Pediatric obesity

Predictive factors for open reduction of operatively treated radial neck fractures in children

INTRODUCTION

Open reduction is a therapeutic option for displaced radial neck fracture in children, which once was considered the last resort because of its potential risk for functional outcomes. This study aimed to identify risk factors for open reduction in operatively treated radial neck fractures in children.

PATIENTS AND METHODS

One hundred and thirty-seven patients with displaced radial neck fractures, treated surgically at our department from January 2010 to December 2021 were retrospectively enrolled. Patients' data of age, sex, injury side, obesity, type of fractures, combined fractures, nerve injury, reduction methods, and delay from injury to surgery were reviewed. Univariate analysis and multivariate logistic regression were used to identify independent risk factors and odds ratios of open reduction.

RESULTS

Overall, 137 patients (62 females and 75 males) with an average of 8.0 ± 2.2 years were analyzed. There were 62 cases of type III fractures and 75 cases of type IV based on the Judet classification. Thirty-two cases had combined fractures and 19 cases presented with nerve injury. The open reduction rate was 24.1 % (33/137). Univariate analysis indicated obesity, fracture type, and combined fractures were significantly associated with open reduction. (P = 0.039, P = 0.000 and P = 0.000, respectively). While multivariate logistic regression analysis showed that only fracture type (OR, 5.18; CI, 1.63-16.46, p = 0.005) and combined fractures (OR, 7.79; CI, 2.97-20.41, p = 0.000) were independent risk factors for open reduction.

CONCLUSIONS

Judet type IV fracture and combined fractures are two significant risk factors for open reduction in operatively treated radial neck fractures in children. These findings will facilitate preoperative decision making, remind surgeons of the risk of failure in closed reduction and the use of new surgical techniques to decrease the open reduction poor outcome rate.

A meta-analysis of weight status and anxiety in children and adolescents

OBJECTIVE

Although some posit that youth who are overweight/obese experience greater amounts of anxiety than their peers who are normal weight, extant literature shows that the association between weight status and anxiety in youth is equivocal. Therefore, the purpose of this study was to elucidate the association between weight status and anxiety in children and adolescents through meta-analytic methods.

METHOD

Electronic databases and review articles were searched for studies including quantitative data on weight status and anxiety in youth aged ≤18 years. Data were analyzed using a random effects model. Putative moderators were selected a priori.

RESULTS

A total of 61 studies yielded 78 effect sizes (N = 180,136) and a small but significant overall summary effect (r = .08; 95% confidence interval, 0.06-0.11; z = 6.41; p < .001). Gender, age group, and type of weight status measure significantly moderated the association. Specifically, studies with girls, children aged 12 years and under, or norm-referenced measures of weight status (e.g., body mass index [BMI] z-score) evidenced significantly higher effect sizes between weight status and anxiety than studies with boys, adolescents aged 13 years and over, or non-norm-referenced measures of weight status (e.g., BMI), respectively. Sample type, publication type, anxiety type, anxiety informant, and race/ethnicity were not significant moderators.

CONCLUSION

Overall, the association between weight status and anxiety is small; however, study or methodological characteristics may modestly influence the effect. Longitudinal studies are needed to determine the directionality of the association, and consequently, the intended target of intervention.

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

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

Timely diagnosis of malalignment of the distal extremities is crucial in morbidly obese juveniles

BACKGROUND/AIMS

To determine i) whether obesity in childhood can be related to malalignment of the distal extremities, ii) the proportion of genu valgum malalignment and abduction setting, and iii) the respective deviation dominance in children who are morbidly obese.

METHODS

31 morbidly obese Caucasian children (16 males) recruited for the STYJOBS Study (ClinicalTrials.gov Identifier NCT00482924) with a mean age of 13.9 ± 0.5 years, a mean height of 162.3 ± 2.7 cm, a mean weight of 90.62 ± 5.0 kg, and a mean BMI of 33.8 ± 1.2 kg/m(2) were clinically examined using the Mikulicz line in order to assess load distribution on the knee joint. 21 participants received a whole-leg X-ray because of a clinically estimated malalignment.

RESULTS

8/31 participants examined were diagnosed with genu valgum, 1/31 with genu varum, and 22/31 did not have any malalignment of the femur or tibia. The majority of genu valgum presentation was due to femoral deviation. Of those without malalignment, 4/22 participants had an abduction setting, while 2/22 showed an adduction of the leg.

CONCLUSION

Genu valgum as a predominant malalignment of the distal extremities is frequent in youth with morbid obesity. Timely guided correction of angular deformity of the knee seems pivotal in order to avoid osteotomy or osteoarthritis later in life.

Body image, body satisfaction and dieting behavior in Japanese preadolescents: The Toyama birth cohort study

OBJECTIVES

To examine the relationships between body image, body satisfaction and dieting behavior in the context of pubertal changes in Japanese preadolescents.

METHODS

A cross-sectional study of dieting behavior among 5,244 preadolescents (2,452 boys and 2,792 girls aged 12-13) born in Toyama prefecture.

RESULTS

The percentages of those who perceived themselves fat, wanted to be thinner, and had tried dieting, which increased with body mass index (BMI), were significantly higher in girls than in boys (34.2% vs. 20.0%, 58.0% vs. 26.0%, and 17.3% vs. 5.7%, respectively). Independent of sex and BMI, those who wanted to be thinner and those who had tried dieting were more frequently observed in those who perceived themselves fat, and those who had tried dieting were more frequently observed in those who wanted to be thinner. Pubertal changes were significantly associated with dieting behavior, but their relationships to body image and body satisfaction differed between sexes; for boys, those who perceived themselves fat were more frequently observed in those without pubertal changes; whereas for girls, those who wanted to be thinner were more frequently observed in those with pubertal changes.

CONCLUSIONS

Dieting behavior of Japanese preadolescents was associated with whether they perceived themselves fat and wanted to be thinner, sometimes independent of whether they were actually overweight. Pubertal changes might induce a positive perspective of growing fat among boys and a desire to be thinner among girls, with the consequence that dieting behavior would be reinforced in those with pubertal changes.

Body image and body satisfaction play important roles in the path to dieting behavior in Japanese preadolescents: The Toyama birth cohort study

OBJECTIVES

To analyze the path to dieting behavior in Japanese preadolescents.

METHODS

A cross-sectional study of dieting behavior among 5,244 preadolescents (2,452 boys and 2,792 girls aged 12-13) born in Toyama prefecture.

RESULTS

While increasing with body mass index (BMI), the percentage of those who had tried dieting was higher in those who perceived themselves fat than in those who perceived themselves thin or average. Of those who wanted to be thinner, 16.1% of boys and 26.8% of girls had tried dieting. Path analysis in nonobese subjects (2,116 boys and 2,334 girls) showed that (1) body image was primarily based on BMI, (2) body image led to body dissatisfaction, and (3) body dissatisfaction led to dieting behavior. Pubertal changes had a significant effect on body image (path coefficient <0)for boys and body satisfaction (path coefficient >0) for girls, in addition to that on BMI. Maternal BMI had a significant effect on BMI but not on body image, body satisfaction, or dieting behavior.

CONCLUSIONS

Body image and body satisfaction play important roles in the path to dieting behavior in Japanese preadolescents. Pubertal changes may reinforce dieting behavior, but the mechanism may differ by sex.

Childhood obesity: a life-long health risk

Childhood obesity has become major health concern for physicians, parents, and health agencies around the world. Childhood obesity is associated with an increased risk for other diseases not only during youth but also later in life, including diabetes, arterial hypertension, coronary artery disease, and fatty liver disease. Importantly, obesity accelerates atherosclerosis progression already in children and young adults. With regard to pathophysiological changes in the vasculature, the striking similarities between physiological changes related to aging and obesity-related abnormalities are compatible with the concept that obesity causes "premature" vascular aging. This article reviews factors underlying the accelerated vascular disease development due to obesity. It also highlights the importance of recognizing childhood obesity as a disease condition and its permissive role in aggravating the development of other diseases. The importance of childhood obesity for disease susceptibility later in life, and the need for prevention and treatment are also discussed.

Childhood obesity: a life-long health risk

Childhood obesity has become major health concern for physicians, parents, and health agencies around the world. Childhood obesity is associated with an increased risk for other diseases not only during youth but also later in life, including diabetes, arterial hypertension, coronary artery disease, and fatty liver disease. Importantly, obesity accelerates atherosclerosis progression already in children and young adults. With regard to pathophysiological changes in the vasculature, the striking similarities between physiological changes related to aging and obesity-related abnormalities are compatible with the concept that obesity causes "premature" vascular aging. This article reviews factors underlying the accelerated vascular disease development due to obesity. It also highlights the importance of recognizing childhood obesity as a disease condition and its permissive role in aggravating the development of other diseases. The importance of childhood obesity for disease susceptibility later in life, and the need for prevention and treatment are also discussed.

Anesthetizing the obese child

The prevalence of childhood obesity is increasing. The focus of this review is the special anesthetic considerations regarding the perioperative management of obese children. With obesity the risk of comorbidity such as asthma, obstructive sleep apnea, hypertension, and diabetes increases. The obese child has an increased risk of perioperative complications especially related to airway management and ventilation. There is a significantly increased risk of difficult mask ventilation and perioperative desaturation. Furthermore, obesity has an impact on the pharmacokinetics of most anesthetic drugs. This has important implications on how to estimate the optimal drug dose. This article offers a review of the literature on definition, prevalence and the pathophysiology of childhood obesity and provides suggestions on preanesthetic evaluation, airway management and dosage of the anesthetic drugs in these patients. The authors highlight the need of supplemental studies on various areas of the subject.

Relationship between pediatric obesity and otitis media with effusion

Although eustachian tube dysfunction and bacterial infection have been shown to cause otitis media with effusion (OME), other etiologies are possible. One of the most common medical conditions in children is obesity, which can have effects throughout the body. Little is known, however, about the relationship between obesity and OME. Obesity may result in altered cytokine expression, gastroesophageal reflux disease, or fat accumulation, all of which may contribute to OME. Conversely, OME may induce taste changes through middle ear cavity inflammation, thus contributing to obesity. A similar pattern of taste change has been shown in patients with gustatory nerve anesthesia. Further research on the relationship between obesity and OME may help to determine the exact etiology of OME and contribute to our knowledge about the causes of obesity.

Complications with flexible nailing of femur fractures more than double with child obesity and weight >50 kg

BACKGROUND

Previous studies report that children above the 95th percentile in weight for their age had an increased risk for complications following titanium elastic nailing for femur fractures. The purpose of this study is to examine whether obesity, defined as body mass index (BMI) > 95th percentile, and/or simple weight correlates with an increased rate of complications.

METHODS

The incidence of complications was compared between obese and non-obese patients and also between patients who weighed >/=50 kg and those <50 kg.

RESULTS

The overall complication rate was 23% (16/71). The complication rate was 17% (10/58) for "non-obese" patients and 46% (6/13) for "obese" patients. This difference was statistically significant (P = 0.03). The complication rate was 46% (6/13) in children who weighed >/=50 kg and 17% (10/58) in children who weighed <50 kg. This difference was also statistically significant (P = 0.03).

CONCLUSIONS

This study demonstrates that obesity (BMI > 95th percentile) and weight over 50 kg predispose patients to increased risk of surgical complications when undergoing flexible elastic nailing for femur fractures. Both obese children and children weighing >/=50 kg were two times more likely to have a complication when undergoing this procedure.

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

OBJECTIVE

Our objective was to formulate practice guidelines for the treatment and prevention of pediatric obesity.

CONCLUSIONS

We recommend defining overweight as body mass index (BMI) in at least the 85th percentile but < the 95th percentile and obesity as BMI in at least the 95th percentile against routine endocrine studies unless the height velocity is attenuated or inappropriate for the family background or stage of puberty; referring patients to a geneticist if there is evidence of a genetic syndrome; evaluating for obesity-associated comorbidities in children with BMI in at least the 85th percentile; and prescribing and supporting intensive lifestyle (dietary, physical activity, and behavioral) modification as the prerequisite for any treatment. We suggest that pharmacotherapy (in combination with lifestyle modification) be considered in: 1) obese children only after failure of a formal program of intensive lifestyle modification; and 2) overweight children only if severe comorbidities persist despite intensive lifestyle modification, particularly in children with a strong family history of type 2 diabetes or premature cardiovascular disease. Pharmacotherapy should be provided only by clinicians who are experienced in the use of antiobesity agents and aware of the potential for adverse reactions. We suggest bariatric surgery for adolescents with BMI above 50 kg/m(2), or BMI above 40 kg/m(2) with severe comorbidities in whom lifestyle modifications and/or pharmacotherapy have failed. Candidates for surgery and their families must be psychologically stable and capable of adhering to lifestyle modifications. Access to experienced surgeons and sophisticated multidisciplinary teams who assess the benefits and risks of surgery is obligatory. We emphasize the prevention of obesity by recommending breast-feeding of infants for at least 6 months and advocating that schools provide for 60 min of moderate to vigorous daily exercise in all grades. We suggest that clinicians educate children and parents through anticipatory guidance about healthy dietary and activity habits, and we advocate for restricting the availability of unhealthy food choices in schools, policies to ban advertising unhealthy food choices to children, and community redesign to maximize opportunities for safe walking and bike riding to school, athletic activities, and neighborhood shopping.

Secular and seasonal trends in obesity in Chilean preschool children, 1996-2004

OBJECTIVES

Chile is a unique example of the nutrition transition, with improvements in undernutrition and subsequent rapid increases in obesity occurring at a rate much faster than in other countries. This study aims to describe the cross-sectional obesity trends in Chilean preschool children from 1996 to 2004.

MATERIALS AND METHODS

Anthropometric measurements from preschool children (ages 2-5) registered in the Junta Nacional de Jardines Infantiles program from 1996 to 2004 were analysed. The weight-for-height z score using the World Health Organization 1977/1985 reference curves for age, sex, height, and weight were defined to estimate overweight and obesity. The overall trends in obesity were described for each study year and generalized estimating equation models were used to describe trends in obesity after adjusting for the correlated nature of repeated measurements in individual children in consecutive years.

RESULTS

The prevalence of obese and overweight children has remained constant in both boys and girls during the past 9 years; however, after adjustment for repeated measurements in individual children, the odds of obesity increased by 30% each year (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.27-1.31, P < 0.001). Furthermore, the odds of obesity were significantly greater in both August and November compared with March.

CONCLUSIONS

The prevalence of obesity in Chilean preschool children continues to be a major public health concern, and cross-sectional trends may underestimate the magnitude of the problem.

An overview of pediatric obesity

Pediatric obesity is increasing worldwide and disproportionately affects the economically and socially disadvantaged. Obese children are at risk of developing the (dys)metabolic syndrome, insulin resistance, early-onset type 2 diabetes mellitus, polycystic ovarian syndrome, hypertension, hyperlipidemia, and obstructive sleep apnoea. Those with diabetes may have mixed features of type 1 and type 2 diabetes mellitus. Pediatric obesity is the result of persistent adverse changes in food intake, lifestyle, and energy expenditure. It may be because of underlying a genetic syndrome or a conduct disorder. Children living in urban settings often lack safe, affordable, and accessible recreational facilities. Tight educational schedules mean less free time, while computer games and television have become preferred recreational activities. More families are eating out or eating take-out meals and processed foods at home because of pressures of work and time constraints. Consumer advertising targeted at children and the ready availability of vending machines encourage unwise food choices. Some children eat excessively because they are depressed, anxious, sad, or lonely. Often families and obese children are aware of the need for healthy eating and exercise but are unable to translate knowledge into weight loss. Population-based measures such as public education, school meal reforms, child-safe exercise friendly environments, and school-based and community-based exercise programs have been shown to be successful to varying degrees, but there remain individuals who will need special help to overcome obesity. Overeating (e.g. binge eating) may be a manifestation of disordered coping behavior but may also be because of defects in the neural and hormonal control of appetite and satiety. New pharmacological approaches are targeting these areas. We need a coordinated approach involving government, communities, and healthcare providers to provide a continuum of population-based interventions, focused screening, and personalized multidisciplinary interventions for the obese child and family.

Childhood obesity and insulin resistance

Insulin resistance (IR) in childhood has importance to the understanding and prevention of the growing epidemic of insulin resistance syndrome (IRS) in adults with attendant obesity, type 2 diabetes (T2DM), atherosclerotic diseases, hypertension, gout, non-alcoholic, steato-hepatitis (NASH), gall bladder disease, nephropathy, polycystic ovarian disease (PCOS), infertility and premature senility. The severity of IR and its' complications in children unfortunately and usually progresses in their pubertal transition to adulthood; affected young children are more likely than adults to have underlying causal monogenic disorders; the sequence of natural history and events give insights into disease pathogeneses, and optimal life style choices that last are best made during the early formative years. Some features of IR in children discussed herein are: a strong tendency to low birth weight for gestational age, adverse effects of adrenarche and therapeutic steroid therapy, predisposition to premature pubarche, acanthosis nigricans, tall stature despite pituitary GH suppression, allergic diathesis, hyperandrogenism and PCOS, dyslipidemia and fatty liver disease, and diagnosis by clinical and biochemical markers of IR including insulin regulated hepatic hormonal binding proteins such as IGFBP-1. The national preoccupation with the "metabolic syndrome" T2DM and obesity, should be appropriately directed to an improved understanding of IR in children and their management, if the looming health crisis in affected adults is to be seriously addressed. The nation is facing its' first generation of children who will be less healthy and die younger than the previous generation (Marks (2005) Presentation to the American Association of Diabetes Educators 32nd Annual Meeting and Exhibition, August 10-13, Washington, DC).

Lifestyle interventions in the treatment of childhood overweight: a meta-analytic review of randomized controlled trials

CONTEXT

Evaluating the efficacy of pediatric weight loss treatments is critical.

OBJECTIVE

This is the first meta-analysis of the efficacy of RCTs comparing pediatric lifestyle interventions to no-treatment or information/education-only controls.

DATA SOURCES

Medline, PsycINFO, and Cochrane Controlled Trials Register.

STUDY SELECTION

Fourteen RCTs targetting change in weight status were eligible, yielding 19 effect sizes.

DATA EXTRACTION

Standardized coding was used to extract information on design, participant characteristics, interventions, and results.

DATA SYNTHESIS

For trials with no-treatment controls, the mean effect size was 0.75 (k = 9, 95% confidence interval [CI] = 0.52-0.98) at end of treatment and 0.60 (k = 4, CI = 0.27-0.94) at follow-up. For trials with information/education-only controls, the mean ES was 0.48 (k = 4, CI = 0.13-0.82) at end of treatment and 0.91 (k = 2, CI = 0.32-1.50) at follow-up. No moderator effects were identified.

CONCLUSIONS

Lifestyle interventions for pediatric overweight are efficacious in the short term with some evidence for extended persistence. Future research is required to identify moderators and mediators and to determine the optimal length and intensity of treatment required to produce enduring changes in weight status.

A rat model of childhood diet-induced obesity: Roux-en-Y gastric bypass induced changes in metabolic parameters and gastric peptide ghrelin

Childhood morbid obesity is reaching epidemic proportions. Roux-en-Y gastric bypass (RYGB) results in many metabolic alterations, including changes in glucose and lipid metabolism, and changes in levels of the gastric hormone, ghrelin. As more children are undergoing RYGB, an animal model would be beneficial to further study RYGB and its subsequent metabolic effects. DIO Sprague Dawley rats underwent RYGB, sham jejunojejunostomy (SH), or no operation (HFC) after 6 weeks of high-fat diet. Non-obese rats fed standard chow (SC) were a final control group. Animals were post-operatively fed standard chow for 7 days before sacrifice. At sacrifice, venous blood and gastric mucosa was collected for metabolic parameters and ghrelin determination. RYGB rats weighed less than SH and HFC (361 +/- 8.8 vs. 437 +/- 9.3 and 443 +/- 6.2 g, P < 0.05). Compared to HFC, RYGB animals had decreased plasma glucose (292 +/- 23 vs. 141 +/- 10 mg/dL), cholesterol (80 +/- 12 vs. 45 +/- 5 mg/dL), triglycerides (138 +/- 37 vs. 52 +/- 7 mg/dL), HDL (43 +/- 5 vs. 20 +/- 3 mg/dL), and free fatty acids (0.72 +/- 0.14 vs. 0.23 +/- 0.02 mEq/L), all P < 0.05. Plasma ghrelin increased in RYGB rats compared to SC and HFC (116.22 +/- 32.27 vs. 31.60 +/- 2.66 and 31.75 +/- 0.75 pg/mL, P < 0.05). In a rat model of RYGB, we demonstrated improved metabolic parameters and increased plasma and gastric mRNA ghrelin levels. The rat model for RYBG appears to be a reasonable model for future study of the cellular and molecular regulatory pathways of obesity and its surgical treatment.

The association between changes in height and obesity in Chilean preschool children: 1996-2004

OBJECTIVES

To establish the association between changes in height and prevalence of obesity between 1996 and 2004 in Chilean preschool children.

RESEARCH METHODS AND PROCEDURES

Children registered in the Junta Nacional de Jardines Infantiles (JUNJI) preschool program were routinely measured three times a year and in consecutive years. Two indices [weight-for-height z-scores (WHZ) and BMI centiles] were used to define obesity. Height-for-age z-scores (HAZ) were used to define stature. Generalized estimating equations were used to describe the relationship between stature and obesity while controlling for repeated measurements in children.

RESULTS

The prevalence of obesity in Chilean preschool children has remained relatively constant over the past 9 years when either index is used. The prevalence of stunted (HAZ<or=2) children has decreased, while the proportion of children who are tall (HAZ>2) has increased. Using WHZ to define obesity, stunted children do not seem to be at increased risk of obesity when compared with children of normal height. Tall children were strongly protected from obesity when either criterion was used to define obesity.

DISCUSSION

The lack of association between stunting and obesity using WHZ>or=2 likely reflects the fact that Chile is in the post-transitional phase of the nutrition transition, and stunting is no longer a risk factor for obesity; however, the associations observed between stunting and BMI suggest that either WHZ or BMI, or both, are inaccurate criteria to define overweight.

CONCLUSIONS

There is a unique relationship between stature and obesity in preschool children that is different from that observed in older children in the same population.

Practitioner review: bridging the gap between research and clinical practice in pediatric obesity

BACKGROUND

Pediatric obesity is a significant public health concern, with rising prevalence rates in both developed and developing countries. This is of particular significance given that overweight children and adolescents are at increased risk for multiple medical comorbidities, as well as psychosocial and behavioral difficulties. The current review highlights findings from the empirical pediatric obesity treatment literature, with particular attention to diet, physical activity, and behavior interventions. Evaluation and treatment considerations relevant to working with overweight children and adolescents with psychiatric comorbidities are reviewed.

METHODS

Review of the relevant treatment literature, with a focus on randomized clinical trials, was conducted. Recommendations regarding treatment of children and adolescents with psychiatric comorbidities are based on relevant prospective studies of the relationship between weight status and psychological variables and studies with adult populations.

RESULTS

Well-established pediatric weight control interventions have been conducted in research settings. These studies provide a starting point, but are limited by homogeneous samples that may exclude participants with psychiatric comorbidities. Practitioners treating obese children and adolescents with psychiatric disorders are encouraged to assess individual, familial, and contextual variables specific to weight (e.g., motivation and existing support to change current eating and physical activity patterns, extent of weight-related conflict within family, impact of weight on current functioning) in order to prioritize treatment objectives.

CONCLUSIONS

The review concludes with a discussion of current empirical and practical challenges, including explicitly targeting obese children and adolescents with psychiatric concerns and determining appropriateness of pursuing weight control interventions in this population.

Musculoskeletal findings in obese children

AIM

A cross-sectional study was conducted to explore osteoarticular alterations in obese children.

METHODS

Twenty-five boys and 24 girls (mean age: 10.8+/-2.07 years) with a body mass index (BMI) above the 95th percentile were compared with 28 boys and 19 girls (controls, mean age: 10.4+/-2.3 years) with a BMI below the 80th percentile.

RESULTS

A higher frequency of at least one osteoarticular manifestation was observed in obese patients (55%) compared with the control group (23%) (P=0.001). A statistically significant association was also found between obesity and lower back pain, genu valgum, genu recurvatum and tight quadriceps. Fibromyalgia tender points (=11) were present at similar frequency in both groups (obese: 3/38 (9%) vs. control: 1/48 (2%)).

CONCLUSION

The present data suggest that obesity has a negative impact on osteoarticular health by promoting biomechanical changes in the lumbar spine and lower extremities.

Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with 'best practice' recommendations

Childhood obesity is a global epidemic and rising trends in overweight and obesity are apparent in both developed and developing countries. Available estimates for the period between the 1980s and 1990s show the prevalence of overweight and obesity in children increased by a magnitude of two to five times in developed countries (e.g. from 11% to over 30% in boys in Canada), and up to almost four times in developing countries (e.g. from 4% to 14% in Brazil). The goal of this synthesis research study was to develop best practice recommendations based on a systematic approach to finding, selecting and critically appraising programmes addressing prevention and treatment of childhood obesity and related risk of chronic diseases. An international panel of experts in areas of relevance to obesity provided guidance for the study. This synthesis research encompassed a comprehensive search of medical/academic and grey literature and the Internet covering the years 1982-2003. The appraisal approach developed to identify best practice was unique, in that it considered not only methodological rigour, but also population health, immigrant health and programme development/evaluation perspectives in the assessment. Scores were generated based on pre-determined criteria with programmes scoring in the top tertile of the scoring range in any one of the four appraisal categories included for further examination. The synthesis process included identification of gaps and an analysis and summary of programme development and programme effectiveness to enable conclusions to be drawn and recommendations to be made. The results from the library database searches (13,158 hits), the Internet search and key informant surveys were reduced to a review of 982 reports of which 500 were selected for critical appraisal. In total 158 articles, representing 147 programmes, were included for further analysis. The majority of reports were included based on high appraisal scores in programme development and evaluation with limited numbers eligible based on scores in other categories of appraisal. While no single programme emerged as a model of best practice, synthesis of included programmes provided rich information on elements that represent innovative rather than best practice under particular circumstances that are dynamic (changing according to population subgroups, age, ethnicity, setting, leadership, etc.). Thus the findings of this synthesis review identifies areas for action, opportunities for programme development and research priorities to inform the development of best practice recommendations that will reduce obesity and chronic disease risk in children and youth. A lack of programming to address the particular needs of subgroups of children and youth emerged in this review. Although immigrants new to developed countries may be more vulnerable to the obesogenic environment, no programmes were identified that specifically targeted their potentially specialized needs (e.g. different food supply in a new country). Children 0-6 years of age and males represented other population subgroups where obesity prevention programmes and evidence of effectiveness were limited. These gaps are of concern because (i) the pre-school years may be a critical period for obesity prevention as indicated by the association of the adiposity rebound and obesity in later years; and (ii) although the growing prevalence of obesity affects males and females equally; males may be more vulnerable to associated health risks such as cardiovascular disease. Other gaps in knowledge identified during synthesis include a limited number of interventions in home and community settings and a lack of upstream population-based interventions. The shortage of programmes in community and home settings limits our understanding of the effectiveness of interventions in these environments, while the lack of upstream investment indicates an opportunity to develop more upstream and population-focused interventions to balance and extend the current emphasis on individual-based programmes. The evidence reviewed indicates that current programmes lead to short-term improvements in outcomes relating to obesity and chronic disease prevention with no adverse effects noted. This supports the continuation and further development of programmes currently directed at children and youth, as further evidence for best practice accumulates. In this synthesis, schools were found to be a critical setting for programming where health status indicators, such as body composition, chronic disease risk factors and fitness, can all be positively impacted. Engagement in physical activity emerged as a critical intervention in obesity prevention and reduction programmes. While many programmes in the review had the potential to integrate chronic disease prevention, few did; therefore efforts could be directed towards better integration of chronic disease prevention programmes to minimize duplication and optimize resources. Programmes require sustained long-term resources to facilitate comprehensive evaluation that will ascertain if long-term impact such as sustained normal weight is maintained. Furthermore, involving stakeholders in programme design, implementation and evaluation could be crucial to the success of interventions, helping to ensure that needs are met. A number of methodological issues related to the assessment of obesity intervention and prevention programmes were identified and offer insight into how research protocols can be enhanced to strengthen evidence for obesity interventions. Further research is required to understand the merits of the various forms in which interventions (singly and in combination) are delivered and in which circumstances they are effective. There is a critical need for the development of consistent indicators to ensure that comparisons of programme outcomes can be made to better inform best practice.

Laparoscopic adjustable gastric banding for the treatment of adolescent morbid obesity in the United States: a safe alternative to gastric bypass

BACKGROUND

Morbid obesity (MO) has reached epidemic proportions and is a major health problem in developed nations. In the adolescent with MO, early intervention can minimize obesity-related comorbidities, avoid premature mortality, improve quality of life, and prevent obesity-related diseases as these patients mature into adulthood. The primary surgical treatment of adolescent patients meeting National Institutes of Health criteria for bariatric surgery has been the gastric bypass (GB). Although GB has led to weight loss and improvement of comorbid conditions, concerns remain over the high incidence of postoperative complications and life-style-altering long-term sequelae of gastrointestinal tract reconstruction. Based on the excellent results from international adult series as well as the authors' own experience of more than 300 adult patients, laparoscopic adjustable gastric banding (LAGB) as an alternative to GB to eligible adolescents was offered.

METHODS

After medical, psychologic, and nutritional screening, 4 patients (ages 17-19 years) with a body mass index of 40 or more (range, 40-61) who failed medical attempts at weight loss were selected for LAGB.

RESULTS

The operative time was 40 to 90 minutes. All patients were discharged on the day of surgery. There were no early complications. One patient had cholecystitis 6 months after surgery requiring laparoscopic cholecystectomy. For the 4 patients, the amount of excess weight loss was 57% at 30 months, 34% at 12 months, 87% at 7 months, and 15% at 4 months, respectively.

CONCLUSIONS

In this preliminary series of the US experience in the use of LAGB for the management of adolescents with MO, the lack of operative morbidity, short operative time/hospital stay, and encouraging initial weight loss mirror the adult experience and illustrate that the LAGB is a safe and effective alternative to GB. These encouraging results support further evaluation of LAGB as a surgical option in a comprehensive adolescent weight loss program.

Children's food consumption patterns have changed over two decades (1973-1994): The Bogalusa heart study

OBJECTIVE

To evaluate types of foods and amounts consumed by 10-year-old children during the period from 1973 to 1994.

DESIGN

One 24-hour dietary recall was collected on each child who participated in one of seven separate cross-sectional surveys of 10-year-olds.Subjects/Setting Dietary intake data was collected on 1,584 10-year-old children (65% Euro American, 35% African American), in Bogalusa, LA, from 1973 to 1994 using SAS 8.0 (1999, SAS Institute Inc, Cary, NC). Statistical analyses performed Data were analyzed to calculate descriptive statistics. Pearson's chi(2) test was used for testing equality of percentage of each food group consumed across the seven surveys. Cochran-Armitage trend test and general linear models were used to test for trends, adjusting for total energy intake, ethnicity, and sex.

RESULTS

The percentage of children consuming, and the mean gram amount consumed, significantly decreased for fats/oils (P<.0001), desserts (P<.0001), candy (P<.0001), eggs (P<.001), and milk (P<.0001). In contrast, the percentage of children consuming, and the mean gram amount consumed, significantly increased for fruits/fruit juices (P<.01), mixed meats (P<.01), poultry (P<.0001), and cheese (P<.0001). Despite a significant decrease in the percentage of children consuming vegetables (P<.01) and beef (P<.01), the mean gram amount consumed did not change. The percentage of children consuming breads/grains, pork, and snacks did not change, but the mean gram amount of salty snacks (P<.001) significantly increased and the amount of breads/grains (P<.01) and pork (P<.01) significantly decreased. The percentage of children consuming sweetened beverages (P<.01) and condiments (P<.001) decreased while the mean gram amount consumed increased (P<.05) and (P<.0001). The mean gram amount of lunch and dinner consumed increased (P<.0001) but snacks decreased (P<.0001), resulting in no change in total gram amount consumed in a 24-hour period.

CONCLUSIONS

Trends in food consumption patterns of children should be considered in the design and implementation of population-based behavior strategies for the promotion of health and prevention of chronic diseases beginning in childhood.

Type 2 diabetes mellitus in children and adolescents: a review from a European perspective

Changes in food consumption and exercise are fueling a worldwide increase in obesity in children and adolescents. As a consequence of this dramatic development, an increasing rate of type 2 diabetes mellitus has been recorded in children and adolescents in the USA and, more recently, in many countries around the world. Both genetic and environmental factors contribute to the pathogenesis of type 2 diabetes. Lower susceptibility in white Caucasians and higher susceptibility in Asians, Hispanics and blacks have been noted. There is a high hidden prevalence and a lack of exact data on the epidemiology of the disease in Europe: in Germany only 70 patients below the age of 15 years were identified in the systematic, nationwide DPV (Diabetessoftware für prospektive Verlaufsdokumentation) diabetes survey, but our calculations suggest that more than 5000 young people in Germany at present would meet the diagnostic criteria of type 2 diabetes. In Australasia, the prevalence of type 2 diabetes is reportedly high in some ethnic groups and again is linked very closely to the obesity epidemic. No uniform and evidence-based treatment strategy is available: many groups use metformin, exercise programmes and nutritional education as a comprehensive approach to treat type 2 diabetes in childhood and adolescence. The lack of clear epidemiological data and a strong need for accepted treatment strategies point to the key role of preventive programmes. Prevention of obesity will help to counteract the emerging worldwide epidemic of type 2 diabetes in youth. Preventive programmes should focus on exercise training and reducing sedentary behaviour such as television viewing, encouraging healthy nutrition and supporting general education programmes since shorter school education is clearly associated with higher rates of obesity and hence the susceptibility of an individual to acquire type 2 diabetes.

Application of laparoscopy for bariatric surgery in adolescents

An epidemic increase in adolescent obesity in the United States has resulted in significant obesity-related comorbidities, previously seen only in adults. Although bariatric surgery is an acceptable alternative for weight loss in severely obese adults, no conclusions have been made about the appropriateness of bariatric surgery for individuals younger than 18 years old. Nonetheless, bariatric surgery is increasingly being performed on adolescents with clinically severe obesity and experience suggests that it is effective and safe. Application of the principles of adolescent growth, development, and compliance is essential to avoid adverse physical, cognitive, and psychosocial outcomes following bariatric surgery. Bariatric surgery should be part of a multidisciplinary approach to the management of adolescents with clinically severe obesity and should be performed by specialists dedicated to pediatric care, in institutions capable of meeting the guidelines for surgical treatment outlined by the American Society of Bariatric Surgery.

Long-term suppression of weight gain, adiposity, and serum insulin by central leptin gene therapy in prepubertal rats: effects on serum ghrelin and appetite-regulating genes

Intracerebroventricular administration of recombinant adeno-associated virus (rAAV) encoding the rat leptin gene (rAAV-lep) to 24-d-old female and male rats suppressed postpubertal weight gain for extended periods by decreasing food consumption and adiposity, as reflected by lowered serum leptin, insulin, and FFA. Serum ghrelin levels were increased in young but not older rats. Central rAAV-lep therapy also increased energy expenditure through nonshivering thermogenesis in younger rats as shown by expression of uncoupling protein mRNA in brown adipose tissue. The sustained decrease in appetite seemingly resulted from attenuation of appetite-stimulating neuropeptide Y and enhancement of appetite-inhibiting melanocortin signalings in the hypothalamus. Neither the onset of pubertal sexual maturation nor reproductive cyclicity in adult female rats was affected by the sustained reduction in energy consumption and weight gain. These findings demonstrate that central leptin gene therapy in prepubertal rats is a novel therapy to control postpubertal weight gain, adiposity, and hyperinsulinemia for extended periods.

Childhood obesity

The prevalence of childhood obesity is rising, and pediatric obesity has become an important public health issue. It can be defined as BMI more than 95th percentile for age and sex, whereas overweight is defined as BMI more than 85th percentile. Using these cut points, more than one quarter of all children and adolescents are either overweight or obese. The recent increases in the prevalence of childhood obesity result from the interaction between a strong genetic predisposition that facilitates storage of fat, easy access to calorically dense foods, and the low levels of physical activity that characterize modern societies. Childhood obesity has pervasive psychosocial and medical consequences in the short term and the long term. Many of these consequences may not be apparent for decades, but the metabolic complications of obesity and the insidious effects of early psychosocial stigmatization are sometimes observed even in young children. For pediatric obesity, behavioral approaches seem moderately efficacious in younger children. Comprehensive programs generally include modification of dietary and activity habits and some degree of parental involvement. Medication for pediatric obesity cannot be recommended currently outside the context of clinical trials. Gastric bypass surgery is effective but should be considered a last resort for the child with life-threatening complications of obesity.