Prevention and treatment of pediatric obesity: an endocrine society clinical practice guideline based on expert opinion

Which Amount of BMI-SDS Reduction Is Necessary to Improve Cardiovascular Risk Factors in Overweight Children?

CONTEXT

Knowing the changes of cardiovascular risk factors (CRFs) in relation to weight loss would be helpful to advise overweight children and their parents and to decide whether drugs should be prescribed in addition to lifestyle intervention.

OBJECTIVE

The objective of the study was to determine the body mass index (BMI)-SD score (SDS) reduction to improve CRFs in overweight children.

DESIGN

This was a prospective observation study.

SETTING

The study was conducted at a specialized outpatient obesity clinic.

PATIENTS

A total of 1388 overweight children (mean BMI 27.9 ± 0.1 kg/m(2), mean age 11.4 ± 0.1 y, 43.8% male, 45.5% prepubertal) participated in the study.

INTERVENTION

The study included a 1-year lifestyle intervention.

MAIN OUTCOME MEASURES

We studied changes of blood pressure (BP), fasting high-density lipoprotein- and low-density lipoprotein-cholesterol, triglycerides, glucose, and homeostasis model assessment (HOMA) of insulin resistance index. Change of weight status was determined by δBMI-SDS based on the recommended percentiles of the International Task Force of Obesity.

RESULTS

BMI-SDS change was associated with a significant improvement of all CRFs except fasting glucose and low-density lipoprotein-cholesterol after adjusting for multiple confounders such as baseline CRFs, age, gender, BMI, pubertal stage, and its changes. BMI-SDS reduction of 0.25-0.5 was related to a decrease of systolic blood pressure (BP) (-3.2 ± 1.4 mm Hg), diastolic BP (-2.2 ± 1.1 mm Hg), triglycerides (-6.9 ± 5.8 mg/dL), HOMA (-0.5 ± 0.3), and triglyceride/high-density lipoprotein)-cholesterol (-0.3 ± 0.2), whereas high-density lipoprotein (HDL)-cholesterol increased (+1.3 ± 1.2 mg/dL). A reduction of greater than 0.5 BMI-SDS led to more pronounced improvement (systolic BP -6.0± 1.3 mm Hg, diastolic BP -5.1 ± 1.3 mm Hg, triglycerides -16.4 ± 7.1 mg/dL, HDL-cholesterol +1.6 ± 1.5 mg/dL, HOMA -0.9 ± 0.3). Per 0.1 BMI-SDS reduction in systolic BP (-1.0 mm Hg), diastolic BP (-0.8 mm Hg), triglycerides (-2.3 mg/dL), HOMA (-0.2), and triglyceride/HDL-cholesterol (-0.5) decreased significantly, whereas HDL-cholesterol (0.2 mg/dL) increased significantly in linear regression analyses and accounted for multiple confounders.

CONCLUSIONS

A BMI-SDS reduction of 0.25 or greater significantly improved hypertension, hypertriglyceridemia, and low HDL-cholesterol, whereas a BMI-SDS greater than 0.5 doubled the effect.

National curves of foetal growth in singleton foetuses of Greek origin

BACKGROUND

Foetal growth monitoring is an essential component of prenatal care with postnatal impact. The aim of the study was to construct reference ranges for foetal biometric parameters in Greek foetuses and to compare them with previously published models.

MATERIALS AND METHODS

Measurements from 1200 Greek foetuses were used to construct normal curves for biparietal diameter (BPD), occipitofrontal diameter (OFD), head circumference (HC), abdominal circumference (AC), femoral length (FL) and the BPD/FL ratio according to the methodology described by Royston and Wright (1998). The model was validated in a second group of 1200 different foetuses using analysis of the corresponding standardized residuals (z-scores). The z-scores which were derived by our model were compared to those calculated using previously published models from other populations.

RESULTS

BPD, OFD, HC, AC, FL and the BPD/FL ratio are accurately described by simple quadratic equations (R(2) > 0·96 for most of the parameters tested). Statistically significant differences were observed for most of the z-scores when our models were compared to previously published models. Less than 10% of our foetuses were < 5th or > 95th centile of the latter models. About 10% of our foetuses were > 95th centile for FL and HC when the INTERGROWTH-21st formulas were used.

CONCLUSION

We present national foetal biometric references. Using charts from other populations (including INTERGROWTH-21st) may be unrepresentative of local populations and lead to misclassification of foetal growth status.

Waist-to-height ratio as a marker of low-grade inflammation in obese children and adolescents

BACKGROUND

The epidemic of childhood obesity is associated with early atherosclerosis. Several reports have related this event to low-grade inflammation described in obesity. CRP and IL6 are markers that correlate with adiposity. The waist-to-height ratio (WtHR) is an anthropometric marker associated with insulin resistance and inflammation. The objective of this study was to assess the correlation between WtHR, metabolic complications and pro-inflammatory factors in obese children and adolescents.

METHODS

Weight, height, waist circumference, glycemia, insulin, CRP, TNF-α and IL-6 were measured in the baseline sample in 280 patients 6-19 years of age with overweight or obesity (OW/OB) and 112 normal-weight controls. Logistic regression was performed using WtHR as an independent variable. p>0.05 STATA11.

RESULTS

Mean WtHR was 0.6±0.06 in OW/OB and 0.43±0.02 in controls (p<0.01). WtHR was increased in 93% of the OW/OB vs. 2% of the controls. In the OW/OB inflammatory markers were significantly increased (p<0.01) compared to the controls (CRP 2.2 vs. 0.8; Il-6 2.9 vs. 2.1; and TNF-α 6.2 vs. 5.5). In the WtHR>0.5, insulin resistence and inflammatory markers were significantly increased (p<0.01) compared to the WtHR<0.5 (HOMA 3.4 vs. 1.4; CRP 2.3 vs. 0.6; Il-6 2.9 vs. 2.1; and TNF-α 6.4 vs. 5.55). In logistic regression, a significant independent association was found between WtHR with CRP (OR1.47), IL6 (OR1.60) and TNF-α (OR1.79).

CONCLUSIONS

Obese children and adolescents have high inflammatory markers that may increase cardiovascular risk. WtHR is associated with low-grade inflammation and may be considered a relevant anthropometric marker in the clinical practice.

Effects of exercise intensity and nutrition advice on myocardial function in obese children and adolescents: a multicentre randomised controlled trial study protocol

INTRODUCTION

The prevalence of paediatric obesity is increasing, and with it, lifestyle-related diseases in children and adolescents. High-intensity interval training (HIIT) has recently been explored as an alternate to traditional moderate-intensity continuous training (MICT) in adults with chronic disease and has been shown to induce a rapid reversal of subclinical disease markers in obese children and adolescents. The primary aim of this study is to compare the effects of HIIT with MICT on myocardial function in obese children and adolescents.

METHODS AND ANALYSIS

Multicentre randomised controlled trial of 100 obese children and adolescents in the cities of Trondheim (Norway) and Brisbane (Australia). The trial will examine the efficacy of HIIT to improve cardiometabolic outcomes in obese children and adolescents. Participants will be randomised to (1) HIIT and nutrition advice, (2) MICT and nutrition advice or (3) nutrition advice. Participants will partake in supervised exercise training and/or nutrition sessions for 3 months. Measurements for study end points will occur at baseline, 3 months (postintervention) and 12 months (follow-up). The primary end point is myocardial function (peak systolic tissue velocity). Secondary end points include vascular function (flow-mediated dilation assessment), quantity of visceral and subcutaneous adipose tissue, myocardial structure and function, body composition, cardiorespiratory fitness, autonomic function, blood biochemistry, physical activity and nutrition. Lean, healthy children and adolescents will complete measurements for all study end points at one time point for comparative cross-sectional analyses.

ETHICS AND DISSEMINATION

This randomised controlled trial will generate substantial information regarding the effects of exercise intensity on paediatric obesity, specifically the cardiometabolic health of this at-risk population. It is expected that communication of results will allow for the development of more effective evidence-based exercise prescription guidelines in this population while investigating the benefits of HIIT on subclinical markers of disease.

TRIAL REGISTRATION NUMBER

NCT01991106.

Obesity impairs lactation performance in mice by inducing prolactin resistance

Obesity reduces breastfeeding success and lactation performance in women. However, the mechanisms involved are not entirely understood. In the present study, female C57BL/6 mice were chronically exposed to a high-fat diet to induce obesity and subsequently exhibited impaired offspring viability (only 15% survival rate), milk production (33% reduction), mammopoiesis (one-third of the glandular area compared to control animals) and postpartum maternal behaviors (higher latency to retrieving and grouping the pups). Reproductive experience attenuated these defects. Diet-induced obese mice exhibited high basal pSTAT5 levels in the mammary tissue and hypothalamus, and an acute prolactin stimulus was unable to further increase pSTAT5 levels above basal levels. In contrast, genetically obese leptin-deficient females showed normal prolactin responsiveness. Additionally, we identified the expression of leptin receptors specifically in basal/myoepithelial cells of the mouse mammary gland. Finally, high-fat diet females exhibited altered mRNA levels of ERBB4 and NRG1, suggesting that obesity may involve disturbances to mammary gland paracrine circuits that are critical in the control of luminal progenitor function and lactation. In summary, our findings indicate that high leptin levels are a possible cause of the peripheral and central prolactin resistance observed in obese mice which leads to impaired lactation performance.

Migraine and lifestyle in childhood

Migraine is one of the most frequently reported somatic complaints in childhood, with a negative impact on health-related quality of life. The incidence of migraine in childhood has substantially increased over the past 30 years, probably due to both increased awareness of the disease and lifestyle changes in this age group. Indeed, several conditions have been identified as risk factors for migraine in childhood. Amongst these, dysfunctional family situation, the regular consumption of alcohol, caffeine ingestion, low level of physical activity, physical or emotional abuse, bullying by peers, unfair treatment in school and insufficient leisure time seem to play a critical role. Nevertheless, there are only few studies about the association between migraine and lifestyle in childhood, due to previous observations specifically focused on "headache" in children. In this brief review, we will concentrate upon recent studies aimed to explore migraine and lifestyle risk factors in childhood.

OB CITY-Definition of a Family-Based Intervention for Childhood Obesity Supported by Information and Communication Technologies

Childhood obesity is becoming one of the 21st century's most important public health problems. Nowadays, the main treatment of childhood obesity is behavior intervention that aims at improve children's lifestyle to arrest the disease. Information and communication technologies (ICTs) have not been widely employed in this intervention, and most of existing ICTs systems are not having a long-term effect. The purpose of this paper is to define a system to support family-based intervention through a state-of-the-art analysis of family-based interventions and related technological solutions first, and then using the analytic hierarchy process to derive a childhood obesity family-based behavior intervention model, and finally to provide a prototype of a system called OB CITY. The system makes use of applied behavior analysis, affective computing technologies, as well as serious game and gamification techniques, to offer long term services in all care dimensions of the family-based behavioral intervention aiming to provide positive effects to the treatment of childhood obesity.

Use of the triglyceride to HDL cholesterol ratio for assessing insulin sensitivity in overweight and obese children in rural Appalachia

BACKGROUND

Studies have suggested that triglyceride to HDL-cholesterol ratio (TRG/HDL) is a surrogate marker of insulin resistance (IR), but information regarding its use in pediatric patients is limited. This study investigated the ability of TRG/HDL ratio to assess IR in obese and overweight children.

METHODS

The sample consisted of de-identified electronic medical records of patients aged 10-17 years (n=223). Logistic regression was performed using TRG/HDL ratio as a predictor of hyperinsulinemia or IR defined using homeostasis model assessment score.

RESULTS

TRG/HDL ratio had limited ability to predict hyperinsulinemia (AUROC 0.71) or IR (AUROC 0.72). Although females had higher insulin levels, male patients were significantly more likely to have hypertriglyceridemia and impaired fasting glucose.

CONCLUSIONS

TRG/HDL ratio was not adequate for predicting IR in this population. Gender differences in the development of obesity-related metabolic abnormalities may impact the choice of screening studies in pediatric patients.

Comparing Outcomes of Two Types of Bariatric Surgery in an Adolescent Obese Population: Roux-en-Y Gastric Bypass vs. Sleeve Gastrectomy

BACKGROUND

Obesity is prevalent among adolescents and is associated with serious health consequences. Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG) are bariatric procedures that cause significant weight loss in adults and are increasingly being performed in adolescents with morbid obesity. Data comparing outcomes of RYGB vs. SG in this age-group are scarce. This study aims to compare short-term (1-6 months) and longer-term (7-18 months) body mass index (BMI) and biochemical outcomes following RYGB and SG in adolescents/young adults.

METHODS

A retrospective study using data extracted from medical records of patients 16-21 years who underwent RYGB or SG between 2012 and 2014 at a tertiary care academic medical center.

RESULTS

Forty-six patients were included in this study: 24 underwent RYGB and 22 underwent SG. Groups did not differ for baseline age, sex, race, or BMI. BMI reductions were significant at 1-6 months and 7-18 months within groups (p < 0.0001), but did not differ by surgery type (p = 0.65 and 0.09, for 1-6 months and 7-18 months, respectively). Over 7-18 months, within-group improvement in low-density lipoprotein (LDL) (-24 ± 6 in RYGB, p = 0.003, vs. -7 ± 9 mg/dl in SG, p = 0.50) and non-high-density lipoprotein (non-HDL) cholesterol (-23 ± 8 in RYGB, p = 0.02, vs. -12 ± 7 in SG, p = 0.18) appeared to be of greater magnitude following RYGB. However, differences between groups did not reach statistical significance. When divided by non-alcoholic steatohepatitis stages (NASH), patients with Stage II-III NASH had greater reductions in alanine aminotransferase levels vs. those with Stage 0-I NASH (-45 ± 18 vs. -9 ± 3, p = 0.01) after 7-18 months. RYGB and SG groups did not differ for the magnitude of post-surgical changes in liver enzymes.

CONCLUSION

RYGB and SG did not differ for the magnitude of BMI reduction across groups, though changes trended higher following RYGB. Further prospective studies are needed to confirm these findings.

Change in Metabolic Profile after 1-Year Nutritional-Behavioral Intervention in Obese Children

Research findings are inconsistent about improvement of specific cardio-metabolic variables after lifestyle intervention in obese children. The aim of this trial was to evaluate the effect of a 1-year intervention, based on normocaloric diet and physical activity, on body mass index (BMI), blood lipid profile, glucose metabolism and metabolic syndrome. Eighty-five obese children aged ≥6 years were analyzed. The BMI z-score was calculated. Fasting blood samples were analyzed for lipids, insulin and glucose. The homeostatic model assessment of insulin resistance (HOMA-IR) was calculated and insulin resistance was defined as HOMA-IR >3.16. HOMA-β%, quantitative insulin sensitivity check index and triglyceride glucose index were calculated. The metabolic syndrome was defined in accordance with the International Diabetes Federation criteria. At the end of intervention children showed a reduction (mean (95% CI)) in BMI z-score (-0.58 (-0.66; -0.50)), triglycerides (-0.35 (-0.45; -0.25) mmol/L) and triglyceride glucose index (-0.29 (-0.37; -0.21)), and an increase in HDL cholesterol (0.06 (0.01; 0.11) mmol/L). Prevalence of insulin resistance declined from 51.8% to 36.5% and prevalence of metabolic syndrome from 17.1% to 4.9%. Nutritional-behavioral interventions can improve the blood lipid profile and insulin sensitivity in obese children, and possibly provide benefits in terms of metabolic syndrome.

Pediatric obesity prevention: From naïve examination of energy imbalance towards strategies that influence the competition for nutrient resources among tissues

Current pediatric obesity interventions have collectively yielded relatively unsuccessful results. In this Field of Vision, we present plausible physiologic underpinnings fostering ineffectiveness of conventional strategies grounded in requisite induction of negative energy imbalance. Moreover, such recommendations exacerbate the underlying metabolic dysfunction by further limiting metabolic fuel availability, lowering energy expenditure, and increasing hunger (recapitulating the starvation response amid apparent nutritional adequacy) which precede and promote obesity during growth and development. The qualitative aspects of musculoskeletal system (i.e., endocrine response, muscle functional capacity) are likely to improve metabolic function and increase nutrient delivery and utilization. An intricate and complex system including multiple feedback mechanisms operates to homeostatically regulate energy balance and support optimal body composition trajectories and metabolic health, during growth and development. Thus, ignoring the interdependencies of regulatory growth processes initiates a nuanced understanding of energy regulation and thus misguided attempts at preventive strategies. Importantly, these gains are not dependent upon weight-loss, rather we suggest can be achieved through resistance training. Collectively, optimizing musculoskeletal health via resistance training elicits augmentation of competitive capacity across systems. Further, substantial gains can be achieved in skeletal muscle mass, strength, and functional capacity through resistance training in a relatively short period of time.

Evaluation of Obesity in School-Age Children

To prevent obesity in middle age, early precautions and interventions are required during childhood. Therefore, it is very important to accurately evaluate the degree of overweight in children. Body mass index (BMI) is widely used worldwide in adults, but not in children. Because standard BMI, which is calculated using the average height and weight for age, changes widely during growth, a constant cut-off point cannot be set for children. An international unified method defining childhood obesity has not been established. In many countries, BMI-for-age percentile (BMI%) value or Z (standard deviation) score is used, whereas in Japan, the percentage of overweight (POW), which is the modified weight-for-height method, is used. We compared BMI% values with POW values obtained using the anthropometric data of elementary and junior high school students based on the Japanese school survey conducted in 2000 and found that the values for the degree of overweight were significantly different between the two methods. It became clear that tall students were easily defined as being overweight, whereas short students tended to be evaluated as being underweight when using BMI%. POW method seemed to be more appropriate than BMI% for school-age children. Abdominal obesity, excess visceral adipose tissue (VAT), is highly associated with obesity-related complications. Waist circumference (WC) is now accepted as an appropriate guide to VAT accumulation. The cut-off value of WC defining excess VAT is 80 cm at the umbilical level in Japanese school-age children. It is not easy to decide the obesity criteria and optimum WC in school-age children. Childhood obesity should be discussed more internationally.

Development of hypertension in overweight adolescents: a review

The upward trend in adolescent hypertension is widely attributed to the adolescent obesity epidemic. Secular trends in adolescent prehypertension and hypertension have risen in congruence with increasing trends in the prevalence of overweight and obesity. The correlation between body mass index and blood pressure in adolescence is moderate to strong in most studies and strongest in those classified as overweight or obese. The mechanisms relating to the development of hypertension in overweight adolescents are unclear; however, a number of nonmodifiable and modifiable factors have been implicated. Importantly, certain clinical and biochemical markers in overweight adolescents are indicative of high risk for hypertension, including family history of hypertension and hyperinsulinemia. These characteristics may prove useful in stratifying overweight adolescents as high or low risk of comorbid hypertension. The treatment of overweight and obesity related hypertension in this population focuses on two key modalities: lifestyle change and pharmacotherapy. These approaches focus almost exclusively on weight reduction; however, a number of emerging strategies target hypertension more specifically. Among adolescents with overt hypertension there are also several factors that indicate higher risk of concurrent subclinical disease, persistent adult hypertension, and adult cardiovascular disease. This group may benefit substantially from more aggressive pharmacological treatments. Limitations in the literature relate to the paucity of studies reporting specific effects for the adolescent age group of overweight and obese individuals. Nonetheless, intervention for adiposity-related hypertension in adolescence may partially mitigate some of the cardiovascular risk in adulthood.

Sustained Benefit Over Four-Year Follow-Up of Michigan's Project Healthy Schools

OBJECTIVES

We determined the sustainability of effects of a school-based intervention to improve health behaviors and cardiovascular risk factors among middle school children.

METHODS

We administered a questionnaire and health screenings to 5 schools in Ann Arbor and 2 schools in Ypsilanti, Michigan. We assessed demographics, physiological factors, diet, physical activity, and sedentary behaviors from 1126 students who received a health curriculum (Project Healthy Schools) in the fall of sixth grade in 2005, 2006, and 2007. We administered the questionnaire and screening again in the spring and each subsequent spring through ninth grade to all available, consenting students.

RESULTS

In the 4 years following the school-based intervention, total cholesterol, low-density lipoprotein cholesterol, and triglycerides improved, and for most years systolic and diastolic blood pressure improved. Serum glucose and body mass index did not change. Physical activity increased and sedentary behaviors diminished.

CONCLUSIONS

Project Healthy Schools is associated with sustainable improvements in both cardiovascular parameters and healthy behaviors.

Successful childhood obesity management in primary care in Canada: what are the odds?

Background. The management of a child presenting with obesity in a primary care setting can be viewed as a multi-step behavioral process with many perceived and actual barriers for families and primary care providers. In order to achieve the goal of behavior change and, ultimately, clinically meaningful weight management outcomes in a child who is considered obese, all steps in this process should ideally be completed. We sought to review the evidence for completing each step, and to estimate the population effect of secondary prevention of childhood obesity in Canada.

Methods. Data from the 2009/2010 Canadian Community Health Survey and from a review of the literature were used to estimate the probabilities for completion of each step. A flow chart based on these probabilities was used to determine the proportion of children with obesity that would undergo and achieve clinically meaningful weight management outcomes each year in Canada.

Results. We estimated that the probability of a child in Canada who presents with obesity achieving clinically meaningful weight management outcomes through secondary prevention in primary care is around 0.6% per year, with a range from 0.01% to 7.2% per year. The lack of accessible and effective weight management programs appeared to be the most important bottleneck in the process.

Conclusions. In order to make progress towards supporting effective pediatric obesity management, efforts should focus on population-based primary prevention and a systems approach to change our obesogenic society, alongside the allocation of resources toward weight management approaches that are comprehensively offered, equitably distributed and robustly evaluated.

Epidemiology of elevated blood pressure and associated risk factors in Chinese children: the SNEC study

Despite the association of childhood blood pressure (BP) with hypertension later in the life course, there remains dearth of information regarding the prevalence and emergence of hypertension in children, especially in China. To investigate the current status of BP, prevalence of elevated BP and related factors in Chinese children, a cross-sectional survey in a representative sample of 9354 Chinese children 5-17 years old was conducted in seven cities in Northeastern China during 2011 and 2012. BP measurements were taken by mercury sphygmomanometer. Elevated BP in children was defined as an average diastolic BP or systolic BP that is in the 95th percentile or higher for their gender, age and height. Overall, total prevalence of elevated BP was 13.8%, and no significant difference between males and females was identified. Multivariate analyses revealed that children having a higher area of residence had a lower of elevated BP. Increased odds for elevated BP were found for individuals who were lean (odds ratio (OR)=2.12; 95% confidence interval (CI): 1.67-2.69), overweight (OR=2.05; 95% CI: 1.74-2.42), obese (OR=3.15; 95% CI: 2.70-3.68), were born with low birth weight (OR=1.26; 95%CI: 1.01-1.63), premature birth (OR=1.46; 95%CI: 1.13-1.88), and were with home coal use (OR=1.24; 95%CI: 1.02-1.52). In conclusion, elevated BP was found to be prevalent in children in urban areas of Northeast China. These results underscore the importance of implementing a package of measures aimed at reducing malleable risk for this cardiovascular condition in school-aged children in Northeast China.

Characteristics of Youth Presenting for Weight Management: Retrospective National Data from the POWER Study Group

BACKGROUND

There are no existing multisite national data on obese youth presenting for pediatric weight management. The primary aim was to describe BMI status and comorbidities among youth with obesity presenting for pediatric weight management (PWM) at programs within the Pediatric Obesity Weight Evaluation Registry (POWER).

METHODS

Data were collected from 2009-2010 among 6737 obese patients ages 2-17. Patients were classified in three groups by BMI (kg/m(2)) cutoffs and percent of the 95th percentile for BMI: (1) obesity; (2) severe obesity class 2; and (3) severe obesity class 3. Weighted percentages are presented for baseline laboratory tests, blood pressure, and demographics. Generalized logistic regression with clustering was used to examine the relationships between BMI status and comorbidities.

RESULTS

Study youth were 11.6 ± 3.4 years of age, 56% female, 31% black, 17% Hispanic, and 53% publicly insured. Twenty-five percent of patients had obesity (n = 1674), 34% (2337) had severe obesity class 2, and 41% (2726) had severe obesity class 3. Logistic regression revealed that males (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5-2.0), blacks (OR, 1.7; 95% CI, 1.5-2.0), age <6 years (OR, 2.0; 95% CI, 1.5-2.6), and public insurance (OR, 1.8; 95% CI, 1.5-2.0) had a higher odds of severe obesity class 3. Severe obesity class 3 was associated with higher odds of laboratory abnormalities for hemoglobin A1c (OR, 1.7; 95% CI, 1.3-2.2), alanine aminotransferase ≥40 U/L (OR, 1.9; 95% CI, 1.3-2.6), and elevated systolic blood pressure (OR, 2.5; 95% CI, 2.0-3.0).

CONCLUSIONS

Youth with obesity need earlier access to PWM given that they are presenting when they have severe obesity with significant comorbidities.

Severe childhood obesity: an under-recognised and growing health problem

Childhood obesity is a serious and urgent public health problem. In the last 10 years, there has been a concerted effort in the USA and globally to develop and implement educational, medical and public health interventions designed to attenuate its growth. The success of these efforts was probably responsible for the plateau in the prevalence rate of childhood obesity noted in the last two years. While the attenuation of the overall prevalence of childhood obesity is promising, data from the same cohort reveal a concerning upward trend in the number of children with severe obesity. The consequences of severe childhood obesity can be devastating. When compared to their moderately obese peers, children with severe obesity are at greater risk for adult obesity, early atherosclerosis, hypertension, type 2 diabetes, metabolic syndrome, fatty liver disease and premature death. The determinants for severe obesity include the same lifestyle, environmental, familial and societal risk factors reported for overweight or obesity. While all these risk factors must be screened for, genetic influences are distinct considerations that may have greater bearing especially with early-onset obesity. Treatments for severe childhood obesity include lifestyle intervention, specialised low-calorie diets and bariatric surgery. Outcomes of these treatments vary, with bariatric surgery clearly the most successful of the three for both short-term and long-term weight loss. Severe obesity in children and adolescents remains a challenging health condition. The enormous medical, emotional and financial burden these children and their families endure signals an urgent need to further investigate and standardise treatment modalities and improve outcomes.

Alanine transferase: An independent indicator of adiposity related comorbidity risk in youth

BACKGROUND

Elevated levels of alanine aminotransferase (ALT) are associated with obesity and are often a consequence of non-alcoholic fatty liver disease (NAFLD). The aim of the present study was to assess the relationship between ALT and risk factors for adiposity-related co-morbidities in a diverse population of middle school children.

METHODS

We measured height, weight, body fatness (bioelectrical impedance), waist circumference, insulin sensitivity, phase 1 insulin release (acute insulin response following intravenous glucose), beta-cell function (acute insulin response corrected for insulin sensitivity), ALT, lipid profiles, and circulating concentrations of interleukin-6 (IL-6), C-reactive protein, adiponectin, and tumor necrosis factor-α (TNF-α) in a multi-ethnic/racial population of 106 middle school students (aged 11-14 years, 45 female) of varying body mass indexes (BMI).

RESULTS

Alanine aminotransferase was significantly correlated with BMI, % body fat, fat mass, waist circumference, fasting insulin, insulin resistance, triglycerides, and was inversely correlated with high-density lipoprotein cholesterol in children, even though all values of ALT were "normal" (range of 4.0-33.0 U/L). ALT was significantly higher in males than females even when corrected for body fatness. Significant correlations with lipids and insulin resistance persisted even when adjusted for age, gender, and body fatness.

CONCLUSION

Even within the normative range, ALT levels were significantly correlated with anthropomorphic and biochemical risk factors for adiposity-related co-morbidities in youth. Therefore, because ALT is correlated with dyslipidemia, insulin resistance, and central fat distribution, it might also serve as a marker of risk for adiposity-related co-morbidities beyond NAFLD.

Evaluation and Treatment of Severe Obesity in Childhood

Pediatric obesity is highly prevalent in developed countries globally (and worsening in developing countries) and threatens to shorten the lifespan of the current generation. At highest risk for weight-related comorbidities including Type 2 diabetes mellitus, non-alcoholic fatty liver disease and dyslipidemia is a sub-set of children with severe obesity, often defined as a body mass index (BMI) percentile ≥99^th percentile for age and sex. The pathophysiology of severe obesity in childhood is complex, resulting from the dynamic interplay of a myriad of individual and societal factors including genetic predisposition and health behaviors contributing to energy imbalance. Approximately 4–6% of children have severe obesity, representing a common scenario encountered by providers, and intervention is critical to halt ongoing weight gain and, when possible, reverse the trend. Clinical approaches promoting behavioral weight loss may result in modest, albeit clinically significant, reductions in BMI; however, such changes are often difficult to maintain long-term. Data regarding the impact of targeted pharmacotherapy including agents such as orlistat are limited in the pediatric population and again only suggest modest results. However, increasing evidence suggest that surgical treatment, as an adjunct to ongoing lifestyle changes, may be a promising option in carefully-screened adolescents with severe obesity and weight-related comorbidities who are motivated to adhere to the long-term treatment needs.

Docosahexaenoic Acid Levels in Blood and Metabolic Syndrome in Obese Children: Is There a Link?

Prevalence of metabolic syndrome is increasing in the pediatric population. Considering the different existing criteria to define metabolic syndrome, the use of the International Diabetes Federation (IDF) criteria has been suggested in children. Docosahexaenoic acid (DHA) has been associated with beneficial effects on health. The evidence about the relationship of DHA status in blood and components of the metabolic syndrome is unclear. This review discusses the possible association between DHA content in plasma and erythrocytes and components of the metabolic syndrome included in the IDF criteria (obesity, alteration of glucose metabolism, blood lipid profile, and blood pressure) and non-alcoholic fatty liver disease in obese children. The current evidence is inconsistent and no definitive conclusion can be drawn in the pediatric population. Well-designed longitudinal and powered trials need to clarify the possible association between blood DHA status and metabolic syndrome.

Is the endocrine research pipeline broken? A systematic evaluation of the Endocrine Society clinical practice guidelines and trial registration

BACKGROUND

Very low quality (VLQ) evidence translates into very low confidence in the balance of risk and benefits based on the estimates drawn from the body of evidence. Consequently, this assessment highlights gaps in the research evidence, i.e. knowledge gaps, for important clinical questions. In this way, expert guideline panels identify priority knowledge gaps that, arguably, should inform the research agenda and prioritize scarce research economical resources. The extent to which the research agenda reflects the knowledge gaps identified in clinical practice guidelines is unknown.

METHODS

A systematic evaluation of the Endocrine Society (ES) clinical practice guidelines portfolio from 2008 to 2014 was conducted with the objectives to identify (1) recommendations in the ES clinical practice guidelines based on VLQ evidence reflecting knowledge gaps in endocrinology, and (2) active research designed to address these gaps by searching the clinical trial registry, clinicaltrials.gov, using terms describing patients (diseases), interventions, comparison, and outcomes.

RESULTS

In 25 ES guidelines, we found 660 recommendations, of which 131 (20 %) were supported by VLQ evidence. Clinical trialists are attempting to answer 28 (21 %) of these knowledge gaps by performing 69 clinical trials.

CONCLUSION

The research enterprise is addressing one in five knowledge gaps identified in clinical practice recommendations in endocrinology. These findings suggest an inefficiency in the allocation of very scarce research economical resources. Linking the research agenda to evidence gaps in clinical practice guidelines may improve both the efficiency of the research enterprise and the translation of evidence into more confident clinical practice.

Building an evidence-base for the training of evidence-based treatments in community settings: Use of an expert-informed approach

In order to make EBTs available to a large number of children and families, developers and expert therapists have used their experience and expertise to train community-based therapists in EBTs. Understanding current training practices of treatment experts may be one method for establishing best practices for training community-based therapists prior to comprehensive empirical examinations of training practices. A qualitative study was conducted using surveys and phone interviews to identify the specific procedures used by treatment experts to train and implement an evidence-based treatment in community settings. Twenty-three doctoral-level, clinical psychologists were identified to participate because of their expertise in conducting and training Parent-Child Interaction Therapy. Semi-structured qualitative interviews were completed by phone, later transcribed verbatim, and analyzed using thematic coding. The de-identified data were coded by two independent qualitative data researchers and then compared for consistency of interpretation. The themes that emerged following the final coding were used to construct a training protocol to be empirically tested. The goal of this paper is to not only understand the current state of training practices for training therapists in a particular EBT, Parent-Child Interaction Therapy, but to illustrate the use of expert opinion as the best available evidence in preparation for empirical evaluation.

Childhood Obesity: Causes, Consequences, and Management

One-third of North American children are overweight or obese. Pathologic obesity accounts for only a small percentage of these cases. The vast majority are the result of a complex interaction of genetic and hormonal, nutritional, physical activity, and physical and social environmental factors. Obesity increases the risk for various cardiometabolic, pulmonary, and psychosocial complications for children, which often continues into adulthood. Multidisciplinary care, focusing on family-centered behavior change, is an evidence-based, essential part of the treatment, along with pharmacologic and surgical options for more complex cases. Prevention and early intervention strategies are key to reversing the obesity epidemic.

Paediatric non-alcoholic fatty liver disease: a practical overview for non-specialists

Non-alcoholic fatty liver disease (NAFLD) is the most common paediatric liver disease with a prevalence of almost 10%; therefore, the majority of affected patients are under the care of general practitioners and non-specialists. The condition is caused by central obesity with insulin resistance with additional factors influencing inflammatory activity (steatohepatitis). Ongoing inflammation leads to fibrosis and end-stage liver disease, though this will usually occur after children have transitioned into adult care. However, their main morbidity and mortality is from type 2 diabetes and complications of atherosclerosis. The minority of children undergo biopsy but currently there is no other method to accurately assess the stage of disease. Management is focused at weight loss through a combination of diet and exercise. Here, we present a current review of paediatric NAFLD aimed at non-specialists, with practice points for implementation.

Diagnostic performance of body mass index to identify obesity as defined by body adiposity in children and adolescents: a systematic review and meta-analysis

BACKGROUND

The ideal means of identifying obesity in children and adolescents has not been determined although body mass index (BMI) is the most widely used screening tool.

OBJECTIVE

We performed a systematic review and meta-analysis of studies assessing the diagnostic performance of BMI to detect adiposity in children up to 18 years.

METHODS

Data sources were EMBASE, MEDLINE, Cochrane, Database of Systematic Reviews Cochrane CENTRAL, Web of Science and SCOPUS up to March 2013. Studies providing measures of diagnostic performance of BMI and using body composition technique for body fat percentage measurement were included.

RESULTS

Thirty-seven eligible studies that evaluated 53 521 patients, with mean age ranging from 4 to 18 years were included in the meta-analysis. Commonly used BMI cut-offs for obesity showed pooled sensitivity to detect high adiposity of 0.73 (confidence interval [CI] 0.67-0.79), specificity of 0.93 (CI 0.88-0.96) and diagnostic odds ratio of 36.93 (CI 20.75-65.71). Males had lower sensitivity. Moderate heterogeneity was observed (I(2) = 48%) explained in meta-regression by differences across studies in race, BMI cut-off, BMI reference criteria (Center for Disease Control vs. International Obesity Task Force) and reference standard method assessing adiposity.

CONCLUSION

BMI has high specificity but low sensitivity to detect excess adiposity and fails to identify over a quarter of children with excess body fat percentage.

Obesity in children with developmental and/or physical disabilities

Children with developmental or physical disabilities, many of whom face serious health-related conditions, also are affected by the current obesity crisis. Although evidence indicates that children with disabilities have a higher prevalence of obesity than do children without disabilities, little is known of the actual magnitude of the problem in this population. To address this concern, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) held a conference on obesity in children with intellectual, developmental, or physical disabilities, bringing together scientists and practitioners in the fields of obesity and disability to foster collaboration, identify barriers to healthy weight status in populations with disabilities, propose avenues to solutions through research and practice, and develop a research agenda to address the problem. This article describes current knowledge about prevalence of obesity in this population, discusses factors influencing obesity risk, and summarizes recommendations for research presented at the conference.

Preventing weight gain and obesity: indirect effects of the family check-up in early childhood

The early signs of obesity are observable in early childhood. Although the most promising prevention approaches are family-centered, few relevant early prevention programs exist. This study evaluated the effects of an evidence-based, home-visiting intervention, the Family Check-Up (FCU), on the trajectory of children's weight gain. The FCU was designed to prevent the development of behavior problems by improving family management practices; children's weight has not been an explicit target. On the basis of previous research and conceptual models, we hypothesized that intervention effects on parenting practices, specifically caregivers' use of positive behavior support (PBS) strategies in toddlerhood, would mediate improvements in children's weight trajectories. A total of 731 indigent caregiver-child dyads from a multisite randomized intervention trial were examined. Observational assessment of parenting and mealtime behaviors occurred from age 2-5 years. The child's body mass index (BMI) was assessed yearly from age 5-9.5 years. Path analysis with a latent growth model revealed a significant indirect effect of the FCU on the trajectory of BMI in later childhood. Improvements in caregivers' PBS in toddlerhood, which was related to the nutritional quality of the meals caregivers served to the child during the mealtime task, served as the intervening process. Furthermore, findings indicate that the FCU prevents progression to overweight and obese status amongst at-risk children. These study results add to existing evidence that has demonstrated that family-based interventions aimed at improving general family management skills are effective at preventing weight gain. Future directions are discussed.

Behavioural early-life exposures and body composition at age 15 years

Background/Objectives:

Previous studies have demonstrated associations between some early-life exposures and later obesity, but most have used body mass index in childhood or adulthood as the outcome. The objective of this study was to investigate whether early-life exposures were associated with directly measured fat and lean mass in adolescence.

Subjects/Methods:

This study used data on 4750 mother–offspring pairs, collected as a part of the Avon Longitudinal Study of Parents and Children, Bristol, UK between 1991 and 1992; associations between behavioural exposures occurring from conception up to 5 years of age (maternal and paternal smoking during pregnancy, breastfeeding, age at introduction to solids, dietary patterns and physical inactivity during early childhood) and offspring body composition measured by dual-energy X-ray absorptiometry at ~15 years were assessed.

Results:

After full adjustment for potential confounders, maternal smoking during pregnancy, having a junk food diet and spending more time watching television in early childhood were all associated with higher fat mass at age 15, whereas maternal smoking, having a healthy diet and playing computer games more frequently in early childhood were all associated with a higher lean mass at age 15. Associations with paternal smoking were generally weaker for both fat and lean mass, but as there was no strong statistical evidence for maternal vs paternal differences, confounding by social factors rather than a direct effect of maternal smoking cannot be ruled out. Early feeding was not associated with fat or lean mass at age 15.

Conclusions:

This study does not provide compelling evidence for associations between most early-life factors and body composition in adolescence. However, possible associations with dietary patterns and physical inactivity in early childhood require further investigation in other cohorts that have direct measurements of adolescent body composition.

A program for obese youth at-risk for diabetes in Qatar

Background: Obesity is an international public health problem well documented in Qatar among children and adolescents and contributes to diabetes, a disease already highly prevalent in the country. We describe an intervention program developed for obese youth conducted by the Qatar Diabetes Association (QDA). Methods: The QDA conducts a 3-day structured program for obese youth at-risk for developing diabetes which includes physical activities, games and workshops aimed to increase awareness and guide improved diet, activity and related lifestyle choices. Using motivational interviewing techniques, obese youth develop action plans to modify diet and exercise which were shared with parents to promote collaboration and support. Results: In 2011, one girls' camp (n = 15, mean age 12 years) and one boys' camp (n = 17, mean age 13 years) were held. All participants were considered obese: girls mean BMI = 31 kg/m2 (standard deviation (SD) 4.2) and boys mean BMI 35 kg/m2 (SD = 4.7). Youth reported fast food consumption at least twice a week by 6 (40 %) of girls and 10 (59 %) of boys and there was low self-declared frequency of daily physical activity (1 girl and 5 boys). Many stated their weight made their life worse due to fatigue, poor agility, or difficulty finding clothes. When individualized coaching was proposed, 87 % and 100 % of girls and boys felt ready to devise an action plan for improved health. Conclusion: The new national preventative healthcare mandate could facilitate modification and expansion of these QDA educational and behavioural intervention programs as part of the wider strategy to combat obesity in Qatar.

Extremely obese children respond better than extremely obese adolescents to lifestyle interventions

What is already known about this subject Lifestyle intervention is regarded as therapy of choice in obese children and adolescents. It is unclear whether extremely obese children and adolescents respond to lifestyle intervention. What this study adds Extremely obese children respond better than obese children to a lifestyle intervention. In contrast, most extremely obese adolescents achieved no weight loss in lifestyle intervention suggesting that other treatment approaches are needed for them.

BACKGROUND

There are conflicting results of treating extreme obesity in childhood by lifestyle interventions in the literature.

METHODS

We analysed the outcome of a 1-year lifestyle intervention in an intention-to-treat approach in 1291 children (mean age 11.0 ± 2.5 years, mean body mass index [BMI] 27.5 ± 4.7 kg m(-2), 55.8% female, 62.4% obese, 37.6% extremely obese (defined by BMI-SDS >2.3) at end of intervention and 1 year later.

RESULTS

The mean BMI-SDS reduction was -0.20 ± 0.32 at end of intervention and -0.14 ± 0.37 1 year after end of intervention compared to baseline (comparing intervention vs. 1 year later P = 0.010). Extremely obese children ≤10 years demonstrated a significantly greater BMI-SDS reduction than obese children ≤10 years (-0.24 ± 0.38 vs. -0.16 ± 0.38, P = 0.021). Extremely obese adolescents >10 years demonstrated a significantly lower BMI-SDS reduction compared to obese adolescents >10 years (-0.05 ± 0.30 vs. -0.15 ± 0.39, P < 0.001). Comparing the BMI-SDS reduction between obese children <10 years and >10 years revealed no significant difference (P = 0.195) in contrast to the comparison between extremely obese children <10 years and >10 years (P < 0.001). The same findings were observed in the follow-up period after the end of intervention.

CONCLUSIONS

Our study demonstrated an encouraging effect of lifestyle intervention in extremely obese children ≤10 years at the end of intervention and 1 year later, but only a limited effect in extremely obese adolescents >10 years.

Insulin and BMI as predictors of adult type 2 diabetes mellitus

BACKGROUND AND OBJECTIVES

Fasting insulin concentrations are increasingly being used as a surrogate for insulin resistance and risk for type 2 diabetes (T2DM), although associations with adult outcomes are unclear. Our objective was to determine whether fasting insulin concentrations in childhood associate with later T2DM.

METHODS

Fasting insulin values were available from 2478 participants in the longitudinal Cardiovascular Risk in Young Finns Study at baseline age 3 to 18 years, along with data on adult T2DM (N = 84, mean age = 39.6 years).

RESULTS

Among 3- to 6-year-olds, a 1-SD increase in fasting insulin was associated with a relative risk (RR) of 2.04 (95% confidence interval [CI], 1.54-2.70) for later T2DM, which remained significant after we adjusted for BMI and parental history of T2DM. For those aged 9 to 18 years, a 1-SD increase in insulin was associated with an RR of 1.32 (95% CI, 1.06-1.65) for T2DM, but this became nonsignificant after we adjusted for BMI and parental history of T2DM. In the latter age group, a 1-SD increase in BMI was associated with an RR of 1.45 (95% CI, 1.21-1.73) for T2DM, with adjustment for insulin and parental history of T2DM not improving this association. BMI in younger children was not associated with later T2DM. In life course analyses, those with T2DM had higher fasting insulin levels in early childhood and later adulthood but not in peripubertal years.

CONCLUSIONS

Elevated fasting insulin concentrations in early childhood, but not adolescence, are independently associated with an elevated risk of T2DM in adulthood.

Evidence update on the treatment of overweight and obesity in children and adolescents

Childhood obesity is associated with increased medical and psychosocial consequences and mortality and effective interventions are urgently needed. Effective interventions are urgently needed. This article reviews the evidence for psychological treatments of overweight and obesity in child and adolescent populations. Studies were identified through searches of online databases and reference sections of relevant review articles and meta-analyses. Treatment efficacy was assessed using established criteria, and treatments were categorized as well-established, probably efficacious, possibly efficacious, experimental, or of questionable efficacy. Well-established treatments included family-based behavioral treatment (FBT) and Parent-Only Behavioral Treatment for children. Possibly efficacious treatments include Parent-Only Behavioral Treatment for adolescents, FBT-Guided Self-Help for children, and Behavioral Weight Loss treatment with family involvement for toddlers, children, and adolescents. Appetite awareness training and regulation of cues treatments are considered experimental. No treatments are considered probably efficacious, or of questionable efficacy. All treatments considered efficacious are multicomponent interventions that include dietary and physical activity modifications and utilize behavioral strategies. Treatment is optimized if family members are specifically targeted in treatment. Research supports the use of multicomponent lifestyle interventions, with FBT and Parent-Only Behavioral Treatment being the most widely supported treatment types. Additional research is needed to test a stepped care model for treatment and to establish the ideal dosage (i.e., number and length of sessions), duration, and intensity of treatments for long-term sustainability of healthy weight management. To improve access to care, the optimal methods to enhance the scalability and implementability of treatments into community and clinical settings need to be established.

Sitting-height measures are related to body mass index and blood pressure levels in children

OBJECTIVE

Sitting height (SH) is an important parameter in the evaluation of children with growth and pubertal disorders. Besides this, it has been viewed as a biomarker of cardiovascular risk, which is increased in adults with relatively short legs. So, the aim of this study was to evaluate the relationship between body proportions and cardiovascular risk markers in children.

SUBJECTS AND METHODS

Eight hundred and seventeen children aged 6-13 years were evaluated. Weight, height, sitting-height (SH), sitting-height/height (SH/H), body mass index (BMI) and blood pressure (BP) were assessed and converted to standard deviation scores (SDS) for age and sex. Statistical analyses were performed.

RESULTS

There was a positive association of BMI SDS with SH and SH/H SDS (p<0.001). Overweight children showed SH 0.8 SDS superior to eutrophic children (p<0.001). SH SDS was also directly related to BP SDS, but this association was not independent of the association between obesity and BP when assessed by multiple regression analyzes.

CONCLUSION

Measures of SH are strongly associated with BMI and BP in children, although the association between SH and BP is probably dependent on the association of both those variables with BMI. This is (an) important information for correct interpretation of SH values in children.

Anti-obesity drugs currently used and new compounds in clinical development

Obesity is a chronic disease which requires treatment. As lifestyle interventions alone hardly ever result in long-term weight loss, pharmacotherapy is an important adjunct to lifestyle measures to improve the induction and maintenance of weight loss. Owing to the limited options currently available for the pharmacological treatment of obesity, it is imperative to develop new safe compounds. This study aims to review the current medications approved by European Medicines Agency and United States Food and Drug Administration (FDA) for the treatment of obesity, focusing essentially on their benefits and risks, as well as on the new drugs which are presently under clinical trials. Moreover, it lists the anti-obesity agents that have been recently withdrawn from the market. A revision of the scientific literature was carried out, through a search on Pubmed for papers published from January 2010 to January 2013. Orlistat (Xenical^®) is currently the only long-term pharmacotherapy for obesity available in the European market, as rimonabant and sibutramine were withdrawn in 2008 and 2010, respectively, due to serious psychiatric and cardiovascular adverse effects. Lorcaserin (Belviq^®) and the association of phentermine and topiramate (Qsymia^TM) were recently approved by FDA. Orlistat suppresses appetite inhibiting gastrointestinal lipase, being its adverse effects mostly gastrointestinal. Lorcaserin activates 5-HT_2C receptors, phentermine is a norepinephrine releasing drug, and topiramate is an anticonvulsivant drug with weight loss properties.

Pharmacological Management of Obesity in Pediatric Patients

Objective: To review current evidence of pharmacological options for managing pediatric obesity and provide potential areas for future research. Data Sources: A MEDLINE search (1966 to October 2014) was conducted using the following keywords: exenatide, liraglutide, lorcaserin, metformin, obesity, orlistat, pediatric, phentermine, pramlintide, topiramate, weight loss, and zonisamide. Study Selection and Data Extraction: Identified articles were evaluated for inclusion, with priority given to randomized controlled trials with orlistat, metformin, glucagon-like peptide-1 agonists, topiramate, and zonisamide in human subjects and articles written in English. References were also reviewed for additional trials. Data Synthesis: Whereas lifestyle modification is considered first-line therapy for obese pediatric patients, severe obesity may benefit from pharmacotherapy. Orlistat is the only Food and Drug Administration (FDA)-approved medication for pediatric obesity and reduced body mass index (BMI) by 0.5 to 4 kg/m2, but gastrointestinal (GI) adverse effects may limit use. Metformin has demonstrated BMI reductions of 0.17 to 1.8 kg/m2, with mild GI adverse effects usually managed with dose titration. Exenatide reduced BMI by 1.1 to 1.7 kg/m2 and was well-tolerated with mostly transient or mild GI adverse effects. Topiramate and zonisamide reduced weight when used in the treatment of epilepsy. Future studies should examine efficacy and safety of pharmacological agents in addition to lifestyle modifications for pediatric obesity. Conclusions: Lifestyle interventions remain the treatment of choice in pediatric obesity, but concomitant pharmacotherapy may be beneficial in some patients. Orlistat should be considered as second-line therapy for pediatric obesity. Evidence suggests that other diabetes and antiepileptic medications may also provide weight-loss benefits, but safety should be further evaluated.

Endocrine check-up in adolescents and indications for referral: A guide for health care providers

The American Academy of Pediatrics recommends that young people between the ages of 11 and 21 years should be seen annually by their pediatricians, since annual checkups can be an important opportunity for health evaluation and anticipatory guidance. Parents of infants and young children are accustomed to regularly visiting a pediatrician for their child's checkups. Unfortunately, when children reach the teen years, these annual checkups may decrease in frequency. In routine check-ups and medical office visits, particular attention should be paid to the possibility of a developmental or endocrine disorder. Early diagnosis and treatment may prevent medical complications in adulthood and foster age-appropriate development. Our purpose is to acquaint readers with the concept, based on current scientific understanding, that some endocrine disorders may be associated with a wide range of deleterious health consequences including an increased risk of hypertension and hyperlipidemia, increased risk of coronary artery disease, type 2 diabetes, significant anxiety and lack of self-esteem. Understanding the milestones and developmental stages of adolescence is essential for pediatricians and all other health providers who care for adolescents. Treating adolescents involves knowledge of a variety of medical, social and legal information; in addition, close working relationships must be established within the adolescent's network to create an effective care system. In summary, we underline the importance of a periodic endocrine checkup in adolescents in order to identify endocrine problems early and develop an approach to treatment for those patients who need help during this time. Indications for endocrine referral for professional and other healthcare providers are also included. These lists are clearly not intended to be comprehensive, but will hopefully serve as a guide for specific clinical circumstances.

Screening for elevated risk of liver disease in preschool children (aged 2-5 years) being seen for obesity management

Objectives:

Elevated alanine aminotransferase can heighten concern for the presence of nonalcoholic fatty liver disease in obese children. Guidelines recommend alanine aminotransferase screening of obese children start at the age of 10 years. We examined alanine aminotransferase values routinely obtained for tertiary obesity care among preschool (2–5 years) and school-age children.

Methods:

Medical records of children attending a tertiary obesity clinic and with alanine aminotransferase measured within 6 months of the initial visit were reviewed. Children with known genetic abnormalities were excluded. Children were grouped by age to focus attention on groups not covered by screening guidelines. Associations with elevated alanine aminotransferase (>30 IU/L) were examined.

Results:

A total of 284 records were analyzed (73 preschool, 143 young school-age (6–9 years), 68 older school-age (10–11 years)). Children were primarily Hispanic and had body mass index ≥ 99th percentile (preschool children 92%, young school-age 73%, older school-age 59%). In all, 26% of preschool children had elevated alanine aminotransferase (young school-age 30%, older school-age 44%). Preschool children with elevated alanine aminotransferase had higher body mass index compared to preschool children with alanine aminotransferase ≤ 30 IU/L (median body mass index 27.8 kg/m² vs 24.0 kg/m²; Mann–Whitney U test, p = 0.003), but there was no disparity for elevated alanine aminotransferase related to Hispanic ethnicity. For older children, Hispanic ethnicity, not body mass index, predicted elevated alanine aminotransferase.

Conclusion:

Alanine aminotransferase elevation was common in these preschool children. Screening severely obese children for elevated alanine aminotransferase should begin at the age of 2 years.

Current approaches to the management of pediatric overweight and obesity

OPINION STATEMENT

Family-based behavioral intervention has been demonstrated to be an effective and safe treatment for childhood obesity and should be considered a first-line treatment option. However, access to such intensive evidence-based treatment is limited and, currently, obesity care is dominated by high intensity behavioral treatment implemented in specialty clinics or less effective low intensity treatments implemented in primary care. However, capitalizing on the established and ongoing relationship between primary care providers and families, primary care providers have an invaluable role in early identification of overweight and obesity, and subsequent referral to an evidence-based treatment. Key aspects of effective treatment include: early intervention, moderate intensity to high intensity intervention of sufficient duration, multicomponent intervention targeting dietary modification, physical activity and behavioral strategies, family involvement and goals targeting family members, and follow-up contact during maintenance. The purpose of this review is to present the current empirically supported treatment options for pediatric obesity including primary care-based interventions and diagnostic tools, multicomponent behavioral intervention with a focus on family-based behavioral intervention, immersion treatment, and pharmacologic and surgical management.

Effects of exercise on BMI z-score in overweight and obese children and adolescents: a systematic review with meta-analysis

BACKGROUND

Overweight and obesity are major public health problems in children and adolescents. The purpose of this study was to conduct a systematic review with meta-analysis to determine the effects of exercise (aerobic, strength or both) on body mass index (BMI) z-score in overweight and obese children and adolescents.

METHODS

Studies were included if they were randomized controlled exercise intervention trials ≥ 4 weeks in overweight and obese children and adolescents 2 to 18 years of age, published in any language between 1990-2012 and in which data were available for BMI z-score. Studies were retrieved by searching eleven electronic databases, cross-referencing and expert review. Two authors (GAK, KSK) selected and abstracted data. Bias was assessed using the Cochrane Risk of Bias Assessment Instrument. Exercise minus control group changes were calculated from each study and weighted by the inverse of the variance. All results were pooled using a random-effects model with non-overlapping 95% confidence intervals (CI) considered statistically significant. Heterogeneity was assessed using Q and I2 while funnel plots and Egger's regression test were used to assess for small-study effects. Influence and cumulative meta-analysis were performed as well as moderator and meta-regression analyses.

RESULTS

Of the 4,999 citations reviewed, 835 children and adolescents (456 exercise, 379 control) from 10 studies representing 21 groups (11 exercise, 10 control) were included. On average, exercise took place 4 x week for 43 minutes per session over 16 weeks. Overall, a statistically significant reduction equivalent to 3% was found for BMI z-score (Χ¯, -0.06, 95% CI, -0.09 to -0.03; Q = 24.9, p = 0.01; I(2)=59.8%). No small-study effects were observed and results remained statistically significant when each study was deleted from the model once. Based on cumulative meta-analysis, results have been statistically significant since 2009. None of the moderator or meta-regression analyses were statistically significant. The number-needed-to treat was 107 with an estimated 116,822 million obese US children and adolescents and approximately 1 million overweight and obese children and adolescents worldwide potentially improving their BMI z-score by participating in exercise.

CONCLUSIONS

Exercise improves BMI z-score in overweight and obese children and adolescents and should be recommended in this population group. However, a need exists for additional studies on this topic.

Overweight and obesity in children and adolescents

Obesity among children, adolescents and adults has emerged as one of the most serious public health concerns in the 21st century. The worldwide prevalence of childhood obesity has increased remarkably over the past 3 decades. The growing prevalence of childhood obesity has also led to appearance of obesity-related comorbid disease entities at an early age. Childhood obesity can adversely affect nearly every organ system and often causes serious consequences, including hypertension, dyslipidemia, insulin resistance, dysglycemia, fatty liver disease and psychosocial complications. It is also a major contributor to increasing healthcare expenditures. For all these reasons, it is important to prevent childhood obesity as well as to identify overweight and obese children at an early stage so they can begin treatment and attain and maintain a healthy weight. At present, pharmacotherapy options for treatment of pediatric obesity are very limited. Therefore, establishing a comprehensive management program that emphasizes appropriate nutrition, exercise and behavioral modification is crucial. The physician's role should expand beyond the clinical setting to the community to serve as a role model and to advocate for prevention and early treatment of obesity.

Bariatric surgery for severely obese adolescents

Severe obesity is increasing in adolescents and is associated with cardiovascular disease, type 2 diabetes mellitus, obstructive sleep apnoea, polycystic ovarian syndrome and a range of musculoskeletal problems. Premature death is the inevitable outcome of persistent severe obesity in adolescents. In adults with severe obesity, medical and lifestyle interventions have been shown to be expensive and less effective in terms of weight loss than has bariatric surgery. The single completed randomised controlled trial in adolescents shows the same outcome. This is supported by meta analyses of bariatric surgery in adolescent subjects. A more aggressive approach to severe obesity, utilising bariatric surgery in selected cases, within the context of a multi-disciplinary team, is required.

Predicting hepatic steatosis in a racially and ethnically diverse cohort of adolescent girls

OBJECTIVE

To develop a risk assessment model for early detection of hepatic steatosis using common anthropometric and metabolic markers.

STUDY DESIGN

This was a cross-sectional study of 134 adolescent and young adult females, age 11-22 years (mean 13.3±2 years) from a middle school and clinics in Madison, Wisconsin. The ethnic distribution was 27% Hispanic and 73% non-Hispanic; the racial distribution was 64% Caucasian, 31% African-American, and 5% Asian, Fasting glucose, fasting insulin, alanine aminotransferase (ALT), body mass index (BMI), waist circumference (WC), and other metabolic markers were assessed. Hepatic fat was quantified using magnetic resonance imaging proton density fat fraction (MR-PDFF). Hepatic steatosis was defined as MR-PDFF>5.5%. Outcome measures were sensitivity, specificity, and positive predictive value (PPV) of BMI, WC, ALT, fasting insulin, and ethnicity as predictors of hepatic steatosis, individually and combined, in a risk assessment model. Classification and regression tree methodology was used to construct a decision tree for predicting hepatic steatosis.

RESULTS

MR-PDFF revealed hepatic steatosis in 16% of subjects (27% overweight, 3% nonoverweight). Hispanic ethnicity conferred an OR of 4.26 (95% CI, 1.65-11.04; P=.003) for hepatic steatosis. BMI and ALT did not independently predict hepatic steatosis. A BMI>85% combined with ALT>65 U/L had 9% sensitivity, 100% specificity, and 100% PPV. Lowering the ALT value to 24 U/L increased the sensitivity to 68%, but reduced the PPV to 47%. A risk assessment model incorporating fasting insulin, total cholesterol, WC, and ethnicity increased sensitivity to 64%, specificity to 99% and PPV to 93%.

CONCLUSION

A risk assessment model can increase specificity, sensitivity, and PPV for identifying the risk of hepatic steatosis and guide the efficient use of biopsy or imaging for early detection and intervention.

Severe obesity among children in New York City public elementary and middle schools, school years 2006-07 through 2010-11

INTRODUCTION

Although studies have shown that childhood obesity overall is on the decline among New York City (NYC) public school children, the prevalence of severe childhood obesity has not been studied.

METHODS

We used height and weight measurements of 947,765 NYC public school students aged 5 to 14 years in kindergarten through 8th grade (K-8), from school years 2006-07 through 2010-11. We used age- and sex-specific body mass index (BMI) percentiles according to Centers for Disease Control and Prevention growth charts to define childhood obesity (BMI ≥ 95th percentile) and severe childhood obesity (BMI ≥120% of 95th percentile) and to identify biologically implausible values (BIV). Multivariable logistic models tested for trends in obesity and severe obesity prevalence. To evaluate misclassification, we recalculated prevalence estimates for the most recent school year (2010-11) including the student records identified as BIV who were also declared severely obese (BMI ≥ 120% of 95th percentile). We refer to this subgroup of BIVs as "high BIV."

RESULTS

Severe obesity among NYC public school students in grades K-8 decreased 9.5% from the 2006-07 school year (6.3%) to the 2010-11 school year (5.7%), and obesity decreased 5.5% (from 21.9% to 20.7%). The prevalence of severe obesity and obesity was highest among minority, poor, and male children. Severe obesity declined in prevalence among every subgroup, with the greatest effect among white students and wealthy students. Severe obesity prevalence increased with age, and obesity prevalence peaked among those aged 7 to 10 years. For the 2010-11 school year, including high BIVs increased severe obesity prevalence from 5.7% to 6.6% and increased obesity prevalence from 20.7% to 21.5%.

CONCLUSION

Among all subgroups of NYC public school children in grades K-8, the reduction in severe obesity was greater than the reduction in overall obesity. Efforts to decrease obesity in NYC have affected the severely obese; however, monitoring of this specific subgroup should continue because of differences in trends and greater health risks.

Parental perceptions of family and pediatrician roles in childhood weight management

OBJECTIVE

To characterize parental perceptions of the respective roles of families and the pediatrician in childhood weight management.

STUDY DESIGN

Structured in-person interviews (n = 69) were conducted with parents of children ages 3-12 years visiting a pediatric clinic. Interview topics included perceptions of weight and associated problems, child weight status and concerns, and the pediatrician's role in weight management. Interviews were coded qualitatively and analyzed thematically.

RESULTS

Nine major themes were developed from the findings. Parents were clear about the health consequences of excess weight but were not clear about the concept of body mass index, often relying on visual cues or symptoms to identify excess weight. Parents relied on pediatricians to identify weight problems and suggest diet and exercise plans, but few recognized them as a link to additional weight-management resources. Parents were divided on the role of the pediatrician in managing child weight and were most interested in receiving tailored nutrition information. Parents preferred family behavioral change strategies over singling out an overweight child. Although parents did not always define their child as overweight, many parents of overweight children did express concerns about their child's weight.

CONCLUSIONS

Parents believe that pediatricians have a central role in identifying childhood weight problems by completing screening tests such as body mass index assessments, interpreting the health implications, and communicating those implications to parents. Ensuring that parents understand the health implications of excess weight is critical given gaps in parental knowledge and confidence with healthy lifestyle changes as well as parental ambivalence toward child-directed interventions.

Current guidelines for weight loss surgery in adolescents: a review of the literature

INTRODUCTION

The purpose of this review was to synthesize current clinical practice guidelines for weight loss surgery in adolescents in the United States and Canada to guide pediatric nurse practitioners in decisions regarding appropriate patient referral and counseling.

METHOD

A comprehensive search of the literature from 2007 until April 2013 was conducted using the PubMed, Embase, and CINAHL databases, including a hand search of references lists of identified articles. Guidelines pertaining exclusively to the use of weight loss surgery and general obesity treatment guidelines that included recommendations about weight loss surgery in adolescents were included in the review.

RESULTS

Variation exists among the guidelines regarding criteria for appropriate age, body mass index, comorbidity, exclusion, and preoperative management. Validation for laparoscopic weight loss surgery techniques in adolescents is provided.

DISCUSSION

Weight loss surgery for morbidly obese adolescents is a medically and psychologically complex decision, and primary care providers need to be equipped to address this decision with their patients and families.

Pediatric fatty liver disease: Role of ethnicity and genetics

Non-alcoholic fatty liver disease (NAFLD) comprehends a wide range of conditions, encompassing from fatty liver or steatohepatitis with or without fibrosis, to cirrhosis and its complications. NAFLD has become the most common form of liver disease in childhood as its prevalence has more than doubled over the past 20 years, paralleling the increased prevalence of childhood obesity. It currently affects between 3% and 11% of the pediatric population reaching the rate of 46% among overweight and obese children and adolescents. The prevalence of hepatic steatosis varies among different ethnic groups. The ethnic group with the highest prevalence is the Hispanic one followed by the Caucasian and the African-American. This evidence suggests that there is a strong genetic background in the predisposition to fatty liver. In fact, since 2008 several common gene variants have been implicated in the pathogenesis of fatty liver disease. The most important is probably the patatin like phospholipase containing domain 3 gene (PNPLA3) discovered by the Hobbs’ group in 2008. This article reviews the current knowledge regarding the role of ethnicity and genetics in pathogenesis of pediatric fatty liver.

Performance of references based on body mass index for detecting excess body fatness in schoolchildren aged 7 to10 years

Objective: To compare the sensitivity and specificity of body mass index (BMI)-based classification systems and to determine the optimal cut-offs for predicting excess body fatness in schoolchildren. Methods: 2795 schoolchildren aged 7 - 10 years were examined. Excess body fatness was defined as the standardized residuals of the sum of three skinfold thickness ranking at or above the 90th percentile. The international BMI-based system recommended by the World Health Organization (WHO-2007) was evaluated on the basis of its sensitivity and specificity for detecting excess body fatness and compared with a national BMI reference (Brazil-2006). Likelihood ratios analysis was used to select the optimal cut-offs in each curve. Results: The two classification systems presented high sensitivity (92.5 - 98.6%) and moderate specificity (75.9 - 85.0%) for both sexes. The optimal BMI cut-offs improved specificity with no marked loss of sensitivity. Using the proposed BMI cut-offs, the post-test probability of predicting excess body fatness for children classified as non-overweight decreased from 10 (pre-test probability) to 1.4% in girls and to 1.1% in boys. For overweight children, this probability increased to more than 46.0%. Conclusion: The results showed that both the WHO-2007 and Brazil-2006 classification systems can be used as screening instruments for excess body fatness, and that one of the limitations of using the BMI-for-age references could be improved by refining the existing cut-offs.