 95% CI:-0.58,-0.10). Children with an early introduction of CF had significantly higher mean BMI (p for linear trend=0.012). Birth order and birthweight were related to childhood BMI significantly. These data suggest that overweight and obesity are nutritional problems among 7 years old Teharani children. The timing of introduction of CF, birth order, and birthweight were independent predictors of childhood BMI. Neither total time of BF nor duration of exclusive breastfeeding was associated with adiposity in children.

Cigarette smoking and brain regulation of energy homeostasis

Cigarette smoking is an addictive behavior, and is the primary cause of cardiovascular and pulmonary disease, and cancer (among other diseases). Cigarette smoke contains thousands of components that may affect caloric intake and energy expenditure, although nicotine is the major addictive substance present, and has the best described actions. Nicotine exposure from cigarette smoke can change brain feeding regulation to reduce appetite via both energy homeostatic and reward mechanisms, causing a negative energy state which is characterized by reduced energy intake and increased energy expenditure that are linked to low body weight. These findings have led to the public perception that smoking is associated with weight loss. However, its effects at reducing abdominal fat mass (a predisposing factor for glucose intolerance and insulin resistance) are marginal, and its promotion of lean body mass loss in animal studies suggests a limited potential for treatment in obesity. Smoking during pregnancy puts pressure on the mother's metabolic system and is a significant contributor to adverse pregnancy outcomes. Smoking is a predictor of future risk for respiratory dysfunction, social behavioral problems, cardiovascular disease, obesity, and type-2 diabetes. Catch-up growth is normally observed in children exposed to intrauterine smoke, which has been linked to subsequent childhood obesity. Nicotine can have a profound impact on the developing fetal brain, via its ability to rapidly and fully pass the placenta. In animal studies this has been linked with abnormal hypothalamic gene expression of appetite regulators such as downregulation of NPY and POMC in the arcuate nucleus of the hypothalamus. Maternal smoking or nicotine replacement leads to unhealthy eating habits (such as junk food addiction) and other behavioral disorders in the offspring.

Systematic Evaluation of Key L-Carnitine Homeostasis Mechanisms during Postnatal Development in Rat

Background

The conditionally essential nutrient, L-carnitine, plays a critical role in a number of physiological processes vital to normal neonatal growth and development. We conducted a systematic evaluation of the developmental changes in key L-carnitine homeostasis mechanisms in the postnatal rat to better understand the interrelationship between these pathways and their correlation to ontogenic changes in L-carnitine levels during postnatal development.

Methods

mRNA expression of heart, kidney and intestinal L-carnitine transporters, liver γ-butyrobetaine hydroxylase (Bbh) and trimethyllysine hydroxylase (Tmlh), and heart carnitine palmitoyltransferase (Cpt) were measured using quantitative RT-PCR. L-Carnitine levels were determined by HPLC-UV. Cpt and Bbh activity were measured by a spectrophotometric method and HPLC, respectively.

Results

Serum and heart L-carnitine levels increased with postnatal development. Increases in serum L-carnitine correlated significantly with postnatal increases in renal organic cation/carnitine transporter 2 (Octn2) expression, and was further matched by postnatal increases in intestinal Octn1 expression and hepatic γ-Bbh activity. Postnatal increases in heart L-carnitine levels were significantly correlated to postnatal increases in heart Octn2 expression. Although cardiac high energy phosphate substrate levels remained constant through postnatal development, creatine showed developmental increases with advancing neonatal age. mRNA levels of Cpt1b and Cpt2 significantly increased at postnatal day 20, which was not accompanied by a similar increase in activity.

Conclusions

Several L-carnitine homeostasis pathways underwent significant ontogenesis during postnatal development in the rat. This information will facilitate future studies on factors affecting the developmental maturation of L-carnitine homeostasis mechanisms and how such factors might affect growth and development.

Lactation and neonatal nutrition: defining and refining the critical questions

This paper resulted from a conference entitled "Lactation and Milk: Defining and refining the critical questions" held at the University of Colorado School of Medicine from January 18-20, 2012. The mission of the conference was to identify unresolved questions and set future goals for research into human milk composition, mammary development and lactation. We first outline the unanswered questions regarding the composition of human milk (Section I) and the mechanisms by which milk components affect neonatal development, growth and health and recommend models for future research. Emerging questions about how milk components affect cognitive development and behavioral phenotype of the offspring are presented in Section II. In Section III we outline the important unanswered questions about regulation of mammary gland development, the heritability of defects, the effects of maternal nutrition, disease, metabolic status, and therapeutic drugs upon the subsequent lactation. Questions surrounding breastfeeding practice are also highlighted. In Section IV we describe the specific nutritional challenges faced by three different populations, namely preterm infants, infants born to obese mothers who may or may not have gestational diabetes, and infants born to undernourished mothers. The recognition that multidisciplinary training is critical to advancing the field led us to formulate specific training recommendations in Section V. Our recommendations for research emphasis are summarized in Section VI. In sum, we present a roadmap for multidisciplinary research into all aspects of human lactation, milk and its role in infant nutrition for the next decade and beyond.

Early determinants of obesity: genetic, epigenetic, and in utero influences

There is an emerging body of work indicating that genes, epigenetics, and the in utero environment can impact whether or not a child is obese. While certain genes have been identified that increase one's risk for becoming obese, other factors such as excess gestational weight gain, gestational diabetes mellitus, and smoking can also influence this risk. Understanding these influences can help to inform which behaviors and exposures should be targeted if we are to decrease the prevalence of obesity. By helping parents and young children change certain behaviors and exposures during critical time periods, we may be able to alter or modify one's genetic predisposition. However, further research is needed to determine which efforts are effective at decreasing the incidence of obesity and to develop new methods of prevention. In this paper, we will discuss how genes, epigenetics, and in utero influences affect the development of obesity. We will then discuss current efforts to alter these influences and suggest future directions for this work.

Associations of infant nutrition with insulin resistance measures in early adulthood: evidence from the Barry-Caerphilly Growth (BCG) study

Background

Previous studies suggest that over-nutrition in early infancy may programme long-term susceptibility to insulin resistance.

Objective

To assess the association of breast milk and quantity of infant formula and cows' milk intake during infancy with insulin resistance measures in early adulthood.

Design

Long-term follow-up of the Barry Caerphilly Growth cohort, into which mothers and their offspring had originally been randomly assigned, between 1972–1974, to receive milk supplementation or not. Participants were the offspring, aged 23–27 years at follow-up (n = 679). Breastfeeding and formula/cows' milk intake was recorded prospectively by nurses. The main outcomes were insulin sensitivity (ISI₀) and insulin secretion (CIR₃₀).

Results

573 (84%) individuals had valid glucose and insulin results and complete covariate information. There was little evidence of associations of breastfeeding versus any formula/cows' milk feeding or of increasing quartiles of formula/cows' milk consumption during infancy (<3 months) with any outcome measure in young adulthood. In fully adjusted models, the differences in outcomes between breastfeeding versus formula/cows' milk feeding at 3 months were: fasting glucose (−0.07 mmol/l; 95% CI: −0.19, 0.05); fasting insulin (8.0%; −8.7, 27.6); ISI₀ (−6.1%; −11.3, 12.1) and CIR₃₀ (3.8%; −19.0, 32.8). There was also little evidence that increasing intakes of formula/cows' milk at 3 months were associated with fasting glucose (increase per quartile of formula/cows' milk intake = 0.00 mmol/l; −0.03, 0.03); fasting insulin (0.8%; −3.2, 5.1); ISI ₀ (−0.9%; −5.1, 3.5) and CIR₃₀ (−2.6%; −8.4, 3.6).

Conclusions

We found no evidence that increasing consumption of formula/cows' milk in early infancy was associated with insulin resistance in young adulthood.

Pathogenesis and prevention of type 2 diabetes: parental determinants, breastfeeding, and early childhood nutrition

Among the factors predisposing to type 2 diabetes in children, adolescents, and young adults, the health and behavior of both the mother and father are critical. Prevention and treatment of parental nutritional disorders (including obesity and malnutrition), promotion of breastfeeding, and avoidance of overfeeding of young children are essential for childhood health and metabolic function. Focusing research and policy on parental influences on childhood health should reduce the risks of obesity and type 2 diabetes in future generations.

The impact of neonatal breast-feeding on growth trajectories of youth exposed and unexposed to diabetes in utero: the EPOCH Study

Objective

To evaluate the influence of breastfeeding on the body mass index (BMI) growth trajectory from birth through 13 years of age among offspring of diabetic pregnancies (ODP) and offspring of non-diabetic pregnancies (ONDP) participating in the EPOCH study.

Subjects

There were 94 ODP and 399 ONDP who had multiple BMI measures obtained from birth throughout childhood. A measure of breast milk-months was derived from maternal self-report to categorize breastfeeding status as adequate (≥6 breast milk-months) or low (<6 breast milk-months). Mixed linear effects models were constructed to assess the impact of breastfeeding on the BMI growth curves during infancy (birth to 27 months) and childhood (27 months to 13 years).

Results

ODP who were adequately breastfed had a slower BMI growth trajectory during childhood (p=0.047) and slower period-specific growth velocity with significant differences between 4 to 6 years of age (p=0.03) and 6 to 9 years of age (p=0.01) compared to ODP with low breastfeeding. A similar pattern was seen in the ONDP, with adequate breastfeeding associated with lower average BMI in infancy (p=0.03) and childhood (p=0.0002) and a slower growth trajectory in childhood (p=0.0002). Slower period-specific growth velocity was seen among the ONDP associated with adequate breastfeeding with significant differences between 12–26 months (p=0.02), 4–6 years (p=0.03), 6–9 years (p=0.0001) and 9–13 years of age (p<.0001).

Conclusion

Our study provides novel evidence that breastfeeding is associated with long-term effects on childhood BMI growth that extend beyond infancy into early and late childhood. Importantly, these effects are also present in the high-risk offspring, exposed to overnutrition during pregnancy. Breastfeeding in the early postnatal period may represent a critical opportunity to reduce the risk of childhood obesity.

Approach to the patient with gestational diabetes after delivery

The diagnosis of gestational diabetes mellitus (GDM) identifies patients with a pancreatic β-cell defect. In some patients, the defect is transient or stable, but in most it is progressive, imparting a high risk of diabetes for at least a decade after the index pregnancy. The β-cell defects in GDM can result from many causes, including genetic variants typical of monogenic forms of diabetes and autoimmunity typical of evolving type 1 diabetes. No specific disease-modifying therapies are available for those patients. The majority of women with GDM have clinical characteristics indicating a risk for type 2 diabetes (T2D). Available evidence indicates that T2D can be prevented or delayed by intensive lifestyle modification and by medications, particularly those that ameliorate insulin resistance. Clinical management should include assessment of glucose tolerance in the postpartum period to detect diabetes or assess diabetes risk. Women who don't have diabetes should be advised about their risk and participate in family planning to prevent subsequent pregnancies with undiagnosed hyperglycemia. All patients should be monitored for rising glycemia indicative of progressive β-cell deterioration. We suggest a combination of fasting glucose and glycosylated hemoglobin measurements for this purpose. Monitoring should be initiated at least annually and should be intensified if glycemia is rising and/or impaired. Lifestyle modification is advised to reduce the risk for T2D. Like monitoring, lifestyle modification should be intensified for rising glycemia and/or development of impaired glucose levels. At present, there is insufficient evidence to recommend medications to prevent T2D. Close follow-up and monitoring will allow initiation of pharmacological treatment as soon as diabetes develops. Children of women with GDM are at increased risk for obesity and diabetes. They should receive education, monitoring, and lifestyle advice to minimize obesity and diabetes risk.

Predictors of growth in children based on 2007 Korean National Growth Charts

BACKGROUND

Postnatal growth patterns in children are associated with various factors within the birth and infancy periods. The aim of the present study was to examine the correlation between growth patterns and parameters including gestational age (GA), birthweight (BW), sex, and feeding method in the records of 61,631 children aged 6-72 months.

METHODS

The data were obtained from the 2007 Korean National Growth Charts provided by the Korean Centers for Disease Control. Data were analyzed using descriptive statistics, Pearson's correlation, and multiple linear regression.

RESULTS

BW and sex were highly correlated with weight and height by 72 months (P < 0.01), with BW being the primary predictor (P < 0.001). Sex was the second predictor of weight and height in children by 66 months (P < 0.01). Feeding method was the predictor of weight in children aged 12-48 months and 60 months (P < 0.05), and was also influential in the height of children by 48 months (P < 0.05). GA was the predictor of weight at 12 months and from 30 to 42 months (P < 0.05).

CONCLUSION

GA, BW, sex and feeding method were the predictors of weight and height among children at different times. Therefore, the present population-based study strengthens the consideration of these factors for routine monitoring of growth patterns in Korean children.

Insulin pump therapy for pregnancy: a primer

Current knowledge and advances in insulin formulations, insulin pump technology, and blood glucose monitoring techniques have improved practitioners' ability to achieve diabetic people's blood glucose targets. Practitioners and pregnant women should bear in mind that important differences exist in glucose metabolism during pregnancy and require a different approach from non-pregnant people to avoid pregnant women's experience being adversely affected. Insulin pump therapy, if used skillfully by practitioners and their pregnant patients, can be especially beneficial for some diabetic women during their pregnancies. Women's healthcare practitioners should endeavor to be familiar with this therapy, even if they are not experts in its full complexity.

Breastfeeding duration, age of starting solids and high BMI risk and adiposity in Indian children

This study utilized data from a prospective birth cohort study on 568 Indian children, to determine whether a longer duration of breastfeeding and later introduction of solid feeding were associated with a reduced higher body mass index (BMI) and less adiposity. Main outcomes were high BMI (>90th within-cohort sex-specific BMI percentile) and sum of skinfold thickness (triceps and subscapular) at age 5. Main exposures were breastfeeding (six categories from 1-4 to ≥21 months) and age of starting regular solid feeding (four categories from ≤3 to ≥6 months). Data on infant-feeding practices, socio-economic and maternal factors were collected by questionnaire. Birthweight, maternal and child anthropometry were measured. Multiple regression analysis that accounted for potential confounders demonstrated a small magnitude of effect for breastfeeding duration or introduction of solid feeds on the risk of high BMI but not for lower skinfold thickness. Breastfeeding duration was strongly negatively associated with weight gain (0-2 years) [adjusted β = -0.12 standard deviation, 95% confidence interval (CI): -0.19 to -0.05 per category change in breastfeeding duration, P = 0.001], and weight gain (0-2 years) was strongly associated with high BMI at 5 years (adjusted odds ratio = 3.8, 95% CI: 2.53-5.56, P < 0.001). In our sample, findings suggest that longer breastfeeding duration and later introduction of solids has a small reduction on later high BMI risk and a negligible effect on skinfold thickness. However, accounting for sampling variability, these findings cannot exclude the possibility of no effect at the population level.

Childhood obesity and cardiovascular disease

Childhood obesity has reached epidemic proportions. Many of these children have risk factors for later disease, including cardiovascular disease. For optimal cardiovascular health, health care professionals must be able to identify children and youth at risk and provide appropriate support as needed. The present article reviews the current medical literature on obesity and cardiovascular disease risk factors in the paediatric population, the long-term cardiovascular consequences of childhood obesity and the importance of early life. Recommendations promoting optimal cardiovascular health in all children and youth are discussed.

Breastfeeding and obesity in Brazilian children

BACKGROUND

The association between breastfeeding and obesity is inconsistent by the literature. This study aims to assess whether obesity is associated to occurrence of breastfeeding and to duration of total and exclusive breastfeeding in Brazilian children.

METHODS

A cross-sectional study was conducted with 764 children enrolled in public and private schools from Viçosa, Minas Gerais, Brazil. Obesity (outcome variable) was defined as body mass index above the +2 standard deviations score using sex and age specific standards of World Health Organization. Exposure was the occurrence and duration of breastfeeding. Potential confounders were controlled by multiple logistic regression analysis and were divided in two groups: children (gender, age, birth weight, gestational age, order of birth, number of siblings, number of persons in the residence, type of school, physical activity patterns and time watching television) and mothers (age, nutritional status, level of education, weight gain during pregnancy, smokes currently and during the pregnancy).

RESULTS

Prevalence of obesity was 10.7%; 6.8% of the children were not breastfed and 59.0% did not receive exclusive breastfeeding. After adjustment for confounding variables by logistic regression analysis, no statistically significant association was observed between obesity and the occurrence and/or duration of total and exclusive breastfeeding. There was no dose-response effect of duration of breastfeeding on prevalence of obesity.

CONCLUSION

Our results do not support the hypothesis that breastfeeding promotion would reduce obesity in this population. Controversial findings regarding this association by literature indicate a need for further investigations.

Developmental Changes in Gut Microbiota and Enzyme Activity Predict Obesity Risk in Rats Arising From Reduced Nests

The aim of the study was to assess the impact of preweaning overnutrition upon the ontogeny of intestinal microbiota, alkaline phosphatase activity (AP) and parameters of growth and obesity in male Sprague-Dawley rats. We tested whether intestinal characteristics acquired in suckling pups could programme the development of enhanced fat deposition during normalized nutrition beyond weaning. Postnatal nutrition was manipulated by adjusting the number of pups in the nest to 4 (small litters - SL) and 10 (normal litters - NL). In the postweaning period both groups were fed with a standard diet. The jejunal and colonic Lactobacillus/Enterococcus (LAB) and the Bacteroides/Prevotella (BAC) were determined using the FISH technique, and the jejunal AP activity was assayed histochemically. At 15 and 20 days of age the SL pups became heavier, displayed increased adiposity accompanied by significantly higher LAB and lower numbers of BAC and with higher AP activity in comparison with rats nursed in NL nests. These differences persisted to day 40 and withdrawal of the previous causal dietary influence did not prevent the post-weaning fat accretion. These results reveal the significance of early nutritional imprint upon the gut microbial/functional development and allow better understanding of their involvement in the control of obesity.

Long-term impact of neonatal breastfeeding on childhood adiposity and fat distribution among children exposed to diabetes in utero

OBJECTIVE

To evaluate whether breastfeeding attenuates increased childhood adiposity associated with exposure to diabetes in utero.

RESEARCH DESIGN AND METHODS

Retrospective cohort study of 89 children exposed to diabetes in utero and 379 unexposed youth with measured BMI, waist circumference, skinfolds, visceral (VAT) and subcutaneous (SAT) abdominal fat. A measure of breast milk-months was derived from maternal self-report and used to categorize breastfeeding status as low (<6) and adequate (≥ 6 breast milk-months). Multiple linear regression was used to model the relationship between exposure to diabetes in utero and offspring adiposity outcomes among youth stratified according to breastfeeding status.

RESULTS

Adequate (vs. low) breastfeeding status was associated with significantly lower BMI, waist circumference, SAT, and VAT at ages 6-13 years. Among youth in the low breastfeeding category, exposure to diabetes in utero was associated with a 1.7 kg/m(2) higher BMI (P = 0.03), 5.8 cm higher waist circumference (P = 0.008), 6.1 cm(2) higher VAT (P = 0.06), 44.6 cm(2) higher SAT (P = 0.03), and 0.11 higher ratio of subscapular-to-triceps skinfold ratio (P = 0.008). Among those with adequate breastfeeding in infancy, the effect of prenatal exposure to diabetes on childhood adiposity outcomes was not significant.

CONCLUSIONS

Adequate breastfeeding protects against childhood adiposity and reduces the increased adiposity levels associated with exposure to diabetes in utero. These data provide support for mothers with diabetes during pregnancy to breastfeed their infants in order to reduce the risk of childhood obesity.

The inter- and intragenerational impact of gestational diabetes on the epidemic of type 2 diabetes

OBJECTIVES

We investigated the contribution of gestational diabetes mellitus (GDM) to the historic epidemic of type 2 diabetes mellitus (T2DM) in Saskatchewan.

METHODS

We constructed a population-level simulation model of the inter- and intragenerational interaction of GDM and T2DM for the period 1956 to 2006. The model was stratified by gender, ethnicity, and age; parameterized with primary and secondary data; and calibrated to match historic time series. Risk of diabetes was sigmoidally trended to capture exogenous factors.

RESULTS

Best-fit calibrations suggested GDM may be responsible for 19% to 30% of the cases of T2DM among Saskatchewan First Nations people, but only for approximately 6% of cases among other persons living in Saskatchewan. The estimated contribution of GDM to the growth in T2DM was highly sensitive to assumptions concerning the post-GDM risk of developing T2DM.

CONCLUSIONS

GDM may be an important driver for the T2DM epidemic in many subpopulations. Because GDM is a readily identifiable, preventable, and treatable condition, investments in prevention, rapid diagnosis, and evidence-based treatment of GDM in at-risk populations may offer substantial benefit in lowering the T2DM burden over many generations. Model-informed data collection can aid in assessing intervention tradeoffs.

Growth patterns of large, small, and appropriate for gestational age infants: impacts of long-term breastfeeding: a retrospective cohort study

BACKGROUND

In several studies, since high and low birth weights are demonstrated as associated with obesity in childhood, these values should be followed up and documented carefully.

OBJECTIVE

The aim of this retrospective cohort study is to demonstrate the variation on body mass index outcomes of large (LGA), small (SGA), appropriate (AGA) for gestational age infants from birth to the end of fourth year of age and the effects of breastfeeding duration on these outcomes.

METHODS AND RESULTS

Four hundred and seven infants were recruited in the study (304AGA, 85 LGA, 18 SGA infants). LGA was frequent in boys and SGA in girls (p = 0.001). The mothers with gestational diabetes mellitus did have LGA infants (10.0% vs. 3.3%) (p = 0.022). The SGA infants performed rapid catch-up growth in the second month while the LGA infants performed catch-down growth in the ninth month. After the first 4 months, there was no difference on the values of BMI depending on breastfeeding time, less or more than 4 months, on the basis of the AGA and LGA infants. However, the body mass index (BMI) of LGA infants breastfed more than 12 months were not different from the AGA; unless the breastfeeding ceased earlier, the means of BMI remained significantly higher until 3 years.

CONCLUSION

Consequently, long duration of breastfeeding might protect LGA infants from childhood obesity risk.

AMPK as Target for Intervention in Childhood and Adolescent Obesity

Childhood obesity is a major worldwide health problem. Intervention programs to ameliorate the rate of obesity have been designed and implemented; yet the epidemic has no end near in sight. AMP-activated protein kinase (AMPK) has become one of the most important key elements in energy control, appetite regulation, myogenesis, adipocyte differentiation, and cellular stress management. Obesity is a multifactorial disease, which has a very strong genetic component, especially epigenetic factors. The intrauterine milieu has a determinant impact on adult life, since the measures taken for survival are kept throughout life thanks to epigenetic modification. Nutrigenomics studies the influence of certain food molecules on the metabolome profile, raising the question of an individualized obesity therapy according to metabolic (and probably) genetic features. Metformin, an insulin sensitizing agent, its known to lower insulin resistance and enhance metabolic profile, with an additional weight reduction capacity, via activation of AMPK. Exercise is coadjutant for lifestyle modifications, which also activates AMPK in several ways contributing to glucose and fat oxidation. The following review examines AMPK's role in obesity, applying its use as a tool for childhood and adolescent obesity.