Obesity, acanthosis nigricans, insulin resistance, and hyperandrogenemia: pediatric perspective and natural history

School and family-based interventions for promoting a healthy lifestyle among children and adolescents in Italy: a systematic review

AIMS

Cardiovascular diseases affect adult population but risk factors develop as a result of known or assumed behavior since childhood. In Italy, up to 22.2% of children are overweight, 10.6% are obese, and 2.5% have severe obesity.

METHODS

We performed a systematic review of the literature to identify studies and initiatives addressing health promotion among children in Italy. Given the high heterogeneity of interventions and outcomes assessed we opted to perform a qualitative synthesis of the results. We described also nonrandomized trial where the intervention of primary prevention was very innovative, explained in detail, and reached an improving outcome for participants.

RESULTS

We identified 11 projects since 1983, only five were randomized control trials. Three involved children and teachers of primary and secondary schools and were based on specific curricular lectures about health. One was based on a game developed for high schools with the purpose to promote healthy lifestyle and physical activity. The fifth project was based on an enhanced physical activity program.

CONCLUSION

Our results show that school and family should be considered as the privileged places for health promotion. In Italy, the development of scientific-validated lifestyle interventions for children is still an unmet need.

Polycystic ovary syndrome and insulin: our understanding in the past, present and future

Insulin resistance is prevalent in women with polycystic ovary syndrome (PCOS), and plays a critical pathophysiologic role in both the metabolic and reproductive complications of PCOS. This review focuses on the contribution of insulin resistance to anovulation in PCOS and to the high risk for Type 2 diabetes, metabolic syndrome and early cardiovasular disease. Key points for clinicians emphasized by this review are the following: PCOS is a clinical diagnosis and alternative diagnoses must be excluded; PCOS carries an inherent risk of insulin resistance and, hence, metabolic consequences for which women with PCOS should be screened regardless of BMI or degree of obesity; and PCOS is associated with infertility and this should be discussed early on in care of women diagnosed with PCOS, recognizing that there are several possible strategies to address infertility in women with PCOS, each with its own risks and benefits.

Social anxiety, depression and self-esteem in obese adolescent girls with acanthosis nigricans

OBJECTIVE

To assess the impact of acanthosis nigricans (AN) on depression symptoms, related quality of life and self-esteem scores in obese adolescent girls.

METHODS

Fifty-nine obese adolescent girls (mean age: 13.19±1.3 years, age range: 12-17 years, mean body mass index: 29.89±3.30) were enrolled in this study. The obese adolescent girls were divided into two groups based on presence or absence of AN. Non-obese healthy adolescents constituted the control group (30 girls, mean age: 13.5±1.4 years). All subjects were evaluated using the Children's Depression Inventory (CDI), the State-Trait Anxiety Inventory for Children (STAI-C), and the modified Rosenberg Self-Esteem Scale (SES). Higher scores indicated more severe depression and anxiety, as well as low self-esteem status.

RESULTS

The AN and non-AN obese groups showed significantly higher CDI, STAI-C and SES scores than the control group, and the two obese groups demonstrated no significant differences for these scores. The AN obese group with higher total testosterone levels (>50 ng/dL) had higher scores for SES (2.55±1.8 vs. 1.42±1.2; p=0.03) than the AN obese group with low total testosterone levels. SES scores significantly correlated with total testosterone levels (r=0.362; p=0.03) and fasting insulin (r=0.462; p=0.03) in the AN obese group.

CONCLUSION

Higher SES scores (low self-esteem status) were determined in obese adolescents with acanthosis and were related to hyperandrogenism. This study also showed that a high testosterone level may be one of the important indicators of low self-esteem status in obese girls with AN.

Steroid hormone profiles in prepubertal obese children before and after weight loss

CONTEXT

Little information is available on the steroid hormone profiles in obese children and their changes after weight loss.

OBJECTIVE

We compared liquid chromatography-tandem mass spectrometry of serum steroid hormone profiles between obese and normal-weight children and studied the differential effects of weight loss on these hormones.

DESIGN

This study was a cross-sectional comparison between obese and normal-weight children and a longitudinal 1-year follow-up study during lifestyle intervention in obese children.

SETTING

The setting of the study was primary care.

PATIENTS

Forty obese prepubertal (mean age 8.5 ± 2.1 years, 48% female, mean body mass index 24.8 ± 3.5 kg/m(2)) and 40 normal-weight children matched for gender, age, and pubertal stage.

INTERVENTION

The study consisted of an outpatient 1-year intervention program based on exercise, behavior, and nutrition therapy.

MAIN OUTCOMES MEASURES

Progesterone, 17-hydroxyprogesterone, 11-deoxycorticosterone, corticosterone, aldosterone, 11-deoxycortisol, cortisol, cortisone, dehydroepiandrosterone sulfate (DHEAS), androstenedione, T, dihydrotestosterone, insulin resistance index of the homeostasis model assessment, and blood pressure were measured.

RESULTS

Prepubertal obese children showed significantly increased androgens (DHEAS, androstenedione, T), mineralocorticoid precursor corticosterone, and glucocorticoids (11-deoxycortisol, cortisol, cortisone) compared with normal-weight children. In contrast to 20 obese children without weight loss, the 20 obese children with substantial weight loss demonstrated a significant decrease of cortisol, cortisone, and corticosterone. Androstenedione and T decreased but DHEAS remained elevated. Changes of the homeostasis model assessment correlated significantly positively with changes of cortisol (r = 0.38) and cortisone (r = 0.43) in partial regression analyses adjusted to changes of weight status.

CONCLUSIONS

In obese prepubertal children, the increased androgens, mineralocorticoid precursors, and glucocorticoids were responsive to weight loss in contrast to DHEAS, suggesting that DHEAS does not seem to be regulated by changes in body mass index.

State of the Art Review: Emerging Therapies: The Use of Insulin Sensitizers in the Treatment of Adolescents with Polycystic Ovary Syndrome (PCOS)

PCOS, a heterogeneous disorder characterized by cystic ovarian morphology, androgen excess, and/or irregular periods, emerges during or shortly after puberty. Peri- and post-pubertal obesity, insulin resistance and consequent hyperinsulinemia are highly prevalent co-morbidities of PCOS and promote an ongoing state of excess androgen. Given the relationship of insulin to androgen excess, reduction of insulin secretion and/or improvement of its action at target tissues offer the possibility of improving the physical stigmata of androgen excess by correction of the reproductive dysfunction and preventing metabolic derangements from becoming entrenched. While lifestyle changes that concentrate on behavioral, dietary and exercise regimens should be considered as first line therapy for weight reduction and normalization of insulin levels in adolescents with PCOS, several therapeutic options are available and in wide use, including oral contraceptives, metformin, thiazolidenediones and spironolactone. Overwhelmingly, the data on the safety and efficacy of these medications derive from the adult PCOS literature. Despite the paucity of randomized control trials to adequately evaluate these modalities in adolescents, their use, particularly that of metformin, has gained popularity in the pediatric endocrine community. In this article, we present an overview of the use of insulin sensitizing medications in PCOS and review both the adult and (where available) adolescent literature, focusing specifically on the use of metformin in both mono- and combination therapy.

Association between androgens, intima-media thickness and the metabolic syndrome in obese adolescent girls

BACKGROUND

While an association between androgens and the metabolic syndrome (MS) is well established in obese women, studies concerning this relationship are scarce in obese adolescent girls. Therefore, we analysed the relationships between androgens, MS and intima-media thickness (IMT) in this age-group.

METHODS

In 160 obese girls (aged 12-18 years, mean BMI: 32.6 +/- 5.0 kg/m((2))), androgens [testosterone, dehydroepiandrosterone sulphate (DHEA-S), androstenedione], SHBG and the components of MS (waist circumference, blood pressure (BP), lipids, uric acid, insulin, glucose, 2 h glucose in oral glucose tolerance test (oGTT)) were studied. Furthermore, IMT was determined in a subgroup of 71 randomly chosen girls.

RESULTS

Testosterone correlated significantly to systolic BP (r = 0.20), diastolic BP (r = 0.24), 2 h glucose in oGTT (r = 0.30), triglycerides (r = 0.19), uric acid (r = 0.17), waist circumference (r = 0.25) and IMT (r = 0.54). These relationships (except for waist circumference and uric acid) were independent of BMI and insulin resistance index homeostasis model assessment. In contrast to testosterone, DHEA-S, androstenedione and SHBG showed no or weaker correlations to any parameter of MS. The 48 girls with MS demonstrated significantly higher testosterone (1.8 +/- 0.7 nmol/l; P = 0.025) and DHEA-S (4.7 +/- 2.3 micromol/l; P = 0.008) concentrations as compared with the 112 girls without MS (mean testosterone 1.5 +/- 0.7 nmol/l, mean DHEA-S 3.6 +/- 2.3 micromol/l).

CONCLUSIONS

Testosterone was significantly related to MS and its components in obese adolescent girls independently of BMI and insulin resistance. As IMT was significantly associated with testosterone, this supports the clinical relevance of this finding.

Endothelial dysfunction in obese non-hypertensive children without evidence of sleep disordered breathing

BACKGROUND

Endothelial dysfunction is a complication of both obesity and obstructive sleep apnea syndrome (OSAS), the latter being highly prevalent among obese children. It is unknown whether obesity causes endothelial dysfunction in children in the absence of OSAS. This study examines endothelial function in obese and non-obese children without OSAS.

METHODS

Pre-pubertal non-hypertensive children were recruited. Endothelial function was assessed in a morning fasted state, using a modified hyperemic test involving cuff-induced occlusion of the radial and ulnar arteries. The absence of OSAS was confirmed by overnight polysomnography. Anthropometry was also performed.

RESULTS

55 obese children (mean age 8.6 +/- 1.4 years, mean BMI z-score: 2.3 +/- 0.3) were compared to 50 non-obese children (mean age 8.0 +/- 1.6 years, mean BMI z-score 0.3 +/- 0.9). Significant delays to peak capillary reperfusion after occlusion release occurred in obese compared to non-obese children (45.3 +/- 21.9 sec vs. 31.5 +/- 14.1 sec, p < 0.01), but no differences in the magnitude of hyperemia emerged. Time to peak reperfusion and percentage of body fat were positively correlated (r = 0.365, p < 0.01).

CONCLUSIONS

Our findings confirm that endothelial dysfunction occurs early in life in obese children, even in the absence of OSAS. Thus, mechanisms underlying endothelial dysfunction in pediatric obesity are operational in the absence of sleep-disordered breathing.

Strategies for the prevention and control of obesity in the school setting: systematic review and meta-analysis

OBJECTIVE

To determine the effectiveness of school-based strategies for obesity prevention and control using methods of systematic review and meta-analysis.

METHODS

Peer-reviewed studies published between 1966 and October 2004 were considered for review. Studies meeting eligibility criteria were published in English, targeted children aged 3-18 in a school setting, reported weight-related outcomes, included a control measurement and had at least a 6-month follow-up period. Studies employed interventions related to nutrition, physical activity, reduction in television viewing or combinations thereof. Weight related data were analyzed using RevMan software.

RESULTS

Sixty-four studies were considered for inclusion. Fourteen did not meet inclusion criteria; 29 were excluded due to poor methodological quality. Twenty-one papers describing 19 studies were included in the systematic review and 8 of these were included in the meta-analysis. Nutrition and physical activity interventions resulted in significant reductions in body weight compared with control ((standardized mean difference, SMD=-0.29, 95% confidence interval (CI)=-0.45 to -0.14), random effects model). Parental or family involvement of nutrition and physical activity interventions also induced weight reduction ((SMD=-0.20, 95%CI=-0.41 to 0.00), random effects model).

CONCLUSION

Combination nutrition and physical activity interventions are effective at achieving weight reduction in school settings. Several promising strategies for addressing obesity in the school setting are suggested, and warrant replication and further testing.

Changes in physiology with increasing fat mass

Obesity has reached epidemic proportions in the USA with a nearly fourfold rise in the prevalence of childhood obesity. There are many possible etiologies of obesity as the adipose tissue plays a significant, complex role in the physiology of fuel metabolism and hormone regulation. The development of obesity represents a pathophysiologic increase in fat mass in which multiple metabolic pathways are deranged. The consequences of these metabolic derangements, including insulin resistance and inflammation, are reflected in obesity-related comorbidities and can be seen in the setting of pediatric obesity. Obese adolescents demonstrate increased rates of early maturation, orthopedic growth abnormalities, diabetes mellitus, obstructive sleep apnea, hypertension, steatosis, and polycystic ovarian syndrome, placing this group of children at risk for long-term health problems and reduced quality of life. Given the negative short- and long-term impact of obesity on children, careful attention should be paid to the unique health issues of this "at-risk" population with both prevention and early intervention strategies.

Vaspin and its correlation with insulin sensitivity indices in obese children

AIM

The aim of this study was to assess the vaspin and adiponectin concentrations on markers of insulin sensitivity and obesity in pubertal obese children and adolescents.

MATERIAL AND METHODS

Plasma vaspin and adiponectin level and its relationships with body mass index standard deviation score (BMI-SDS), insulin sensitivity and lipids were analyzed in 33 pubertal obese children (19 girls and 14 boys) and 36 healthy control children (18 girls and 18 boys) aged 11-16 years. Insulin resistance was evaluated by homeostasis model assessment (HOMA-IR) and fasting glucose-to-insulin ratio (FGIR). Plasma vaspin and adiponectin concentrations were determined with radioimmunoassay.

RESULTS

Mean vaspin levels were found significantly higher and inversely, adiponectin levels were found significantly lower in obese pubertal group than control subjects. Vaspin levels were positively correlated with BMI-SDS, triglycerides, fasting insulin and HOMA-IR and negatively correlated with adiponectin levels and FGIR. Adiponectin levels were positively correlated with high density lipoprotein-chloesterol, FGIR and negatively correlated with vaspin, BMI-SDS, fasting insulin and HOMA-IR.

CONCLUSION

We found higher vaspin and lower adiponectin levels in obese children and these adipokines were significantly correlated with insulin sensitivity indices in this age.

Age- and ethnic-specific elevation of ALT among obese children at risk for nonalcoholic steatohepatitis (NASH): implications for screening

The objectives are to: (1) characterize ethnic-specific differences in alanine aminotransferase (ALT) elevation among obese children, (2) investigate the earliest ages at which significant ALT elevation occurs, and (3) determine associations between ALT and biochemical parameters. A cohort of 134 multiethnic obese children and adolescents was analyzed retrospectively. ALT levels > or =45 U/L or <45 U/L, denoting high or normal risk, were used to categorize obese children's risk for developing nonalcoholic steatohepatitis. In all, 60% of Hispanics had high-risk ALT levels compared with 12% of whites and 8% of blacks. A significantly higher proportion of boys had ALT > or = 45 U/L (49.4%, vs 37.9% for girls, P = .002); 17.5% were Hispanic boys less than 7 years old. Obese Hispanic children, particularly boys, not only have higher ALT levels but present alarmingly young with high-risk levels. This study highlights a discrete subgroup of children who may present with fatty liver at a younger age and should be screened earlier.

Energy expenditure of the physical activity across the curriculum intervention

Physical activity is frequently a component of interventions designed to diminish weight gain in children. It is essential to determine whether the energy expenditure (EE) elicited by these interventions is sufficient to reduce the rate of weight gain.

PURPOSE

To quantify the EE of the Physical Activity across the Curriculum (PAAC) intervention. This intervention involved two 10-min physically active academic lessons per day, taught by classroom teachers.

METHODS

We assessed EE of PAAC in 19 males and 19 females using both an indirect calorimeter (IC) (COSMED K4b(2)) and an accelerometer (ActiGraph) (AC). Independent t-tests were used to evaluate gender differences. Dependent t-tests were used to examine the difference between EE assessed by IC and AC. The agreement between EE measured by IC and estimated by AC was evaluated using a Bland-Altman plot. A Pearson correlation between EE measured by IC and estimated by AC was calculated.

RESULTS

There were no significant gender differences for age, BMI, or EE; therefore, analyses by gender were not performed. The mean EE measured by IC was 3.1 +/- 1.0 kcal x min(-1) (3.4 METs). Mean EE estimated by AC (1.8 +/- 0.9 kcal x min(-1)) was significantly lower (P < 0.05) than EE measured by IC (mean underestimation = 1.3 kcal x min(-1)). The Bland-Altman plot suggested increased underestimation with increased levels of EE. The 95% limits of agreement were large (-2.8 to +0.3 kcal x min(-1)). The correlation between EE measured by IC and estimated by AC was r = 0.68 (P < 0.001).

CONCLUSION

PAAC elicited a level of EE that may prevent excessive weight gain in children. AC significantly underestimated the EE of PAAC lessons and may not provide useful EE estimates in this context.

Childhood obesity and skeletal maturation assessed with Fishman's hand-wrist analysis

INTRODUCTION

The purpose of this study was to determine whether increased body mass index is associated with accelerated skeletal maturation.

METHODS

The skeletal ages of 107 children, aged 9 to 16 years, were determined by using Fishman's hand-wrist analysis. The difference between chronologic age and dental age was analyzed against body mass index, sex, and age.

RESULTS

The mean differences between chronologic and skeletal ages for normal weight, overweight, and obese subjects were 0.51 years, 0.44 years, and 1.00 years, respectively. Although there was a trend for obese subjects to have accelerated skeletal maturation compared with overweight and normal-weight subjects, the difference was not statistically significant. Skeletal age differences significantly decreased with increasing age. The mean skeletal age differences were 0.90 year for 9- to 13-year-olds and 0.26 year for 13- to 16-year-olds. Mean skeletal age did not differ significantly by sex.

CONCLUSIONS

Overweight or obese children did not have significantly accelerated skeletal maturation after adjusting for age and sex.

WITHDRAWN: Strategies for the prevention and control of obesity in the school setting: systematic review and meta-analysis

The authors hereby retract the e-publication dated July 31, 2007, entitled, 'Strategies for the prevention and control of obesity in the school setting: systematic review and meta-analysis,' and are submitting a revised version with the same title. A secondary review of the manuscript took place following its initial acceptance, resulting in additional statistical analyses along with some pertinent revisions to the accompanying narrative.

Assessment of abnormal glucose homeostasis and insulin resistance in Turkish obese children and adolescents

BACKGROUND

The worldwide increase in the prevalence of childhood obesity is reaching epidemic proportions and is associated with a dramatic rise in cases of type 2 diabetes. We determined the prevalence of impaired glucose regulation and insulin resistance in obese children and adolescents.

METHODS

A total of 196 obese children [SD score (SDS) of body mass index (BMI): 2.17 +/- 0.03], aged 7-18 years, including 86 male subjects, underwent an oral glucose tolerance test (1.75 g glucose/kg body weight). We used the modified WHO criteria adapted for children for abnormal glucose homeostasis. Homeostasis model assessment was used to estimate insulin resistance in all subjects. The insulin sensitivity index was also determined in subjects.

RESULTS

Of the total of 196 obese children, 15 (6.6%) had an abnormal fasting glucose level. Of the 196 obese children, 35 (18%) had impaired glucose tolerance (IGT) and 83 (43%) had insulin resistance. Of the 196 obese children were six (3%) diagnosed with type 2 diabetes. Insulin resistance indices were correlated well with the degree of abnormal glucose tolerance.

CONCLUSIONS

IGT, insulin resistance and type 2 diabetes are far more common in obese Turkish children than previously thought. Early treatment in obese children and adolescents with IGT constitutes a strategy of reversing the progression to beta-cell failure and preventing type 2 diabetes.

The impact of obesity on severely injured children and adolescents

PURPOSE/BACKGROUND

In conjunction with the obesity epidemic in adults, we are starting to see an increase of obesity in children and adolescents. Obesity has been identified as risk factor for poor outcomes in adult trauma patients, but has not been investigated adequately in younger patients. The purpose of this study was to investigate the impact of obesity on the outcomes of a severely injured population of children and adolescents.

METHODS

Retrospective review of traumatized children (age 6-12) and adolescents (age 13-19) admitted to the intensive care unit (ICU) at an urban, level I trauma center from 1998 to 2003. The trauma registry and ICU database were used for data acquisition. Height and weight were recorded for each patient upon admission to the ICU and used to calculate body mass index (BMI). Patients were categorized as either lean (BMI <95th percentile for age) or obese (BMI > or =95th percentile for age). The two groups were compared regarding admission demographics, vital signs, mechanism of injury, patterns of injury, Injury Severity Score, and operations required. Outcomes evaluated were need for and length of mechanical ventilation, complications, length of hospital and ICU stay, and mortality.

RESULTS

There were 316 pediatric and adolescent trauma patients (262 [83%] lean, mean BMI = 23 kg/m2 and 54 [17%] obese, mean BMI = 33 kg/m2) admitted to the ICU. The lean and obese groups were similar regarding age, sex, mechanism of injury, admission vitals, injury severity, and operations required. Injury patterns were similar, except obese patients had less severe head injuries. Although there was no difference in mortality among obese (15%) and non-obese (9%) patients (P = .39), obese children did have more complications (41% vs 22%, P = .04). In addition, obese patients required longer ICU stays (8 +/- 9 vs 6 +/- 6 days, P = .05) after severe trauma.

CONCLUSIONS

Despite similar admission characteristics and less severe head injuries, obese children and adolescents have more complications and require longer ICU stays than their lean counterparts.

Evaluation of ovarian functionality after a dietary treatment in obese women with polycystic ovary syndrome

In women with polycystic ovary syndrome (PCOS) weight loss is associated with an improvement in insulin sensitivity and a reduction of the insulin concentration in the plasma. It is clear, then, that the first therapeutic approach that can be considered in obese PCOS patients for restoration of the menstrual cycle should be a diet. The aim of our study was to examine the effect of long-term caloric restriction on the clinical and biochemical abnormalities in obese PCOS women. The results obtained make it clear that caloric restriction for 4 weeks causes an increase in SHBG and decreases of free testosterone and insulin, with consequent improvement of the clinical picture.

Clinical course of genetic diseases of the insulin receptor (type A and Rabson-Mendenhall syndromes): a 30-year prospective

The interaction of insulin with its cell surface receptor is the first step in insulin action and the first identified target of insulin resistance. The insulin resistance in several syndromic forms of extreme insulin resistance has been shown to be caused by mutations in the receptor gene. We studied 8 female patients with the type A form of extreme insulin resistance and 3 patients (2 male and 1 female) with the Rabson-Mendenhall syndrome and followed the natural history of these patients for up to 30 years. The 11 patients ranged in age from 7 to 32 years at presentation. All 11 patients had extreme insulin resistance, acanthosis nigricans, and hyperandrogenism in the female patients, and all but 1 were of normal body weight. This phenotype strongly predicts mutations in the insulin receptor: of the 8 patients studied, 7 were found to have mutations. Similar results from the literature are found in other patients with type A and Rabson-Mendenhall syndromes and leprechaunism. The hyperandrogenic state resulting from hyperinsulinemia and insulin resistance in these patients was extreme: 6 of 8 patients had ovarian surgery to correct the polycystic ovarian syndrome and elevation of serum testosterone. By contrast, a larger group of insulin-resistant patients who were obese with hyperandrogenism, insulin resistance, and acanthosis nigricans (HAIR-AN syndrome) did not have a high probability of mutations in the insulin receptor. The morbidity and mortality of these patients were high: 3 of 11 died, 9 of 11 were diabetic and 1 had impaired glucose tolerance, and 7 of 9 patients had 1 or more severe complication of diabetes. Our literature review revealed that the mortality of leprechaunism is so high that the term leprechaunism should be restricted to infants or young children under 2 years of age. Analogous to patients with the common forms of type 2 diabetes, these patients had a heterogeneous course. In 2 patients who were able to maintain extremely high endogenous insulin production, the fasting blood glucose remained normal even though post-glucose-challenge levels were elevated. Most patients, however, required large doses of exogenous insulin to ameliorate the severe hyperglycemia. Preliminary results of a recent study suggest that recombinant leptin administration may benefit these patients with severe insulin resistance.

Relation between acanthosis nigricans and insulin sensitivity in overweight Hispanic children at risk for type 2 diabetes

OBJECTIVE

To investigate in a population of Hispanic children if 1) the presence of acanthosis nigricans (AN) is related to insulin sensitivity (S(i)) independent of adiposity and 2) scale scoring AN severity adds to the clinical estimation of insulin sensitivity, above and beyond the presence or absence AN alone.

RESEARCH DESIGN AND METHODS

The study population, 131 Hispanic overweight children (mean BMI percentile 97.0 +/- 3.1, 72 boys, 59 girls, ages 8-13 years, mean Tanner stage 2.4 +/- 1.5) with a family history of type 2 diabetes, underwent a physical examination of the neck to determine AN absence or presence (0-1), AN extent score (0-4 scale), AN texture score (0-3 scale), and an AN combined score (extent + texture; 0-7 scale). S(i) was measured by the frequently sampled intravenous glucose tolerance test and minimal modeling. Multivariate linear regression analysis was used to determine the role of BMI and AN in predicting S(i).

RESULTS

BMI was the main predictor of S(i), explaining approximately 41% of the variance. The presence of AN explained an additional 4% of the variability in S(i); scale scoring of AN extent or texture did not significantly improve the prediction.

CONCLUSIONS

Although AN is an independent risk factor for insulin resistance in overweight Hispanic children at risk for type 2 diabetes, body adiposity is the primary determinant of insulin sensitivity. In addition, scale scoring AN seems of minimal usefulness in clinically estimating the severity of insulin resistance over and above assessing the presence or absence of AN and calculating BMI.

Screening for and treatment of polycystic ovary syndrome in teenagers

Polycystic ovary syndrome (PCOS) usually arises during puberty and is marked by hyperinsulinemia and hyperandrogenism. Adolescents with PCOS are at an increased risk of developing health problems later on in life such as type 2 diabetes, cardiovascular disease, and infertility. Furthermore, the physical signs of PCOS can be detrimental to a teenage girl's self-image. Early diagnosis and treatment of PCOS in adolescents are essential in ensuring adulthood health and restoring self-esteem. Treatments for an adolescent with PCOS include diet and exercise, metformin, and oral contraceptive pills. Each of these options has been shown to be effective in improving certain aspects of PCOS, and probably the best treatment plan involves some combination of them.

Prevention of pediatric overweight and obesity

The dramatic increase in the prevalence of childhood overweight and its resultant comorbidities are associated with significant health and financial burdens, warranting strong and comprehensive prevention efforts. This statement proposes strategies for early identification of excessive weight gain by using body mass index, for dietary and physical activity interventions during health supervision encounters, and for advocacy and research.

Steatohepatitis in children

Steatohepatitis in children occurs in the childhood version of non-alcoholic fatty liver disease (NAFLD), as a result of hepatotoxicity and with certain genetic/metabolic diseases. Until recently, NAFLD was considered to be rare in children. It is now recognized as an important childhood liver disease, especially because childhood obesity is much more common. Children with NAFLD may present as young as 4 years old; males tend to predominate; fibrosis is often found on liver biopsy and cirrhosis has been reported. Treatment for childhood NAFLD currently consists of weight reduction plus regular aerobic exercise; vitamin E may be an effective adjunctive therapy. Drug hepatotoxicity and genetic/metabolic diseases that can cause fatty liver, such as Wilson's disease and cystic fibrosis, must be excluded since treatment is radically different. Other causes of chronic hepatitis, such as chronic viral hepatitis, must also be excluded. Multisystemic inherited diseases with hyperinsulinaemia plus insulin resistance may have NAFLD as hepatic involvement and should be identified.

Association of acanthosis nigricans with hyperinsulinemia compared with other selected risk factors for type 2 diabetes in Cherokee Indians: the Cherokee Diabetes Study

OBJECTIVE

To report prevalence rates of acanthosis nigricans (AN) and hyperinsulinemia and the association of AN with hyperinsulinemia compared with other known or suspected risk factors for type 2 diabetes in young American Indians.

RESEARCH DESIGN AND METHODS

A random sample of Cherokee Nation members aged 5-40 years was invited to participate in the Cherokee Diabetes Study, a cross-sectional study of type 2 diabetes and its risk factors in a young American Indian population. Data were collected by personal interview, medical history, physical examination (including anthropometric and blood pressure measurements and examination of the neck for AN), and laboratory analyses of blood specimens. Levels of insulin, lipids, and glucose were measured on fasting blood specimens. Diabetes status was determined according to the American Diabetes Association criteria.

RESULTS

A total of 2,205 participants were examined. Overall prevalence rates for AN and hyperinsulinemia were 34.2 and 47.2%, respectively. In general, the rates for both increased with age and degree of Indian heritage and were higher in female subjects, overweight/obese individuals, those with type 2 diabetes, and those with a parental history of type 2 diabetes. In addition, both had significantly higher age- and sex-adjusted means for selected known or suspected risk factors for type 2 diabetes. AN remained significantly associated with hyperinsulinemia (P = 0.0001) in multivariate analysis.

CONCLUSIONS

AN is independently associated with hyperinsulinemia and therefore may be useful as an early indicator of high risk for diabetes.

Nutritional issues for adolescents

This article describes important issues for the nutritional health of adolescents. The issues discussed include dietary factors involved in cardiovascular and cancer disease risk; osteoporosis and bone mineralization; overweight and obesity; related risk factors such as type 2 diabetes; and eating disorders. The discussion focuses on nutritional issues for the general adolescent population, rather than high-risk adolescents. Data are primarily drawn from large, population-based studies using representative samples of adolescents.

Childhood obesity

The pediatrician's approach to overweight was best summarized by Bruch 25 years ago: The pediatrician plays an important role in the prevention of obesity. From birth on, feeding a child always involves a dual task--namely, offering food in appropriate amounts and gearing it to the child's expression of his needs. Only in this way can he develop discriminating awareness and become active in establishing self-regulation.... If a child is fed when he is hungry, played with when he needs attention, and encouraged to be active when he is restless, he is not likely to grow up inhibited and passive or overstuffed and helpless, unable to control his eating because every discomfort is misinterpreted as a need to eat.

[The ovary and insulin resistance]

Insulin resistance appears to be responsible of approximately half of the cases of polycystic ovaries, the other half being probably provoked by an anomaly of the stimulation of ovaries by an excess of LH. Nevertheless, it is likely that in most cases the two factors conjugate. The excess of androgen production by the ovarian stroma is one of the major symptoms of this disease. Today, however, the diagnosis is carried mainly with the assistance of ultra-sounds which, besides the increased ovarian volume, have permitted to discover an increased ovarian stromal vascularity. Two essential datas derive from the whole works: the increased frequency of ovarian hyperstimulation syndrome and the great number of metabolic complications which requires an endocrinological supervision. But the most recent works focus on the extension to all ages of this form of pathology: from the intra-uterine life to the post menopause; and on the hereditary character of this disease. The mystery remains concerning the mechanism of the favourable effect in clomifene resistant PCOS, of surgical and laparoscopic methods of ovulation induction to which it may be useful to resort after mature consideration. More recently the benefit at the administration of metformine has been confirmed by several works.

Childhood and adolescent obesity. Prevalence and significance

The prevalence of children and adolescents with body mass index (BMI) of greater than 95th percentile has doubled in the last 2 decades (present prevalence is 10.9%) and there is a 50% increase in the prevalence of those with a BMI greater than 85th percentile (present prevalence is 22.0%) in the US. There are substantial risks for morbidity in obese children even before they reach adulthood. Further, if obesity in childhood persists into the adult years, the morbidity and mortality is greater than if the obesity developed in the adult. Screening using appropriate historical and physical data will reveal those children most in need of modification of weight gain.

Resistência à insulina na pubarca precoce - Relação com os androgênios

O objetivo deste estudo foi descrever o perfil da insulina e determinar sua relação com o hiperandrogenismo na pubarca precoce (PP). Avaliamos 23 meninas com PP devido à adrenarca precoce e 5 controles (C) pré-puberais normais (7,3±1,1 x 7,1±1,8 anos). Os níveis de sulfato de deidroepiandrosterona (SDHEA), testosterona (T) e globulina ligadora dos hormônios sexuais (SHBG) foram medidos. O índice de massa corporal (IMC) e o índice do androgênio livre (IAL) foram calculados. O teste oral de tolerância à glicose (G) foi realizado; sendo calculadas a relação de jejum da insulina (I) pela G (FIGR= I/G) e as áreas abaixo das curvas da G e I (AACG e AACI). A FIGR > 22 foi considerada como sugestiva de resistência a I (RI). O IMC foi maior na PP do que nos C: 18,8±3,0 x 15,5±1,6, p= 0,03. Os níveis de SDHEA (71,7±40,6 x 34,2±6,9µg/dl, p= 0,02), T (0,41±0,4 x 0,17±0,1nmol/L, p= 0,02) e IAL (0,73±0,7 x 0,17±0,04, p= 0,001) foram maiores na PP, enquanto a SHBG (63,7±23,1 x 110,2±23,9nmol/L, p= 0,0006) foi menor. A FIGR foi sugestiva de RI em 44% dos casos de PP, mas os níveis de G, I, a AACG, a AACI e a FIGR foram semelhantes aos C. Na PP foi observada correlação inversa entre SDHEA e I (r = -0,43, p= 0,04) e entre SHBG e IMC (r = -0,74, p = 0,0001) e AACI (r=-0,36, p= 0,09). A AACI mostrou uma correlação positiva com o IMC (r=0,56, p= 0,006) e a FIGR (r= 0,86, p= 0,0001). Embora o hiperandrogenismo adrenal possa não ter um efeito adverso sobre a sensibilidade à I na infância, como demonstrado pela correlação inversa entre o SDHEA e a I em meninas com PP, a presença da FIGR sugestiva de RI foi relativamente comum, permanecendo incerta a relação entre os níveis dos androgênios adrenais e a sensibilidade à insulina.

Premature adrenarche--normal variant or forerunner of adult disease?

Adrenarche is the puberty of the adrenal gland. The descriptive term pubarche indicates the appearance of pubic hair, which may be accompanied by axillary hair. This process is considered premature if it occurs before age 8 yr in girls and 9 yr in boys. The chief hormonal product of adrenarche is dehydroepiandrosterone (DHEA) and its sulfated product DHEA-S. The well documented evolution of adrenarche in primates and man is incompatible with either a neutral or harmful role for DHEA and implies most likely a positive role for some aspect of young adult pubertal maturation and developmental maturation. Premature adrenarche has no adverse effects on the onset and progression of gonadarche in final height. Both extra- and intraadrenal factors regulate adrenal androgen secretion. Recent studies have shown that premature adrenarche in childhood may have consequences such as functional ovarian hyperandrogenism, polycystic ovarian syndrome, and insulin resistance in later life, sometimes already recognizable in childhood or adolescence. Premature adrenarche may thus be a forerunner of syndrome X in some children. The association of these endocrine-metabolic abnormalities with reduced fetal growth and their genetic basis remain to be elucidated.

Nonalcoholic steatohepatitis in children

BACKGROUND

Nonalcoholic steatohepatitis occurs commonly in adults with obesity or diabetes mellitus. There are only a few reports of this condition in children.

METHODS

Prospective consecutive clinical series.

RESULTS

Between December 1985 and April 1995, 36 children (21 boys, 15 girls) were diagnosed with nonalcoholic steatohepatitis at the Hospital for Sick Children, Toronto. The median age at diagnosis was 12 years (range, 4-16 years). Most patients were referred because of elevated serum aminotransferases or abnormal hepatic sonogram. Thirty patients (83%) were obese. Two patients had diabetes mellitus at diagnosis, and it developed later in two. Fifteen patients had palpable hepatomegaly, and one of these had splenomegaly. None had physical signs of chronic liver disease. Thirteen of 36 patients had acanthosis nigricans. Serum aminotransferases were elevated in all but one patient. Tests for Wilson disease and chronic hepatitis B and C were negative. Serum lipid profiles were abnormal in 18 patients: 7 had hypercholesterolemia, and 11 had hypertriglyceridemia. Twenty-four of 31 examined had abnormal liver sonograms suggestive of fatty infiltration. Twenty-four patients underwent percutaneous liver biopsy: all showed large-droplet fat. Inflammation was present in 88% and fibrosis-cirrhosis in 75%. One 10-year-old patient had established cirrhosis at diagnosis.

CONCLUSIONS

Nonalcoholic steatohepatitis occurs in children, is clinically diverse, and may not be benign.

Acanthosis nigricans

Acanthosis nigricans is a lesion affecting localized areas of the skin in persons with obesity and/or hyperinsulinemia. Roughening of the skin correlates with histological papilomatosis and the apparent darkening is due to hyperkeratosis. Biochemical mechanisms for developing this hyperplastic lesion are unclear, but likely involve local cutaneous growth factors. Cross sectional surveys of unselected populations have demonstrated that young children have low prevalences of obesity and acanthosis nigricans, but the prevalences of both increase with increasing age until plateaus are reached after the age of ten. Nearly 40% of Native American teenagers have acanthosis nigricans, whereas about 13% of African American, 6% of Hispanic, and less than 1% of white, non-Hispanic children aged 10-19 have clinically apparent acanthosis nigricans. We conclude that the presence of this skin lesion is a clinical surrogate of laboratory-documented hyperinsulinemia. Acanthosis nigricans identifies a subgroup within an ethnic group who have the highest insulin concentration, the most severe insulin resistance, and thus the highest risk for the development of type 2 diabetes.

Childhood obesity

Approximately 10% of children are obese. Twin and adoption studies demonstrate a large genetic component to obesity, especially in adults. However, the increasing prevalence of obesity over the last 20 years can only be explained by environmental factors. In most obese individuals, no measurable differences in metabolism can be detected. Few children engage in regular physical activity. Obese children and adults uniformly underreport the amount of food they eat. Obesity is particularly related to increased consumption of high-fat foods. BMI is a quick and easy way to screen for childhood obesity. Treating childhood obesity relies on positive family support and lifestyle changes involving the whole family. Food preferences are influenced early by parental eating habits, and when developed in childhood, they tend to remain fairly constant into adulthood. Children learn to be active or inactive from their parents. In addition, physical activity (or more commonly, physical inactivity) habits that are established in childhood tend to persist into adulthood. Weight loss is usually followed by changes in appetite and metabolism, predisposing individuals to regain their weight. However, when the right family dynamics exist--a motivated child with supportive parents--long-term success is possible.

How possible is the prevention of polycystic ovary syndrome development in adolescent patients with early onset of hyperandrogenism

The polycystic ovary syndrome has a pubertal onset, with menstrual cycle irregularities and infertility in adulthood, as well as general health hazards such as increased risk for diabetes mellitus and myocardial infarction. Thus, prevention would be important. But as specific etiological factors are not known, nor is specific intervention. In order to use long-term intervention programs in children and adolescents, particularly rigid criteria must be used regarding proven safety and efficacy. In obese subjects, weight loss is very important, having beneficial effects on most aspects of the syndrome, such as subjective symptoms, infertility, hyperinsulinemia and related metabolic aberrations, and long-term health risks. Well controlled, long-term follow-up studies are needed on the role of prepubertal hyperandrogenism, hyperinsulinemia, gonadotropins, and ovarian morphological aspects in the development of PCOS, and possibilities of prevention.

Obesity evaluation and treatment: Expert Committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services

OBJECTIVES

The development of recommendations for physicians, nurse practitioners, and nutritionists to guide the evaluation and treatment of overweight children and adolescents.

METHODS

The Maternal and Child Health Bureau, Health Resources and Services Administration, the Department of Health and Human Services convened a committee of pediatric obesity experts to develop the recommendations.

RESULTS

The Committee recommended that children with a body mass index (BMI) greater than or equal to the 85th percentile with complications of obesity or with a BMI greater than or equal to the 95th percentile, with or without complications, undergo evaluation and possible treatment. Clinicians should be aware of signs of the rare exogenous causes of obesity, including genetic syndromes, endocrinologic diseases, and psychologic disorders. They should screen for complications of obesity, including hypertension, dyslipidemias, orthopedic disorders, sleep disorders, gall bladder disease, and insulin resistance. Conditions that indicate consultation with a pediatric obesity specialist include pseudotumor cerebri, obesity-related sleep disorders, orthopedic problems, massive obesity, and obesity in children younger than 2 years of age. Recommendations for treatment evaluation included an assessment of patient and family readiness to engage in a weight-management program and a focused assessment of diet and physical activity habits. The primary goal of obesity therapy should be healthy eating and activity. The use of weight maintenance versus weight loss to achieve weight goals depends on each patient's age, baseline BMI percentile, and presence of medical complications. The Committee recommended treatment that begins early, involves the family, and institutes permanent changes in a stepwise manner. Parenting skills are the foundation for successful intervention that puts in place gradual, targeted increases in activity and targeted reductions in high-fat, high-calorie foods. Ongoing support for families after the initial weight-management program will help families maintain their new behaviors.

CONCLUSIONS

These recommendations provide practical guidance to pediatric clinicians who evaluate and treat overweight children.

Health Consequences of Obesity in Youth: Childhood Predictors of Adult Disease

Obesity now affects one in five children in the United States. Discrimination against overweight children begins early in childhood and becomes progressively institutionalized. Because obese children tend to be taller than their nonoverweight peers, they are apt to be viewed as more mature. The inappropriate expectations that result may have an adverse effect on their socialization. Many of the cardiovascular consequences that characterize adult-onset obesity are preceded by abnormalities that begin in childhood. Hyperlipidemia, hypertension, and abnormal glucose tolerance occur with increased frequency in obese children and adolescents. The relationship of cardiovascular risk factors to visceral fat independent of total body fat remains unclear. Sleep apnea, pseudotumor cerebri, and Blount's disease represent major sources of morbidity for which rapid and sustained weight reduction is essential. Although several periods of increased risk appear in childhood, it is not clear whether obesity with onset early in childhood carries a greater risk of adult morbidity and mortality.

Obesity is now the most prevalent nutritional disease of children and adolescents in the United States. Although obesity-associated morbidities occur more frequently in adults, significant consequences of obesity as well as the antecedents of adult disease occur in obese children and adolescents. In this review, I consider the adverse effects of obesity in children and adolescents and attempt to outline areas for future research. I refer to obesity as a body mass index greater than the 95th percentile for children of the same age and gender.

Endocrine and metabolic abnormalities in adolescents with a PCOS-like condition: consequences for adult reproduction

The polycystic ovary syndrome (PCOS) has a perimenarcheal onset. Increased luteinizing hormone (LH) and androgen concentrations are common among anovulatory adolescents and some also have hyperinsulinemia. Many will later have normal ovulatory cycles, whereas others with several co-existing abnormalities will develop full-blown PCOS with menstrual cycle irregularities and infertility in adulthood.

Non-insulin-dependent diabetes mellitus in childhood and adolescence

NIDDM in children and adolescents represents a heterogeneous group of disorders with different underlying pathophysiologic mechanisms. Most subtypes of NIDDM that occur in childhood are uncommon, but some, such as early onset of "classic" NIDDM, seem to be increasing in prevalence. This observed increase is thought to be caused by societal factors that lead to sedentary lifestyles and an increased prevalence of obesity. In adults, hyperglycemia frequently exists for years before a diagnosis of NIDDM is made and treatment is begun. Microvascular complications, such as retinopathy, are often already present at the time of diagnosis. Children are frequently asymptomatic at the time of diagnosis, so screening for this disorder in high-risk populations is important. Screening should be considered for children of high-risk ethnic populations with a strong family history of NIDDM with obesity or signs of hyperinsulinism, such as acanthosis nigricans. Even for children in these high-risk groups who do not yet manifest hyperglycemia, primary care providers can have an important role in encouraging lifestyle modifications that might delay or prevent onset of NIDDM.

Clinical implications of hyperinsulinaemia in women

In the polycystic ovary syndrome, hyperinsulinaemia is commonly found in women with hirsutism, oligomenorrhoea and acanthosis nigricans and this subset of patients possess adverse risk factors for coronary artery disease, particularly reduced HDL2 concentrations. Conversely, raised serum insulin concentrations are not common in women with PCOS in whom raised serum LH concentrations or regular menstrual cycles are present. We postulate that both direct ovarian and indirect actions of insulin (through changes in IGFI-I, IGFBP-I and SHBG concentrations) play important roles in determining androgen concentrations in women. Many intriguing questions follow from this link between the control of nutrition and reproduction and many old observations required re-examination in this new light. Vital to our understanding in this field will be the cause of moderate hyperinsulinaemia, the action of insulin on the normal ovary, and the importance of adverse surrogate risk factors for heart disease in hyperinsulinaemic women.

Autosomal dominant insulin resistance syndrome due to postbinding defect

We investigated a family in which at least 4 men in 3 generations had a syndrome of obesity, mild mental retardation, delayed puberty, macroorchidism, acanthosis nigricans, hyperinsulinemia, and later overt insulin-resistant diabetes mellitus (non-insulin-dependent diabetes mellitus, NIDDM). The patients have markedly curly scalp hair, deficient face and body hair. Their teeth were healthy and normal in size and position. The clinical and biochemical findings and characteristics of the insulin receptors investigated in fibroblasts are reported. There was normal insulin binding to fibroblasts in the 2 brothers and their father. However, insulin-stimulated RNA synthesis was decreased as compared to that of normal control individuals. These findings suggest a postbinding defect of insulin action. The pedigree documents an autosomal dominant mode of inheritance. The diagnosis is of practical importance since it enables medical supervision of gene carriers in a preclinical state of atherosclerotic complications and overt diabetes. The findings in this family have relevance also to the explanation of familial mild mental retardation and to the study of different forms of insulin resistance due to a disturbance in biosignal transfer.

Partial lipodystrophy syndromes--a further male case

Details are presented of a boy with partial lipodystrophy. Only one male case has previously been described with this condition. The spectrum of partial lipodystrophy syndromes and the inheritance thereof are discussed in relation to our case.

Rearrangement of chromosome 15 in the region q11.2----q12 in an individual with obesity syndrome and her normal mother

Rearrangement of the proximal long arm of chromosome 15 have been found in most patients with the Prader-Willi syndrome (PWS) and in some with Angelman syndrome. We present an individual with syndromic obesity and her normal mother, who both have an abnormal chromosome 15. The proposita is a 26-year-old women with marked obesity, acanthosis, nigricans, short fingers, and severe cone degeneration of the retina. She has high plasma insulin levels, hypothyroidism, and an empty sella on CT scan. High-resolution chromosome banding demonstrated an increase in band 15q12. Further analysis showed the same abnormal 15 in her normal mother but not in her normal sister. This case and recent reports in the literature indicate that duplication of chromosome 15q in the PWS region may be associated with a syndrome of obesity, acanthosis nigricans, empty sella, and rodcore dystrophy as well as with a normal phenotype. Whether normal individuals with such a duplication carry increased risk of having offspring with an obesity syndrome is yet to be determined.