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

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.

Obesity and headache/migraine: the importance of weight reduction through lifestyle modifications

The aim of this study is to determine a possible relationship between prevalence, frequency, and severity of migraine and obesity. All pertinent data from the literature have been critically examined and reviewed in order to assess the possible relationship between obesity and migraine, in particular migraine frequency and disability in children, as well as in adult population studies. Prevalence, frequency, and severity of migraine appear to increase in relation to the body mass index, although this evidence is not supported by all the studies examined. Data from literature suggest that obesity can be linked with migraine prevalence, frequency, and disability both in pediatric and adult subjects. These data have important clinical implications and suggest that clinicians should have a special interest for weight reduction of obese children suffering from migraine, prescribing and supporting intensive lifestyle modifications (dietary, physical activities, and behavioral) for the patient and the entire family.

Treatment Strategies to Prevent Renal Damage in Hypertensive Children

Hypertension secondary to chronic kidney disease prevails in earlier childhood and obesity-related primary hypertension in adolescence. Both are associated with a high risk of renal and cardiovascular morbidity. In children with chronic kidney disease, uncontrolled hypertension may accelerate progression to end-stage renal disease before adulthood is reached and increase a child’s risk of cardiac death a thousand-fold. Obesity-related hypertension is a slow and silent killer, and though early markers of renal damage are recognized during childhood, end-stage renal disease is a risk in later life. Renal damage will be a formidable multiplier of cardiovascular risk for adults in whom obesity and hypertension tracks from childhood. Management options to prevent renal damage will vary for these different target groups. This review provides a summary of the available renoprotective strategies in order to aid physicians involved in the care of this challenging group of children.

High blood pressure in children and its correlation with three definitions of obesity in childhood

Background

Several authors have correlated the increase of cardiovascular risk with the nutritional status, however there are different criteria for the classification of overweight and obesity in children.

Objectives

To evaluate the performance of three nutritional classification criteria in children, as definers of the presence of obesity and predictors of high blood pressure in schoolchildren.

Methods

Eight hundred and seventeen children ranging 6 to 13 years old, enrolled in public schools in the municipality of Vila Velha (ES) were submitted to anthropometric evaluation and blood pressure measurement. The classification of the nutritional status was established by two international criteria (CDC/NCHS 2000 and IOTF 2000) and one Brazilian criterion (Conde e Monteiro 2006).

Results

The prevalence of overweight was higher when the criterion of Conde e Monteiro (27%) was used, and inferior by the IOTF (15%) criteria. High blood pressure was observed in 7.3% of children. It was identified a strong association between the presence of overweight and the occurrence of high blood pressure, regardless of the test used (p < 0.001). The test showing the highest sensitivity in predicting elevated BP was the Conde e Monteiro (44%), while the highest specificity (94%) and greater overall accuracy (63%), was the CDC criterion.

Conclusions

The prevalence of overweight in Brazilian children is higher when using the classification criterion of Conde e Monteiro, and lower when the criterion used is IOTF. The Brazilian classification criterion proved to be the most sensitive predictor of high BP risk in this sample.

Is left ventricular diastolic dysfunction independent from presence of hypertension in metabolic syndrome? An echocardiographic study

BACKGROUND

It has been shown that left ventricular diastolic dysfunction (LVDD) develops in patients with metabolic syndrome (MetS). However, there is not sufficient evidence in the literature to determine whether this condition is due to increase in blood pressure, which is frequently encountered in MetS. The purpose of this study was to test the hypothesis whether LVDD in MetS is independent from the presence of hypertension.

METHODS

A total of 60 patients diagnosed with MetS and 30 healthy people, who were age- and gender-matched with the patient group, were included in the study as the control group. In the study group, 30 of the patients were normotensive whereas the other 30 had hypertension. Conventional echocardiographic examinations and tissue Doppler imaging were performed besides measurements of demographic and biochemical parameters.

RESULTS

In the hypertensive MetS group, early diastolic filling flow (E), early diastolic mitral annular velocity (E'), and E/A ratio were significantly lower compared to the control group. Late diastolic filling flow (A), deceleration time (DT), late diastolic mitral annular velocity (A'), and E/E' ratio were higher in the hypertensive MetS group than the control group. In the normotensive MetS group, E, E', and E/A ratio were also lower compared to the control group whereas DT, A', and E/E' ratio were higher.

CONCLUSION

These findings support the idea that LVDD may develop in patients with MetS even in the absence of hypertension. In addition, co-existence of hypertension with MetS contributes to further worsening of diastolic functions.

Bariatric surgery in monogenic and syndromic forms of obesity

Currently, no topic is more controversial in bariatric surgery than performing these procedures on children with monogenic and syndromic forms of obesity. The medical community and the caregivers of those patients are struggling to find a solution that can alleviate their suffering and save their life. In all forms of obesity, dieting and physical activity do not result in significant weight loss and is associated with a high rate of weight regain. Additionally, effective medical therapy is not available yet. While there is significant debate about the risks and benefits of bariatric surgery in the adolescent population, there is an increasing number of studies that demonstrate the success of this option for the appropriate patients. Similarly, our experience demonstrated the same success not only in normal children and adolescents but also in those with monogenic and syndromic form of obesity.

Genetic modifiers of obesity and bariatric surgery outcomes

Obesity is a highly heritable trait. While acute and chronic changes in body weight or obesity-related comorbidities are heavily influenced by environmental factors, there are still strong genomic modifiers that help account for inter-subject variability in baseline traits and in response to interventions. This review is intended to provide an up-to-date overview of our current understanding of genetic influences on obesity, with emphasis on genetic modifiers of baseline traits and responses to intervention. We begin by reviewing how genetic variants can influence obesity. We then examine genetic modifiers of weight loss via different intervention strategies, focusing on known and potential modifiers of surgical weight loss outcomes. We will pay particular attention to the effects of patient age on outcomes, addressing the risks and benefits of adopting early intervention strategies. Finally, we will discuss how the field of bariatric surgery can leverage knowledge of genetic modifiers to adopt a personalized medicine approach for optimal outcomes across this widespread and diverse patient population.

Laparoscopic vertical sleeve gastrectomy for adolescents with morbid obesity

Obesity is a worldwide epidemic, and surgical weight loss operations have been performed for over 20 years. Laparoscopic sleeve gastrectomy was first performed as part of the biliopancreatic diversion over 30 years ago. Recently, laparoscopic sleeve gastrectomy has led to excellent excess weight loss with limited morbidity, especially compared to Roux-en-Y gastric bypass. In adolescents, laparoscopic sleeve gastrectomy is an excellent option to provide excess weight loss and remission of comorbid conditions without long-term malabsorptive risks.

Metformin in the treatment of obese children and adolescents at risk of type 2 diabetes

Metformin is the first-line treatment for type 2 diabetes (T2D) in adults, children and young people, particularly in obese or overweight patients. Many studies have demonstrated that metformin is associated with weight reduction in adults and in prevention or delay of T2D onset in those who are at increased risk. In 2012, metformin was recommended by the UK National Institute for Health and Care Excellence as a treatment option in adults aged 18 years or over, who remain at high risk of T2D, despite participation in an intensive lifestyle-change programme. Prevalence of childhood obesity is increasing and is associated with elevated long-term risk of T2D and other adverse cardio-metabolic events; however, consensus is lacking on intervention strategies aimed at reducing this risk. This article discusses the rationale and evidence for the use of metformin in obese children and young people at high risk of T2D.

Accuracy of Neck Circumference in Classifying Overweight and Obese US Children

Objective. To evaluate classification accuracy of NC and compare it with body mass index (BMI) in identifying overweight/obese US children. Methods. Data were collected from 92 children (boys: 61) aged 7 to 13 over a 2-year period. NC, BMI, and percent of body fat (BF%) were measured in each child and their corresponding cut-off values were applied to classify the children as being overweight/obese. Classification accuracy of NC and BMI was systematically investigated for boys and girls in relation to true overweight/obesity categorization as assessed with a criterion measure of BF% (i.e., Bod Pod). Results. For boys, Cohen's κ (0.25), sensitivity (38.1%), and specificity (85.0%) of NC were smaller in comparison with Cohen's κ (0.57), sensitivity (57.1%), and specificity (95.0%) of BMI in relation to BF% categorization. For girls, Cohen's κ (0.45), sensitivity (50.0%), and specificity (91.3%) of NC were smaller in comparison with Cohen's κ (0.52), sensitivity (50.0%), and specificity (95.7%) of BMI. Conclusion. NC measurement was not better than BMI in classifying childhood overweight/obesity and, for boys, NC was inferior to BMI. Pediatricians and/or pediatric researchers should be cautious or wary about incorporating NC measurements in their pediatric care and/or research.

Treatment of obesity-related hypertension in children and adolescents

The obesity epidemic has become a common concern among pediatricians, with an estimated 32 % of US children and adolescents classified as overweight and 18 % as obese. Along with the increase in obesity, a growing body of evidence demonstrates that chronic diseases, such as Type 2 diabetes, primary hypertension, and hyperlipidemia, once thought to be confined solely to adulthood, are commonly seen among the obese in childhood. Following a brief summary of the diagnosis and evaluation of hypertension in obese children and adolescents, this review will highlight recent research on the treatment of obesity-related hypertension. Pharmacologic and non-pharmacologic treatment will be discussed. Additionally, current and emerging therapies for the primary treatment of obesity in children and adolescents, which have been gaining in popularity, will be reviewed.

Effects of exercise in the treatment of overweight and obese children and adolescents: a systematic review of meta-analyses

PURPOSE

Conduct a systematic review of previous meta-analyses addressing the effects of exercise in the treatment of overweight and obese children and adolescents.

METHODS

Previous meta-analyses of randomized controlled exercise trials that assessed adiposity in overweight and obese children and adolescents were included by searching nine electronic databases and cross-referencing from retrieved studies. Methodological quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) Instrument. The alpha level for statistical significance was set at P ≤ 0.05.

RESULTS

Of the 308 studies reviewed, two aggregate data meta-analyses representing 14 and 17 studies and 481 and 701 boys and girls met all eligibility criteria. Methodological quality was 64% and 73%. For both studies, statistically significant reductions in percent body fat were observed (P = 0.006 and P < 0.00001). The number-needed-to treat (NNT) was 4 and 3 with an estimated 24.5 and 31.5 million overweight and obese children in the world potentially benefitting, 2.8 and 3.6 million in the US. No other measures of adiposity (BMI-related measures, body weight, and central obesity) were statistically significant.

CONCLUSIONS

Exercise is efficacious for reducing percent body fat in overweight and obese children and adolescents. Insufficient evidence exists to suggest that exercise reduces other measures of adiposity.

Factors associated with adherence to the Mediterranean diet among adolescents living in Sicily, Southern Italy

The present study aimed to examine the factors associated with increased Mediterranean diet (MD) adherence among a sample of Italian adolescents. A cross-sectional survey was conducted on 1135 students (13-16 years) attending 13 secondary schools of Sicily, southern Italy. Validated instruments were used for dietary assessment and the KIDMED score to assess adolescents' adherence to the MD. A higher adherence to the MD was associated with high socioeconomic status (Odds Ratio [OR] 1.53, 95% Confidence Interval [CI]: 1.03-2.26) and high physical activity (OR 1.19, 95% CI: 1.02-1.70), whereas lower adherence was associated with living in an urban environment (OR 0.65, 95% CI: 0.44-0.97) and being obese (OR 0.59, 95% CI: 0.37-0.94). The adolescents' KIDMED scores were inversely associated with adolescents' intake of sweets, fast foods, fried foods, and sugary drinks, and directly with fruit, vegetables, pasta, fish, and cheese intakes. Urban-living adolescents were less likely to eat fruit and more prone to consume meat, sugary drinks, and fast food than rural-living adolescents. The latter were more likely to eat sweets and snacks. A general poor quality of food consumption in Italian adolescents away from the MD was reported, especially among those living in urban areas.

Transition to adult care in adolescent obesity: a systematic review and why it is a neglected topic

Transition in pediatric health care involves the purposeful, planned movement of patients from pediatric to adult services. Following the significant increases in long-term survival of chronic childhood diseases in the 1980s, transition has taken on an increasing importance in the management of these chronic diseases. In Australia, there is a conspicuous lack of programs/guidelines for transitioning adolescents with obesity. The authors sought to determine if this is an international phenomenon that should be addressed. This study aimed to identify what formal transition services or guidelines exist internationally for adolescents with overweight/obesity. Two systematic reviews of the published and 'gray' literature were implemented via searches of relevant databases, search engines and websites. The primary review eligibility criteria were documents published between 1982 and 2012 including any aspect of transitioning adolescents with overweight/obesity from pediatric to adult weight management services. The secondary review included current clinical practice guidelines/statements on pediatric obesity management published between 1992 and 2012, and transition recommendations contained within. Non-English language documents were excluded. Relevant text from eligible documents was systematically identified and extracted, and a qualitative synthesis of the data was prepared. Overall, 2272 unique records were identified from the literature searches. Three eligible articles were identified by the primary review. The secondary review identified 24 eligible guidelines/statements. In total, six of the identified documents contained information on transition in adolescent obesity-the most detailed documents provided only a brief statement recommending that transition from pediatric to adult weight management services should take place. In conclusion, internationally there is an absence of published intervention programs/policies, and brevity of clinical guidance and expert opinion, on the transition of adolescents with obesity making this a priority research area. Consideration is given to the reasons why transition in adolescent obesity is a neglected topic.

Paediatric gastroenterology evaluation of overweight and obese children referred from primary care for suspected non-alcoholic fatty liver disease

BACKGROUND

Screening overweight and obese children for non-alcoholic fatty liver disease (NAFLD) is recommended by paediatric and endocrinology societies. However, gastroenterology societies have called for more data before making a formal recommendation.

AIM

To determine whether the detection of suspected NAFLD in overweight and obese children through screening in primary care and referral to paediatric gastroenterology resulted in a correct diagnosis of NAFLD.

METHODS

Information generated in the clinical evaluation of 347 children identified with suspected NAFLD through screening in primary care and referral to paediatric gastroenterology was captured prospectively. Diagnostic outcomes were reported. The diagnostic performance of two times the upper limit of normal (ULN) for alanine aminotransferase (ALT) was assessed.

RESULTS

Non-alcoholic fatty liver disease was diagnosed in 55% of children identified by screening and referral. Liver disease other than NAFLD was present in 18% of those referred. Autoimmune hepatitis was the most common alternative diagnosis. Children with NAFLD had significantly (P < 0.05) higher screening ALT (98 ± 95) than children with liver disease other than NAFLD (86 ± 74). Advanced fibrosis was present in 11% of children. For the diagnosis of NAFLD, screening ALT two times the clinical ULN had a sensitivity of 57% and a specificity of 71%.

CONCLUSIONS

Screening of overweight and obese children in primary care for NAFLD with referral to paediatric gastroenterology has the potential to identify clinically relevant liver pathology. Consensus is needed on how to value the risk and rewards of screening and referral, to identify children with liver disease in the most appropriate manner.

Five recent expert recommendations on the treatment of childhood and adolescent obesity: toward an emerging consensus--a stepped care approach

BACKGROUND

Various organizations published five sets of expert recommendations recently: 2007 Healthcare Organizations' Four Stage Model; 2006 Canadian Clinical Practice Guidelines; 2008 The Endocrine Society Recommendations; 2009 Seven Step Model; and 2010 US Preventive Task Force Recommendations.

METHODS

We compared the recommendations' approaches and conclusions pertaining to four treatments (self-help groups, outpatient cognitive-behavior therapy [CBT], immersion CBT, and surgery).

RESULTS

All of the expert committees supported using intensive dietary, physical activity, and cognitive-behavioral counseling; two of the five groups discouraged reliance on educational interventions alone, and two of the groups explicitly promoted a stepped-care approach.

CONCLUSIONS

Greatest benefits may accrue by encouraging healthcare providers and parents to view medical management and education as foundations to change, but to pursue increasingly intensive viable options until overweight and obese children make clinically significant progress toward improved health and happiness.

Lifestyle intervention in childhood obesity: changes and challenges

Lifestyle interventions are regarded as the therapy of choice in children with obesity. The efficiency of lifestyle intervention for childhood obesity has been proven by several randomized controlled trials and meta-analyses. Even a stable weight in a growing child with obesity is associated with an improvement in cardiovascular risk factors and comorbidities of obesity. In particular, children aged 5-12 years and children with overweight rather than obesity profit from lifestyle interventions. However, in clinical practice, the degree of weight loss with lifestyle intervention is only moderate, and the success rate 2 years after onset of an intervention is low (<10% with a decrease in BMI SD score of <0.25). Nevertheless, the difficulty of a child with overweight or obesity to reduce their weight might be attributable to not only a lack of motivation but also genetic background and/or adaptive changes in basal metabolic rate, hunger and satiety hormones that occur with weight loss. We must accept that lifestyle interventions are successful only in a subgroup of children with obesity. Regardless, the techniques used and the education of therapists need to be improved. If lifestyle interventions do not result in weight loss in a child with obesity, drug treatment to reduce cardiovascular risk factors should be initiated but is currently seldom performed.

Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: a scientific statement from the American Heart Association

Severe obesity afflicts between 4% and 6% of all youth in the United States, and the prevalence is increasing. Despite the serious immediate and long-term cardiovascular, metabolic, and other health consequences of severe pediatric obesity, current treatments are limited in effectiveness and lack widespread availability. Lifestyle modification/behavior-based treatment interventions in youth with severe obesity have demonstrated modest improvement in body mass index status, but participants have generally remained severely obese and often regained weight after the conclusion of the treatment programs. The role of medical management is minimal, because only 1 medication is currently approved for the treatment of obesity in adolescents. Bariatric surgery has generally been effective in reducing body mass index and improving cardiovascular and metabolic risk factors; however, reports of long-term outcomes are few, many youth with severe obesity do not qualify for surgery, and access is limited by lack of insurance coverage. To begin to address these challenges, the purposes of this scientific statement are to (1) provide justification for and recommend a standardized definition of severe obesity in children and adolescents; (2) raise awareness of this serious and growing problem by summarizing the current literature in this area in terms of the epidemiology and trends, associated health risks (immediate and long-term), and challenges and shortcomings of currently available treatment options; and (3) highlight areas in need of future research. Innovative behavior-based treatment, minimally invasive procedures, and medications currently under development all need to be evaluated for their efficacy and safety in this group of patients with high medical and psychosocial risks.

The lipid fraction of human milk initiates adipocyte differentiation in 3T3-L1 cells

BACKGROUND

The prevalence of childhood obesity has increased worldwide over the past decade. Despite evidence that human milk lowers the risk of childhood obesity, the mechanism is not fully understood.

AIMS

We investigated the direct effect of human milk on differentiation of 3T3-L1 preadipocytes.

STUDY DESIGN AND SUBJECTS

3T3-L1 preadipocytes were treated with donated human milk only or the combination of the standard hormone mixture; insulin, dexamethasone (DEX), and 3-isobututyl-1-methylxanthine (IBMX). Furthermore, the induction of preadipocyte differentiation by extracted lipids from human milk was tested in comparison to the cells treated with lipid extracts from infant formula. Adipocyte differentiation, specific genes as well as formation of lipid droplets were examined.

RESULTS

We clearly show that lipids present in human milk initiate 3T3-L1 preadipocyte differentiation. In contrast, this effect was not observed in response to lipids present in infant formula. The initiation of preadipocyte differentiation by human milk was enhanced by adding the adipogenic hormone, DEX or insulin. The expression of late adipocyte markers in Day 7 adipocytes that have been induced into differentiation with human milk lipid extracts was comparable to those in control cells initiated by a standard adipogenic hormone cocktail.

CONCLUSIONS

These results demonstrate that human milk contains bioactive lipids that can initiate preadipocyte differentiation in the absence of the standard adipogenic compounds via a unique pathway.

Calculating cardiac risk in obese adolescents before and after onset of lifestyle intervention

Prevalence and severity of obesity in adolescents is increasing worldwide. The obesity-associated cardiovascular risk factors (CRF) determine cardiac risk as demonstrated by longitudinal studies. Fat distribution and not overall fat mass determines the cardiac risk, since intra-abdominal adipose tissue is especially related to CRFs. Besides classical CRFs such as hypertension, dyslipidemia and impaired glucose metabolism, a proinflammatory and prothrombotic state in obesity is associated with cardiac risk. Adipocytokines such as adiponectin are related to cardiac risk and may present useful predictors of cardiac mortalities in future. Measurement of the carotid intima-media thickness is a new promising noninvasive marker for early cardiovascular changes including atherosclerosis. The therapy of choice to prevent cardiac events in obesity is lifestyle intervention of obese adolescents. However, in clinical practice, the weight loss in lifestyle interventions is only moderate and drug treatment of CRFs is seldom performed.

Family-based behavioural intervention program for obese children: an observational study of child and parent lifestyle interpretations

Background

Family-based behavioural intervention programs (FBIPs) against childhood obesity have shown promising results, but the mediating mechanisms have not been identified. The aim of this study was to examine changes in obese childreńs lifestyle habits during a 2-year FBIP according to their own and parents’ reports, the concordance between these reports and the correlations to change in post-intervention z-BMI.

Methods

An observational study of 26 children (8.3–12.0 years) and their parents participating in a 2-year FBIP was performed. Weight and height were measured from baseline to 12 months after the end of the program. Eating habits and physical- and sedentary activity were reported separately by children and parents. Data were analysed with regard to concordance between parents’ and children’s reports and association between the lifestyle reports and change in z-BMI at the study endpoint using descriptive statistics and parametric and non-parametric tests.

Results

According to both children’s and parents’ reports, the level of physical activity among the children had increased after the intervention as well as the agreement between the informants’ reports. According to the children, eating habits had improved, while the parents’ reports showed an improvement only with regard to binge eating. The concordance between children and parents regarding eating habits was slight to fair also after the intervention. No statistically significant associations between changes in lifestyle reports and changes in z-BMI were observed.

Conclusions

Child and parent reports of physical activity were found to converge and display an improvement in a 2-year FBIP, while the reports on eating habits showed a more refractory pattern. Changes in concordance and agreement between children and parents reports did not correlate with weight reduction. Further methods development and studies of the processes during family-based interventions against childhood obesity are warranted.

Perceived weight, not obesity, increases risk for major depression among adolescents

This study examined the association between major depression, obesity and body image among adolescents.

METHODS

Participants were 4175 youths 11-17 years of age sampled from the community who were interviewed using the Diagnostic Interview Schedule for Children and Adolescents, Version IV, completed a self-report questionnaire, and had their weight and height measured. There were 2 measures of body image: perceived weight and body satisfaction. Obesity was associated with increased risk of depression, with no controls for covariates. However, when the association was examined in models which included weight, major depression, and body image measures and covariates, there was no association between major depression and body weight, nor between body satisfaction and major depression. Perceived overweight was strongly and independently associated with body weight (O.R. = 2.62). We found no independent association between major depression and body weight. If there is an etiologic link between major depression and body weight among adolescents, it most likely operates through processes involving components of body image. Future research should focus on the role of depression and body image in the etiology of obesity.

Participatory action research in the implementing process of evidence-based intervention to prevent childhood obesity: project design of the "Healthy Future" study

OBJECTIVE

To describe the design of the developmental project Healthy Future that aims to implement a new evidence-based program for the prevention of childhood obesity and collaboration and sharing of work between specialist and community health care professionals in parts of a county in western Norway.

METHODS

Comprehensive participatory planning and evaluation (CPPE) process as an action-oriented research approach was chosen, using mixed data sources, mixed methods, and triangulation.

DISCUSSION

A bottom-up approach might decrease the barriers when new evidence-based childhood prevention interventions are going to be implemented. It is crucial not only to build partnership and shared understanding, motivation, and vision, but also to consider the frames of the organizations, such as competencies, and time to carry out the interventions at the right level of health care service and adapt to the overweight children and their families needs.

CONCLUSION

The developmental process of new health care programs is complex and multileveled and requires a framework to guide the process. By CPPE approach evidence-based health care practice can be delivered based on research, user knowledge, and provider knowledge in the field of childhood overweight and obesity in a certain context.

Does excess weight interfere with bone mass accumulation during adolescence?

Obesity and osteoporosis are important global health problems characterized by increasing prevalence with high impact on morbidity and mortality. The objective of this review was to determine whether excess weight during adolescence interferes with bone mass accumulation. If bone mineral gain can be optimized during puberty, adults are less likely to suffer from the devastating complications of osteoporosis. The increased fracture risk in obese children has also been attributed to a lower bone mass for weight compared to non-obese children. Thus, adiposity present in this age group may not result in the protection of bone mass, in contrast to what has been observed in adults. However, studies involving adolescents have reported both protective and detrimental effects of obesity on bone. The results and mechanisms of these interactions are controversial and have not been fully elucidated, a fact highlighting the extreme relevance of this topic and the need to monitor intervening and interactive variables.

Clinical review: Bariatric surgery following treatment for craniopharyngioma: a systematic review and individual-level data meta-analysis

OBJECTIVES

Craniopharyngiomas are rare low-grade tumors located in the hypothalamic and/or pituitary region. Hypothalamic involvement and treatment resulting in hypothalamic damage are known to lead to development of "hypothalamic obesity" (HyOb) in 50% of cases. The management of HyOb, associated with eating disorders and rapid comorbidities, is an important issue. Bariatric surgery is the most effective therapy for weight loss in patients with severe exogenous obesity. The aim of this systematic review and meta-analysis was to determine the 12-month outcome of bariatric surgery for HyOb due to craniopharyngioma treatment.

METHODS AND RESULTS

Relevant studies were identified by searches of the MEDLINE and EMBASE databases until January 2013. A total of 21 cases were included: 6 with adjustable gastric banding, 8 with sleeve gastrectomy, 6 with Roux-en-Y gastric bypass, and 1 with biliopancreatic diversion. After data pooling, mean weight difference was -20.9 kg after 6 months (95% confidence interval [CI], -35.4, -6.3) and -15.1 kg after 12 months (95% CI, -31.7, +1.4). The maximal mean weight loss was achieved by the gastric bypass group: -31.0 kg (95% CI, -77.5, +15.5) and -33.7 kg (95% CI, -80.7, +13.3) after 6 and 12 months, respectively.

CONCLUSIONS

In this largest ever published study on the effect of bariatric surgery on obesity after craniopharyngioma treatment, we observed an important weight loss after 1 year of follow-up. Larger studies are warranted to establish appropriate selection criteria and the best surgical technique to perform bariatric surgery.

A 360-degree overview of paediatric NAFLD: recent insights

Non-alcoholic fatty liver disease (NAFLD) is a multi-faceted disorder, which ranges from simple steatosis to non-alcoholic steatohepatitis (NASH) with/without fibrosis. The effects of specific risk factors, such as obesity and sedentary lifestyle, on predisposing genetic settings eventually lead to the development of NAFLD in children. The complex interplay between genes and environment in NAFLD pathogenesis is sustained by multiple mechanisms that involve liver crosstalk with other organs and tissues, especially gut and adipose tissue. Unfortunately, natural history of paediatric NAFLD is lacking, and the etiopathogenesis is still in the process of being defined. Potential early predictors and suitable non-invasive diagnostic tools can be discovered based on the pathogenetic mechanisms and histological patterns. This will also help design novel treatments and a comprehensive and successful management strategy for patients. In this review, we discuss the recent advances made in genetics, etiopathogenesis, diagnosis, and therapeutic management of NAFLD, focusing especially on the obesity-related steatotic liver condition.

GrowthHormone Research Society workshop summary: consensus guidelines for recombinant human growth hormone therapy in Prader-Willi syndrome

CONTEXT

Recombinant human GH (rhGH) therapy in Prader-Willi syndrome (PWS) has been used by the medical community and advocated by parental support groups since its approval in the United States in 2000 and in Europe in 2001. Its use in PWS represents a unique therapeutic challenge that includes treating individuals with cognitive disability, varied therapeutic goals that are not focused exclusively on increased height, and concerns about potential life-threatening adverse events.

OBJECTIVE

The aim of the study was to formulate recommendations for the use of rhGH in children and adult patients with PWS.

EVIDENCE

We performed a systematic review of the clinical evidence in the pediatric population, including randomized controlled trials, comparative observational studies, and long-term studies (>3.5 y). Adult studies included randomized controlled trials of rhGH treatment for ≥ 6 months and uncontrolled trials. Safety data were obtained from case reports, clinical trials, and pharmaceutical registries.

METHODOLOGY

Forty-three international experts and stakeholders followed clinical practice guideline development recommendations outlined by the AGREE Collaboration (www.agreetrust.org). Evidence was synthesized and graded using a comprehensive multicriteria methodology (EVIDEM) (http://bit.ly.PWGHIN).

CONCLUSIONS

Following a multidisciplinary evaluation, preferably by experts, rhGH treatment should be considered for patients with genetically confirmed PWS in conjunction with dietary, environmental, and lifestyle interventions. Cognitive impairment should not be a barrier to treatment, and informed consent/assent should include benefit/risk information. Exclusion criteria should include severe obesity, uncontrolled diabetes mellitus, untreated severe obstructive sleep apnea, active cancer, or psychosis. Clinical outcome priorities should vary depending upon age and the presence of physical, mental, and social disability, and treatment should be continued for as long as demonstrated benefits outweigh the risks.

Waist circumference measurement site does not affect relationships with visceral adiposity and cardiometabolic risk factors in children

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

A number of anatomic sites are used for the measurement of waist circumference. A number of studies have documented differences in the absolute values of waist circumference measurements across these common sites in adults. It is unclear whether waist circumference measurement site alters the relationship with abdominal adiposity and cardiometabolic risk factors in children.

WHAT THIS STUDY ADDS

The absolute values of waist circumference at four anatomic locations (minimal, midway, iliac, umbilicus) differed and this affected prevalence of high (≥90th percentile) waist circumference. The relationships between waist circumference values at four anatomic locations and both depot-specific adiposity and cardiometabolic risk factors were similar across race and sex groups.

BACKGROUND

Different waist circumference (WC) measurement sites are used in clinical and epidemiological settings.

OBJECTIVES

To examine differences in WC measurement at four anatomic sites and how each WC measurement relates to visceral adipose tissue (VAT) and cardiometabolic risk factors in children.

METHODS

A total of 371 white and African-American children aged 5 to 18 years had WC measured at four sites: minimal waist, midpoint between the iliac crest and the lowest rib, superior border of the iliac crest and the umbilicus. Abdominal VAT was measured using magnetic resonance imaging and cardiometabolic risk factors were defined using National Heart, Lung and Blood Institute guidelines. Relationships between WC sites and VAT and risk factors were explored in each race-by-sex group.

RESULTS

All WC sites were highly correlated (r = 0.97 to 0.99). Differences in absolute mean WC values existed in all race-by-sex groups, and this affected the prevalence of high WC (≥90th percentile). Values were lowest for minimal waist and highest for umbilicus. Age-controlled partial correlations between WC and logVAT VAT were 0.81-0.89 (all P < 0.001) and between WC and cardiometabolic risk factors were -0.24 to -0.41 and 0.19 to 0.52 (all P < 0.05).

CONCLUSIONS

  While the absolute values of WC at four anatomic locations differed, the relationships between WC values and both VAT and cardiometabolic risk factors were similar within all race-by-sex groups.

The effect of participation in school-based nutrition education interventions on body mass index: a meta-analysis of randomized controlled community trials

OBJECTIVE

The aim of this study was to evaluate the effectiveness of school-based nutrition education interventions in reducing or preventing overweight and obesity among children and adolescents.

METHODS

We conducted a systematic search of 14 databases until May 2010 and cross-reference check in 8 systematic reviews (SRs) for studies published that described randomized controlled trials conducted in schools to reduce or prevent overweight in children and adolescents. An additional search was carried out using PubMed for papers published through May 2012, and no further papers were identified. Body mass index (BMI) was the primary outcome. The title and abstract review and the quality assessment were performed independently by two researchers. The software EPPI-Reviewer3 was used to store, manage and analyze all data. This SR is registered at ClinicalTrials.gov (NCT00985972).

RESULTS

From the 4888 references initially retrieved, only 8 met the eligibility criteria for a random-effects meta-analysis. The total population consisted of 8722 children and adolescents. Across the studies, there was an average treatment effect of -0.33 kg/m(2) (-0.55, -0.11 95% CI) on BMI, with 84% of this effect explained by the highest quality studies.

CONCLUSION

This systematic review provides evidence that school-based nutrition education interventions are effective in reducing the BMI of children and adolescents.

The clinical treatment of childhood obesity

With the rising prevalence of childhood obesity, pediatricians are increasingly called upon to treat clinically overweight children. The primary treatment options are behavioral lifestyle modification, pharmacotherapy, and surgery. The cornerstone of childhood obesity treatment is lifestyle modification and has been shown to be effective in improving the severity of overweight and obesity. Several guidelines discuss appropriate methods for lifestyle modification in overweight and obese children. This review will summarize three recent guidelines/recommendations (released by the Scottish Intercollegiate Network, the American Academy of Pediatrics, and the United Kingdom National Institute for Health and Clinical Excellence) and describe by way of example, a current child obesity treatment program in the United States (Duke University Medical Center). Finally, evidence for pharmacologic and surgical treatment options will also be discussed, which can be valuable treatment options for select patients.

Pharmacotherapy for childhood obesity: present and future prospects

Pediatric obesity is a serious medical condition associated with significant comorbidities during childhood and adulthood. Lifestyle modifications are essential for treating children with obesity, yet many have insufficient response to improve health with behavioral approaches alone. This review summarizes the relatively sparse data on pharmacotherapy for pediatric obesity and presents information on obesity medications in development. Most previously studied medications demonstrated, at best, modest effects on body weight and obesity-related conditions. It is to be hoped that the future will bring new drugs targeting specific obesity phenotypes that will allow clinicians to use etiology-specific, and therefore more effective, anti-obesity therapies.

Childhood obesity: Determinants, evaluation, and prevention

Childhood obesity is a grave issue, which needs to be addressed urgently because it leads to several medical and psychosocial problems in children. High prevalence is being increasingly reported in children from developing countries as well. The combination of our genetic propensity to store fat, the ready availability of calorie dense foods, and sedentary lifestyle promotes overweight. The child's food environment at home and parental obesity are strong determinants. Urban poor in developed countries and urban rich in developing countries are both at risk. In developing countries, a number of beliefs passed down over generations are other important determinants. Evaluation includes assessing the child's lifestyle, excluding weight-promoting medication history; poor linear growth needs endocrine evaluation; genetic syndromes should be considered if there are clinical pointers. Overweight children should be evaluated for hypertension, dyslipidemia, T2DM, and NAFLD. Therapeutic lifestyle changes targeting food habits and physical activity through parental participation and social support are the cornerstones of preventing childhood obesity. Active travel and play by making the built environment more accessible, ban on 'junk' food advertising, and effective health education through active participation of clinicians, school systems, and the media will go a long way in reversing anticipated trends in childhood obesity.

Behavioral Interventions and Cardiovascular Risk in Obese Youth: Current Findings and Future Directions

The identification and early intervention of pediatric obesity is critical to reducing cardiovascular disease (CVD). Family-based behavioral interventions have consistently demonstrated efficacy in reducing adiposity and CVD risk factors (i.e., blood pressure, cholesterol, fasting glucose levels, insulin resistance, metabolic syndrome). Even modest weight loss in severely obese youth can lead to sustained improvement in CVD risk factors. However, weight regain following treatment cessation remains a challenge in the contemporary obesogenic environment. Intensive family-based interventions spanning socioenvironmental contexts (i.e., home, peer, community) show promise in sustaining weight loss in the long-term. Despite having effective treatments for pediatric obesity and CVD risk factors, families rarely have access to these programs and so increasing the role of healthcare providers in screening and referral efforts is imperative. Moving forward, it is also essential to establish communication and cooperative networks across sectors build sustainable prevention and intervention programs and to provide cohesive health messages.

Physical activity, energy intake, and obesity prevalence among urban and rural schoolchildren aged 11–12 years in Japan

The prevalence of childhood overweight and obesity has been shown to differ among regions, including rural–urban regional differences within nations. This study obtained simultaneous accelerometry-derived physical activity, 24 h activity, and food records to clarify the potential contributing factors to rural–urban differences in childhood overweight and obesity in Japan. Sixth-grade children (n = 227, 11–12 years old) from two urban elementary schools in Kyoto and four rural elementary schools in Tohoku participated in the study. The children were instructed to wear a pedometer that included a uniaxial accelerometer and, assisted by their parents, keep minute-by-minute 24 h activity and food records. For 12 children, the total energy expenditure was measured by the doubly labeled water method that was used to correct the Lifecorder-predicted activity energy expenditure and physical activity level. The overweight and obesity prevalence was significantly higher in rural than in urban children. The number of steps per day, activity energy expenditure, physical activity level, and duration of walking to school were significantly lower in rural than in urban children. In contrast, the reported energy intake did not differ significantly between the regions. The physical activity and duration of the walk to school were significantly correlated with body mass index. Rural children had a higher prevalence of overweight and obesity, and this may be at least partly caused by lower physical activity, especially less time spent walking to school, than urban children.

Comorbidities in overweight children and adolescents: do we treat them effectively?

OBJECTIVE

The aim was to analyze the effectiveness of treatment concerning obesity-associated comorbidities in clinical practice.

METHODS

A total of 11,681 overweight children with ≥ 6-month follow-up treated at 175 centers specialized in pediatric obesity care in Central Europe were included in this analysis (mean body mass index (BMI) 29.0 ± 5.6 kg m(-)(2), standard deviation score body mass index (SDS-BMI) 2.48 ± 0.54, 45% boys, age 11.4 ± 2.8 years). The changes of weight status, blood pressure, fasting lipids and glucose, and oral glucose tolerance tests were documented by standardized prospective quality documentation software (APV).

RESULTS

After follow-up of in median 1.2 (interquartile range 0.9-2.2) years, a mean reduction of -0.15 SDS-BMI was achieved. The prevalence of prehypertension (37->33%) and hypertension (17->12%) decreased, while prevalences of triglycerides >150 mg dl(-1) (22->21%), low-density-lipoprotein-cholesterol >130 mg dl(-1) (15->14%), impaired fasting glucose (6->6%) and impaired glucose tolerance (9->8%) remained stable. Drug treatment according to cutoffs recommended in European obesity guidelines were not frequently indicated (hypertension: 10%; dyslipidemia: 1%, type 2 diabetes <1%). None of the children with dyslipidemia received lipid-lowering drugs and only 1.4% of the children with hypertension were treated with antihypertensive drugs.

CONCLUSIONS

Achieving sufficient weight loss to improve obesity associated comorbidities was difficult in clinical practice. Drug treatment of hypertension, dyslipidemia and type 2 diabetes was rarely performed even if it was indicated only in a minority of the overweight children. Future analyses should identify reasons for this insufficient drug treatment of comorbidities and analyze whether the benchmarking processes of APV improve medical care of childhood obesity.

The effects of initial and subsequent adiposity status on diabetes mellitus

BACKGROUND

Obesity in adulthood is associated with increased risk for diabetes mellitus (DM). It is uncertain whether this risk is attenuated in adulthood who are overweight or obese initially but not obese subsequently.

METHODS AND RESULTS

The data were collected in 1992 and then again in 2007 from the same group of 687 participants (male: 58.1%, age: 48.1 ± 6.2 years).The participants were categorized into four groups on the basis of adiposity status in 1992 and 2007: group I included subjects with a normal BMI in 1992 and 2007; group II, those with a normal BMI in 1992 who were overweight or obese in 2007; group III, those who were overweight or obese in 1992 but normal BMI in 2007; and group IV, those who were overweight or obese in 1992 and 2007. With group I as reference, the HR is 0.818 for group II (95% CI: 0.341-1.962, p=0.653), 2.231 for group III (95% CI: 1.087-4.579, p=0.029) and 1.855 for group IV (95% CI: 1.049-3.279, p=0.034) after adjustment for confounders. It was not significantly different between groups I and II, as well as between groups III and IV.

CONCLUSION

In adulthood, becoming nonobese could not reverse the adverse effects of obesity on DM, as compared with the subjects who persist being overweight or obese. Keeping weight in the normal BMI range should be emphasized in the public for preventing DM.

Adolescent bariatric surgery

Overall it is clear that bariatric surgical intervention in appropriately selected adolescents is effective at both adequate weight loss and resolution of weight related co-morbidities in the short and medium term. Long-term results are being conducted currently to assess durability of bariatric surgical interventions. We believe that adolescents undergoing bariatric evaluation have unique needs and until more long-term data are available, the indications for surgery should be stricter than those used in adults. All of the bariatric procedures discussed must be performed in the background of positive behavioral modifications over a period of time. If lifestyle modification fails, these adolescents can gain weight by overcoming the physiologic effects of the surgery as they eat high calorie foods at very frequent intervals. Finally, close postoperative follow-up is required with active management of weight loss/gain, co-morbidities, and postoperative complications should they occur.

Laparoscopic sleeve gastrectomy in 108 obese children and adolescents aged 5 to 21 years

OBJECTIVE

To report experience with laparoscopic sleeve gastrectomy (LSG) in 108 severely obese children and adolescents.

BACKGROUND

Obesity during childhood and adolescence can be accompanied by serious long-term adverse health and longevity outcomes. With increased use of bariatric surgery to treat obesity in these patients, diverse guidelines have been published, most of which exclude children aged younger than 14 years. Few reports describe LSG in children and adolescents, delaying determining its safety and effectiveness and developing guidance regarding its use.

METHODS

A retrospective review of LSG performed from March 2008 through February 2011 by a single surgeon at King Saud University Hospitals, Riyadh, Saudi Arabia, included 108 patients aged 5 through 21 years.

RESULTS

Patients attending follow-up visits at 3 (n = 88), 6 (n = 76), 12 (n = 41), and 24 (n = 8) months postoperatively experienced median excess weight loss (EWL) of 28.9%, 48.1%, 61.3%, and 62.3%, respectively. At 6 and 12 months follow-up, 42.1% (n = 32) and 73.2% (n = 30) of patients achieved at least 50% EWL, whereas 7.9% (n = 6) and 4.9% (n = 2) had 25% or less EWL, respectively. There were no serious postoperative complications and no adverse sequelae developed during the current follow-up. Available comorbidity data indicate resolution of dyslipidemia, 21 of 30 (70.0%); hypertension, 27 of 36 (75.0%); prehypertension, 15 of 18 (83.3%); symptoms of obstructive sleep apnea, 20 of 22 (90.9%); diabetes, 15 of 16 (93.8%); and prediabetes, 11 of 11 (100.0%).

CONCLUSIONS

LSG resulted in successful short-term weight loss in more than 90% of pediatric patients and 70% or more comorbidity resolution during up to 24 months of follow-up. Long-term data are necessary to evaluate persistence of weight loss and maturation to adulthood.

Metabolic changes after a hypocaloric, low-glycemic-index diet in obese children

BACKGROUND

A low glycemic index (LGI) diet has been proposed as a treatment for obesity in adults; few studies have evaluated LGI diets in obese children.

AIM

The purpose of the study was to compare the effects of two diets, with similar energy intakes, but different glycemic indexes in a pediatric outpatient setting.

SUBJECTS AND METHODS

A parallel- group, randomized controlled trial was conducted, and 22 obese outpatient children with a body mass index (BMI) Z-score >2 (11 females and 11 males, BMI 28.9±2.9 kg/m²) were included in the study. Patients were randomly allocated to a hypocaloric LGI (GI:60), or to a hypocaloric high glycemic index (HGI) diet (GI:90). The LGI and HGI diets were almost equivalent for macronutrient composition. Anthropometric and biochemical parameters were measured at baseline and after 6 months.

RESULTS

In both groups there were significant decreases in BMI, BMI Z-score, blood pressure, and high-sensitivity C-reactive protein. Only LGI diets produced a significant decrease in waist circumference and homeostasis model assessment. Analysis of variance demonstrated that the BMI Z-score decrease from baseline values was significantly greater after the LGI diet than after the HGI diet [-0.20 (95% confidence interval (CI) -0.29 to -0.10) vs -0.34 (95%CI -0.43 to -0.24)], mean difference between groups -0.14 (95%CI -0.27 to -0.01), p<0.05). Changes in triglyceride concentrations were significantly lower in LGI as compared to HGI diet (p<0.05).

CONCLUSIONS

This study demonstrates that a hypocaloric LGI diet has beneficial metabolic effects in comparison to a hypocaloric HGI diet in obese children.

Screening in child health: studies of the efficacy and relevance of preventive care practices

BACKGROUND

Pediatric screening enables the prevention or early detection of diseases and developmental disturbances in infancy and childhood. Screening is a standard component of pediatric practice in many countries, but its scientific basis is not well known.

METHODS

The scientific justification for pediatric screening beyond the neonatal period is presented on the basis of a selective review of the literature on some aspects of pediatric screening.

RESULTS

The level of evidence varies highly among pediatric screening interventions and can be difficult to determine because of confounding variables. Parent counseling is associated with improvements in child-raising competence, accident prevention, and reading behavior. The early detection of abnormalities in a child's motor, linguistic, mental, or social development is possible and often leads to effective early interventions. Cyanotic congenital heart defects can be detected with 63% sensitivity and 99.8% specificity; cerebral palsy can be diagnosed with 33% to 100% sensitivity and 52.3% to 100% specificity (different figures from multiple studies). Physical therapy seems to improve some manifestations of cerebral palsy. Motor development at 90 days is correlated with motor development at 57 months (72% sensitivity, 91% specificity). A developmental quotient above 85 in a two-year-old child is correlated with an intelligence quotient above 85 when the child is 7 years old.

CONCLUSION

There is an increasing amount of scientific evidence in favor of pediatric screening. Nonetheless, further epidemiological studies are needed.

Let's move our next generation of patients toward healthy behaviors

Health care professionals in all disciplines who care for adults have the opportunity to improve the health of the next generation. The prevalence of overweight and obesity continues to rise in children and adults around the world. As providers caring for adults, our primary goal is to address the health needs of our patients. However, it is important to recognize that counseling our patients who have children can lead them to adopt model behaviors that will be imitated by their children (and therefore improve the weight status and reduce health risks for their children). Additionally, many patients are more motivated to adopt behavior changes for the sake of their children than for their own health. All of 2012's 11-year-old children may be our adult patients in 10 years - especially if they have already developed weight-related health problems. Anything we do to address childhood obesity is an investment in the health of our patient panels, both now and in the future. While counseling may feel futile at times, there is strong evidence for the power of counseling to shape patient behavior. Counseling adult patients about healthy behaviors will benefit not only our patients today but our patients in the future as well.