Pediatric obesity. An overview of etiology and treatment

Familial early-onset obesity in Turkish children: variants and polymorphisms in the melanocortin-4 receptor (MC4R) gene

OBJECTIVES

Genetic factors have a key role in childhood obesity with higher rates in children than adults. Among the monogenic types of non-syndromic obesity, melanocortin-4 receptor (MC4R) deficiency is the most frequent cause. Beside pathogenic variants, single-nucleotide polymorphisms in MC4R gene are also associated with lower energy expenditure. The aim of this study was to estimate the frequency of MC4R variants and polymorphisms in a cohort of Turkish children and adolescents with severe early-onset obesity, and to understand the clinical features of patients.

METHODS

Patients, 1-17 years of age, with the onset of obesity before 10 years of age and a body mass index (BMI) standard deviation score (SDS) of >2.3, and who had a family history of early-onset obesity in at least one of their first-degree relatives were included in the study. Beside routine blood tests genetic analyses for MC4R gene were performed.

RESULTS

Analyses of MC4R revealed previously known variations in three (3.5%) patients, and pathogenic polymorphisms related with obesity in four (4.7%) patients. BMI SDS values were between 2.8 and 5.5 SDS in the pathogenic variant carrier group, and 2.8-4.9 SDS in the polymorphism group. Mean BMI SDS in variant-negative group was 3.4 ± 0.82.

CONCLUSIONS

Investigation of the MC4R in individuals with early-onset obesity and presence of obesity first-degree relatives is important. Hypertension is a rare comorbidity compared to other causes. Contrary to studies reporting that insulin resistance was absent or very rare, we found it as a frequent finding in both pathogenic variants and polymorphisms of MC4R.

Effect of high-intensity interval training in adolescents with asthma: The eXercise for Asthma with Commando Joe's® (X4ACJ) trial

BACKGROUND

Higher levels of cardiorespiratory fitness are associated with reduced asthma severity and increased quality of life in those with asthma. Therefore, the purpose of this study was to evaluate the effectiveness of a 6-month high-intensity interval training (HIIT) intervention in adolescents with and without asthma.

METHODS

A total of 616 adolescents (334 boys; 13.0 ± 1.1 years, 1.57 ± 0.10 m, 52.6 ± 12.9 kg, mean ± SD), including 155 with asthma (78 boys), were recruited as part of a randomized controlled trial from 5 schools (4 control and 1 intervention). The 221 intervention participants (116 boys; 47 asthma) completed 6 months of school-based HIIT (30 min, 3 times per week, 10-30 s bouts at >90% age-predicted maximum heart rate with equal rest). At baseline, mid-intervention, post-intervention, and 3-month follow-up, measurements for 20-m shuttle run, body mass index (BMI), lung function, Pediatric Quality of Life Inventory, Paediatric Asthma Quality of Life Questionnaire, and Asthma Control Questionnaire were collected. Additionally, 69 adolescents (39 boys (of the 36 with asthma there were 21 boys)) also completed an incremental ramp test. For analysis, each group's data (intervention and control) were divided into those with and without asthma.

RESULTS

Participants with asthma did not differ from their peers in any parameter of aerobic fitness, at any time-point, but were characterized by a greater BMI. The intervention elicited a significant improvement in maximal aerobic fitness but no change in sub-maximal parameters of aerobic fitness, lung function, or quality of life irrespective of asthma status. Those in the intervention group maintained their BMI, whereas BMI significantly increased in the control group throughout the 6-month period.

CONCLUSION

HIIT represents an effective tool for improving aerobic fitness and maintaining BMI in adolescents, irrespective of asthma status. HIIT was well-tolerated by those with asthma, who evidenced a similar aerobic fitness to their healthy peers and responded equally well to a HIIT program.

Association of Obesity with Hearing Impairment in Adolescents

Hearing loss (HL) is the third most common chronic physical condition in the United States. Obesity has become an increasingly important public health concern, as the prevalence in children, adolescents and adults has increased over the past few decades. The objectives of this study is to investigate whether obesity is associated with audiometric notches indicative of noise-induced hearing loss (NIHL), speech frequency hearing loss (SFHL), and high frequency hearing loss (HFHL) in adolescent participants of the National Health and Nutrition Examination Survey 2007–2010. The prevalence of overall audiometric notches in the adolescent population was 16.0% with higher prevalence in females than males. The prevalence of SFHL and HFHL were higher in males than females (SFHL, 7.3% vs. 5.4%, respectively; and HFHL 14.3% vs. 8.1%, respectively). Obese adolescents had a higher adjusted OR to have audiometric notches (OR = 1.93; 95% CI: 1.33–2.81) and HFHL (OR = 1.95; 95% CI: 1.19–3.21). Continued preventative efforts towards reducing obesity might also help to reduce the risk for HL and NIHL.

Expert's Choice: 2018's Most Exciting Research in the Field of Pediatric Exercise Science

This commentary highlights 23 noteworthy publications from 2018, selected by leading scientists in pediatric exercise science. These publications have been deemed as significant or exciting in the field as they (a) reveal a new mechanism, (b) highlight a new measurement tool, (c) discuss a new concept or interpretation/application of an existing concept, or (d) describe a new therapeutic approach or clinical tool in youth. In some cases, findings in adults are highlighted, as they may have important implications in youth. The selected publications span the field of pediatric exercise science, specifically focusing on: aerobic exercise and training; neuromuscular physiology, exercise, and training; endocrinology and exercise; resistance training; physical activity and bone strength; growth, maturation, and exercise; physical activity and cognition; childhood obesity, physical activity, and exercise; pulmonary physiology or diseases, exercise, and training; immunology and exercise; cardiovascular physiology and disease; and physical activity, inactivity, and health.

Mitochondrial - nuclear genetic interaction modulates whole body metabolism, adiposity and gene expression in vivo

We hypothesized that changes in the mitochondrial DNA (mtDNA) would significantly influence whole body metabolism, adiposity and gene expression in response to diet. Because it is not feasible to directly test these predictions in humans we used Mitochondrial-Nuclear eXchange mice, which have reciprocally exchanged nuclear and mitochondrial genomes between different Mus musculus strains. Results demonstrate that nuclear-mitochondrial genetic background combination significantly alters metabolic efficiency and body composition. Comparative RNA sequencing analysis in adipose tissues also showed a clear influence of the mtDNA on regulating nuclear gene expression on the same nuclear background (up to a 10-fold change in the number of differentially expressed genes), revealing that neither Mendelian nor mitochondrial genetics unilaterally control gene expression. Additional analyses indicate that nuclear-mitochondrial genome combination modulates gene expression in a manner heretofore not described. These findings provide a new framework for understanding complex genetic disease susceptibility.

Early Infant Feeding of Formula or Solid Foods and Risk of Childhood Overweight or Obesity in a Socioeconomically Disadvantaged Region of Australia: A Longitudinal Cohort Analysis

In southwestern Sydney the timing of introduction of formula and solids may be associated with risk of childhood overweight or obesity, and this may vary by age at breastfeeding cessation during first year. We included 346 infants from southwestern Sydney using the longitudinal study for Australian children (LSAC), who at baseline were singleton, full term, and normal weight births. The outcome risk of overweight or obesity was measured at every two-year interval of children aged 0 or 1 year at baseline until they reached age 10 or 11, defined by body mass index (BMI) ≥ 85th percentile, using the Centre for Disease Control and Prevention growth charts. Age at introduction to formula or solids was dichotomized at four months. We used mixed effects logistic regression for performing all analyses with and without adjusting for mother’s BMI, age during pregnancy, and social disadvantage index. Missing data were estimated using multivariate normal imputation having 25 imputations. The odds of overweight or obesity were significantly higher among infants introduced to formula or solids at ≤4 months compared to those introduced at >4 months in both unadjusted (odds ratio = 2.3262, p = 0.023) and adjusted (odds ratio = 1.9543, p = 0.0475) analyses. The odds of overweight or obesity when age at formula or solids introduction was held fixed at ≤4 months, increased significantly (odds ratio = 2.0856, p = 0.0215) for children stopping breastfeeding at age ≤4 months compared to >4 months. Thus, increasing the prevalence of breast-feeding without any formula or solids to 4–6 months in southwest Sydney should be a worthwhile public health measure.

Efficacy of Exercise Intervention for Weight Loss in Overweight and Obese Adolescents: Meta-Analysis and Implications

BACKGROUND

The global rise in obesity prevalence among children and adolescents has been linked to modifiable lifestyle factors, including lack of physical activity. However, no known meta-analysis has been conducted on the effects of exercise intervention on body composition and cardiometabolic risk factors in overweight and obese adolescents.

OBJECTIVES

The aim of this study was to (1) estimate whether exercise intervention meaningfully improves body composition and cardiometabolic risk factors in overweight and obese adolescents; and (2) discuss the implications of the findings in terms of primary healthcare provision and public health policy, using New Zealand as an exemplar context.

DATA SOURCES

Electronic databases (PubMed, Web of Science, SPORTDiscus, Google Scholar) from inception to May 2015. The reference lists of eligible articles and relevant reviews were also checked.

STUDY SELECTION

Inclusion criteria were (1) randomized controlled trial; (2) structured exercise intervention, alone or combined with any other kind of intervention; (3) control group received no structured exercise or behavioural modification designed to increase physical activity; (4) participants overweight or obese (body mass index [BMI] ≥85th percentile); and (5) participants aged between 10 and 19 years.

APPRAISAL AND SYNTHESIS METHODS

Initially, 1667 articles were identified. After evaluation of study characteristics, quality and validity, data from 13 articles (15 trials) involving 556 participants (176 male, 193 female, 187 unknown) were extracted for meta-analysis. Meta-analyses were completed on five body composition parameters and ten cardiometabolic parameters. Effect sizes (ESs) were calculated as mean differences, as well as standardized mean differences in order to determine effect magnitude.

RESULTS

Exercise intervention reduced BMI (mean 2.0 kg/m², 95 % CI 1.5-2.5; ES moderate), body weight (mean 3.7 kg, 95 % CI 1.7-5.8; ES small), body fat percentage (3.1 %, 95 % CI 2.2-4.1; ES small), waist circumference (3.0 cm, 95 % CI 1.3-4.8; ES small), but the increase (improvement) in lean mass was trivial (mean 1.6 kg, 95 % CI 0.5-2.6). The response to an oral glucose tolerance test following exercise intervention was for a decrease in the area under the curve for insulin (mean 162 μU/μl, 95 % CI 93-231; ES large) and blood glucose (mean 39 mg/dl, 95 % CI 9.4-69; ES moderate). Improvements in the homeostatic model assessment were also noted (mean 1.0, 95 % CI 0.7-1.4; ES moderate) and systolic blood pressure (mean 7.1 mmHg, 95 % CI 3.5-10.7; ES moderate). The effects of exercise on total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, fasting insulin and fasting blood glucose were inconclusive.

LIMITATIONS

Most of the included trials were short term (6-36 weeks) and 13 had methodological limitations. Additionally, the meta-analyses for some of the secondary outcomes had a small number of participants or substantial statistical heterogeneity.

CONCLUSIONS

The current evidence suggests that exercise intervention in overweight and obese adolescents improves body composition, particularly by lowering body fat. The limited available evidence further indicates that exercise intervention may improve some cardiometabolic risk factors.

Human development: from conception to maturity

Abstract The main objective of this review was to describe and emphasize the care that a woman must have in the period prior to pregnancy, as well as throughout pregnancy and after the birth of the baby, cares and duties that should continue to be followed by mother and child throughout the first years of the child’s life. Such cares are of nutritional, behavioral and lifestyle natures, and also involve the father and the whole family. Human development, from conception to maturity, consists of a critical and important period due to the multitude of intrinsic genetic and environmental factors that influence, positively or negatively, the person's entire life. The human being, who originated and passed his/her first phase of development in the womb, receives influence from different factors: a) of parental origin (father and mother), including health and lifestyle of the father and mother, genetic inheritance, nutrition of the mother prior to and during pregnancy; b) events that affected the mother and hence the child under development in intrauterine life, at birth (delivery), during perinatal period, and throughout the early years of life. The fragility of development continues throughout the preschool, school and adolescent periods during which proper nutrition with a balanced lifestyle is essential and depends on guidance from the parents, caregivers and teachers.

Assessment of left ventricular mass index could predict metabolic syndrome in obese children

BACKGROUND

Childhood obesity is a major risk factor for cardiovascular diseases in children and adults.

OBJECTIVES

The purpose of this study was to evaluate the serum leptin level and the cardiac changes in normotensive obese children and to study the relationship between left ventricular mass index (LVMI) and serum leptin with the parameters of metabolic syndrome (MS) in obese children.

METHODS

This study was conducted in al Jeddani Hospital and Ibn Sina College Hospital in Saudi Arabia in the period from July 2012 to December 2013, and included 82 obese children. Their mean age was 10.2 ± 2.8 years; they were divided into 25 obese children with MS and 57 obese children without MS, and 40 healthy age- and sex-matched children were also included in the study as a control group. All children were subjected to clinical assessment including standing height, body weight, body mass index (BMI), waist circumference (WC), and blood pressure measurements. All children received an echocardiographic examination (2-dimensional, M-mode, Doppler, and tissue Doppler echocardiograpy) and laboratory assessment of serum leptin level, fasting glucose, fasting insulin, the homeostatic model assessment for insulin resistance (HOMA) index, total cholesterol, triglycerides, and high- and low-density lipoprotein profile.

RESULTS

BMI, BMI standard deviation score, WC, fasting glucose, fasting insulin, HOMA index and the serum leptin level were significantly higher in obese children compared to control group (p < 0.05). The LVMI were increased in the obese compared to the control group (p < 0.001) while left ventricle systolic and diastolic functions did not differ in obese versus control group (p > 0.05). There was a significant positive correlation between both LVMI and serum leptin level in comparison to BMI, WC, fasting glucose, fasting insulin, HOMA, triglycerides, and low-density lipoprotein in all obese children, especially the MS group. However, there was a significant negative correlation between both LVMI and serum leptin level in comparison to high-density lipoprotein.

CONCLUSION

Assessment of LVMI as routine echocardiographic examinations and serum leptin level might be a feasible and reliable method for the evaluation of obesity and its related cardiovascular risks during childhood that can predict metabolic syndrome and insulin resistance.

Cryolipolysis versus laser lipolysis on adolescent abdominal adiposity

BACKGROUND

Noninvasive body contouring is one of the fastest growing segments of the cosmetic aesthetic industry. There is increased public demand for procedures with fewer side effects and shorter recovery times. Cryolipolysis and Laser lipolysis have been used as treatments for localized body contouring.

OBJECTIVE

To compare the effect of Cryolipolysis versus Laser lipolysis on adolescent's abdominal adiposity.

DESIGN

Randomized, controlled trial.

SUBJECTS

Forty-five obese adolescents of both sexes ranged in age from 13 to 16 years participated in this study were to be categorized into three groups of equal number (each group 15 subjects) randomly selected from population.

METHODS

Participants were randomly assigned to three groups. Group A was received (Cryolipolysis and diet), Group B was received (Laser lipolysis and diet), Group C was received (only diet) all groups were observed for 8 weeks. Weight and height scale for (change in weight), tape measurement for (waist-hip ratio), skinfold caliper, and MRI.

RESULTS

There was no significant difference between three groups post-treatment in BMI and body weight P-value were (0.2, 0.42, 0.67), respectively. There was a significant improvement for Cryolipolysis group in waist-hip ratio, Suprailiac skin fold, and subcutaneous adipose tissue than other groups P-value (0.001).

CONCLUSIONS

Cryolipolysis has a favorable effect than Laser lipolysis in the reduction of waist-hip ratio, skin folds at Suprailiac level and subcutaneous adipose tissue (SAT), there is no significant difference between them in the reduction of BMI and body weight. All groups did not have an effect on VAT.

Associations between a common variant near the MC4R gene and serum triglyceride levels in an obese pediatric cohort

Polymorphisms near the MC4R gene may be related to an increased risk for obesity, but studies of variations in this gene and its relation to cardiometabolic profiles and food intake are scarce and controversial. The aim of this study is to evaluate the influence of the variants rs12970134 and rs17782313 near the MC4R gene in food intake, binge eating (BE) behavior, anthropometric parameters, body composition, metabolic profile, and cardiometabolic risk factors in obese children and adolescents. This is a cross-sectional study that included obese children and adolescents. We evaluated anthropometric, metabolic parameters and cardiometabolic risk factors, including hypertension, impaired fasting glucose, hypertriglyceridemia, and low HDL-cholesterol. BE was assessed through the BE scale, and a 24-h recall was used to evaluate total caloric intake and percentage of macronutrients and types of dietary fat. The MC4R variants rs12970134 and rs17782313 were genotyped using TaqMan assay. To assess the magnitude of risk, a logistic regression adjusted for Z-BMI, age, and gender was performed, adopting the significance level of 0.05. The study included 518 subjects (52.1 % girls, 12.7 ± 2.7 years old, Z-BMI = 3.24 ± 0.57). Carriers of the variant rs17782313 exhibit increased triglyceride levels (108 ± 48 vs. 119 ± 54, p = 0.034) and an increased risk of hypertriglyceridemia (OR 1.985, 95 % CI 1.288-3.057, p = 0.002). There was no association of the SNP rs12970134 with clinical, metabolic, or nutritional parameters. The variant rs12970134 and rs17782313 did not influence food intake or the presence of BE. The variant rs17782313 is associated with an increased risk of hypertriglyceridemia in obese children and adolescents.

The effects of continuous vs intermittent exercise on lipid profile in obese children

Methods:

A randomised pretest–posttest design was implemented to compare the effects of continuous and intermittent exercise, measuring lipid profiles in obese children before and after the intervention. Thirty obese children (11 male and 19 female; age range: 12–15 years; body mass index ≥25) were randomised into two exercise intervention groups to engage in an 8-week exercise programme consisting of either continuous exercise (Group A) or intermittent exercise (Group B).

Results:

Data showed that there was a significant decrease in total cholesterol, triglycerides and low-density lipoprotein (LDL) cholesterol and a significant increase in high-density lipoprotein (HDL) cholesterol in both groups following intervention. There was a significant improvement in the lipid profile results of Group B compared with Group A.

Conclusions:

Intermittent exercise programmes are more effective than continuous exercise programmes in improving lipid profiles in children with obesity. Findings from this research could lead to improved health outcomes in obese patients by increasing aerobic capacity, wellness and metabolic fitness.

Viewpoint article: Childhood obesity--looking back over 50 years to begin to look forward

The last 50 years have seen the emergence of childhood obesity as a major public health concern and a condition now regularly encountered in routine general paediatric practice. Causes are extremely complex, bringing together multifactorial environmental factors and individual genetics, and we still do not have a clear understanding of why some children appear predisposed to exaggerated and sometimes extreme weight gain. Overweight and obese children of today face an uncertain future. They are likely to experience higher rates of type 2 diabetes and heart disease, as well as many other health problems. However, while the prevalence of childhood obesity has progressively increased over the last few decades, so has research into its underlying causes. This has led to large-scale trials aimed at improving prevention or treatment. As data have emerged from such studies, we have begun to accept that the heterogeneity of obesity means that broad 'common sense' strategies to address diet and activity will not lead to success on their own. Now is the time to begin to build on this information, dispelling myths and beliefs, in order to focus research efforts and take first steps towards more sophisticated strategies that go beyond the surface behaviours that simply potentiate obesity. Through carefully designed studies, aimed at tackling fundamental questions missed in the hasty development of 'common sense' approaches, will come answers that can lead to the development of more effective community- and health-care-orientated prevention and treatment programmes.

Age and sex differences in childhood and adulthood obesity association with phthalates: analyses of NHANES 2007-2010

BACKGROUND

Exposure to environmental chemicals may play a role in the development of obesity. Evidence suggests phthalate exposure may be associated with obesity in children and adults.

OBJECTIVE

To examine the association of ten urinary phthalate metabolites mono-n-butyl phthalate (MnBP), mono-ethyl phthalate (MEP), mono-isobutyl phthalate (MiBP), mono-2-ethyl-5-carboxypentyl phthalate (MECPP), mono-2-ethyl-5-hydroxyhexyl phthalate (MEHHP), mono-(2-ethyl-5-oxohexyl) phthalate (MEOHP), mono-2-ethylhexyl phthalate (MEHP), mono-benzyl phthalate (MBzP), mono-(carboxylnonyl) phthalate (MCNP), and mono-(carboxyoctyl) phthalate (MCOP) grouped by molecular weight of their parent compounds with body weight outcomes in children, adolescent and adult participants in the National Health and Nutrition Examination Survey (NHANES) 2007-2010.

METHODS

We performed multinomial logistic regression to analyze the association between obesity and urinary phthalate metabolite concentrations in children and adolescents and adults.

RESULTS

Low molecular weight (LMW) phthalate metabolites (MnBP, MEP and MiBP) are significantly (p<0.05) associated with higher odds for obesity in male children and adolescents. High molecular weight (HMW) phthalate metabolites (MECPP, MEHHP, MEOHP, MEHP, MBzP, MCNP, and MCOP) and di-2-ethylhexyl phthalate (DEHP) metabolites (MEHHP, MEOHP, MEHP and MECPP) are significantly (p<0.05) associated with higher OR for obesity in all adults. Additionally, DEHP metabolites are significantly associated with obesity in all female adults; whereas DEHP and HMW metabolites are significantly associated with OR for obesity in males 60 years and older.

CONCLUSIONS

We found age and sex differences in the association between urinary phthalate metabolite concentrations and body weight outcomes. Reverse causation cannot be excluded since overweight and obese people will have more fat mass, they may store more phthalates, thus leading to higher excretion concentrations.

Mitochondrial genetics and obesity: evolutionary adaptation and contemporary disease susceptibility

Obesity is a leading risk factor for a variety of metabolic diseases including cardiovascular disease, diabetes, and cancer. Although in its simplest terms, obesity may be thought of as a consequence of excessive caloric intake and sedentary lifestyle, it is also evident that individual propensity for weight gain can vary. The etiology of individual susceptibility to obesity seems to be complex-involving a combination of environmental-genetic interactions. Herein, we suggest that the mitochondrion plays a major role in influencing individual susceptibility to this disease via mitochondrial-nuclear interaction processes and that environmentally influenced selection events for mitochondrial function that conveyed increased reproductive and survival success during the global establishment of human populations during prehistoric times can influence individual susceptibility to weight gain and obesity.

Understanding academic clinicians' varying attitudes toward the treatment of childhood obesity in Canada: a descriptive qualitative approach

BACKGROUND

This qualitative study aims to understand academic physicians' attitudes towards the treatment of pediatric obesity in Canada.

METHODS

A stratified sample of 24 participants (surgeons, pediatricians, family practitioners) were recruited from 4 Canadian regions. Semi-structured interviews were conducted and transcribed. A codebook was developed through iterative data reduction and conceptual saturation ensured. Validity was ensured through triangulation, audit trail, and member-checking.

RESULTS

This study revealed 45 themes with regional, specialty, and experiential differences. Quebec and Ontario emphasized education of physicians and parents to improve treatment and favored surgical intervention. Half of surgeons felt surgery was the only successful treatment option, while non-surgeons favored behavioral interventions. Experienced physicians in Western Canada desired more evidence to improve patient care, while inexperienced physicians focused on early detection and home environments. Across Canada participants advocated for program development and system change. Respondents expressed family involvement as integral to treatment success and shifting away from blame and moving towards a healthy lifestyles approach.

CONCLUSIONS

Canadian regional differences in physicians' attitudes towards pediatric obesity treatment exist, influenced by experience and specialty. We will understand how themes identified in this study influence real life clinical decision making by applying these results to create a discrete choice-based conjoint survey.

Exercise and diet-induced weight loss attenuates oxidative stress related-coronary vasoconstriction in obese adolescents

Obesity is a disease of oxidative stress (OS). Acute hyperoxia (breathing 100 % O(2)) can evoke coronary vasoconstriction by the oxidative quenching of nitric oxide (NO). To examine if weight loss would alter the hyperoxia-related coronary constriction seen in obese adolescents, we measured the coronary blood flow velocity (CBV) response to hyperoxia using transthoracic Doppler echocardiography before and after a 4-week diet and exercise regimen in 6 obese male adolescents (age 13-17 years, BMI 36.5 ± 2.3 kg/m(2)). Six controls of similar age and BMI were also studied. The intervention group lost 9 ± 1 % body weight, which was associated with a reduced resting heart rate (HR), reduced diastolic blood pressure (BP), and reduced RPP (all P < 0.05). Before weight loss, hyperoxia reduced CBV by 33 ± 3 %. After weight loss, CBV only fell by 15 ± 3 % (P < 0.05). In the control group, CBV responses to hyperoxia were unchanged during the two trials. Thus weight loss: (1) reduces HR, BP, and RPP; and (2) attenuates the OS-related coronary constrictor response seen in obese adolescents. We postulate that: (1) the high RPP before weight loss led to higher myocardial O(2) consumption, higher coronary flow and greater NO production, and in turn a large constrictor response to hyperoxia; and (2) weight loss decreased myocardial oxygen demand and NO levels. Under these circumstances, hyperoxia-induced vasoconstriction was attenuated.

Parent-Led Activity and Nutrition (PLAN) for healthy living: design and methods

Child obesity has become an important public health concern, especially in rural areas. Primary care providers are well positioned to intervene with children and their parents, but encounter many barriers to addressing child overweight and obesity. This paper describes the design and methods of a cluster-randomized controlled trial to evaluate a parent-mediated approach utilizing physician's brief motivational interviewing and parent group sessions to treat child (ages 5-11 years) overweight and obesity in the primary care setting in Southern Appalachia. Specific aims of this pilot project will be 1) to establish a primary care based and parent-mediated childhood overweight intervention program in the primary care setting, 2) to explore the efficacy of this intervention in promoting healthier weight status and health behaviors of children, and 3) to examine the acceptability and feasibility of the approach among parents and primary care providers. If proven to be effective, this approach may be an exportable model to other primary care practices.

Influence of contextual and individual level risk factors on adiposity in a preschool child cohort in Ho Chi Minh City, Vietnam

OBJECTIVE

To identify risk factors associated with changes in BMI and sum of skinfold thickness (SSF) in a cohort of preschool children in Ho Chi Minh City (HCMC), Vietnam.

METHODS

This one year follow-up study, using multi-stage cluster sampling, was conducted from 2005-2006 with 526 children aged 4-5 years in preschools in urban HCMC. Information on neighborhood, preschool and home environments, socio-economic status, the child and parental characteristics were collected using interview-administered questionnaires. Dietary intake and physical activity were measured using modified, validated questionnaires. Weight, height, and triceps, subscapular and suprailiac skinfold thickness were measured. Generalized estimating equations (GEEs) were used to assess the longitudinal relationships between the risk factors and the development of adiposity.

RESULTS

A variety of factors at different levels were associated with changes in BMI and SSFs. As safety of the neighborhood increased, BMI and SSFs decreased (coefficients for BMI: -0.59; 95% CI: -1.16 to -0.01 for girls and -0.80; 95% CI: -1.53, -0.08 for boys, and coefficients for SSFs: -2.71; 95% CI: -5.07, -0.35 for girls and -4.16, 95% CI: -8.28, -0.05). Having both parents overweight was strongly predictive of an increase in BMI (1.18, 0.21-2.16). Maternal pre-pregnant BMI status, breast-feeding, and high birth weight were also related to change in adiposity.

CONCLUSION

Contextual variables in the community and home environment, and parental characteristics appeared to be more important than individual factors for explaining on changes in adiposity in this child population.

The association between urinary concentrations of dichlorophenol pesticides and obesity in children

BACKGROUND

Increasing prevalence of childhood obesity has been seen in the United States and other parts of the world. Environmental chemical exposures might play a role in the worldwide obesity epidemic.

OBJECTIVE

This study was conducted to assess the association of exposure to environmental pesticides with childhood obesity.

METHODS

A total of 6770 subjects aged 6-19 years were selected from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Survey (NHANES). Exposure to environmental pesticides was determined based on the concentrations of pesticide residues in urine. Multivariate logistic regression was performed using SAS 9.1.3 to assess the association between pesticide levels in urine and childhood obesity with the adjustment of potential confounders, including age, gender, race, income, and total fat intake.

RESULTS

A dose-dependent increase in prevalence of obesity was observed in the groups with inter-quartile urinary concentrations of 2,5-dichlorophenol (2,5-DCP). Logistic regression revealed a significant association between adjusted third (Q3) (AOR: 1.47; 95% CI: 1.09, 1.97) and fourth (Q4) (AOR: 1.44; 95% CI: 1.06, 1.95) inter-quartile urinary 2,5-DCP levels and childhood obesity. However, urinary concentrations of 2,4-dichlorophenol were not shown to be significantly associated with childhood obesity.

CONCLUSION

This study suggests a possible relationship between exposure to 2,5-DCP and obesity in children.

Effects of caloric restriction on cardiovascular aging in non-human primates and humans

Approximately one in three Americans has some form of cardiovascular disease (CVD), accounting for one of every 2.8 deaths in the United States in 2004. Two of the major risk factors for CVD are advancing age and obesity. An intervention able to positively impact both aging and obesity, such as caloric restriction (CR), may prove extremely useful in the fight against CVD. CR is the only environmental or lifestyle intervention that repeatedly has been shown to increase maximum life span and to retard aging in laboratory rodents. This article reviews evidence that CR in nonhuman primates and people has a positive effect on risk factors for CVD.

The influence of a high intensity physical activity intervention on a selection of health related outcomes: an ecological approach

Background

Cardiovascular disease (CVD) is the main cause of mortality throughout the world. With accumulating evidence suggesting that CVD has its origins in childhood, it is unsurprising that research into obesity prevalence within school aged youth is burgeoning.

Within this study our primary objective will be to examine whether high intensity interval training (HIT) improves the CVD risk profile of secondary school aged adolescents. Our secondary objective will be to identify the prevalence of CVD risk factors and examine factors associated with these in adolescents aged 15 - 18 years.

Method/Design

A South Lanarkshire school of low socioeconomic status (SES) was selected to participate in the study intervention. Participants from secondary 5 (15 - 17 years) and 6 (16 - 18 years) will be recruited for this study. Participants from secondary 6 will be randomly assigned to Group A (HIT) or Group B (moderate-vigorous) and will perform each protocol three times weekly. The secondary 5 participants will act as the control group. Data collection will take place during the Physical Education (PE) lessons and on school premises and will include: anthropometrical variables (height, weight, waist and hip circumferences, skinfold thickness at two sites), physiological responses (blood pressure, aerobic fitness, heart rate (HR) response, vertical jump performance, 10-metre (m) sprint, 50-m sprint and 505-agility test), diet (self-reported seven-day food diary), physical activity (Physical Activity Questionnaire for Adolescents (PAQ-A)) and blood tests (fasting glucose, insulin, total cholesterol (TC), high-density lipoprotein (HDL), high-sensitivity C-reactive protein (hs-CRP), fibrinogen (Fg), interleukin-6 (IL-6), adiponectin (high molecular weight), triglyceride and plasminogen activator inhibitor-1 (PAI-1). An environmental audit of the secondary school and the health related quality of life (HRQOL) of the participants will also be measured. Finally, all exercise sessions will be video recorded and rate of perceived exertion (RPE) and mood states will also be taken after each exercise session.

Discussion

Our study may be able to demonstrate a time efficient means of reducing CVD risk factors in adolescents.

Trial Registration

NCT01027156

Mechanical stimulation of mesenchymal stem cell proliferation and differentiation promotes osteogenesis while preventing dietary-induced obesity

Mesenchymal stem cells (MSCs) are defined by their ability to self-renew and differentiate into the cells that form mesodermal tissues such as bone and fat. Low magnitude mechanical signals (LMMS) have been shown to be anabolic to bone and have been recently reported to suppress the development of fat in normal animals fed a regular diet. Using male C57BL/6J mice, the ability of LMMS (0.2g, 90-Hz signal applied for 15 min/d, 5 d/wk) to simultaneously promote bone formation and prevent diet-induced obesity was correlated to mechanical influences on the molecular environment of the bone marrow, as indicated by the population dynamics and lineage commitment of MSCs. Six weeks of LMMS increased the overall marrow-based stem cell population by 37% and the number of MSCs by 46%. Concomitant with the increase in stem cell number, the differentiation potential of MSCs in the bone marrow was biased toward osteoblastic and against adipogenic differentiation, as reflected by upregulation of the transcription factor Runx2 by 72% and downregulation of PPARgamma by 27%. The phenotypic impact of LMMS on MSC lineage determination was evident at 14 wk, where visceral adipose tissue formation was suppressed by 28%, whereas trabecular bone volume fraction in the tibia was increased by 11%. Translating this to the clinic, a 1-yr trial in young women (15-20 yr; n = 48) with osteopenia showed that LMMS increased trabecular bone in the spine and kept visceral fat at baseline levels, whereas control subjects showed no change in BMD, yet an increase in visceral fat. Mechanical modulation of stem cell proliferation and differentiation indicates a unique therapeutic target to aid in tissue regeneration and repair and may represent the basis of a nonpharmacologic strategy to simultaneously prevent obesity and osteoporosis.

Effects of a 12-week Exercise Training Programme on Aerobic Fitness, Body Composition, Blood Lipids and C-Reactive Protein in Adolescents with Obesity

Introduction: Developing effective exercise programmes for the paediatric population is a strategy for decreasing obesity and is expected to help in eventually limiting obesity-associated long-term health and societal impact. In this study, the effects of a 12-week twice weekly additional exercise training, which comprised a combination of circuit-based resistance training and aerobic exercises, in additional to typical physical education sessions, on aerobic fitness, body composition and serum C-reactive protein (CRP) and lipids were analysed in 13- to 14-year-old obese boys contrasted with a control group. Materials and Methods: Both the exercise group (EG, n = 12) and control group (CG, n = 12) participated in the typical 2 sessions of 40-minute physical education (PE) per week in schools, but only EG participated in additional 2 sessions per week of 45 to 60 minutes per session of exercise training, which comprised a combination of circuit-based resistance training and aerobic exercises maintained at 65% to 85% maximum heart rate (HRmax = 220 - age). Body composition was measured using dual energy X-ray absorptiometry (DEXA). Fasting serum CRP and blood lipids were analysed pre- and post-exercise programme. Aerobic fitness was measured by an objective laboratory submaximal exercise test, PWC170 (Predicted Work Capacity at HR 170 bpm). Results: Exercise training significantly improved lean muscle mass, body mass index, fitness, resting HR, systolic blood pressure and triglycerides in EG. Serum CRP concentrations were elevated at baseline in both groups, but training did not result in a change in CRP levels. In the CG, body weight increased significantly at the end of the 12-week period. Conclusion: This study supports the value of an additional exercise training programme, beyond the typical twice weekly physical education classes, to produce physiological benefits in the management of obesity in adolescents, including prevention of weight gain. Key words: Aerobic fitness, Body composition, C-reactive protein, Exercise training, Obese adolescents

Constructs of health and environment inform child obesity prevention in American Indian communities

OBJECTIVE

Obesity prevention efforts have had limited success in American Indian (AI) populations. More effective prevention programs might be designed using insights into linkages between parental health beliefs, environmental constraints and healthy lifestyle choices.

METHODS AND PROCEDURES

Focus group sessions (n = 42 participants) were conducted to explore parental perspectives on children's health, diet and physical activity in three Wisconsin Tribal communities. Focus group questions were derived from preliminary interviews and observations on environmental barriers surrounding nutrition and physical activity.

RESULTS

Two broad thematic areas emerged from the focus groups: child health themes and environmental themes. Health themes included views of child health (emphasizing emotional health), views on parenting, and assessment of risks to child safety. Environmental (social and physical) themes included assessments of personal support networks, assessments of local facilities and programs, and values regarding household relationships. A provisional model of family behaviors related to child nutrition and physical activity was developed to better understand these themes and the potential tensions among them.

DISCUSSION

Understanding the unique cultural constructs of health and environment of AI communities can inform decision making in community-level prevention research. The proposed model served as a useful starting point for designing healthy lifestyle interventions in these AI communities. This model may also be applicable to other minority communities.

Child overweight interventions in rural primary care practice: a survey of primary care providers in southern Appalachia

Child overweight has reached an epidemic level throughout the United States. A total of 65 primary care providers in southern Appalachia were surveyed to understand current issues in addressing child overweight in rural primary care practice. The study shows that while providers realized the importance of child overweight intervention, many were not ready and did little to address child overweight in their practices. The providers' skill levels in addressing child overweight were generally less than sufficient. Common barriers to child overweight treatment included lack of parental motivation and involvement, lack of supportive services, and lack of clinician time. In conclusion, rural primary care is facing many challenges in addressing child overweight. However, with more training in behavioral intervention skills and through establishing a family-based intervention and a group visit approach, primary care providers could play a more active role in the fight against the epidemic of child overweight.

Body mass index measurement in schools

BACKGROUND

School-based body mass index (BMI) measurement has attracted much attention across the nation from researchers, school officials, legislators, and the media as a potential approach to address obesity among youth.

METHODS

An expert panel, convened by the Centers for Disease Control and Prevention (CDC) in 2005, reviewed and provided expertise on an earlier version of this article. The panel comprised experts in public health, education, school counseling, school medical care, and a parent organization. This article describes the purposes of BMI measurement programs, examines current practices, reviews existing research, summarizes the recommendations of experts, identifies concerns, and provides guidance including a list of safeguards and ideas for future research.

RESULTS

The implementation of school-based BMI measurement for surveillance purposes, that is, to identify the percentage of students in a population who are at risk for weight-related problems, is widely accepted; however, considerable controversy exists over BMI measurement for screening purposes, that is, to assess the weight status of individual students and provide this information to parents with guidance for action. Although some promising results have been reported, more evaluation is needed to determine whether BMI screening programs are a promising practice for addressing obesity.

CONCLUSIONS

Based on the available information, BMI screening meets some but not all of the criteria established by the American Academy of Pediatrics for determining whether screening for specific health conditions should be implemented in schools. Schools that initiate BMI measurement programs should evaluate the effects of the program on BMI results and on weight-related knowledge, attitudes, and behaviors of youth and their families; they also should adhere to safeguards to reduce the risk of harming students, have in place a safe and supportive environment for students of all body sizes, and implement science-based strategies to promote physical activity and healthy eating.

The Gene-Diet Attica investigation on childhood obesity (GENDAI): overview of the study design

BACKGROUND

There is limited evidence on the role of genetic and environmental factors in the etiology of childhood obesity, a major health problem worldwide.

METHODS

The Gene-Diet Attica Investigation on childhood obesity (GENDAI) evaluates the contributions to and pivotal interactions of genetic, dietary and physical activity variables on children's weight. We describe the design, methodology, and present preliminary data. So far, 920 participants have been enrolled and the final projected sample is 1000 fifth- and sixth-grade students from selected elementary schools in Attica (10-14 years). In this school-based cross-sectional study, more than 400 variables describing anthropometric, dietary, clinical, genetic, sociodemographic and other lifestyle characteristics were collected from participating children and their families.

RESULTS

Increased body mass index was identified in 39.3% of subjects (30.5% overweight and 8.8% obese), with males presenting a more unfavorable metabolic profile, i.e., higher blood lipids, glucose, and insulin, compared to females. Normal-weight children had a significant advantage when compared to all children of increased weight in terms of lipid profile and insulin, as well as behaviors examined. Specifically, normal-weight children exhibited less skipping of meals and less sedentary activities.

CONCLUSIONS

The overall high prevalence of overweight and obesity in the current population is significant and underscores the need for environmental and genetic information that will shed light on the phenomenon of childhood obesity.

How active are we? Levels of routine physical activity in children and adults

The accurate measurement of physical activity is fraught with problems in adults, but more especially in children because they have more complex and multi-dimensional activity patterns. In addition, the results of different studies are often difficult to interpret and compare, because of the diversity of methodological approaches, differences in data analysis and reporting, and the adoption of varying definitions of what constitutes an appropriate level of activity. Furthermore, inactivity is seldom quantified directly. Although there exists an extensive literature documenting the health benefits of regular physical activity in adults, activity-health relationships in children are not clear-cut. Current recommendations reinforce the concept of health-related activity, accumulating 30 min moderate-intensity exercise on at least 5 d/week (adults) and 1 h moderate-intensity exercise/d (children). Evidence suggests a high prevalence of inactivity in adults, but whether or not inactivity is increasing cannot be assessed currently. Similarly, no definite conclusions are justified about either the levels of physical activity of children, or whether these are sufficient to maintain and promote health. Data to support the belief that activity levels in childhood track into adulthood are weak. Inactivity is associated with an increased risk of weight gain and obesity, but causality remains to be established. In children there is strong evidence to demonstrate a dose-response relationship between the prevalence and incidence of obesity and time spent viewing television. Future research should focus on refining methodology for physical activity assessment to make it more sensitive to the different dimensions and contexts of activity in different age-groups.

Are dietary intakes and eating behaviors related to childhood obesity? A comprehensive review of the evidence

The purpose of this article is to comprehensively review studies that have examined the relation between diet and childhood obesity. The review specifically considers the roles of total energy intake and energy density; dietary composition; individual foods, food groups, and dietary patterns; beverage consumption; and eating behaviors. The paper also discusses methodological considerations and future research directions and concludes by summarizing the evidence presented and highlighting the ethical issues surrounding providing dietary advice.

Effect of obesity on inflammatory markers and renal functions

AIM

To examine the relationship between inflammation criteria and body mass index in otherwise-healthy obese schoolchildren and to evaluate the effect of obesity on renal functions.

METHODS

Sixty-five otherwise-healthy obese children (median age 10.8 y, range 7.1-16.5 y; median body mass index 26.8 kg/m(2), range 19.9-38.7 kg/m(2)) and 20 healthy controls (median age 12.4 y, range 10.1-17.1 y; median body mass index 18.8 kg/m(2), range 17.3-23.1 kg/m(2)) were included. Blood and urine samples were taken from every child.

RESULTS

Children in the obese and control groups had similar age and sex distributions (p>0.05). Inflammatory mediators were higher in obese children (p<0.05). A significant positive correlation was found between glomerular filtration rate and body mass index in the whole study group (r=0.39, p=0.001). A positive correlation was found between body mass index standard deviation and inflammatory mediators and glomerular filtration rate. No significant difference existed regarding protein and microalbumin excretion in the urine.

CONCLUSION

Inflammatory mediators increased significantly in obese children, and the glomerular filtration rate increased as the body mass index increased. To prevent obesity-related complications in adulthood, it is important to take measures to prevent development of obesity during childhood.

Knowledge of healthy diets among adolescents in eastern Saudi Arabia

BACKGROUND

Bad dietary habits, such as eating high-fat/high-energy food, can contribute to obesity in adolescents, which tends to persist into adulthood. The objective of this study was to determine the level and sources of knowledge about foods and healthy diets among male and female adolescents.

METHODS

This was a cross-sectional study of a sample of male (n=1240) and female (n=1331) adolescents from third grade, intermediate and all three grades of secondary school students in the Al-Khobar Area, eastern province of Saudi Arabia. A self-administered questionnaire was used to collect information.

RESULTS

Approximately 51% of the male and 65% of the female students recognized unsaturated fats as healthy foods. However, 10% of the males and 8% of females reported saturated fats as healthy food items. About 49% of the males and 66% of the females correctly defined cholesterol. Dietary knowledge of both male and female students on the dangers of unhealthy foods and the benefits of fiber-rich diets was found to be unsatisfactory. The main sources of knowledge about health and disease reported by the male and female respondents were television (58% and 61%, respectively), magazines (31% and 39%) and daily newspaper (33% and 34%). Primary health care centers (PHCCs) staff were the least source of knowledge (17% and 16%).

CONCLUSIONS

Knowledge of healthy diets among school students was inadequate. It is recommended that health education and information about healthy eating habits and lifestyle be included in school curricula.

Undetected hepatomegaly in obese children by primary care physicians: a pitfall in the diagnosis of pediatric nonalcoholic fatty liver disease

The diagnostic evaluation of nonalcoholic fatty liver disease (NAFLD) relies on the initial detection of hepatomegaly or elevated serum aminotransferases by the primary care provider. In this investigation, the aptitude of the primary care provider to identify children with hepatomegaly and initiate an evaluation for NAFLD is determined. The physical examination findings and requests for diagnostic testing of 18 primary care physicians (and pediatric gastroenterologists) on 11 obese school-aged children, including a subset of children with hepatomegaly and NAFLD, were analyzed. In children with NAFLD, clinicians detected hepatomegaly in 1.4% of encounters and requested serum liver chemistries in 12.5% of encounters. Hepatomegaly is detected poorly in obese children by primary care physicians and thereby increases the likelihood of a delayed or omitted evaluation for NAFLD.

Dietary factors are not associated with high levels of obesity in New Zealand Pacific preschool children

Pacific children living in New Zealand (NZ) are prone to excessive weight gain. In this study, we assessed the anthropometric status of 2- to 5-y-old Pacific children (n = 60) in relation to their macronutrient intakes. Measurements of height (n = 56), weight (n = 60), midarm circumference, and triceps skinfold thickness (n = 58), and 2-d weighed food records (n = 60) and demographic data were collected. Z-score results (mean +/- SD) showed that these children were tall (0.61 +/- 1.1) and heavy (1.67 +/- 1.1) for their age, and had high arm-muscle-area-for-height (geometric mean, 2.05). Over 64 and 45% of children were classified as overweight (including obesity) and obese, respectively. The percentage of energy contributed by fat in their diets met recommendations. In contrast, the percentage of energy contributed by sugar was high. The macronutrient intakes of children classified as obese (n = 32) compared with non-obese (n = 24) did not differ; however, their adjusted energy intakes were higher [5.79 (1.4) vs. 4.97 (1.4) MJ/d; P = 0.01]. Overweight and obesity were very common among very young NZ Pacific children, although the dietary etiology was not elucidated. These results emphasize the urgent need for obesity prevention for NZ Pacific children that begins early in life to avoid a future public health crisis.

Parental obesity and higher pre-intervention BMI reduce the likelihood of a multidisciplinary childhood obesity program to succeed--a clinical observation

OBJECTIVE

To assess the effects and identify factors associated with success of a combined, structured multidisciplinary weight management program in obese children and adolescents.

METHODS

Seventy-seven obese children (age 6-16 years) participated in a 12-month combined dietary-behavioral-exercise intervention. Thirty-seven (age and maturity comparable) obese children who did not participate in the structured program served as controls. Body weight, BMI, and BMI percentiles were measured at baseline, after 6 months, and at the end of the intervention.

RESULTS

The combined intervention was associated with a significant decrease in BMI (from 25.9+/-0.4 to 24.5+/-0.4 kg/m2, p <0.0005) and BMI percentile (from 97.3+/-0.2% to 92.6+/-0.9%, p <0.0005). In contrast, obese children who did not participate in the structured program gained weight (from 51.4+/-3.6 to 57.7+/-3.7 kg, p <0.0005), increased their BMI (from 25.2+/-1.0 to 26.6+/-0.9 kg/m2, p <0.0005), and had a non-significant increase in BMI percentiles (from 94.9+/-0.8% to 95.4+/-0.9%, NS). Children with higher BMI percentiles and parental overweight tended to respond less favorably to the combined multidisciplinary program (p <0.01).

CONCLUSIONS

A prolonged (12 mo), combined, structured multidisciplinary intervention for childhood obesity resulted in a significant decrease in BMI and BMI percentiles. Higher pre-intervention BMI percentiles and parental obesity were associated with less favorable responses to the combined intervention.

Obesity prevention in children: physical activity and nutrition

The current environmental experience of young children includes few opportunities for physical activity and an overabundance of high calorie foods. Sedentary lifestyles and poor nutrition challenge children who are predisposed to metabolic disorders. Obesity is a logical response to this challenge. To prevent clinically significant obesity and later metabolic disease in predisposed youth, all sectors of society must work together to support strategies to change public opinion and behavior across the life span. Parental education in all medical settings is strongly recommended, especially if the parent(s) are obese, beginning with the first pregnancy visit to the physician. Schools should be primary targets for efforts to educate parents concerning the reduction of TV, computer games, and unhealthy snacks. Schools should be encouraged to adopt vending machine policies that promote healthy drinks and food in appropriate portion sizes and discouraged from providing unhealthy food as rewards for positive behavior or academic accomplishment. Schools should provide daily physical education and frequent periods of unstructured play in young children. Clinical treatment should be both encouraged and financially supported in children who are already overweight. Community wide efforts to increase awareness and promote environments that encourage physical activity and healthy nutrition are needed.

Obesity in patients with craniopharyngioma: assessment of food intake and movement counts indicating physical activity

Patients with childhood-onset craniopharyngioma (CP) often suffer from obesity. We evaluated two important etiological factors of obesity development, energy intake and physical activity. Energy intake was supposed to be high due to a disturbed hypothalamic regulation of appetite. We used a validated nutritional diary to determine the 1-wk food intake in 27 CP patients (12 with intrasellar tumors and 15 with hypothalamic tumors) and 1027 controls who were a representative sample of the 7- to 16-yr-old German population. In 2 accelerometry settings, we determined movement counts indicating physical activity. Nineteen CP patients were comparable to 26 controls for age and body mass index. One setting was a clinical one during weight reduction; the other was an out-patient setting. Daily energy intake was 1916 +/- 677 kcal (mean +/- SD) in intrasellar CP patients, 2075 +/- 877 kcal in hypothalamic CP patients, and 2476 +/- 815 kcal in non-CP controls. Patients suffering from CP showed fewer movement registrations [clinical setting, 228 vs. 298 cpm for obese controls (P = 0.01); out-patient setting, 228 vs. 282 cpm for controls (P = 0.08)]. Differences were most pronounced during leisure time (382 cpm in CP patients vs. 546 cpm in obese controls; P = 0.002; clinical setting). Our findings suggest that reduced physical activity, rather than increased energy intake, in CP patients is responsible for the obesity development noted in these subjects.