Characterisation of morbidity in a UK, hospital based, obesity clinic

Adolescents diabetes awareness test (ADAT): Tool development and psychometrics evaluation research

BACKGROUND

During the last two decades, several reports have indicated an increase in the number of type-2 diabetes among adolescents. Therefore, an assessment of adolescents' awareness of this disease deserves serious consideration. This study aims at designing a psychometric tool for assessing adolescents' awareness of type-2 diabetes.

METHODS AND MATERIAL

In this methodological research, 770 students attending 10 middle schools (five girls "schools and five boys" schools) from Tehran participated in the study. The questionnaire was designed by examining the relevant literature and the existing questionnaires, as well as considering the research team's comments, and the initial pool of items with 57 questions was designed. Face validity, content validity, and construct validity were calculated to determine the validity of the instrument. Reliability was measured via internal consistency coefficient (ICC) and internal consistency reliability was measured with Cronbach Alpha. SPSS 16 was used for data analysis.

RESULTS

The questionnaire was initially designed with 57 items. Based on the results of CVR and CVI, five questions were removed. The average CVR and CVI were 0.75 and 0.82, respectively. Following exploratory factor analysis, the 30 questions in the questionnaire were categorized into five dimensions: public awareness, symptoms, behavioral risk factors, long-term effects, and medium-term effects. The internal reliability was calculated for the whole questionnaire-ICC = 0.87 with a Cronbach alpha coefficient of 0.80.

CONCLUSIONS

The resulting questionnaire on adolescents' awareness of type-2 diabetes, with 30 questions in five dimensions, can be employed by researchers for its high factor loading in factor analysis and its standard psychometric properties.

Metformin for Weight Gain Associated with Second-Generation Antipsychotics in Children and Adolescents: A Systematic Review and Meta-Analysis

BACKGROUND

Weight gain is a potentially concerning side effect of second-generation antipsychotics (SGAs). Metformin, a biguanide with antihyperglycemic effects, is used to manage weight gain in adults treated with SGAs.

OBJECTIVE

The objective of this study was to perform the first systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the effects of metformin on weight gain in children and adolescents treated with SGAs.

METHODS

Based on a pre-registered protocol (PROSPERO-CRD42017074839), we searched the PubMed, EMBASE, PsychoINFO, BIOSIS, Science Direct, Cochrane Central, and ClinicalTrials.gov electronic databases through March 2018 (with no restrictions on language, date, or type of publication) for RCTs that assessed the effect of metformin or placebo on body weight in children or adolescents (< 18 years of age) treated with selected SGAs (risperidone, aripiprazole, olanzapine, and clozapine) for any psychiatric disorder. We also contacted relevant drug manufacturers for possible additional pertinent studies/data. A random effects model was used and the quality of the included RCTs was assessed using the Cochrane Risk of Bias tool.

RESULTS

Five RCTs (205 participants in total) were included in the meta-analysis. We found a significant weight decrease in the metformin group compared with placebo after 4, 12, and 16 weeks of treatment {mean difference - 0.98 kg (95% confidence interval [CI] - 1.26, - 0.69); - 1.83 kg (95% CI - 2.47, - 1.18); and - 3.23 kg (95% CI - 5.59, - 0.86), respectively}. A weight decrease at weeks 2 and 8 did not reach statistical significance. The decrease in body mass index (BMI) paralleled that of weight, with a significant effect at weeks 4, 12, and 16. Overall, four studies were rated as unclear, and one study was rated as high, risk of bias.

CONCLUSION

Meta-analytical evidence shows that metformin might decrease weight in children/adolescents treated with SGAs but additional high-quality evidence is needed. Clinicians need to be aware that this use of metformin is currently off-label.

A Narrative Review of Medical and Genetic Risk Factors among Children Age 5 and Younger with Severe Obesity

Severe obesity defined as an age- and gender-specific body mass index ≥120% of the 95th percentile in children younger than 5 years is well recognized as a significant challenge for prevention and treatment. This article provides an overview of the prevalence, classification of obesity severity, patterns of weight gain trajectory, medical and genetic risk factors, and comorbid disorders among young children with an emphasis on severe obesity. Studies suggest rapid weight gain trajectory in infancy, maternal smoking, maternal gestational diabetes, and genetic conditions are associated with an increased risk for severe obesity in early childhood. Among populations of young children with severe obesity seeking care, co-morbid conditions such as dyslipidemia and fatty liver disease are present and families report behavioral concerns and developmental delays. Children with severe obesity by age 5 represent a vulnerable population of children at high medical risk and need to be identified early and appropriately managed.

Plasma adrenomedullin level in children with obesity: relationship to left ventricular function

BACKGROUND

Obese children are at increased risk for abnormal cardiac structure and function. Little is known about adrenomedullin (AM), a cytokine produced in various organs and tissues, as a biomarker of cardiac hypertrophy in obese children. This study aimed to assess the plasma AM levels in a cohort of obese children and its relationship to left ventricular (LV) functions.

METHODS

The study included 60 obese children and 60 non-obese children matched for age and gender as control group. Blood pressure, serum lipid profile, fasting glucose, insulin and plasma AM and the homeostatic model assessment of insulin resistance (HOMA-IR) were measured. Cardiac dimensions and LV functions were assessed using conventional echocardiography.

RESULTS

Compared to control subjects, obese children had higher blood pressure (P = 0.01), insulin (P = 0.001), HOMA-IR (P = 0.001), and AM (P = 0.001). Moreover, obese children had higher LV mass index (LVMI) (P = 0.001), indicating LV hypertrophy; prolonged isovolumic relaxation times (P = 0.01), prolonged mitral deceleration time (DcT) (P = 0.01) and reduced ratio of mitral E-to-mitral A-wave peak velocity (P = 0.01), indicating LV diastolic dysfunction. Laboratory abnormalities were only present in children with LV hypertrophy. In multivariate analysis in obese children with LV hypertrophy, AM levels were positively correlated with LVMI [odds ratio (OR) 1.14, 95% confidence interval (Cl) 1.08-1.13, P = 0.0001] and mitral DcT (OR 2.25, 95% CI 1.15-2.05, P = 0.01) in the presence of higher blood pressure and HOMA-IR. A cut-off value of AM at 52 pg/mL could differentiate obese children with and without left ventricular hypertrophy at a sensitivity of 94.32% and specificity of 92.45%.

CONCLUSIONS

Plasma AM levels may be elevated in obese children particularly those with LV hypertrophy and is correlated with higher blood pressure and insulin resistance. Measurement of plasma AM levels in obese children may help to identify those at high risk of developing LV hypertrophy and dysfunction.

Determining rates of overweight and obese status in children using electronic medical records: Cross-sectional study

OBJECTIVE

To determine the prevalence of overweight and obese status in children by age, sex, and visit type, using data from EMRALD^® (Electronic Medical Record Administrative data Linked Database).

DESIGN

Heights and weights were abstracted for children 0 to 19 years of age who had at least one well-child visit from January 2010 to December 2011. Using the most recent visit, the proportions and 95% CIs of patients defined as overweight and obese were compared by age group, sex, and visit type using the World Health Organization growth reference standards.

SETTING

Ontario.

PARTICIPANTS

Children 0 to 19 years of age who were rostered to a primary care physician participating in EMRALD and had at least one well-child visit from January 2010 to December 2011.

MAIN OUTCOME MEASURES

Proportion and 95% CI of children with overweight and obese status by age group; proportion of children with overweight and obese status by sex (with male sex as the referent) within each age group; and proportion of children with overweight and obese status at the most recent well-child visit type compared with other visit types by age group.

RESULTS

There were 28 083 well-child visits during this period. For children who attended well-child visits, 84.7% of visits had both a height and weight documented. Obesity rates were significantly higher in 1- to 4-year-olds compared with children younger than 1 (6.1% vs 2.3%; P < .001), and in 10- to 14-year-olds compared with 5- to 9-year-olds (12.0% vs 9.0%; P < .05). Both 1- to 4-year-old boys (7.2% vs 4.9%; P < .01) and 10- to 14-year-old boys (14.5% vs 9.6%; P < .05) had higher obesity rates compared with girls. Rates of overweight and obese status were lower using data from well-child visits compared with other visits.

CONCLUSION

Electronic medical records might be useful to conduct population-based surveillance of overweight or obese status in children. Methodologic standards, however, should be developed.

Childhood cardiovascular risk factors, a predictor of late adolescent overweight

Background:

We conducted a prospective study to elucidate the effects of increased cardiovascular risk factors on future weight gain and also the relation between body mass index (BMI) and other cardiovascular risk factors in children and adolescents.

Materials and Methods:

This study was conducted on 1525 nonobese children and adolescents with an age range of 3-16 years old, participating in the 1^st phase and follow-up phases of Tehran Lipid and Glucose Study. The subjects were evaluated 4 times with a 3-year time interval regarding lipid profile status and BMI, and other cardiovascular disease (CVD) risk factors. All the cases had a BMI <85% and had been appraised in at least two evaluation points.

Results:

Cardiovascular risk factors, high-density lipoprotein (HDL) (P = 0.019), low-density lipoprotein (P = 0.016), triglyceride (TG) (P < 0.001), and blood pressure (BP) (P = 0.001); had significant effects on weight gain. There was also no difference between boys and girls and no age trend for increasing weight in both groups. The associations between BMI with cardiovascular risk factors were assessed cross-sectionally. For both sexes, BMI was significantly correlated to systolic and diastolic BP and TG (P = 0.05). For girls, BMI was significantly related to HDL (P = 0.05) regardless to age, but in boys, the relation of BMI with HDL only increased with age (P = 0.05).

Conclusion:

Increased CVD risk factors are predictors of future overweight in childhood and adolescent and increased weight is linked significantly with dyslipidemia and hypertension in this age group.

The effect of antidepressants and antipsychotics on weight gain in children and adolescents

Psychiatric illness in the paediatric population is increasing and the weight effect of medications for these problems is often unclear. A comprehensive literature search was undertaken to identify studies reporting weight in relation to antipsychotic and antidepressant use in children and adolescents. From 636 articles, 42 were selected for review. Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) do not cause weight gain and may lead to improvements in weight status over the short, but not, long term. Antipsychotics were generally associated with weight gain. In drug comparison studies, risperidone had a larger weight gain effect than lithium, divalproex sodium and pimozide. Studies assessing the weight-protective effects of augmentation therapy with metformin or topiramate show less weight gain with addition of these agents. In conclusion, prescribing of SSRIs and SNRIs may be associated with improvements in weight status in children and adolescents but trials assessing their use in obesity, outside of established psychiatric illness, are limited and still experimental. Youth prescribed antipsychotic medication should be monitored for exaggerated weight gain and in those where obesity is a pre-existing concern agents other than olanzapine, clozapine and risperidone may be advantageous.

Childhood obesity: Current and novel approaches

The prevalence of childhood obesity has increased over the last fifty years by approximately 5% per decade, and approximately a quarter of all children are now either overweight or obese. These children have a significantly increased risk of many future health problems including adult obesity, type 2 diabetes and heart disease. Despite this relentless increase, common-sense approaches aimed at prevention and treatment have failed to solve the problem. Current approaches at prevention have faced major challenges with some progress in implementing smaller scale programs and social marketing, but little action on broad public policy approaches which often appears unpalatable to society or individual governments. Meanwhile, treatment approaches have mainly focused on lifestyle change, and novel approaches are urgently needed. Prevention needs to shift to improving maternal health prior to conception, with more research focussed on the impact of early years in programming offspring to future overweight/obesity. Likewise, treatment paradigms need to move from simply thinking that obesity can be solved by readdressing diet and activity levels. Novel approaches are needed which take into consideration the complex physiology which regulates early childhood growth and the development of obesity in susceptible individuals.

Changing eating behaviours to treat childhood obesity in the community using Mandolean: the Community Mandolean randomised controlled trial (ComMando)--a pilot study

BACKGROUND

Around one in five children in England is obese when they leave primary school. Thus far, it has not been demonstrated that primary care interventions to manage childhood obesity can achieve significant weight reduction. Training obese children to eat more slowly as an adjunct to other healthy lifestyle behaviour change has been shown to increase weight reduction in a hospital setting.

OBJECTIVES

This pilot study aimed to test recruitment strategies, treatment adherence, clinic attendance and participants' experiences of using a device [Mandolean® (previously Mandometer®, Mikrodidakt AB, Lund, Sweden)] to slow down speed of eating as an adjunct to dietary and activity advice in treating obesity in primary school-aged children.

DESIGN

A two-arm, parallel, randomised controlled trial with a qualitative study embedded within the pilot. Randomisation occurred after informed consent and baseline measures were collected. Participants were randomised by the Bristol Randomised Trials Collaboration randomisation service with allocation stratified by hub and minimised by age of the child, gender, and baseline body mass index (BMI) standard deviation score (BMI z-value) of the child, and by BMI of the study parent (obese/not obese).

SETTING

General practices across Bristol, North Somerset and South Gloucestershire primary care trusts.

PARTICIPANTS

Children (BMI ≥ 95th percentile) aged 5-11 years and their families.

INTERVENTION

Standard care comprised dietary and activity advice by trained practice nurses. Adjunctive Mandolean training (the intervention) educated participants to eat meals more slowly and to rate levels of fullness (satiety). Mandolean is a small computer device attached to a weighing scale that provides visual and oral feedback during meals while generating a visual representation of levels of satiety during the meal. Participants were encouraged to eat their main meal each day from the Mandolean. One parent was also given a Mandolean to use when eating with the child.

OUTCOME MEASURES

Outcomes for the pilot were recruitment of 36 families to the trial in the 9-month pilot phase, that meals would be eaten at least five times a week off a Mandolean by 90% of patients randomised to the intervention arm, that 80% of patients in both arms would attend the weight management clinic appointment 3 months post randomisation and that > 60% of children using Mandolean would demonstrate a reduction in speed of eating from baseline within 3 months of randomisation.

RESULTS

None of the criteria for progression to the main trial were reached. Despite numerous pathways being available for referral, only 21 (13 to standard care, eight to intervention arm; 58%) of the target 36 families were recruited in the pilot phase. Less than 20% of those randomised to Mandolean used the device at least five times a week. The > 60% target for slowing down of eating speed by 3 months was unmet. Attendance at the weight management clinic in general practice hubs for both arms of the study at 3 months was 44% against a target of 80%.

CONCLUSIONS

This pilot trial failed to meet its objectives in terms of recruitment, treatment adherence, demonstration of a reduction in speed of eating in sufficient numbers of children, and attendance at follow-up appointments. Despite a high prevalence of childhood obesity in the geographical area and practices signing up for the trial, this study, like many others, demonstrates a failure of families to engage with and respond to primary care weight management interventions. We need to understand why the target population seems inured to the health message that childhood obesity is a significant health-care issue and identify the barriers to seeking help and then acting on positive health behaviour retraining. Only when we have fully understood the general public's perceptions of childhood obesity and have identified ways of engaging target populations can we hope to develop interventions that can work in a primary or community-based setting.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN90561114.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 47. See the NIHR Journals Library website for further project information.

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.

Where should we measure waist circumference in clinically overweight and obese youth?

AIMS

Waist circumference (WC) measurement is a useful tool in the assessment of overweight/obese individuals, but standard measures may miss an apron of 'overhanging' fat (termed 'panniculus'). The objective of this study was to assess whether, in clinically overweight/obese youth, 'pannicular' WC better correlates with fat mass than a standard WC measurement.

METHODS

Standard and pannicular WC, alongside body composition (BC) measures, were collected from 181 consultations on 127 overweight and obese children/adolescents (52% male; mean (standard deviation) age 12.5 (3.4) years). Correlation coefficients describe associations between WC and measures of BC, and between ΔWC and ΔBC, while linear regression models assessed which of the WC measures explained more of the variability in BC and ΔBC over time.

RESULTS

Standard and pannicular WC were highly correlated (r = 0.95). Correlation coefficients with measures of BC were generally greater for pannicular than standard WC, with greatest correlations seen for whole body (r = 0.94 vs. 0.85, respectively) and truncal (r = 0.86 vs. 0.77) fat mass. Furthermore, pannicular and Δpannicular WC explained more variability in truncal fat and Δtruncal fat than the standard measure of WC.

CONCLUSIONS

These data show that pannicular, rather than standard, WC measurements better correlate with absolute measures of fat mass, and their change over time, in clinically overweight/obese youth.

Sleep duration predicts cardiometabolic risk in obese adolescents

OBJECTIVE

To examine the independent contributions of objectively measured sleep duration and fragmentation on cardiometabolic risk accumulation in free-living obese adolescents.

STUDY DESIGN

Characteristics of metabolic syndrome (waist circumference, mean arterial pressure, fasting high-density lipoprotein cholesterol, triglycerides, glucose) were measured in obese adolescents and standardized residuals (z-scores) were summed (inverse high-density lipoprotein cholesterol) to create a continuous cardiometabolic risk score (cMetScore), adjusted for age, sex, and race. Sleep and physical activity were objectively measured in habitual, free-living conditions for 7 days (SenseWear Pro3, BodyMedia, Pittsburgh, Pennsylvania; n = 37; 54% female, ages 11-17 years). Associations between sleep duration and cMetScore were assessed via multiple linear regression.

RESULTS

Body mass index, total sleep time, and sleep session length were each correlated with cMetScore (P < .05 all). Total sleep time was inversely and independently associated with cMetScore (r = -0.535, P = .001) and was the best independent predictor of metabolic risk.

CONCLUSIONS

Sleep duration inversely predicts cardiometabolic risk in obese adolescents, even when we controlled for various measures of physical activity, anthropometry, and adiposity. Further research should investigate the biological mechanism of this relationship and the potential treatment effect of sleep intervention in decreasing cardiometabolic risk in this population.

Metformin in obese children and adolescents: the MOCA trial

CONTEXT

Childhood obesity is increasingly associated with type 2 diabetes (T2D). Metformin reduces the risk for T2D in adult obese nondiabetic patients, but the evidence in obese children and young people is inconclusive.

OBJECTIVE

The objective of the study was to assess the effect of metformin on body mass index sd score (BMI-SDS), metabolic risk factors, and adipokines.

DESIGN

This was a prospective, randomized, double-blind, placebo-controlled trial.

SETTING

The study was conducted at six pediatric endocrine centers in the United Kingdom.

PARTICIPANTS

One hundred fifty-one obese children and young people with hyperinsulinemia and/or impaired fasting glucose or impaired glucose tolerance (metformin: 74, placebo: 77). The study was comprised of 67.5% females, 65.6% postpubertal individuals, and 23.8% British Asian or Afro-Caribbean participants. The age range was 8-18 yr, the mean age was 13.7 (SD 2.3) yr, and the mean BMI-SDS was +3.4 (SD 0.5).

INTERVENTIONS

The intervention included metformin 1 g in the morning and 500 mg in the evening vs. placebo for 6 months.

MAIN OUTCOME MEASURE

The main outcome measure was a reduction in BMI-SDS at 6 months. Secondary outcomes included insulin and glucose levels from oral glucose tolerance tests, alanine aminotransferase (ALT), and adiponectin to leptin ratio (ALR) at 3 and 6 months.

RESULTS

Metformin was associated with a significant reduction in BMI-SDS compared with placebo at 6 months [mean difference -0.1 SD (95% confidence interval -0.18 to -0.02), P = 0.02]. Significant improvements at 3 months were found in the metformin group: fasting glucose, -0.16 mmol/liter (-0.31 to -0.00), P = 0.047; ALT, 19% (5-36%), P = 0.008; and ALR, 32% (4-67%), P = 0.02.

CONCLUSIONS

Metformin therapy has a beneficial treatment effect over placebo for BMI-SDS, fasting glucose, ALT, and ALR ratio at 3 months, with changes in BMI-SDS sustained at 6 months.

Serum levels of pigment epithelium-derived factor (PEDF) are positively associated with acanthosis nigricans in obese adolescents

INTRODUCTION

Circulating pigment epithelium-derived factor, or serine protease inhibitor F1, is upregulated during adipogenesis, contributing to obesity-induced insulin resistance. Furthermore, pigment epithelium-derived factor is abundant in stage I melanosomes and has been reported to increase pigment granules and the appearance of mature melanosomes in retinal pigment epithelium. As acanthosis nigricans is a well-recognized clinical marker of insulin resistance, we hypothesized that increased pigment epithelium-derived factor might be associated with the generation of acanthosis nigricans.

METHODS

Acanthosis nigricans, anthropometric measurements, circulating total PEDF and metabolic profiles were assessed in 28 obese adolescents in a hospital-based obesity clinic.

RESULTS

Subjects with acanthosis nigricans (n = 10) showed greater plasma levels of pigment epithelium-derived factor (PEDF) than those without [geometric mean 23.55 (range 15.2-40.2) vs. 9.01 (range 5.5-18.7) μg/ml; P < 0.001]. Although pigment epithelium-derived factor was positively correlated with the homeostasis model assessment for insulin resistance (HOMA-IR) (r = 0.779, P < 0.001; 95% CI 0.573-0.892), as previously reported, for the same degree of insulin resistance, those with acanthosis nigricans exhibited a 2.1-fold (95%CI 2.0-2.3) higher level of pigment epithelium-derived factor.

CONCLUSIONS

While acanthosis nigricans is undoubtedly associated with insulin resistance, its appearance is not ubiquitous in patients at any given level of HOMA-IR. The higher levels of pigment epithelium-derived factor in those with acanthosis nigricans compared with those without, with similar levels of resistance, suggest that pigment epithelium-derived factor levels are associated with acanthosis nigricans.

Paediatric obesity research in early childhood and the primary care setting: the TARGet Kids! research network

Primary paediatric health care is the foundation for preventative child health. In light of the recent obesity epidemic, paediatricians find themselves at the frontline of identification and management of childhood obesity. However, it is well recognized that evidence based approaches to obesity prevention and subsequent translation of this evidence into practice are critically needed. This paper explores the role of primary care in obesity prevention and introduces a novel application and development of a primary care research network in Canada—TARGet Kids!—to develop and translate an evidence-base on effective screening and prevention of childhood obesity.

The effectiveness of a primary care-based pediatric obesity program

The objective of this retrospective cohort study was to evaluate the effectiveness of the Duke University Healthy Lifestyles Program (HLP), a primary care-based childhood obesity treatment program. The study population included obese 2- through 19-year-old patients who entered the HLP between October 2006 through December 2008 and who had a visit to the HLP between the sixth and eighth month after entry. Most of the 282 patients were female (57%) and non-Hispanic/non-White (61%). The median age was 11 years. At baseline, the mean body mass index standard deviation score (BMI SDS) was 2.51, and patients achieved a mean reduction in BMI SDS of 0.10 (standard deviation = 0.20). For patients with baseline and follow-up measures of comorbidities, there were improvements in blood pressure, triglycerides, total cholesterol, and insulin resistance (P < .05). The patients in our obesity program demonstrated a small reduction in the severity of obesity. Improvements occurred in some obesity-associated comorbidities.

Vitamin D status and glucose homeostasis in obese children and adolescents living in the tropics

BACKGROUND

Pediatric obesity continues to rise and has become a major health problem worldwide. Vitamin D deficiency has been increasing among obese non-Asian children and is associated with abnormal glucose homeostasis in obese adults. However, data on the vitamin D status and its association with glucose homeostasis in obese children residing in tropical Asian countries are unavailable.

OBJECTIVE

To assess vitamin D status and glucose homeostasis in obese Thai children.

PATIENTS AND METHODS

A total of 150 obese, and 29 healthy non-obese children and adolescents were enrolled. Weight, height, body mass index (BMI) and waist circumference were obtained. All obese children underwent an oral glucose tolerance test with glucose and insulin measurements. Plasma 25-hydroxyvitamin D (25-OHD) and calciotropic blood chemistries were measured in all participants. Insulin sensitivity indices were calculated from the measured glucose and insulin levels.

RESULTS

Approximately 25% of the obese children and adolescents had impaired glucose tolerance, impaired fasting plasma glucose (FPG) and diabetes. Seventeen out of 150 (11.3%) obese children and 3 out of 29 (10.3%) non-obese children had vitamin D deficiency, which was defined as a 25-OHD level of <50 nmol l(-1). Glucose tolerance and insulin sensitivity indices were comparable between obese children with sufficient vitamin D and those with vitamin D deficiency. There were no relationships among serum 25-OHD; weight, height, and BMI standard deviation scores; insulin sensitivity indices; FPG and insulin; and 2-h plasma glucose and insulin levels.

CONCLUSION

Vitamin D deficiency is not as prevalent in obese Thai children as in obese non-Asian children from high-latitude countries. Adiposity per se is unlikely to be a determinant of vitamin D status in these obese individuals. There was no association between vitamin D deficiency and abnormal glucose homeostasis.

Does sleep duration predict metabolic risk in obese adolescents attending tertiary services? A cross-sectional study

STUDY OBJECTIVES

To determine, in a clinical sample of obese adolescents, whether shorter sleep duration is associated with metabolic risk and obesity severity.

DESIGN

Cross-sectional study.

SETTING

Tertiary care weight-management clinic in Cincinnati, OH, USA.

PARTICIPANTS

133 obese adolescents aged 10-16.9 years.

INTERVENTIONS

N/A.

MEASUREMENTS

Multifaceted sleep duration data were examined with fasting venipuncture and anthropometric data collected during clinical care.

PRIMARY OUTCOME

presence of metabolic syndrome.

SECONDARY OUTCOMES

waist circumference, triglycerides, HDL-cholesterol, blood pressure, glucose, insulin resistance (HOMA-IR), and body mass index (BMI).

PREDICTORS

Sleep duration by (1) parent-report, (2) self-report, and (3) multi-night actigraphy.

ANALYSIS

Relationships between sleep duration and each outcome were examined via regression models, adjusted for potential confounders.

RESULTS

Regardless of how measured, sleep duration showed no strong association with metabolic syndrome (OR 1.1 to 1.5, P = 0.2 to 0.8), BMI (β -0.03 to -0.01, P = 0.2 to 0.8), or most other outcomes. Lower triglycerides were predicted by shorter sleep duration by self-report (β 12.3, P = 0.01) and actigraphy (β 13.6, P = 0.03), and shorter parent-reported sleep duration was associated with higher HDL-cholesterol (β = -2.7, P = 0.002).

CONCLUSIONS

Contrary to expectations, sleep duration was not associated with metabolic outcomes, and showed limited associations with lipid profiles. Although inadequate sleep may affect other areas of functioning, it appears premature to expect that lengthening sleep will improve BMI or metabolic outcomes in clinical samples of obese adolescents.

New directions in childhood obesity research: how a comprehensive biorepository will allow better prediction of outcomes

BACKGROUND

Childhood obesity is associated with the early development of diseases such as type 2 diabetes and cardiovascular disease. Unfortunately, to date, traditional methods of research have failed to identify effective prevention and treatment strategies, and large numbers of children and adolescents continue to be at high risk of developing weight-related disease.

AIM

To establish a unique 'biorepository' of data and biological samples from overweight and obese children, in order to investigate the complex 'gene × environment' interactions that govern disease risk.

METHODS

The 'Childhood Overweight BioRepository of Australia' collects baseline environmental, clinical and anthropometric data, alongside storage of blood samples for genetic, metabolic and hormonal profiles. Opportunities for longitudinal data collection have also been incorporated into the study design. National and international harmonization of data and sample collection will achieve required statistical power.

RESULTS

Ethical approval in the parent site has been obtained and early data indicate a high response rate among eligible participants (71%) with a high level of compliance for comprehensive data collection (range 56% to 97% for individual study components). Multi-site ethical approval is now underway.

CONCLUSIONS

In time, it is anticipated that this comprehensive approach to data collection will allow early identification of individuals most susceptible to disease, as well as facilitating refinement of prevention and treatment programs.

Sleep and obesity in preschool children

OBJECTIVE

To examine the relationship between sleep and obesity in children 3 to 4 years old in Shanghai, China.

STUDY DESIGN

A total of 1311 Chinese children from 10 kindergarten classes in Shanghai, aged 3 to 4 years, who were participating in the kindergarten entrance health examination in 2000, were included in the study. Body weight and height were measured, and a questionnaire was given to the children's parents about sleep and physical and social characteristics of the children and their family. The main outcome measure was obesity, defined as body mass index (kg/m2) > or = 95th percentile for the children.

RESULTS

Compared with children reporting > or = 11 hours of sleep per night, the odds ratio for childhood obesity was 4.76 (95% CI, 1.28-17.69) for children with <9 hours of sleep, and 3.42 (95% CI, 1.12-10.46) for children with 9.0 to 9.4 hours of sleep, after adjustment for age, sex, and other risk factors. Children with caregivers who slept less, who had mothers with higher education, or who co-slept with caregivers had less nighttime sleep than other children.

CONCLUSION

Short sleep duration is positively associated with obesity in preschool children, and short nighttime sleep duration is significantly related to bedtime and co-sleeping with caregivers.

Spectrum and management of hypertriglyceridemia among children in clinical practice

OBJECTIVES

The prevalence and identification of hypertriglyceridemia in youths will likely will increase in the future as a consequence of childhood obesity and increased screening for dyslipidemias. We sought to review our clinical experience with hypertriglyceridemia, evaluate factors associated with increased triglyceride levels, and review treatment options to provide guidance for management.

METHODS

Clinical review of data for all patients who had > or =1 elevated triglyceride level (>4 mmol/L [>350 mg/dL]) while being monitored in a specialized lipid disorders clinic was performed.

RESULTS

The study population consisted of 76 patients with 761 clinic visits. Hypertriglyceridemia was secondary to lifestyle factors for 13 patients. The rest had primary hypertriglyceridemia, with 32 patients having familial combined hypertriglyceridemia and hypercholesterolemia (type II), 25 patients having primary hypertriglyceridemia (type IV), 4 patients having familial lipase deficiency (type I), and 2 patients having hyperlipoproteinemia E2/E2 phenotype (type III). Triglyceride levels were highest in type I and III hypertriglyceridemia (>10 mmol/L [>900 mg/dL]), followed by type IV and adiposity-related hypertriglyceridemia (>4 mmol/L [>350 mg/dL]) and finally type II familial combined hypertriglyceridemia and hypercholesterolemia (>2 mmol/L [>180 mg/dL]). A total of 34 patients received 37 trials of drug therapy as part of triglyceride level management (bile acid-binding resins, n = 12; fibrates, n = 19; statins, n = 6). Triglyceride levels were found to decrease over time with the use of fibrates, to increase with the use of bile acid-binding resins, and not to change with the use of statins.

CONCLUSIONS

Lifestyle modifications remain the primary therapeutic avenue for the management of pediatric hypertriglyceridemia. We propose an algorithm for the management of this heterogeneous population to guide clinicians in their treatment decisions.

Consequences of Childhood Obesity

Introduction: The incidence of childhood obesity is rising across the globe, and obesity related co-morbidities are increasing concomitantly in the paediatric population. Materials and Meth- ods: PubMed search for research and review papers on complications of childhood obesity was performed. Results: The consequences of childhood obesity can be broadly classified into medical and psychosocial consequences. Medical consequences include metabolic complications such as diabetes mellitus, hypertension, dyslipidaemia and non-alcoholic fatty liver disease, and me- chanical problems such as obstructive sleep apnoea syndrome and orthopaedic disorders. Psychological and social consequences are prevalent but often overlooked. Local data on these complications were also discussed. Conclusion: Childhood obesity is associated with significant morbidities, which not only have immediate impact on the health of the obese children, but also significantly increase the risk of morbidities in adulthood. Key words: Medical consequence, Psychosocial consequence

Prevalence of acanthosis nigricans in relation to anthropometric measures: community-based cross-sectional study in Korean pre-adolescent school children

BACKGROUND

This cross-sectional study was performed to assess the prevalence of acanthosis nigricans (AN) across various anthropometric measures and to identify the cut-offs for anthropometric indices of adiposity for development of AN in Asian preadolescent school children.

METHODS

Body mass index (BMI), percentage weight for height (PWH), percentage body fat (PBF), and AN of the neck were evaluated in children in the fifth grade of all elementary schools in one metropolitan, Korean city (2117 boys and 1916 girls, mean age 10.9 +/- 0.6 years, mean BMI 18.6 +/- 3.3 kg/m(2)).

RESULTS

The prevalence of AN was 8.4% in boys and 5.1% in girls, and was proportional to the BMI, PWH, and PBF. The prevalence of AN rose steeply in the 80th and 90th percentiles of the BMI, PWH, and PBF in boys and girls, respectively. According to receiver operating characteristic analysis, AN was observed in boys with BMI >22.2 kg/m(2), and in girls with BMI >21.2 kg/m(2), which are below the current criteria for childhood obesity (local BMI 95th percentile and International Obesity Task Force BMI 30 kg/m(2)).

CONCLUSIONS

AN has a good correlation with level of adiposity, and was already present in overweight children that were not considered obese by definition.

Prevalence of metabolic syndrome (MS) in children and adolescents with varying degrees of obesity

OBJECTIVE

Childhood obesity is increasingly common and is associated with health problems; in particular, obesity plays a central role in the metabolic syndrome (MS). We estimated the prevalence of MS in Caucasian children and adolescents with varying degrees of obesity.

PATIENTS AND METHODS

We studied 191 obese [body mass index (BMI) > 97th percentile] children and adolescents. Obesity was stratified on the basis of a threshold BMI z-score and subjects were classified as moderately (z-score 2-2.5) or severely obese (z-score > 2.5). Seventy-six, nonobese subjects were recruited into a comparison group. Thirty-one of them were of normal weight (BMI < 75th percentile) and 45 overweight (BMI 75th-97th percentile). Patients were classified as having MS if they met three or more of the following criteria for age and sex: BMI > 97th percentile, triglyceride levels > 95th percentile, high density lipoprotein (HDL) cholesterol level < 5th percentile, systolic or diastolic blood pressure > 95th percentile and impaired glucose tolerance (blood glucose level: 7.8-11.1 mmol/l at 2 h). Insulin resistance was calculated using the homeostasis model assessment for insulin resistance (HOMA-IR) and impaired insulin sensitivity was defined as a HOMA-IR > or = 2.5 in prepubertal patients and HOMA-IR > 4 in pubertal subjects.

RESULTS

The overall prevalence of MS was 13.9% and was present in 12.0% of moderately obese and 31.1% of severely obese subjects; no overweight or normal weight subjects met the criteria for MS. The rate of the MS increased progressively with increasing BMI categories (P < 0.001). Severely obese patients had a threefold increased risk with respect to moderately obese patients.

CONCLUSIONS

The prevalence of the MS is higher in obese as opposed to nonobese subjects and increases with severity of obesity.

Body mass index status is effective in identifying metabolic syndrome components and insulin resistance in Pacific Island teenagers living in New Zealand

Although adults of Pacific ethnicity living in New Zealand have more than double the prevalence of diabetes and cardiovascular disease than the general population, little is known regarding the presence of risk factors for these disorders among young Pacific Islanders. The study aim was to examine relationships between body composition, glucose and lipid metabolism, and components of the metabolic syndrome (MS) in a community sample of Pacific Island (PI) teenagers living in Dunedin. Anthropometry, body composition (dual-energy x-ray absorptiometry), glucose and lipid metabolism, insulin resistance (homeostasis model assessment [HOMA2], McAuley index), and components of MS were assessed in 80 PI teenagers (aged 15-18 years). Results showed that 6 participants had full MS, 2 had high fasting blood glucose values (>7.0 mmol/L), 55 had high adiposity, and 21 had insulin resistance. Assessment of the components of MS by body mass index (BMI) status showed that obese participants (n = 29) had a high prevalence (86.2% had one or more component), whereas only 10.5% of those with healthy BMI status (n = 19) had any MS component. Elevated fat mass had substantial effects on fasting insulin values, HOMA2, and the McAuley index because in data adjusted for age, sex, and lean mass, a 10% greater fat mass was associated with a 4.7% increase in fasting insulin, a 5.3% rise in HOMA2, and a 2.3% decrease in the McAuley index. Our results suggest that the antecedents of cardiovascular disease and type 2 diabetes mellitus occur frequently in young Pacific Islanders having high adiposity. We conclude that community studies of PI adolescents should focus on assessing risk factors whenever BMI values are high.

Elevated glucose concentrations during an oral glucose tolerance test are associated with the presence of metabolic syndrome in childhood obesity

AIMS

To investigate whether changes in glucose concentrations during an OGTT in obese children reflect the presence of peripheral insulin resistance and/or cardiovascular risk factors more closely than single measurements of fasting plasma glucose (FPG).

METHODS

One hundred and twenty-two obese children attending our Paediatric Obesity Service underwent formal OGTTs, following the measurement of blood pressure and fasting levels of insulin, glucose and lipid profiles in the majority. Fasting insulin was used as a surrogate measure of insulin sensitivity. Three different child-specific definitions for metabolic syndrome were used to identify clustering of cardiovascular risk factors in 65 of these children.

RESULTS

In the whole group, 10.7% had IGT but changes in glucose during the OGTT were not influenced by age, sex, pubertal status or raw (or age- and sex-adjusted) body mass index (BMI). During the OGTT, FPG, glucose at 60 min and area under the glucose curve correlated highly with fasting insulin. Children with metabolic syndrome (defined using any of three definitions) had comparable FPG levels to those without metabolic syndrome, but they demonstrated significantly elevated glucose levels at 60 min. On sub-group analysis, obese children with normal carbohydrate metabolism were significantly more likely to have a 1 h glucose level > or = 7.8 mmol/l if they had metabolic syndrome (P = 0.026).

CONCLUSIONS

These data suggest that an elevated 1 h post-load glucose measurement is seen in obese children who have a coexistent clustering of cardiovascular risk factors.

Fasting nonesterified fatty acid profiles in childhood and their relationship with adiposity, insulin sensitivity, and lipid levels

OBJECTIVE

The objective of this study was to examine the major constituent of nonesterified fatty acids in children with respect to auxologic parameters, insulin sensitivity, and lipid levels, because nonesterified fatty acid levels are elevated in obesity and are important in the development of comorbidities.

METHODS

Fasting blood samples were obtained from 73 children (43 girls; 49 obese; median [range] age: 11.4 [0.9-17.6] years). Concentrations of the major circulating nonesterified fatty acids (myristate, palmitate, oleate, stearate, and arachidate) were determined by gas chromatography mass spectrometry, alongside measurement of insulin, adiponectin, and lipid profiles.

RESULTS

The sum of all nonesterified fatty acids was significantly higher in obese versus normal-weight children, although gender (but not age or puberty) was an important determinant, with the difference remaining significant only in boys. Overall, obese children had higher concentrations of myristate, palmitate, and oleate but not stearate or arachidate. Age was an important determinant of myristate and arachidate, whereas gender proved more important for palmitate and stearate. Fasting insulin concentrations were not associated with either total nonesterified fatty acid concentrations or any of the individual nonesterified fatty acids, although a positive correlation was found between adiponectin and total nonesterified fatty acid concentrations that was independent of obesity status and that seemed mediated by changes in palmitate and stearate. Serum total cholesterol and low-density lipoprotein (but not high-density lipoprotein) levels seemed to correlate positively with circulating concentrations of palmitate, oleate, and stearate, whereas serum triacylglycerols correlated with myristate, palmitate, and oleate concentrations.

CONCLUSIONS

Nonesterified fatty acid concentrations are elevated in obese children, primarily as a result of increases in myristate, palmitate, and oleate. Independent effects of nonesterified fatty acids on circulating adiponectin levels and lipid parameters were observed, although we found no relationship between nonesterified fatty acid concentrations and the insulin resistance identified with obesity.