Reference centile curves for body fat percentage, fat-free mass, muscle mass and bone mass measured by bioelectrical impedance in Asian Indian children and adolescents

Effect of metformin adjunct therapy on cardiometabolic parameters in Indian adolescents with type 1 diabetes: a randomized controlled trial

Introduction

Insulin resistance is being increasingly reported in type-1 Diabetes (T1D) and is known to accelerate microvascular complications. The Asian Indian population has a higher risk of double diabetes development compared to Caucasians. Hence, we studied the effect of adding Metformin to standard insulin therapy on glycemic control, insulin sensitivity (IS), cardiometabolic parameters and body composition in Indian adolescents with T1D.

Methods

A Randomized controlled trial was conducted spanning 9 months (Registration number:CTRI/2019/11/022126). Inclusion: Age 10-19 years, T1D duration>1year, HbA1c>8% Exclusion: Uncontrolled vascular complications/comorbidities, Metformin intolerance, concomitant drugs affecting insulin sensitivity. Participants were randomized to Metformin/Placebo (n=41 each) groups and age, sex, duration-matched. Assessments were performed at baseline, 3 and 9 months.

Results

82 participants aged 14.7 ± 3years (40 females) were enrolled, with a mean diabetes duration of 5.2 ± 2.3 years. Over 9 months, HbA1c decreased significantly by 0.8 (95% confidence interval: -1.2 to -0.3) from 9.8 ± 1.8% to 9.1 ± 1.7% on Metformin but remained largely unchanged (difference of 0.2, 95% confidence interval: -0.7 to 0.2) i.e. 9.9 ± 1.6% and 9.7 ± 2.2% on placebo. HbA1c improvement correlated negatively with baseline IS (EGDR:r= -0.3;SEARCH:r = -0.24, p<0.05) implying better HbA1c-lowering in those with decreased initial IS. CGM-based glycemic variability (standard deviation) reduced by 6.3 mg/dL (95% confidence interval: -12.9 to 0.2) from 100.2 ± 19.1 mg/dL to 93.7 ± 19.9 mg/dL in those on Metformin (p=0.05) but not placebo (94.0 ± 20.5; 90.0 ± 22.6 mg/dL). Insulin sensitivity: CACTIexa & SEARCH scores demonstrated no change with Metformin but significant worsening on placebo. Significant increase in LDL-C(42%), total cholesterol(133.6 to 151.1 mg/dL), triglyceride (60.0 to 88.0 mg/dL) and carotid intima-media thickness was noted on placebo but not Metformin. Weight, BMI, fat Z-scores increased significantly on placebo but not Metformin. Adverse events (AE) were minor; AE, compliance and safety parameters were similar between the two groups.

Conclusion

Metformin as an adjunct to insulin in Asian Indian adolescents with T1D demonstrated beneficial effect on glycemic control, glycemic variability, IS, lipid profile, vascular function, weight and body fat, with a good safety profile when administered for 9 months.

Effect of Yoga or Physical Exercise on Muscle Function in Rural Indian Children: A Randomized Controlled Trial

BACKGROUND

Synergistic effects of yoga or physical exercise (PE) along with protein supplementation on children's muscle function in rural India have not been studied. Hence, we aimed to study the effect of yoga and PE along with protein supplementation on muscle function in healthy 6- to 11-year-old rural Indian children post 6 months of intervention.

METHODS

A randomized controlled trial on 232 children, recruited into 3 groups, each receiving 1 protein-rich ladoo (148 kcal, 7 g protein/40 g ladoo-an Indian sweet snack) daily and performing (1) yoga (n = 78) for 30 minutes 5 times per week, (2) PE (n = 76) for 30 minutes 5 times per week, or (3) control group (n = 78) no additional exercise. Maximum power, maximum voluntary force (Fmax), and grip strength (GS) were measured. Data were analyzed using paired t tests and a 2-way mixed analysis of variance with post hoc Bonferroni adjustment.

RESULTS

GS, maximum power, and Fmax within yoga group increased significantly (P < .05) from baseline to endline. GS and Fmax increased significantly within PE group postintervention (P < .001). In controls, GS increased (P < .05) at endline. No significant effect of the intervention was observed on the change in maximum power (P > .05) postintervention. The 2 exercise groups showed significant increase in Fmax compared with the control group (P < .05). Similarly, increase in GS was significantly higher in both the exercise groups compared with the control group (P < .05). No significant difference was observed in change in muscle function between the 2 exercise groups (P > .05).

CONCLUSIONS

Structured physical activity along with protein supplementation resulted in improved muscle function in children. Yoga and PE showed a comparable impact on muscle force.

Adiponectin-leptin ratio as a marker of cardio-metabolic risk in Indian children and youth with type 1 diabetes

OBJECTIVES

Adiponectin/leptin ratio (ALR) is a promising novel marker of cardio-metabolic risk in patients with metabolic syndrome. Our aim was to study the association of adiponectin-leptin ratio with markers of obesity and adiposity and also to assess its usefulness as a marker of increased cardiometabolic risk (CMR) in Indian children and youth with type 1 diabetes mellitus.

METHODS

This observational study included 79 children and youth with type 1 diabetes (T1DM) (10-21 years) having disease duration>6 months. Demographic data and laboratory findings were obtained from patients' records. Patients with ALR<1 were categorised as having increased CMR and those with ALR>1 were categorised as having no CMR.

RESULTS

ALR showed a significant negative correlation with body mass index (BMI), waist and hip circumference and body fat percentage (p<0.05). Body fat percentage was the single most important predictor of ALR. Children and youth with increased CMR had higher weight, BMI, waist and hip circumferences and body fat percentage as compared to those with no CMR (p<0.05). In T1DM children with dyslipidemia, ALR was significantly lower as compared to those without dyslipidemia (p<0.05).

CONCLUSIONS

ALR may be a useful marker for adiposity and increased cardiometabolic risk in Indian children and youth with type 1 diabetes mellitus.

Body-Fat-Percentile Curves for Thai Children and Adolescents

This study aimed to generate sex-specific percentile curves for the percentage of body fat (PBF) in Thai children using a bioelectrical impedance analysis (BIA). The secondary objective of this study was to determine the association between body fat and other anthropometric measurements. A cross-sectional study was conducted on 3455 Thai school children aged 6-18 years. The body-fat contents were measured using BIA. Smoothed percentile curves of PBF were derived using a scatter plot with a smooth curve fitted by the Loess method. The correlations between the body fat and the anthropometric measurements were assessed using the Spearman's rank correlation. The 50th and lower body-fat-percentile curves of the boys slowly increased until age 12, after which they slightly decreased until age 15 and then slightly increased until age 18. In the higher boys' percentiles, the body fat sharply increased until age 11 and then decreased until age 18. In the girls, the PBF percentiles increased steadily from 6 to 18 years. The body-mass index was strongly correlated with PBF and fat mass in both sexes. The waist-to-height ratios showed strong correlations with PBF and fat mass in the boys but were moderate in the girls. The use of PBF percentile curves can be an additional metric for the evaluation of obesity in Thai children.

Influence of ecoregional and lifestyle factors on growth and body composition of I ndian children and adolescents aged 9–18 years—A multicenter study

OBJECTIVES

Ecoregion comprises all the environmental factors such as climate, vegetation, geomorphology, and soil taken together. The objectives of this study were to (1) assess differences in growth and body composition (BC) in 9-18-year-old children and adolescents (CA), across six ecoregions of India, (2) evaluate and compare the magnitude of the effect of ecoregional and lifestyle factors (LSF) on growth and BC in urban (U) and rural (R) children and adolescents, and (3) reassess the applicability of Bergmann's Rule and Allen's Rule to humans.

SUBJECTS AND METHODS

Data on 1845 CA (925 boys; 920 girls) were collected (2016-2017) from urban and rural areas of six ecoregions of India. Anthropometric and BC parameters were measured; Z-scores were computed. Lifestyle Index score (LIS) based on LSF-(socioeconomic status [SES], diet, physical activity) was computed (categorized as low, medium, high-indicates better LSF). Univariate analysis was performed to estimate effect size.

RESULTS

Significant differences were observed in growth and BC across urban and rural ecoregions. CA with high LIS were taller and heavier than those with low LIS (p < .05). Ecoregion had greater effect on growth (Partial eta square (η² ) for R = 0.136 vs. U = 0.057) and BC (η² for R = 0.094 vs. U = 0.058) of rural CA than urban (p < .01). LSF had more effect on the BC of urban CA (η²  = 0.017) than rural (η²  = 0.002, p < .01).

CONCLUSION

Disparities among the six ecoregions were not large enough to fully support Bergmann's Rule and Allen's Rule. Ecoregion had greater effect on growth and BC of rural CA than urban, while lifestyle factors had more effect on the BC of urban CA.

Vitamin D status and determinants in Indian children and adolescents: a multicentre study

Studies performed on Indian children to assess vitamin-D status have been on small sample sizes, limited to specific geographical locations and used non-standard methods to measure 25(OH)D₃. This multicentre study assessed 25(OH)D₃ concentrations from dried blood spots (DBS) in 5–18-year-old Indian children and adolescents using a standardized protocol and identified factors contributing towards vitamin D deficiency. Cross-sectional, observational school-based study was conducted by multi-stage stratified random sampling. A city and nearby village were selected from 6 Indian states covering wide geographical areas. Demography, anthropometry, body-composition, dietary-intakes and DBS samples were collected. 25(OH)D₃ was assessed from DBS using Liquid chromatography with tandem-mass spectrometry. Vitamin-D status was assessed in 2500 children; with additional data collected on a subset (n = 669) to assess predictors. Mean vitamin-D concentration was 45.8 ± 23.9 nmol/L, 36.8% of subjects had sufficient vitamin-D (> 50 nmol/L); rural subjects and boys had higher concentrations (p < 0.05). On regression analysis, younger age, female-gender, overweight and urban residence significantly contributed to deficiency. More than half the Indian children/adolescents were vitamin-D deficient or insufficient. Our study reinforces vitamin-D deficiency as a major public health problem and the need for supplementation, food fortification and educating the population as initiatives required to improve sufficiency status.

Impact of decreased physical activity due to COVID restrictions on cardio-metabolic risk parameters in Indian children and youth with type 1 diabetes

BACKGROUND AND AIMS

Implementation of COVID restrictions following lockdown led to changes in routines of subjects with type 1 diabetes due to closure of schools and outdoor activities. The aim of this study was to assess the impact of decreased physical activity due to COVID restrictions on cardio-metabolic risk parameters (waist circumference, laboratory and body composition parameters) in Indian children and youth with T1D.

METHODS

This observational study included 312 participants (2-21 years) with T1DM having disease duration of ≥6 months. Demographic, anthropometric, body composition data and investigations were recorded at two time points (during COVID restrictions when children came for follow up, pre COVID restriction data from medical and electronic records).

RESULTS

Glycemic control improved during COVID restrictions (Hba1c: 9.8 ± 2.0%) as compared to pre COVID restrictions (Hba1C: 10.0 ± 1.9%) (p < 0.05). However, due to significant reduction in physical activity (p < 0.05) there was significant increase in waist circumference z-scores (-0.9 ± 1.1 vs -1.6 ± 1.1), body fat percentage z-scores (-0.2 ± 1.0 vs -0.3 ± 0.9) and lipid parameters like cholesterol, low density lipid cholesterol and triglyceride concentrations (p < 0.05) without any significant change in body mass index z-scores (p > 0.05).

CONCLUSIONS

Prolonged COVID restrictions, although led to modest improvement in glycemic control, there was worsening of cardio-metabolic risk factors or indices of adiposity like waist circumference, body fat percentage and lipid parameters which could be attributed to decreased time spent in physical activity.

Prevalence of nephropathy in Indian children and youth with type 1 diabetes mellitus

OBJECTIVES

Children with type 1 diabetes (T1D) having diabetic nephropathy (DN) are at increased risk of developing end stage renal disease. The present study aimed to determine the prevalence of DN and its predictors in Indian children and youth with T1D.

METHODS

This cross-sectional study included 319 children and youth (2.6-21 years) with T1D having disease duration of at least 2 years. Demographic data and laboratory findings were obtained using standard questionnaires and protocols. Diagnosis of diabetic nephropathy was based on albuminuria on two occasions within a period of 3 months.

RESULTS

The prevalence of DN in our study subjects was 13.4%. 7.5% subjects were known cases of diabetic nephropathy on treatment with enalapril. Hypertension was found in 14.3% subjects with DN in contrast to 4.1% without DN (p<0.05). Duration of diabetes and estimated glucose disposal rate were the important predictors of DN. Interestingly, of the 43 children with DN, 11.3% (n=8) were under 10 years age.

CONCLUSIONS

We found a high prevalence of DN in children and youth with T1D including in children under the age of 10 years. Early screening and timely intervention are required to retard the disease progression and avoid end stage renal disease.

A Study on New IAP 2015 Growth References in Rural South Indian Children

OBJECTIVES

To ascertain the utility of the new pan Indian 2015 IAP references in rural South Indian children and the ability of new IAP charts to recognise children with abnormal cardiometabolic risk factors in 10 to 16 y age group.

METHODS

Among school health camps conducted at two centres of Tamil Nadu- rural Vellore and rural Erode- height, weight, waist circumference, blood pressure, triceps skin-fold thickness and body fat percentage were measured by trained pediatricians and Z-scores calculated. The anthropometric measures were studied as per IAP 2015 references and compared to other national and international references. Their utility in identification of malnutrition and cardiometabolic risk ascertained.

RESULTS

A total of 420 children (210 from Erode and 210 from Vellore) in the age group of 10 to 16 y were included in the study. New IAP references recognized more short stature (4.2 vs. 3%), wasting (11 vs. 1.5%) and overweight (14.2 vs. 13.2%) children compared to old IAP charts. The Z-scores of anthropometric measures as per New IAP 2015 references had significant correlation with old IAP and other international data (p < 0.05). It was noted that new IAP charts could detect 83.3%, old IAP chart 50% and WHO 83.3% of subjects with malnutrition. New IAP charts could detect 70.3% cardiometabolic risk associated with over nutrition compared to old IAP (57.4%) and WHO (51.8%).

CONCLUSIONS

There is a significant prevalence of both under nutrition and overweight in rural setting. IAP 2015 reference is useful to diagnose children with under nutrition and overweight including abnormal cardiometabolic risk.

Reference centile curves for mid-upper arm circumference for assessment of under- and overnutrition in school-aged Indian children and adolescents

OBJECTIVES

Malnutrition is common in developing countries and is not restricted to young children. It has been suggested that measuring mid-upper arm circumference (MUAC) is an easy, accurate, and low-cost method of identifying malnutrition in the early stages. The aims of this study were to construct age- and sex-specific MUAC reference centiles, and to define and validate cutoffs for assessment of under- and overnutrition in Indian children 5 to 17 y of age.

METHODS

This was a cross-sectional, multicentric, observational study conducted in seven schools in seven states from June 2018 to November 2019. The study included 6680 healthy 5- to17-y-old children. MUAC was measured using non-stretch tapes (UNICEF). Sex-specific MUAC percentiles were computed for age and height. Cutoffs for MUAC z-scores for thinness and overnutrition were defined and validated for healthy school children (n = 726) and children with cancer (n = 500).

RESULTS

Reference centiles for MUAC for age (and height) for boys and girls are presented. Cutoffs defined for thinness and for obesity were -0.7 and +1.5 z-score, respectively (corresponding to 25th and 95th percentiles of the MUAC for age/height). For ease of use, rounded cutoffs for thinness were 16 and 18.5 cm from 5 to 9 and 10 to 14 y of age, respectively, in both sexes, and a cutoff of 22 cm in boys and 20 cm in girl from 15 to 17 y of age. For obesity, 20 and 25.5 cm from 5 to 9 and 10 to 14 y of age, respectively, in both girls and boys and a rounded cutoff of 29 cm in boys and 27 cm in girls from 15 to17 y are proposed.

CONCLUSIONS

We presented MUAC percentiles and cutoffs for screening for thinness and overnutrition in Indian children from 5 to 17 y of age. These data may also be used in children with cancer and other chronic disorders with growth failure.

Body Fat Mass, Percent Body Fat, Fat-Free Mass, and Skeletal Muscle Mass Reference Curves for Czech Children Aged 6-11 Years

Background: Negative lifestyle trends are reflected in overweight and obese children, in which their lack of physical activity results in decreased muscle mass. This study aimed to define age- and sex-specific reference curves for body fat mass (BFM), skeletal muscle mass (SMM), fat-free mass (FFM), and percent body fat (%BF) in Czech children. Methods: Body composition was measured by segmental bioelectrical impedance (BIA, InBody 720). The research sample included 2093 children aged 6–11 years (1008 boys and 1085 girls). Only children whose parents provided informed consent were included. Statistical analysis was performed using SPSS v. 22. The statistical analysis was performed separately by age and sex. Anthropometric data were summarized as means and standard deviation. The percentile curves (P3, P10, P25, P50, P75, P90, and P97) of BFM, FFM, %BF, and SMM were calculated using the gamlss package in R 3.4.2 (R Foundation for Statistical Computing, Vienna, Austria). Results: This study developed age- and gender-specific percentile curves of SMM, FFM, BFM, and %BF for Czech children aged 6–11 years. During childhood, BFM and %BF increased in boys, peaking at approximately 11 years of age. Girls displayed a different pattern of age-related changes in BFM and %BF compared to that in boys. These parameters gradually increased during childhood. This pattern was also observed for SMM and FFM in both sexes. Conclusions: The purpose of this study was to serve as a reference to improve methods to evaluate body composition in Czech children and for comparison with studies worldwide.

Body Fat in Children with Chronic Kidney Disease - A Comparative Study of Bio-impedance Analysis with Dual Energy X-ray Absorptiometry

Introduction:

Nutritional impairment in patients with chronic kidney disease (CKD) is due to decreased body stores of both protein and fat. We need a tool that can be used in clinics to determine and monitor fat composition with a special focus on normalizing fat measurements to height in these children. Bio-impedance analysis (BIA), a portable and simple tool, has been used to estimate body fat in children with CKD but needs validation against the reference tool dual energy X-ray absorptiometry (DXA). The purpose of the cross-sectional study was to estimate the prevalence of low body fat in children with stages 2-5 CKD (non-dialysis) and CKD 5D (dialysis), and to compare fat measures from two different methods namely BIA and DXA.

Method:

Children in stages 2–5 CKD (n = 19) and in CKD 5D (n = 14) were recruited for assessment of fat mass (FM, Kg) by BIA and DXA, from which percent body fat (BF %) and fat mass index (FMI, Kg/M²) were obtained. Low body fat was defined as <5^th age and gender centile for BF% or FMI by DXA and BF% by BIA.

Results:

Low body fat was detected equally using BF% and FMI in 18% of children by DXA while only 12% were detected using BF% by BIA. In children with CKD2–5, a good degree of reliability was found with FMI measurements (ICC 0.76 CI [0.48,0.9]) and poor reliability in children with CKD 5D (ICC 0.58 CI [0.1,0.84]). BF% had poor to fair reliability in the children with CKD 2-5 and CKD 5D (ICC 0.64 [0.28,0.84] and 0.53 [0.02,0.82]), respectively. Comparing BF% and FMI obtained by BIA and DEXA, BIA overestimated BF% by 3.5% in comparison to DXA.

Conclusion:

In children with CKD, body fat is preserved in the majority. Among the two measures of fat, BF% estimated by BIA did not compare well with DXA while FMI measure was comparable with a lower bias. However, due to lack of reference values in Indian children for FMI obtained by BIA, BIA cannot be used to measure fat in this population.

Body composition of children with moderate and severe undernutrition and after treatment: a narrative review

BACKGROUND

Until recently, undernourished children were usually assessed using simple anthropometric measurements, which provide global assessments of nutritional status. There is increasing interest in obtaining more direct data on body composition to assess the effects of undernutrition on fat-free mass (FFM) and its constituents, such as muscle and organs, and on fat mass (FM) and its regional distribution.

MAIN TEXT

Recent studies show that severe-acute undernutrition, categorised as 'wasting', is associated with major deficits in both FFM and FM that may persist in the long-term. Fat distribution appears more central, but this is more associated with the loss of peripheral fat than with the elevation of central fat. Chronic undernutrition, categorised as 'stunting', is associated with deficits in FFM and in specific components, such as organ size. However, the magnitude of these deficits is reduced, or - in some cases - disappears, after adjustment for height. This suggests that FFM is largely reduced in proportion to linear growth. Stunted children vary in their FM - in some cases remaining thin throughout childhood, but in other cases developing higher levels of FM. The causes of this heterogeneity remain unclear. Several different pathways may underlie longitudinal associations between early stunting and later body composition. Importantly, recent studies suggest that short children are not at risk of excess fat deposition in the short term when given nutritional supplementation.

CONCLUSION

The short- and long-term functional significance of FFM and FM for survival, physical capacity and non-communicable disease risk means that both tissues merit further attention in research on child undernutrition.

Low muscle mass and strength in pediatrics patients: Why should we care?

Skeletal muscle plays major roles in metabolism and overall health across the lifecycle. Emerging evidence indicates that prenatal (maternal diet during pregnancy and genetic defects) and postnatal factors (physical activity, hormones, dietary protein, and obesity) influence muscle mass acquisition and strength early in life. As a consequence, low muscle mass and strength contributes to several adverse health outcomes during childhood. Specifically, studies demonstrated inverse associations of muscle mass and strength to single and clustered metabolic risk factors. The literature also consistently reports that low muscle mass and strength are associated with reduced bone parameters during growth, increasing the risk of osteoporosis in old age. Furthermore, muscle mass gains are associated with improved neurodevelopment in the first years of life. Given these negative implications of low muscle mass and strength on health, it is crucial to track muscle mass and strength development from childhood to adolescence. Several body composition techniques are currently available for estimation of muscle mass, all with unique advantages and disadvantages. The value of ultrasound as a technique to measure muscle mass is emerging in pediatric research with potential for translating the research findings to clinical settings. For the assessment of muscle strength, the handgrip strength test has been widely employed but without a standardized protocol. Although further research is needed to define normative data and cut points for the low muscle mass and strength phenotype, the use of such non-invasive medical monitoring is a promising strategy to identify early abnormalities and prevent low muscle mass in adulthood.

Limitations of Fat-Free Mass for the Assessment of Muscle Mass in Obesity

BACKGROUND

A high amount of adipose tissue limits the accuracy of methods for body composition analysis in obesity.

OBJECTIVES

The aim was to quantify and explain differences in fat-free mass (FFM) (as an index of skeletal muscle mass, SMM) measured with bioelectrical impedance analysis (BIA), dual energy X-ray absorptiometry (DXA), air displacement plethysmography (ADP), and deuterium dilution in comparison to multicompartment models, and to improve the results of BIA for obese subjects.

METHODS

In 175 healthy subjects (87 men and 88 women, BMI 20-43.3 kg/m2, 18-65 years), FFM measured by these methods was compared with results from a 3- (3C) and a 4-compartment (4C) model. FFM4C was compared with SMM measured by magnetic resonance imaging.

RESULTS

BIA and DXA overestimated and ADP underestimated FFM in comparison to 3C and 4C models with increasing BMI (all p < 0.001). -Differences were largest for DXA. In obesity, BIA results were improved: valuecorrected = -valueuncorrected - a(BMI - 30 kg/m2), a = 0.256 for FFM and a = 0.298 for SMM. SMM accounts for 45% of FFM in women and 49% in men.

CONCLUSIONS

In obesity, the use of FFM is limited by a systematic error of reference methods. In addition, SMM accounts for about 50% of FFM only. Corrected measurement of SMM by BIA can overcome these drawbacks.