Interdisciplinary behavioral intervention for life-threatening obesity in an adolescent with Prader-Willi syndrome - a case report

Inpatient medical management of severe pediatric obesity: Literature review and case reports

Pediatric obesity rates continue to rise steeply with significant adverse effects on health outcomes across the lifespan. Significant obesity can affect the efficacy, side effects, and ability to use certain treatment, medication, or imaging modalities needed in the evaluation and management of acute pediatric conditions. Inpatient settings are rarely used as an opportunity for weight counseling and thus there is a paucity of clinical guidelines on how to manage severe obesity in the inpatient setting. We present a literature review and three patient cases with single-center protocol for non-surgical management of severe obesity in children admitted for other acute medical reasons. We performed a PubMed review from January 2002 to February 2022 utilizing keywords: "inpatient," "obesity," and "intervention." For our cases, we identified three patients with severe obesity acutely impacting their health while admitted for medical treatment who concurrently underwent acute, inpatient, weight loss regimens at a single children's hospital. The literature search yielded 33 articles describing inpatient weight loss treatments. Three patients met case criteria, all three of which demonstrated a decrease in their weight in excess percent of the 95th percentile after inpatient weight-management protocol implementation (% reduction BMI_p95: 16%-30%). This highlights obesity acutely limits or impacts specific medical care required during inpatient admissions in pediatric patients. It also suggests that implementation of an inpatient weight-management protocol during admission may provide an opportune setting to support acute weight loss and overall improved health outcomes in this high-risk cohort.

The modified Atkins diet in children with Prader-Willi syndrome

BACKGROUND

Prader-Willi Syndrome (PWS) is the most common genetic cause of obesity. Various dietary strategies have been used for weight management for people with PWS.

METHODS

This was a clinical feasibility study to test the use of the Modified Atkins Diet (low carbohydrate and high fat) for children with PWS ages 6-12 years who were overweight/obese. Participants went on the Modified Atkins Diet for 4 months and then returned to have anthropometry repeated including repeat labs and behavior questionnaires.

RESULTS

Seven children (ages 6-12) were enrolled in the study. Four participants completed the 4-month diet trial; two were unable to comply with the diet and stopped prematurely. One patient lost 2.9 kg; the others maintained their weight. Adverse effects were increases in LDL (expected based on larger studies) and hypercalciuria (with no renal stones) for one patient. Positive effects on hyperphagia and behavior were noted subjectively by families.

CONCLUSION

The Modified Atkins Diet can be a feasible low carbohydrate option for children with Prader-Willi Syndrome for weight management. Long-term use of the diet in patients with Prader-Willi Syndrome needs to be studied further.

Physical activity and maximal oxygen uptake in adults with Prader-Willi syndrome

BACKGROUND

Prader-Willi Syndrome (PWS) is the most common genetic syndrome causing life-threatening obesity. Strict adherence to a low-calorie diet and regular physical activity are needed to prevent weight gain. Direct measurement of maximal oxygen uptake (VO₂ max), the "gold standard" for assessing aerobic exercise capacity, has not been previously described in PWS.

OBJECTIVES

Assess aerobic capacity by direct measurement of VO₂ max in adults with PWS, and in age and BMI-matched controls (OC), and compare the results with values obtained by indirect prediction methods.

METHODS AND PATIENTS

Seventeen individuals (12 males) age: 19-35 (28.6 ± 4.9) years, BMI: 19.4-38.1 (27.8 ± 5) kg/m² with genetically confirmed PWS who exercise daily, and 32 matched OC (22 males) age: 19-36 (29.3 ± 5.2) years, BMI: 21.1-48.1 (26.3 ± 4.9) kg/m². All completed a medical questionnaire and performed strength and flexibility tests. VO₂ max was determined by measuring oxygen consumption during a graded exercise test on a treadmill.

RESULTS

VO₂ max (24.6 ± 3.4 vs 46.5 ± 12.2 ml/kg/min, p < 0.001) and ventilatory threshold (20 ± 2 and 36.2 ± 10.5 ml/kg/min, p < 0.001), maximal strength of both hands (36 ± 4 vs 91.4 ± 21.2 kg, p < 0.001), and flexibility (15.2 ± 9.5 vs 26 ± 11.1 cm, p = 0.001) were all significantly lower for PWS compared to OC. Predicted estimates and direct measurements of VO₂ max were almost identical for the OC group (p = 0.995), for the PWS group, both methods for estimating VO₂ max gave values which were significantly greater (p < 0.001) than results obtained by direct measurements.

CONCLUSIONS

Aerobic capacity, assessed by direct measurement of VO₂ max, is significantly lower in PWS adults, even in those who exercise daily, compared to OCs. Indirect estimates of VO₂ max are accurate for OC, but unreliable in PWS. Direct measurement of VO₂ should be used for designing personal training programs and in clinical studies of exercise in PWS.

Disorders of Sleep and Ventilatory Control in Prader-Willi Syndrome

Prader-Willi syndrome (PWS) is an imprinted genetic disorder conferred by loss of paternal gene expression from chromosome 15q11.2-q13. Individuals with PWS have impairments in ventilatory control and are predisposed toward sleep disordered breathing due to a combination of characteristic craniofacial features, obesity, hypotonia, and hypothalamic dysfunction. Children with PWS progress from failure to thrive during infancy to hyperphagia and morbid obesity during later childhood and onward. Similarly, the phenotype of sleep disordered breathing in PWS patients also evolves over time from predominantly central sleep apnea in infants to obstructive sleep apnea (OSA) in older children. Behavioral difficulties are common and may make establishing effective therapy with continuous positive airway pressure (CPAP) more challenging when OSA persists after adenotonsillectomy. Excessive daytime sleepiness (EDS) is also common in patients with PWS and may continue after OSA is effectively treated. We describe here the characteristic ventilatory control deficits, sleep disordered breathing, and excessive daytime sleepiness seen in individuals with PWS. We review respiratory issues that may contribute to sudden death events in PWS patients during sleep and wakefulness. We also discuss therapeutic options for treating sleep disordered breathing including adenotonsillectomy, weight loss, and CPAP. Lastly, we discuss the benefits and safety considerations related to growth hormone therapy.

Lifestyle interventions targeting changes in body weight and composition among youth with an intellectual disability: A systematic review

Over the past three decades, the potential effects of lifestyle interventions targeting changes in body weight and composition (weight, body mass index, fat mass, waist circumference) among adults with an intellectual disability (ID) have been examined in various systematic reviews. Nevertheless, since the middle of the 1980s, the potential effects of these interventions for youth with an ID remain an open question. The purpose of this article is to review the effects of lifestyle interventions targeting changes in body weight and composition among youth with an ID. This review will focus on changes in body weight and composition, healthy lifestyle, and secondary health conditions. A systematic review of English- and French-language studies, published between 1981 and 2013, was performed on Academic Search Complete, PsycARTICLES, Medline and Scopus. The nine studies included in this review focused mainly on: a sample with a wide age range (e.g., 7-22 years); males; overweight-obese youth having a mild-to-moderate ID with Down or Prader-Willi syndrome; physical activity interventions; cohort pre- and post-test designs with/without a control group; and changes in body weight and composition. Taken together, results from these studies suggest successful changes in weight, body mass index and fat mass. However, intervention effects on healthy lifestyle and secondary health conditions are scarce and inconclusive. Given the weaknesses of the reviewed studies, the present findings should be considered preliminary and indicative of the need for future research.

Hyperphagia: current concepts and future directions proceedings of the 2nd international conference on hyperphagia

OBJECTIVE

Hyperphagia is a central feature of inherited disorders (e.g., Prader-Willi Syndrome) in which obesity is a primary phenotypic component. Hyperphagia may also contribute to obesity as observed in the general population, thus raising the potential importance of common underlying mechanisms and treatments. Substantial gaps in understanding the molecular basis of inherited hyperphagia syndromes are present as are a lack of mechanistic of mechanistic targets that can serve as a basis for pharmacologic and behavioral treatments.

DESIGN AND METHODS

International conference with 28 experts, including scientists and caregivers, providing presentations, panel discussions, and debates.

RESULTS

The reviewed collective research and clinical experience provides a critical body of new and novel information on hyperphagia at levels ranging from molecular to population. Gaps in understanding and tools needed for additional research were identified.

CONCLUSIONS

This report documents the full scope of important topics reviewed at a comprehensive international meeting devoted to the topic of hyperphagia and identifies key areas for future funding and research.

Specific treatment of Prader-Willi syndrome through cyclical rehabilitation programmes

PURPOSE

 To evaluate retrospectively the efficiency of our rehabilitation programme for patients with Prader-Willi Syndrome. In total, 49 patients were examined, 21 female and 28 male, the youngest in their late teens. Prader-Willi syndrome is generally characterised by cognitive impairment, behavioural abnormalities, and hyperphagia. Patients are usually considerably adverse to any form of physical exercise, and despite hormonal therapy, weight control in adult patients can be difficult.

METHODS

 Four times a year, disease-specific residential programmes were organised, each lasting 4 weeks. The patients were restricted to a 1500 Kcal diet. In addition, they were required to do 6.5 h of physical exercise daily, stamina being built up by using music therapy, psychomotor therapy, education and entertainment activities.

RESULTS

BMI decreased by 2.1 average points in every residential session. For three patients who attended our treatments regularly, a reduction of 8.9 points over 6 years was recorded. An attendance of at least three sessions per year seemed to be necessary to substantially reduce weight.

CONCLUSIONS

A multidisciplinary approach and a daily calorie-counted diet can lead to significant weight loss in teenage and adult PWS patients. This approach would also be suitable in treating patients with other obesity syndromes with mental retardation.