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

Strategies to prevent cardiovascular disease in Singapore: A call to action from Singapore Heart Foundation, Singapore Cardiac Society and Chapter of Cardiologists of the Academy of Medicine, Singapore

Introduction

In 2022, the Minister for Health of Singapore launched Healthier SG, a national strategy in championing the shift towards a population health approach.

Method

The Singapore Heart Foundation conducted a series of roundtable discussions, also attended by representatives of the Singapore Cardiac Society and the Chapter of Cardiologists of the Academy of Medicine Singapore. During the meetings, the authors formulated interventions supportive of Healthier SG that specifically aimed to uplift the state of cardiovascular (CV) preventive care in Singapore.

Results

In line with Healthier SG, the authors propose a 3-pronged approach ("Healthier Heart SG") to augment the success of Healthier SG in achieving good CV outcomes. This proposal includes the following components: (1) a call to update the standards of care in addressing the 5 main modifiable risk factors of cardiovascular disease (CVD); (2) patient education through cooperation between healthcare professionals and community partners for a whole-of-system approach; and (3) support for integrated care, including access to cardiac rehabilitation in the community, improved referral processes and access to nutrition/dietetics counselling and tobacco cessation, optimal use of information technology, and continued CV research.

Conclusion

Healthier Heart SG would bring the standards of care and CV care delivery in Singapore closer to achieving the vision of proactive prevention of CVD and CV morbidity and mortality. This can only be achieved through the concerted efforts of healthcare professionals, policymakers and community partners, coupled with the cooperation of community members.

Trends in serum uric acid levels among Korean children and adolescents between 2016 and 2020: a nationwide study

The aim of this study was to examine trends in serum uric acid (SUA) levels over a recent 5-year period according to age, sex, obesity, and abdominal obesity among Korean children and adolescents. We conducted a serial cross-sectional analysis using nationally representative data from the Korea National Health and Nutritional Examination Survey from 2016 to 2020. The study outcome was trends in SUA levels. SUA trends were analyzed by survey-weighted linear regression analysis considering the survey year as a continuous variable. SUA trends were also analyzed for subgroups based on age, sex, abdominal obesity, or obesity. This study included 3,554 children and adolescents aged 10-18 years. SUA increased significantly over the study period in boys (p for trend = 0.043), but not in girls (p for trend = 0.300). In age-specific analyses, SUA increased significantly in the 10-12 years group (p for trend = 0.029). After adjusting for age, SUA increased significantly in the obese group of both boys (p for trend = 0.026) and girls (p for trend = 0.023), but not in the overweight, normal, or under-weight groups of either sex. After adjusting for age, SUA increased significantly in the abdominal obesity group of boys (p for trend = 0.017) and girls (p for trend = 0.014), but not in the non-abdominal obesity group of either sex.   Conclusion: In the current study, SUA levels significantly increased in both boys and girls with obesity or abdominal obesity. Further studies of the effect of SUA on health outcomes in boys and girls with obesity or abdominal obesity are needed. What is Known: • High serum uric acid (SUA) is a risk factor for various metabolic diseases, including gout, hypertension, and type 2 diabetes. What is New: • SUA levels increased in boys and the 10-12 years group of Korean children and adolescents. • SUA levels increased significantly in Korean children and adolescents with obesity or central obesity.

A comprehensive review on clinically proven medicinal plants in the treatment of overweight and obesity, with mechanistic insights

Background and objectives

Obesity has become a global health issue, more precisely, a pandemic throughout the present world due to its high prevalence in the recent era. Increased risk of morbidity and mortality in obese patients can be attributed to its association with the development of different life-threatening conditions. Plants are considered one of the most important sources of bioactive molecules which are used against a wide range of health disorders. This systematic review explores the efficacy as well as the safety profile of commonly used medicinal plants in the management of obesity that may help people to maintain a healthy weight.

Methods

This review is based on comprehensive literature searches from PubMed, Science Direct, Scopus, and Google Scholar databases using the keywords- "plants in obesity", "plants used in weight reduction" or keywords that are similar to those. Medicinal plants which have been clinically proven for their anti-obesity effect have only been selected for this study and attempts to investigate beneficial effects and adverse effects along with their mechanism of action have also been taken in this review.

Results

A significant reduction of weight in both human and other animals are exhibited by the extracts of Phaseolus vulgaris, green coffee, Yerba Mate, green tea, Gynostemma pentaphyllum, and the combination of Cissus quadrangularis/Irvingia gabonensis. All of those plant extracts seemed to work on different physiological pathways and none of those extracts showed any notable adverse effects in human or animal models.

Conclusion

Our review suggests that the discussed medicinal plants are effective in reducing the weight of obese patients without causing notable adverse reactions. Although further study is necessary to confirm their exact molecular mechanism and safety in human use.

Quality of life improvements following one year of setmelanotide in children and adult patients with Bardet-Biedl syndrome: phase 3 trial results

BACKGROUND

Bardet-Biedl syndrome is a rare genetic disease associated with hyperphagia and early-onset, severe obesity. There is limited evidence on how hyperphagia and obesity affect health-related quality of life in patients with Bardet-Biedl syndrome, and on how management of these symptoms may influence disease burden. This analysis evaluated changes in health-related quality of life in adults and children with Bardet-Biedl syndrome in a Phase 3 trial following 1 year of setmelanotide treatment (ClinicalTrials.gov identifier: NCT03746522).

METHODS

Patients with Bardet-Biedl syndrome and obesity received 52 weeks of treatment with setmelanotide and completed various self-reported health-related quality of life measures. Patients aged < 18 years or their caregiver completed the Pediatric Quality of Life Inventory (PedsQL; meaningful improvement, 4.4-point change); adults aged ≥ 18 years completed the Impact of Weight on Quality of Life Questionnaire-Lite (IWQOL-Lite; meaningful improvement range, 7.7-12-point change). Descriptive outcomes were reported in patients with data both at active treatment baseline and after 52 weeks of treatment.

RESULTS

Twenty patients (< 18 years, n = 9; ≥ 18 years, n = 11) reported health-related quality of life at baseline and 52 weeks. For children and adolescents, PedsQL score mean change from baseline after 52 weeks was + 11.2; all patients with PedsQL impairment at baseline (n = 4) experienced clinically meaningful improvement. In adults, IWQOL-Lite score mean change from baseline was + 12.0. Of adults with IWQOL-Lite impairment at baseline (n = 8), 62.5% experienced clinically meaningful improvement. In adults, IWQOL-Lite score was significantly correlated with changes in percent body weight (P = 0.0037) and body mass index (P = 0.0098).

CONCLUSIONS

After 1 year of setmelanotide, patients reported clinically meaningful improvements across multiple health-related quality of life measures. This study highlights the need to address the impaired health-related quality of life in Bardet-Biedl syndrome, and supports utility of setmelanotide for reducing this burden. Trial Registration NCT03746522. Registered November 19, 2018, https://clinicaltrials.gov/ct2/show/NCT03746522 .

Increasing Trends in Obesity-Related Cardiovascular Risk Factors in Romanian Children and Adolescents-Retrospective Study

Childhood obesity has become a global public health issue and its assessment is essential, as an obese child is a future overweight or obese adult. Obesity is no longer a matter of exercising more and eating less, with several factors coming into play and dictating the pattern of fat accumulation and the ease/difficulty of reducing it. In the current paper, we aimed to analyze the cardiovascular impact of obesity in a large number of patients alongside the paraclinical changes that occur due to weight gain, and to perform an analysis on the increase in prevalence throughout our research. The main cardiovascular conditions identified were hypertension (15.36%), septal or concentric hypertrophic cardiomyopathy (11.15%), atherosclerosis risk (13.04%), and hypercholesterolemia (20.94%). We have used echocardiography to measure the thickness of epicardial adipose tissue (useful for assessing the patient's cardiovascular risk), and we observed that it was greater in children with moderate and severe obesity alongside diastolic dysfunction of the left ventricle in the whole group, without any connection with hypertension or coronary impairment. Obese children will be affected by increased cardiovascular mortality and morbidity in adulthood and they may experience early cardiovascular dysfunction. We want to strongly underline the importance and necessity of programs for the early detection and prevention of obesity and its complications, especially since interesting phenomena such as the "obesity paradox" exist and prove that obesity is far less understood than it is at a first glance.

Magnetic Resonance Imaging to Assess Body Composition Change in Adolescents With Obesity After Sleeve Gastrectomy

OBJECTIVES

Metabolic and bariatric surgery is the most effective weight loss treatment for severe obesity. The number of adolescents undergoing sleeve gastrectomy is increasing. We investigated changes in body composition in adolescents undergoing sleeve gastrectomy 12-26 weeks post-operatively using whole-body magnetic resonance imaging (WB-MRI).

METHODS

This prospective cohort study assessed changes in adipose tissue compartments (ie, visceral, subcutaneous, and intermuscular) and muscle in 18 obese adolescents, ages 14-19, 89% female, with body mass index z -score of 2.6 ± 0.25 (range 2.16-3.2). All underwent WB-MRI 1.5-17 weeks pre-operatively and 12-26 weeks post-operatively.

RESULTS

Pre- and post-operative WB-MRI showed decreases in all adipose tissue compartments, as well as decreased skeletal muscle and liver fat fraction ( P < 0.0001). The post-operative percentage loss of adipose tissue in subcutaneous, visceral, and intermuscular compartments (89.0%, 5.8%, 5.2%, respectively) was similar to the pre-operative percentages of corresponding adipose tissue compartments (90.5%, 5.0%, 4.5%, respectively). Of note, participants with obstructive sleep apnea had significantly higher pre-operative volume of subcutaneous and intermuscular adipose tissue than participants without obstructive sleep apnea ( P = 0.003).

CONCLUSIONS

We found, contrary to what is reported to occur in adults, that pre-operative percentage loss of adipose tissue in subcutaneous, visceral, and intermuscular compartments was similar to the post-operative percentage loss of corresponding adipose tissue compartments in adolescents 12-26 weeks after sleeve gastrectomy.

A Copeptin as a Predictor Marker for Insulin Resistance Among Women with Polycystic Ovary Syndrome

Background:

A polycystic ovarian syndrome (PCOS) is a common endocrine syndrome in which women have a wide range of clinical presentations; insulin resistance was linked to its pathogenesis.

Objective:

We aimed to investigate the copeptin role as a predictive marker of insulin resistance among PCOS women.

Material and Methods:

In University Hospital, we included 280 women, with 140 of them being healthy controls. 140 out of 280 cases of PCOS subdivided into two groups depending on the insulin resistance; group 1 with homeostasis model assessment for the insulin resistance < 2.5. Group 2 with homeostasis model assessment for the insulin resistance >2.5. The evaluation of body mass index and blood pressure for all besides the blood sampling for estimation of a follicular stimulating hormone, luteinizing hormone, prolactin, estradiol, sex hormone-binding globulin, total testosterone, fasting insulin dehydroepiandrosterone sulfate, C-reactive protein, plasma glucose, free androgen index, and plasma copeptin using the Copeptin-Human EIA Kit besides the transvaginal ultrasound for ovarian assessment.

Results:

When compared to other groups, PCOS women with positive insulin resistance >2.5 had a significantly higher plasma copeptin level. The ROC curve calculated a 1.94 pmol/L; plasma copeptin cutoff value for detecting the insulin resistance in PCOS with 88 % sensitivity value and 36 % specificity, AUC was 0.88.

Conclusion:

The significant positive relationship between serum copeptin and insulin resistance with high sensitivity implies its usefulness as a marker of insulin resistance among PCOS patients with a high prediction of its complication.

Role of Psychologists in Pediatric Endocrinology

The care of youth managed within pediatric endocrine clinics is complex and requires a multi- or interdisciplinary approach. Psychosocial aspects of chronic health conditions are well-documented. Clinical practice guidelines outline the importance of routine psychosocial screening and support for youth with diabetes and obesity. This article outlines the diverse role of psychologists in pediatric endocrinology, including screening, in-clinic intervention, outpatient psychological services, and inpatient consultation. Although research exists documenting the effectiveness of behavioral interventions to improve adherence and health-related quality of life, cost analysis research is emerging.

Changes in adiponectin:leptin ratio among older adults with obesity following a 12-month exercise and diet intervention

Background

Excess adiposity is characterized by alterations in adipokine secretion such that circulating leptin concentrations are increased with reductions in adiponectin. An emerging biomarker for the assessment of this adipose tissue (AT) dysfunction is the adiponectin:leptin (AL) ratio. A low AL ratio may be suggestive of dysfunctional AT and, consequently, a heightened cardiometabolic disease risk. This ancillary study investigated the relationship between the AL ratio and cardiometabolic health among community-dwelling older adults with obesity, as well as the effects of a 12-month exercise and diet intervention on changes in the AL ratio.

Methods

Participants (n = 163, 70.2 ± 4.7 years, 38.0% male) were randomized to the exercise only group, exercise + nutrient-dense weight maintenance group (exercise + weight maintenance), or exercise + nutrient-dense caloric restriction of 500 kcal/d group (exercise + intentional weight loss) (clinicaltrials.gov #NCT00955903). Total and regional adiposity as determined by magnetic resonance imaging (MRI) and dual-energy X-ray absorptiometry (DXA), anthropometrics, and cardiometabolic biomarkers were assessed at baseline and 12 months.

Results

The AL ratio was significantly (p < 0.05) inversely correlated with body mass index, waist circumference, measures of adiposity, and insulin among all participants at baseline. Among females only, significant positive and inverse correlations were also observed between this ratio and high-density lipoprotein cholesterol and the inflammatory biomarkers high sensitivity C-reactive protein and interleukin-6, respectively. While controlling for biological sex, a significant time by intervention group interaction effect (p < 0.05) was observed such that the AL ratio significantly increased from baseline to study completion among participants in the exercise + weight maintenance group and exercise + intentional weight loss group. Post hoc analysis revealed that the exercise + intentional weight loss group exhibited a significantly greater AL ratio at study completion compared to other groups (p < 0.05 all).

Conclusions

Results are in support of the AL ratio as a measure of AT dysfunction among older adults. Furthermore, results suggest that a 12-month exercise and diet intervention with intentional weight loss assists in improving the AL ratio in this population.

Weight management in youth with rapid-onset obesity with hypothalamic dysregulation, hypoventilation, autonomic dysregulation, and neural crest tumor (ROHHAD-NET): literature search and case report

OBJECTIVES

Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, autonomic dysregulation, and neural endocrine tumor (ROHHAD-NET) syndrome is a youth-onset constellation of symptoms including rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation. Despite growing understanding of the clinical classification of this syndrome there is limited investigation into treatment of the rapid-onset obesity which can be progressive and life-limiting. The purpose of this case report is to describe the clinical timeline and treatment of severe obesity in a patient with of ROHHAD-NET and propose recommendations for the treatment of associated obesity.

CASE PRESENTATION

We present the case of a 10-year-old female with a clinical presentation consistent with ROHHAD-NET who achieved clinically meaningful weight loss with a combination of lifestyle modification and anti-obesity pharmacotherapies. We report on the use of three separate pharmacological agents and ultimately the referral for bariatric surgery.

CONCLUSIONS

Given that early-onset obesity and hypoventilation are life-limiting components of this condition, early recognition and treatment are essential to improve health outcomes.

A 24-month metformin treatment study of children with obesity: Changes in circulating GDF-15 and associations with changes in body weight and visceral fat

BACKGROUND

Metformin treatment for 24 months in children with obesity lowers body mass index (BMI), reduces liver fat, and normalizes endocrine-metabolic parameters.

OBJECTIVE

Here we study whether circulating GDF-15 levels were raised by such metformin treatment and whether they related to changes in body weight and visceral fat in children with obesity.

METHODS

The study population consisted of 18 pre-pubertal/early pubertal children with obesity who had participated in a randomized double-blind clinical trial receiving metformin (850 mg/day) or placebo for 24 months. Circulating GDF-15, BMI and abdominal visceral and liver fat (magnetic resonance imaging) were assessed at 0, 6, 12 and 24 months.

RESULTS

Results showed that metformin-treated children had higher GDF-15 levels at 6 and 12 months. Higher rises of circulating GDF-15 associated with more loss of body weight and visceral fat.

CONCLUSION

In conclusion, the concept that GDF-15 is among the mediators of metformin's normalizing effects in individuals with obesity is herewith extended into childhood.

The evolution of glucose-insulin homeostasis in children with β-thalassemia major (β -TM): A twenty-year retrospective ICET- A observational analysis from early childhood to young adulthood

BACKGROUND

Thalassemia guidelines recommend oral glucose tolerance test (OGTT), starting from the age of 10 years, or earlier in the presence of iron overload.

OBJECTIVE

The aim of this retrospective study was to review and document the changes of glucose-insulin homeostasis from early childhood to young adulthood in β-thalassemia major (β -TM) patients with impaired fasting glucose (IFG) and normal OGTT.

METHODS

All data of the clinical patients' records of 18 β -TM patients' from September 1983 to September 2021 were included in the study. Annual or biennial OGTT results, for a duration of 15-20 years, were available for all patients.

RESULTS

The main findings are: a) IFG in children with β -TM represents a risk factor for the development of glucose dysregulation (GD) at later age; b) fluctuations of glucose homeostasis during follow-up were observed mainly in β-TM patients with IFG at baseline; and c) the primary defect of GD appears to be a low degree insulin resistance (IR), as estimated by HOMA-IR, followed by an insulin secretion defect.

CONCLUSION

These results are noteworthy as they revealed that firstly, the baseline IFG predicts future development of GD, and secondly, that almost half of patients with IFG at the outset had normal glucose handling 15 years later. Understanding the sequence of abnormalities in the progression from normal glucose homeostasis to GD and identifying the risk factors for the glycometabolic defects in thalassemic patients might help in the formulation of interventions.

Obesity Indices for Predicting Functional Fitness in Children and Adolescents With Obesity

Objectives: We aimed to determine the obesity indices that affect 6-min walk test (6-MWT) distance in children and adolescents with obesity and to compare the 6-MWT distance of obese subjects with that of normal-weight subjects. Methods: Obese children and adolescents aged 8-15 years and normal-weight age- and gender-matched controls were enrolled. All participants performed the 6-MWT; respiratory muscle strength (RMS), including maximal inspiratory pressure and maximal expiratory pressure; and spirometry. Data between groups were compared. In the obesity group, correlation between obesity indices and pulmonary function testing (6-MWT, RMS, and spirometry) was analyzed. Results: The study included 37 obese and 31 normal-weight participants. The following parameters were all significantly lower in the obesity group than in the normal-weight group: 6-MWT distance (472.1 ± 66.2 vs. 513.7 ± 72.9 m; p = 0.02), forced expiratory volume in one second/forced vital capacity (FEV1/FVC) (85.3 ± 6.7 vs. 90.8 ± 4.5%; p < 0.001), forced expiratory flow rate within 25-75% of vital capacity (FEF25-75%) (89.8 ± 23.1 vs. 100.4 ± 17.3 %predicted; p = 0.04), and peak expiratory flow (PEF) (81.2 ± 15 vs. 92.5 ± 19.6 %predicted; p = 0.01). The obesity indices that significantly correlated with 6-MWT distance in obese children and adolescents were waist circumference-to-height ratio (WC/Ht) (r = -0.51; p = 0.001), waist circumference (r = -0.39; p = 0.002), body mass index (BMI) (r = -0.36; p = 0.03), and chest circumference (r = -0.35; p = 0.04). WC/Ht was the only independent predictor of 6-MWT distance by multiple linear regression. Conclusions: Children and adolescents with obesity had a significantly shorter 6-MWT distance compared with normal-weight subjects. WC/Ht was the only independent predictor of 6-MWT distance in the obesity group.

Time-Limited Eating and Continuous Glucose Monitoring in Adolescents with Obesity: A Pilot Study

Due to its simplicity, time-limited eating (TLE) may represent a more feasible approach for treating adolescents with obesity compared to other caloric restriction regimens. This pilot study examines the feasibility and safety of TLE combined with continuous glucose monitoring (CGM) in adolescents. Fifty adolescents with BMI ≥95th percentile were recruited to complete a 12-week study. All received standard nutritional counseling, wore a CGM daily, and were randomized to: (1) Prolonged eating window: 12 h eating/12 h fasting + blinded CGM; (2) TLE (8 h eating/16 h fasting, 5 days per week) + blinded CGM; (3) TLE + real-time CGM feedback. Recruitment, retention, and adherence were recorded as indicators of feasibility. Weight loss, dietary intake, physical activity, eating behaviors, and quality of life over the course of the intervention were explored as secondary outcomes. Forty-five participants completed the study (16.4 ± 1.3 years, 64% female, 49% Hispanic, 75% public insurance). There was high adherence to prescribed eating windows (TLE 5.2 d/wk [SD 1.1]; control 6.1 d/wk [SD 1.4]) and daily CGM wear (5.85 d/wk [SD 4.8]). Most of the adolescents (90%) assigned to TLE reported that limiting their eating window and wearing a CGM was feasible without negative impact on daily functioning or adverse events. There were no between-group difference in terms of weight loss, energy intake, quality of life, physical activity, or eating behaviors. TLE combined with CGM appears feasible and safe among adolescents with obesity. Further investigation in larger samples, with a longer intervention duration and follow-up assessments are needed.

Physiological and Lifestyle Factors Associated With Abnormal Blood Pressure in Adolescents Before and After a School-Based Wellness Program in Michigan: A Report From Project Healthy Schools

PURPOSE

Hypertension (HTN) is associated with increased cardiovascular risk and unhealthy lifestyles in adults. However, data on both physiological and lifestyle factors associated with abnormal blood pressure (BP) in adolescents, as well as the effectiveness of interventions in improving these factors among adolescents with abnormal BP, is scarce.

METHODS

Students enrolled in a middle-school-based wellness program, Project Healthy Schools (PHS), between 2005-2016 were eligible. Three systolic (SBP) and diastolic (DBP) BP measurements were taken pre-PHS and post-PHS; averages of the final two were analyzed. Students were grouped by baseline BP: abnormal BP (≥90th percentile for SBP and/or DBP, or ≥120/80 mmHg) or normal BP (<90th percentile for SBP and/or DBP, or <120/80 mmHg). Demographics, physiologic measures, and health behaviors were compared between groups pre- and post-PHS.

RESULTS

Of 2,865 students, 812 (28.3%) had abnormal BP. Median SBP was 119 mmHg in abnormal BP students and 103 mmHg in normal BP students (p < .001). Females were less likely to have abnormal BP than males (48.4% vs. 51.6%, p < .01). Pre-PHS, abnormal BP students were more likely to be overweight (62.3% vs. 28.2%, p < .001) or obese (38.9% vs. 11.3%, p < .001) than normal BP students. Their total cholesterol, triglycerides, random glucose, resting, and recovery heart rates were also higher, and they had worse dietary and sedentary habits. Post-PHS, abnormal BP students demonstrated greater reduction in SBP (-4.0 vs. 2.8 mmHg, p < .001) and DBP (-3.3 vs. .8 mmHg, p < .001) than normal BP students.

CONCLUSIONS

Abnormal BP was prevalent and associated with worse cardiometabolic health parameters and behaviors at baseline. Abnormal BP students demonstrated significant improvements in BP post-PHS, suggesting school-based programs may be effective as nonpharmacological lifestyle interventions in this population.

Pediatric obesity and perioperative medicine

PURPOSE OF REVIEW

Childhood obesity is a public health emergency that has reached a pandemic level and imposed a massive economic burden on healthcare systems. Our objective was to provide an update on (1) challenges of obesity definition and classification in the perioperative setting, (2) challenges of perioperative patient positioning and vascular access, (3) perioperative implications of childhood obesity, (3) anesthetic medication dosing and opioid-sparing techniques in obese children, and (4) research gaps in perioperative childhood obesity research including a call to action.

RECENT FINDINGS

Despite the near axiomatic observation that obesity is a pervasive clinical problem with considerable impact on perioperative health, there have only been a handful of research into the many ramifications of childhood obesity in the perioperative setting. A nuanced understanding of the surgical and anesthetic risks associated with obesity is essential to inform patients' perioperative consultation and their parents' counseling, improve preoperative risk mitigation, and improve patients' rescue process when complications occur.

SUMMARY

Anesthesiologists and surgeons will continue to be confronted with an unprecedented number of obese or overweight children with a high risk of perioperative complications.

Epidemiology of Obesity and Hypertension in School Adolescents Aged 15-17 from the Region of Central Poland-A Cross-Sectional Study

The aim of this cross-sectional study was to assess the prevalence of abnormal weight and anthropometric parameters along with abnormal blood pressure values in adolescents in Poland. Anthropometric measurements were taken in the studied age group and the correlation between these values and blood pressure values and the diagnosis of hypertension was analyzed. The main aim of the study was to characterize the particular age group in the selected population: 690 students aged 15–17 years were examined. Blood pressure and anthropometric values including height, weight, circumferences of the hips, abdomen and arms, as well as skinfolds on the back of the arm, below the scapula and the stomach, were taken. The following indexes were calculated: WHR (waist to hip ratio), WHtR (waist to height ratio), BAI (body adiposity index-hip to height ratio) and BMI (body mass index). Mean SBP (systolic blood pressure) was 112.3 (standard deviation (SD) 12.2) mmHg, and DBP (diastolic blood pressure) was 66.9 (SD 6.9) mmHg. The prevalence of hypertension in the studied group was 5.8% (3.2% boys, 2.6% girls) and prehypertension was present in 4.4% (1.6% boys, 2.8% girls). The prevalence of excess body weight was 23.6%-obesity 11.3% (40 girls, 27 boys) and overweight 12.3% (50 girls, 34 boys). Correlations between BMI and waist, hip and arm circumference, subscapular and abdominal skinfold thickness, WHtR and BAI were r = 0.86, r = 0.84, r = 0.88, r = 0.81, r = 0.75, r = 0.88 and r = 0.81, respectively (p < 0.05). Significant differences (p < 0.05) of SBP and DBP values, depending on weight category, as defined by BMI, were observed. Abnormal blood pressure values occur in one tenth and abnormal body weight in almost a quarter of the studied population. Obese and overweight children have higher SBP and DBP values compared to children with normal body weight.

Visceral Adiposity Index (VAI) in Children and Adolescents with Obesity: No Association with Daily Energy Intake but Promising Tool to Identify Metabolic Syndrome (MetS)

(1) Background. Visceral adiposity index (VAI) has been recently identified as a new cardiometabolic risk marker reflecting abdominal fat distribution and dyslipidaemia. The aim of the present paper was to evaluate the relationship between VAI, daily energy intake and metabolic syndrome (MetS) in a cohort of obese Caucasian children and adolescents, aged 8 to 15 years. (2) Methods. Consecutive Italian children and adolescents with obesity, according to World Health Organization were enrolled. Anthropometric parameters and blood pressure were measured. Fasting blood samples have been analyzed for lipids, insulin and glucose levels. MetS was diagnosed using identification and prevention of dietary- and lifestyle-induced health effects in children and infants (IDEFICS) or International Diabetes Federation (IDF) criteria according to age. Homeostatic model assessment index (HOMA-IR), quantitative insulin sensitivity check index (QUICKI), A body shape index (ABSI) and VAI were calculated. Multivariable logistic regression analyses with sex, age and each anthropometric parameter (body mass index (BMI) z-score, ABSI, waist-to-height ratio (WHR)) or VAI was performed to predict MetS. Receiver operation curve (ROC) analysis was used to define the optimal VAI cut-off to identify MetS. Multiple regression was performed to predict the BMI z-score and VAI from daily energy intake after adjusting for age and sex. (3) Results. Six hundred and thirty-seven (313 boys and 324 girls) children and adolescents with obesity with median age 11 (interquartile range 10–13) years were included in the analysis. MetS was diagnosed in 79 patients. VAI correlated with BMI, WHR, ABSI, HOMA-IR, QUICKI, systolic blood pressure, low- and high-density lipoprotein cholesterol, triglycerides and triglycerides-to-HDL ratio (p < 0.050). Optimal VAI cut-off (AUC) values to identify MetS were 1.775 (0.774), 1.685 (0.776) and 1.875 (0.797) in the whole population, boys and girls, respectively. Energy intake was positively associated with BMI z-score but no association was found with VAI. (4) Conclusion. VAI is a promising tool to identify MetS in children and adolescents with obesity and should be used in the management of abdominal obesity together with dietary assessment.

Trends in prescribing anti-obesity pharmacotherapy for paediatric weight management: Data from the POWER Work Group

INTRODUCTION

To better inform the field of obesity medicine, we set out to describe the current use of pharmacotherapy meant to improve patient weight status among a group of clinicians connected through the Paediatric Obesity Weight Evaluation Registry (POWER), as well as reasons behind clinicians' use or non-use of the medications.

METHODS

Paediatric weight management (PWM) programs participating in POWER were asked to complete a program profile survey in 2014 (n = 30) and 2017 (n = 33); questions about pharmacotherapy use were included. Descriptive statistics were used to identify: (a) the proportion of PWM programs offering obesity pharmacotherapy; (b) the medications most commonly prescribed; and (c) reasons among non-prescribers for not offering pharmacotherapy.

RESULTS

The 2014 and 2017 surveys were completed by 29 PWM programs (97%) and 30 PWM programs (91%), respectively. Twenty-one programs completed both surveys. In 2014, 10 (34%) programs reported offering pharmacologic agents specifically for weight control, whereas in 2017, 16 (53%) reported offering pharmacotherapy for a primary indication of weight loss. Metformin was reported as the most commonly used agent in 2014, and topiramate in 2017. Largest reported increases in use over time were for topiramate and phentermine.

DISCUSSION

Our survey results demonstrate that a majority of this group of PWM programs offered pharmacotherapy to promote weight loss in patients with complications or associated medical conditions. There was a trend indicating increasing use over time, despite the significant gap regarding pharmacotherapy use in the literature.

CONCLUSIONS

These data suggest the need for (a) additional robust paediatric drug trials to further develop the evidence base guiding use or non-use of pharmacotherapy in paediatric weight management, and (b) increased understanding of both facilitators and barriers to prescribing anti-obesity pharmacotherapy for youth with obesity.

Gender medicine: Lessons from COVID-19 and other medical conditions for designing health policy

Gender-specific differences in the prevalence, incidence, comorbidities, prognosis, severity, risk factors, drug-related aspects and outcomes of various medical conditions are well documented. We present a literature review on the extent to which research in this field has developed over the years, and reveal gaps in gender-sensitive awareness between the clinical portrayal and the translation into gender-specific treatment regimens, guidelines and into gender-oriented preventive strategies and health policies. Subsequently, through the lens of gender, we describe these domains in detail for four selected medical conditions: Asthma, obesity and overweight, chronic kidney disease and coronavirus disease 2019. As some of the key gender differences become more apparent during adolescence, we focus on this developmental stage. Finally, we propose a model which is based on three influential issues: (1) Investigating gender-specific medical profiles of related health conditions, rather than a single disease; (2) The dynamics of gender disparities across developmental stages; and (3) An integrative approach which takes into account additional risk factors (ethnicity, socio-demographic variables, minorities, lifestyle habits etc.). Increasing the awareness of gender-specific medicine in daily practice and in tailored guidelines, already among adolescents, may reduce inequities, facilitate the prediction of future trends and properly address the characteristics and needs of certain subpopulations within each gender.

Evaluation of Physical Activity and Lifestyle Interventions Focused on School Children with Obesity Using Accelerometry: A Systematic Review and Meta-Analysis

Despite the existence of global recommendations for physical activity and lifestyle to avoid childhood obesity, there are no specific recommendations for school-age children. The aim of this meta-analysis was to measure the effects of current interventions with a physical activity component on body mass index (BMI) Z-score and on the moderate and vigorous physical activity (MVPA) time, measured by accelerometry, and focused on children with obesity. Randomized controlled trial studies (RCTs) based on physical activity interventions focused on children with obesity (6 to 12 years old) from January 1991 to August 2018 were included. The post-intervention mean and standard deviation of the BMI Z-score and MVPA engaged time were extracted to calculate the results using random effects models. Of a total of 229 studies considered potentially eligible, only 10 RCTs met the inclusion criteria. There were improvements in the BMI Z-score for physical activity intervention groups, compared with non-intervention children in addition to a significant increase in time engaged in MVPA. In conclusion, interventions with a physical activity component in school-children with obesity seem to be effective at reducing BMI and producing an increase in time spent engaged in physical activity. Therefore, interventions based on physical activity should be considered one of the main strategies in treating childhood obesity.

Exploration of the Association Between Obesity and Cognitive Impairment in Chinese Children with Mild or Moderate Obstructive Sleep Apnea-Hypopnea Syndrome

PURPOSE

To explore the association between obesity and cognitive impairment in children with mild or moderate obstructive sleep apnea-hypopnea syndrome (OSAHS).

DESIGN AND METHODS

A total of 71 children with obesity and 71 age- and sex- matched children who were non-obese were included. The Wechsler Intelligence Scale for Children fourth edition (WISC-IV) was adopted to evaluate the cognition of the participating children. Pearson and partial correlation analysis were performed to investigate the relationships between neurocognitive functions and demographic and polysomnography parameters. Two-way Analysis of Variance was performed to evaluate the effect of obesity and apnea-hypopnea index (AHI) on cognitive functions.

RESULTS

Full-scale intelligence quotient (FSIQ, 92.4 ± 12.3 vs. 98.6 ± 13.1; P < 0.01), verbal comprehension index (VCI, 92.8 ± 10.8 vs. 98.7 ± 10.9; P < 0.01), working memory index (WMI, 92.6 ± 11.3 vs. 96.5 ± 11.0; P = 0.04) and perceptual reasoning index (PRI, 93.8 ± 12.1 vs. 99.2 ± 12.5; P < 0.01) were significantly lower in the children with obesity compared with those in the control group. Partial correlation analysis showed that FSIQ were negatively and significantly correlated with body mass index (BMI, r = -0.347, P < 0.01) and AHI (r = -0.304, P < 0.01). Two-way ANOVA revealed that both obesity and AHI had independent effects on FSIQ (both P < 0.05). The interaction between the effect of obesity and AHI on cognitive functions was not significant, indicating that obesity is a risk factor of cognitive impairment independent of AHI.

CONCLUSIONS

Obesity aggravates cognitive impairment in children with mild or moderate OSAHS.

PRACTICE IMPLICATIONS

Children diagnosed with OSAHS and obesity are recommended to control their body weight for the prevention, management and treatment of cognitive impairment.

Evaluation of Different Adiposity Indices and Association with Metabolic Syndrome Risk in Obese Children: Is there a Winner?

Body shape index (ABSI) and triponderal mass index (TMI) have been recently associated with cardiovascular risk in adults. A cross-sectional study was conducted to evaluate the relationship between different anthropometric adiposity indexes and metabolic syndrome (MetS) in Caucasian obese children and adolescents. Consecutive obese children aged ≥7 years have been enrolled. Anthropometric parameters, body composition (by bioelectrical impedance), and systolic and diastolic blood pressure have been measured. Fasting blood samples have been analyzed for lipids, insulin, glucose. A multivariate logistic regression analyses, with body mass index z-score, waist to height ratio, ABSI z-score, TMI, conicity index as predictors for MetS (IDEFICS and IDF criteria according to age) has been performed. Four hundred and three (179 boys and 224 girls) obese children, aged 7-20 years, have been evaluated. When we explored the joint contribution of each anthropometric and adiposity index of interest and BMIz on the risk of MetS, we found that the inclusion of ABSIz improved the prediction of MetS compared to BMIz alone. ABSI-BMI can be a useful index for evaluating the relative contribution of central obesity to cardiometabolic risk in clinical management of obese children and adolescents.

Pediatric Obesity, Hypertension, Lipids

PURPOSE OF REVIEW

The rise of the pediatric obesity pandemic over the past 40 years has sharpened focus on the management of obesity, hypertension and lipid abnormalities in children. Multiple studies demonstrate that these risk factors track from childhood into adulthood predisposing individuals to premature atherosclerotic cardiovascular disease and putting them at risk for early morbidity and mortality.

RECENT FINDINGS

Importantly, obesity, hypertension and lipid problems are individual risk factors that can occur independently. Multiple studies have shown that each risk factor causes target organ damage in children. Intensive and focused lifestyle modifications can improve a child's subclinical disease and decrease the risk for future morbidity.

SUMMARY

Childhood offers a unique opportunity at primordial and primary prevention of atherosclerotic cardiovascular disease. Clinicians must focus on targeting these highly prevalent conditions and applying lifestyle modification and then pharmacologic or surgical therapies as needed.

Family Encouragement of Healthy Eating Predicts Child Dietary Intake and Weight Loss in Family-Based Behavioral Weight-Loss Treatment

Introduction: Social support for healthy eating can influence child eating behaviors; however, little is known about the impact of social support during family-based behavioral weight-loss treatment (FBT). This study aimed to determine the impacts of both baseline and change in family support on change in child diet and weight during FBT. Methods: Children (n = 175; BMI percentile ≥85th; ages 7-11; 61.1% female; 70.9% white) and a participating parent completed 4 months of FBT. Parents were active participants and learned social support-related strategies (i.e., praise and modeling of healthy eating). Child perceived family encouragement and discouragement for healthy eating, child diet quality (via 24-hour recalls), and child weight were assessed pre- and post-FBT. Results: Family encouragement for healthy eating increased during FBT, and this increase was related to increases in child healthy vegetable intake and overall diet quality, as well as decreases in refined grains consumed. Low pre-FBT family encouragement predicted greater increases in healthy vegetable intake, greater weight reduction, and greater increases in family encouragement for healthy eating. Family discouragement for healthy eating did not change during treatment nor did it predict dietary or weight outcomes. Conclusions: FBT successfully improves family encouragement, which is associated with improvements in child diet. Furthermore, even children who began treatment with low family encouragement for healthy eating show great improvements in dietary intake and weight during treatment. Results suggest that changes in child eating behavior during treatment is influenced by active, positive parenting techniques such as praise of healthy eating rather than negative family support.

Exercise in the treatment of childhood obesity

Changing lifestyles reduce the time spent by children on physical activity during the day. The result is an increasing frequency of childhood obesity, which has become one of the most common chronic diseases of childhood. Furthermore, the treatment of obesity in childhood is quite difficult, and the most common problem is non-compliance with obesity treatment. The path that will facilitate the adaptation to treatment comprises nutrition regulation and increased daily physical activity and psychological support. Diet alone leads to a significant reduction in both fat and non-fat body mass. However, adding exercise to dietary therapy improves weight loss by maintaining non-fat body mass. Even though exercise alone has little effect on weight loss, it provides a significant reduction in mortality. Moreover, regular physical exercise is also an important factor in regulating body composition during growth. However, changes in the child’s body during growth affect the motor power and performance, so it is necessary to plan the exercise according to the individual characteristics, age and sex of the child. Short-term frequent exercises are more entertaining and more accessible forms of exercise (dancing at home) for children, and enhance compliance with treatment. Starting treatment as soon as possible will also increase behavioral effectiveness and compliance. This paper focuses on the basics of exercise therapy, which is extremely beneficial for both healthy and obese children.

Dietary phytochemical index and overweight/obesity in children: a cross-sectional study

OBJECTIVE

The aim of the present study was to examine the relationship between the dietary phytochemical index (DPI) and overweight/obesity in children. This cross-sectional study was comprised of 356 children aged 7 to 10 years-old study in the city of Tehran, Iran. The dietary intake of participants was collected using a validated food frequency questionnaire. The DPI was calculated based on the daily energy derived from phytochemical-rich foods. The definition of overweight and obesity was based on the criteria developed by the US Chronic Disease Center for prevention and health promotion.

RESULTS

The overall prevalence of overweight/obesity was 35.1%. The mean (standard deviation) of the DPI was 14.25 (4.13), 24.12 (2.64), 35.41 (3.62) and 61.52 (16.47) in the first, second, third and fourth quartiles (Q), respectively. Subjects in the higher quartiles of DPI had a significantly higher intake of dietary fiber, vitamin C, and potassium compared to those in the lower quartiles. In the multiple regression analysis, subjects in the highest quartile of DPI had significantly lower odds of being overweight/obese compared to those in the first quartile [odds ratio and 95% confidence intervals for Q4 vs. Q1: 0.47 (0.25, 0.87); P for trend = 0.02].

Acceptability of Hospital-Based Pediatric Weight Management Services among Patients and Families: A Narrative Synthesis

High rates of attrition from pediatric weight management services are well documented in the literature; however, studies reporting on acceptability of "real-world" services have not previously been reviewed. This narrative synthesis aimed to summarize quantitative and qualitative research reporting on satisfaction of families who attended a secondary or tertiary pediatric weight management service. Electronic databases were searched for studies of family and/or patient satisfaction with hospital-based pediatric weight management services. Included articles were scored on their methodological quality. Searches returned 4509 articles of which 17 were eligible. Education, practical strategies to assist behavior change and the approach of staff were reported as the most valued service aspects. Practical, organizational, and service content issues were reported as the primary reasons for poor engagement or discontinuation of treatment. The majority of recommendations for service improvement related to service content, with the following subthemes: program content, delivery of the weight management intervention, individualized treatment, and treatment expectations. Potential strategies for reducing attrition and improving consumer satisfaction include assessment of families' readiness to change at the outset of treatment and implementation of treatment non-negotiables. Development of a standardized measure of patient satisfaction for use in pediatric weight management service development, evaluation, and comparison is recommended.

Improving the assessment and management of obesity in UK children and adolescents: the PROMISE research programme including a RCT

Background

Five linked studies were undertaken to inform identified evidence gaps in the childhood obesity pathway.

Objectives

(1) To scope the impact of the National Child Measurement Programme (NCMP) (study A). (2) To develop a brief evidence-based electronic assessment and management tool (study B). (3) To develop evidence-based algorithms for identifying the risk of obesity comorbidities (study B). (4) To conduct an efficacy trial of the Healthy Eating and Lifestyle Programme (HELP) (study C). (5) To improve the prescribing of anti-obesity drugs in UK adolescents (study D). (6) To investigate the safety, outcomes and predictors of outcome of adolescent bariatric surgery in the UK (study E).

Methods

Five substudies – (1) a parental survey before and after feedback from the National Childhood Measurement Programme, (2) risk algorithm development and piloting of a new primary care management tool, (3) a randomised controlled trial of the Healthy Eating and Lifestyle Programme, (4) quantitative and qualitative studies of anti-obesity drug treatment in adolescents and (5) a prospective clinical audit and cost-effectiveness evaluation of adolescent bariatric surgery in one centre.

Results

Study A – before the National Childhood Measurement Programme feedback, three-quarters of parents of overweight and obese children did not recognise their child to be overweight. Eighty-seven per cent of parents found the National Childhood Measurement Programme feedback to be helpful. Feedback had positive effects on parental knowledge, perceptions and intentions. Study B – risk estimation models for cardiovascular and psychosocial comorbidities of obesity require further development. An online consultation tool for primary care practitioners is acceptable and feasible. Study C – the Healthy Eating and Lifestyle Programme, when delivered in the community by graduate mental health workers, showed no significant effect on body mass index at 6 months (primary outcome) when compared with enhanced usual care. Study D – anti-obesity drugs appear efficacious in meta-analysis, and their use has expanded rapidly in the last decade. However, the majority of prescriptions are rapidly discontinued after 1–3 months of treatment. Few young people described positive experiences of anti-obesity drugs. Prescribing was rarely compliant with the National Institute for Health and Care Excellence guidance. Study E – bariatric surgery appears safe, effective and highly cost-effective in adolescents in the NHS.

Future work and limitations

Work is needed to evaluate behaviour and body mass index change in the National Childhood Measurement Programme more accurately and improve primary care professionals’ understanding of the National Childhood Measurement Programme feedback, update and further evaluate the Computer-Assisted Treatment of CHildren (CATCH) tool, investigate delivery of weight management interventions to young people from deprived backgrounds and those with significant psychological distress and obtain longer-term data on anti-obesity drug use and bariatric surgery outcomes in adolescence.

Trial registration

Current Controlled Trials ISRCTN99840111.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 8, No. 3. See the NIHR Journals Library website for further project information.

Awareness, Care and Treatment In Obesity maNagement to inform Haemophilia Obesity Patient Empowerment (ACTION-TO-HOPE): Results of a survey of US patients with haemophilia and obesity (PwHO) and their partners and caregivers

BACKGROUND

The ACTION study identified barriers to initiating and maintaining weight loss in patients with obesity; however, joint-related issues (pain, mobility and bleeding) may affect perceptions of patients with haemophilia and obesity (PwHO).

AIM

To identify patient and caregiver insights on the unique challenges of PwHO.

METHODS

Following IRB approval, adults who self-identified as PwHO, spouses/partners of adult PwHO, and caregivers of adolescent PwHO (aged 12-17 years) completed an online survey between December 2017 and April 2018.

RESULTS

Respondents included 124 adult PwHO, 45 spouses/partners and 42 caregivers. By calculated BMI, most adults were overweight (43%) or had obesity (51%); this differed from self-reported weight category. PwHO goals were improving health conditions (60%), having more energy (54%), reducing risks of weight (46%), and losing any weight (44%). Issues related to joint health were secondary for PwHO but frequently reported by spouses/parents. Most perceived weight loss to be a high priority (66%) and their responsibility (64%) but required a complete lifestyle change (63%). Most anticipated that weight loss would reduce joint pain (62%), bleeding (58%) and factor use (52%) and increase mobility (62%). Weight discussions with healthcare providers (HCPs) were commonly reported (51%). HCP discussions targeted improving health conditions (46%), achieving any weight loss (44%), being more active (73%) and improving eating habits (72%). Most PwHO (65%) perceived obesity as a disease and believe that 10% weight loss would be extremely beneficial (78%). In the past 5 years, 80% discussed being overweight and 68% losing weight; a minority reported being successful (9%) or somewhat successful (38%) with weight loss. More realistic or specific (51%/47%) goals, resources (46%), referrals to weight-loss programmes (41%) or dietitians (38%), meals or recipes (54%/50%), local or national (42%/41%) programmes for PwHO and success stories of PwHO (40%) are needed or would be helpful.

CONCLUSIONS

PwHO, spouse/partners and caregivers exhibited awareness of general and haemophilia-specific consequences of excess body weight. Most have tried general approaches to improve eating and increase activity with little success and desire more education on weight management and more details on specific actionable recommendations distributed through existing haemophilia channels. These insights will better inform the creation of weight-loss programmes for this community.

Kids N Fitness: A Group-based Pediatric Weight Management Curriculum Adapted for a Clinical Care Model

BACKGROUND

The current AAP clinical practice guidelines for the management of pediatric obesity recommend a structured, comprehensive, multi-disciplinary clinical intervention. However, there is a gap in the current literature on standardized curriculums for implementation of such programs. The objective of the present study is to adapt an evidenced-based, family- centered, weekly, weight management curriculum that addresses nutritional, physical activity and behavioral topics for a clinical care model at a tertiary care children's hospital.

METHODS

The curriculum was adapted for use in six individual sessions offered monthly by a multidisciplinary team, including a health educator, physician, dietitian, physical therapist and psychologist. Each provider offered specific feedback and curriculum adaptation based on their specialty. All team members completed training with scheduled treatment fidelity monitoring during implementation. To evaluate the effectiveness of the adapted curriculum, 60 adolescents, ages 14-18 years, with overweight or obesity, and at least one family member, will complete the six month intervention. The primary outcome is mean change in zBMI and %BMIp95 at six month and 18 months. Secondary outcomes include retention, satisfaction, effect on metabolic factors and activity level.

CONCLUSION

There is a paucity of literature on utilizing a standard curriculum in clinical weight management programs. Drawing from evidenced-based curriculum to strengthen clinical care creates an opportunity to improve existing clinical programs and potentially increase access and implementation of the current treatment recommendations for this high risk population.

Efficacy of "Mentoring to Be Active" on Weight Loss, Body Mass Index, and Body Fat among Obese and Extremely Obese Youth in Rural Appalachia

PURPOSE

This study compares the efficacy of a behavioral skills mentoring program (Mentored Planning to Be Active [MBA]) to a teacher-led program (Planning to Be Active [PBA]) for increasing physical activity in Appalachian teens on health outcomes (weight loss, body mass index (BMI), and body fat).

METHODS

Secondary analysis of a larger group-randomized controlled trial was conducted in 20 rural Appalachian schools. Descriptive Pearson correlations and multivariate analyses with between-subject effects were conducted. Effect sizes (ES) using Cohen's d and odds ratios (OR) with 95% confidence intervals were calculated.

FINDINGS

The obese MBA group lost 77.5% more weight by T3 compared to the PBA group; T2 was (F = 8.51, P = .000) and T3 was (F = 7.62, P = .000). ES was 0.34. OR = 1.45 (95% CI: 0.558-3.792) at T2 and OR = 3.32 (95% CI: 1.103-9.978) at T3. Extremely obese in the MBA group lost 80.0% more weight compared to the PBA group; T2 was (F = 5.23, P = .025) and at T3 (F = 6.33, P = .015) ES was 0.58. OR = 4.36 (95% CI: 0.981-19.34). Extremely obese females lost more weight compared to males (F = 4.75, P = .034). BMI and body fat had similar results; youth in the MBA group had the most improvement.

CONCLUSIONS

Rural Appalachian youth are disproportionately extremely obese. BMI does not capture adiposity or cardiovascular risk. BMI, BMI percentile, raw weight, fat mass, and percent body fat are more complete analyses of adiposity and cardiovascular risk.

Pattern and Features of Pediatric Endocrinology Referrals: A Retrospective Study in a Single Tertiary Center in Italy

Introduction: The knowledge of the pattern and the features of pediatric endocrinology referrals is crucial to optimize resources and guide public health interventions. We explored the numbers and the reasons for referral to a pediatric endocrinology outpatient clinic and investigated their features in terms of assignment of priority ranks, sex, age differences, the prevalence of pathological findings among referred cases, and the agreement among referrals, final diagnosis, treatment, and follow-up. Methods: Retrospective study with data collection for pediatric endocrinology first visits between November 2012 and February 2019 in a tertiary center. Results: A total of 1930 first visits were performed with an overall number of referrals of 2,165, and an increasing trend over the years. The most frequent referral reasons were slow growth, precocious puberty, and obesity; 14% of visits were classified as "urgent" (<7 days), 35% as "deferrable" (<30 days), and 51% as "planned" (<180 days). Sex and age differences among referrals were detected, with criticality in the appropriate timing for referral. Thirty-eight percent of patients had pathological findings. In 4% of the cases the final diagnosis was not concordant with the reason for referral. Treatment was prescribed in 35% of cases, and 67% returned at least for one follow-up visit. Conclusion: The study highlighted the need to target medical education of primary care on the definition of priority ranks, the need for more extended observation periods for subclinical or para-physiological conditions, the appropriate timing for referral, based on the definition of conditions or the best window of intervention.

Short- and long-term safety and efficacy of bariatric surgery for severely obese adolescents: a narrative review

The selection criteria, safety, and efficacy of bariatric surgery are well established in adults but are less well defined for severely obese adolescents. The number of severely obese adolescents who could benefit from weight loss surgery is increasing, although referral rates have plateaued. Surgical options for these adolescents are controversial and raise several questions. Recent studies, including the prospective Teen-Longitudinal Assessment of Bariatric Surgery Study and the Adolescent Morbid Obesity Surgery Study, help answer these questions. Early bariatric surgical intervention improves body mass index but, more importantly, improves cardiovascular and metabolic co-morbidities of severe obesity. A review of the medical, psychosocial, and economic risks and benefits of bariatric surgery in severely obese adolescents is a step toward improving the management of a challenging and increasing population. We describe the current knowledge of eligibility criteria, preoperative evaluation, surgical options, outcomes, and referral barriers of adolescents for bariatric surgery.

Effects of metformin administration on endocrine-metabolic parameters, visceral adiposity and cardiovascular risk factors in children with obesity and risk markers for metabolic syndrome: A pilot study

Background

Metformin treatment (1000–2000 mg/day) over 6 months in pubertal children and/or adolescents with obesity and hyperinsulinism is associated with a reduction in body mass index (BMI) and the insulin resistance index (HOMA-IR). We aimed to ascertain if long-term treatment (24 months) with lower doses of metformin (850 mg/day) normalizes the endocrine-metabolic abnormalities, improves body composition, and reduces the carotid intima-media thickness (cIMT) in pre-puberal and early pubertal children with obesity.

Methods

A pilot double-blind, placebo-controlled trial was conducted on 18 pre-puberal and early pubertal (Tanner stage I-II) children with obesity and risk markers for metabolic syndrome. Patients were randomly assigned (1:1) to receive metformin (850 mg/day) or placebo for 24 months. Clinical, biochemical (insulin, lipids, leptin, and high-sensitivity C-reactive protein [hsCRP]), and imaging (body composition [dual-energy X-ray absorptiometry and magnetic resonance imaging]) parameters as well as cIMT (ultrasonography) were assessed at baseline and at 6, 12, and 24 months.

Results

The 12-month treatment tend to cause a reduction in weight standard deviation scores (SDS), BMI-SDS, leptin, leptin–to–high-molecular-weight (HMW) adiponectin ratio, hsCRP, cIMT, fat mass, and liver fat in metformin-treated children compared with placebo. The effect of metformin on the reduction of BMI-SDS, leptin, leptin-to-HMW adiponectin ratio, hsCRP, and liver fat seemed to be maintained after completing the 24 months of treatment. No changes in insulin sensitivity (HOMA-IR) or adverse effects were detected.

Conclusion

In this pilot study, metformin treatment in pre-puberal and early pubertal children with obesity seemed to improve body composition and inflammation markers. Our data encourage the development of future fully powered trials using 850 mg/day metformin in young children, highlighting its excellent tolerance and potential long-term benefits.

Childhood obesity: an overview of laboratory medicine, exercise and microbiome

In the last few years, a significant increase of childhood obesity incidence unequally distributed within countries and population groups has been observed, thus representing an important public health problem associated with several health and social consequences. Obese children have more than a 50% probability of becoming obese adults, and to develop pathologies typical of obese adults, that include type 2-diabetes, dyslipidemia and hypertension. Also environmental factors, such as reduced physical activity and increased sedentary activities, may also result in increased caloric intake and/or decreased caloric expenditure. In the present review, we aimed to identify and describe a specific panel of parameters in order to evaluate and characterize the childhood obesity status useful in setting up a preventive diagnostic approach directed at improving health-related behaviors and identifying predisposing risk factors. An early identification of risk factors for childhood obesity could definitely help in setting up adequate and specific clinical treatments.

Childhood and Adolescent Obesity in the United States: A Public Health Concern

Childhood and adolescent obesity have reached epidemic levels in the United States. Currently, about 17% of US children are presenting with obesity. Obesity can affect all aspects of the children including their psychological as well as cardiovascular health; also, their overall physical health is affected. The association between obesity and other conditions makes it a public health concern for children and adolescents. Due to the increase in the prevalence of obesity among children, a variety of research studies have been conducted to discover what associations and risk factors increase the probability that a child will present with obesity. While a complete picture of all the risk factors associated with obesity remains elusive, the combination of diet, exercise, physiological factors, and psychological factors is important in the control and prevention of childhood obesity; thus, all researchers agree that prevention is the key strategy for controlling the current problem. Primary prevention methods are aimed at educating the child and family, as well as encouraging appropriate diet and exercise from a young age through adulthood, while secondary prevention is targeted at lessening the effect of childhood obesity to prevent the child from continuing the unhealthy habits and obesity into adulthood. A combination of both primary and secondary prevention is necessary to achieve the best results. This review article highlights the health implications including physiological and psychological factors comorbidities, as well as the epidemiology, risk factors, prevention, and control of childhood and adolescent obesity in the United States.

The future burden of obesity in Canada: a modelling study

OBJECTIVES

We applied the validated Obesity Population Risk Tool (OPoRT) to estimate the future burden of obesity in Canada using baseline risk factors attained through routinely collected survey data.

METHODS

OPoRT was developed using logistic regression with sex-specific generalized estimating equations to predict the 10-year prevalence of obesity (outcome BMI ≥ 30.0) among adults 18 and older. The algorithm includes 17 predictive factors, including socio-demographic and health behavioural characteristics. OPoRT demonstrated excellent discrimination (C-statistic ≥ 0.89) and achieved calibration. We applied OPoRT to Canadian Community Health Survey (2013/14) data to predict the future prevalence of obesity in Canada for a variety of population subgroups.

RESULTS

The predicted burden of obesity grew from 261 cases per 1000 in 2013/14 to 326 cases per 1000 in 2023/24 corresponding to a total of 8.54 million individuals with obesity. The burden is expected to be higher among males (347 cases per 1000) than females (305 cases per 1000). Individuals aged 35-49 had the highest predicted burden of obesity (374 cases per 1000) and the largest number of predicted cases (2.42 million), while individuals in the ≥ 65 age group had the lowest predicted burden (236 cases per 1000). The number of individuals with obesity per 1000 is highest among those severely food insecure (452 cases per 1000), compared with food secure individuals (324 cases per 1000).

CONCLUSIONS

OPoRT can be used to estimate the future population burden of obesity, to identify priority subgroups at an elevated risk. Burden estimates should be reflected in approaches to curb the future burden of obesity.

Intervention Study on the Efficacy and Safety of Platycodon grandiflorus Ethanol Extract in Overweight or Moderately Obese Adults: A Single-Center, Randomized, Double-Blind, Placebo-Controlled Trial

Platycodon grandiflorus root extract (PGE) has shown various properties, such as anti-hyperlipidemia, anti-diabetic, and anti-obesity, but mostly in animal studies. Therefore, we conducted a preliminary study on the anti-obesity effect of PGE in 108 Korean adults (aged 20–60 years, 30 kg/m² ≥ body mass index ≥ 23 kg/m²). The participants were randomly assigned to four groups and were administered the placebo, PGE571 (571 mg as PGE), PGE1142 (1142 mg as PGE), and PGE2855 (2855 mg as PGE), independently, for 12 weeks. Body composition, nutrient intake, computed tomography scan, and plasma adipokines, as well as hepatic/renal function markers, were assessed. The PGE571 group revealed a significant decrease in body fat mass and body fat percentage when compared with the placebo group. Moreover, the total abdominal and subcutaneous fat areas were significantly decreased following PGE (PGE2855 group) supplementation. These results provide useful information on the anti-obesity effect of PGE for overweight and obese adult humans.

Time-Limited Eating in Pediatric Patients with Obesity: A Case Series

Background

Time Limited Eating (TLE) is an effective strategy for management of obesity in adults, but there is a paucity of data that have examined its use in the clinical management of children with obesity. A TLE approach involves interspersing normal daily caloric intake with periods of prolonged calorie restriction several times per week. TLE may actually be more feasible, non-stigmatizing, flexible and effective in children, especially for adolescents, compared to alternatives like daily caloric or macronutrient restriction. This is because TLE removes the need for intensive counting of daily calorie intake or macronutrient content and focuses on a straightforward task of consuming food during a pre-specified time period. Also it avoids periods of extended caloric restriction which may interfere with growth and/or risk evoking development of eating behaviors. This case series describes four patients who trialed a TLE approach in a clinical weight management clinic and describes BMI reduction at 4 months.

Case Presentation

To date, 4 patients, ages 5-15, with varying underlying pathologies (i.e. Bardet Biedl Syndrome (BBS), previously healthy, craniopharyngioma and epilepsy) have tried a TLE type approach (16-hour fast/8-hour feed for 3-5 days per week) for 4 months and have demonstrated an average decrease in their BMI z-score compared to baseline of -0.24 SD. Patients and their families reported high degrees of satisfaction with this dietary approach.

Conclusions

Families were very satisfied with the TLE intervention and reported it was feasible, flexible and sustainable to implement in a real life setting and associated with decreased zBMI. Further investigation is required to determine if this approach is effective in both the short and long term as a weight management technique.

A Comparison of the Impact of Two Methods of Nutrition-Behavioral Intervention on Selected Auxological and Biochemical Parameters in Obese Prepubertal Children-Crossover Preliminary Study

Obese children are exposed to short and long-term health consequences, such as dyslipidemia, hypertension and diabetes mellitus. For these reasons, the prevention and treatment of obesity in the pediatric population is a challenge for health care professionals. The aim of this study was to evaluate whether an intensive intervention based on diet and physical activity has a better impact on the auxological and biochemical parameters than standard care (intervention). The study included 20 children (six boys, 14 girls), of the mean age 8.9 (SD 1.4) before puberty. The participants were randomly assigned to two groups: Group I (starting treatment with intensive intervention), and II (starting treatment with standard intervention). After three months, the groups were switched. The comparison of the two interventions in the study group indicates a better effectiveness of intensive intervention in the improvement of anthropometric parameters and majority of biochemical ones (except for insulin concentration, HOMA IR index and LDL cholesterol). As the result of intensive intervention, the mean % of weight-to-height excess and hip circumference decreased significantly (p < 0.005). Our results confirm that complex intervention based on systematic control visits, including personalized dietitian counselling and physician care, during the weight reduction process is more effective than a one-off standard visit.

Early weight loss in adolescents following bariatric surgery predicts weight loss at 12 and 24 months

BACKGROUND

Growing evidence supports the efficacy of paediatric bariatric surgery. However, there is a paucity of data examining adolescent outcomes post surgery. Among adults, studies have shown that early weight loss is associated with long-term weight loss. Therefore, the aim of our study was to investigate the association between early weight loss at 3 months with longer-term weight loss at 12 and 24 months in adolescents post surgery. We hypothesized that patients who have greater weight loss within the first 3 months will have greater weight loss at 12 and 24 months post surgery.

METHODS

A retrospective chart review of bariatric surgery patients (n = 28) was conducted. Anthropometric measurements at baseline and 3, 12, and 24 months were analysed.

RESULTS

Percent of excess weight loss (%EWL) at 3, 12, and 24 months were 33.6 ± 11.3%, 55.0 ± 20.5%, and 55.1 ± 27.1%, respectively. %EWL at 3 months was positively associated with %EWL at 12 and 24 months (P < 0.05). Receiver operating characteristic curve results identified a cut-off of greater than or equal to 30%EWL at 3 months predicted successful weight loss, defined as greater than or equal to 50%EWL at 12 and 24 months.

CONCLUSION

These findings demonstrate that majority of weight loss among adolescents occurs within the first postoperative year. Greater %EWL by 3 months post surgery predicts successful and sustained weight loss over time.

Current therapeutic strategies in treating obesity in children and adolescents - review of the literature

The present paper is a review of current knowledge concerning the most appropriate strategy in the conservative therapy of obese children and adolescents. It presents an account of the combined mode of therapy consisting of behavioral and dietary counseling with appropriate physical activity (also using the support of modern media and devices). The rise in obesity is usually a long-lasting process involving genetic predispositions but also environmental factors which can be modified. The treatment of obesity should be focused on these modified factors and be a lifelong treatment, not merely a short period of exercise or a diet program. Successful therapy depends on the cooperation of the medical team with children and their parents or caregivers.

Costs of Preparing to Implement a Family-Based Intervention to Prevent Pediatric Obesity in Primary Care: a Budget Impact Analysis

The costs associated with implementing evidence-based programs for pediatric obesity contribute to a lack of widespread adoption. This study examined the costs of preparing to implement the Family Check-Up 4 Health (FCU4Health), a family-centered behavioral program for the prevention of pediatric obesity and excess weight gain in primary care. Budget impact analysis was used to estimate the cost of preparing to implement FCU4Health (i.e., the activities to prepare for, but prior to, offering the service to families). Electronic cost capture methods were used to prospectively track personnel time associated with implementation preparation activities. We also estimated the cost of replicating these preparatory activities to inform future decisions to adopt the program and associated budgetary planning. The total cost of FCU4Health implementation preparation in three clinics and developing delivery materials and infrastructure was $181,768, for an average of $60,589 per clinic. Over two thirds of the total cost were personnel related, the largest of which was associated with the time spent developing automated fidelity coding for monitoring (20%), developing and tailoring clinical materials (16%), and training FCU4Health coordinators (15%). Due to these development costs associated with an initial implementation, that we anticipate would not be repeated in full, we estimated the cost to prepare FCU4Health for implementation in a future initiative will range from $15,195 to $17,912 per clinic. This study is a critical step towards equipping decision-makers with comprehensive short-term information about expected costs that are incurred immediately after choosing to adopt an evidence-based program.

Child and parent reports of children's depressive symptoms in relation to children's weight loss response in family-based obesity treatment

BACKGROUND

Studies of the association between children's depressive symptoms and obesity treatment response show mixed results. Different measurement may contribute to the inconsistent findings, as children's depressive symptoms are often based on parent-report about their child rather than child self-report.

OBJECTIVES

We assessed both child- and parent-report of child depressive symptoms as predictors of children's obesity treatment response.

METHODS

Children with overweight/obesity (body mass index [BMI] ≥ 85th percentile; N = 181) and their parents reported on children's depressive symptoms prior to family-based behavioral weight loss treatment.

RESULTS

Child percent overweight reduction from baseline to post-treatment was not predicted by child self-reported depressive symptoms or parent-report of child symptoms (P > 0.80), but was significantly predicted by the interaction between child self-report and parent-report on child (β = 0.14, P = 0.05). In analyses using clinical cutoffs, amongst children with high self-reported symptoms, those whose parents reported low child depressive symptoms had greater reduction in percent overweight (t = 2.67, P = 0.008), whereas amongst children with low self-reported symptoms, parent ratings were not associated with treatment outcome.

CONCLUSIONS

Including both child self-report and parent-report of child depressive symptoms may inform obesity care. Research is needed to examine differences amongst child and parent depressive symptom reports and strategies to address symptoms and optimize pediatric obesity treatment.

Hyperuricemia in Children and Adolescents: Present Knowledge and Future Directions

Recent evidence suggests that hyperuricemia is an important condition in children and adolescents, particularly in association with noncommunicable diseases. This review aims to summarize our current understanding of this condition in pediatric patients. An analysis of serum uric acid reference values in a healthy population indicates that they increase gradually with age until adolescence, with differences between the sexes arising at about 12 years of age. This information should be taken into consideration when defining hyperuricemia in studies. Gout is extremely rare in children and adolescents, and most patients with gout have an underlying disease. The major causes of hyperuricemia are chronic conditions, including Down syndrome, metabolic or genetic disease, and congenital heart disease, and acute conditions, including gastroenteritis, bronchial asthma (hypoxia), malignant disorders, and drug side effects. The mechanisms underlying the associations between these diseases and hyperuricemia are discussed, together with recent genetic information. Obesity is a major cause of hyperuricemia in otherwise healthy children and adolescents. Obesity is often accompanied by metabolic syndrome; hyperuricemia in obese children and adolescents is associated with the components of metabolic syndrome and noncommunicable diseases, including hypertension, insulin resistance, dyslipidemia, and chronic kidney disease. Finally, strategies for the treatment of hyperuricemia, including lifestyle intervention and drug administration, are presented.

Association between Alanine Aminotransferase and Growth Hormone: A Retrospective Cohort Study of Short Children and Adolescents

Objective

This study aimed to examine the relationship between serum alanine aminotransferase (ALT) and growth hormone (GH) in children and adolescents with short stature.

Methods

In this retrospective cohort study, 670 Chinese children and adolescents with short stature were included, and 253 of them received recombinant human GH (rhGH) therapy. Anthropometric and biochemical indicators were measured. GH peak levels were assessed after provocation tests with L-dopa and insulin. The subjects were divided into 3 groups according to the GH peak level. The association between the GH peak and ALT was analyzed. The change of ALT during rhGH therapy was assessed by a generalized additive mixed model.

Results

Serum ALT and incidence of ALT elevation were both decreased across the GH tertiles (P = 0.002, 0.012, respectively). A univariate analysis showed that the GH peak was negatively associated with ALT (β: -0.12; 95%CI: -0.22, -0.02; P = 0.023). Furthermore, multiple linear stepwise regression analysis demonstrated that the GH peak was independently related to ALT after adjusting for other confounding variables (β: -0.12; 95%CI: -0.24, -0.00; P = 0.042). Besides, mean values of the change in ALT from baseline displayed that, during the early stages of rhGH treatment, serum ALT level indicated a temporary upward trend, but it subsequently gradually decreased (β: -0.16; 95%CI: -0.23, -0.09; P < 0.001).

Conclusions

GH secretion level was strongly negatively correlated with ALT in short children and adolescents. And rhGH therapy could reduce ALT level over time.

Effectiveness of modified health belief model-based intervention to reduce body mass index for age in overweight junior high school students in Thailand

Purpose

The purpose of this paper is to determine the effectiveness of a modified HBM-based intervention to reduce body mass index (BMI) for age in overweight junior high school students.

Design/methodology/approach

A cluster-randomized controlled trial was conducted in the first and second years of a junior high school in the center of Thailand. In total, 24 classrooms were randomly assigned to a modified health belief model intervention arm (HBMIA), and 24 classrooms were randomly assigned to a traditional school health education arm (control). In total, 479 students who were overweight (BMI forage = median +1 SD, aged 12–15 years) participated in the study. The HBMIA used the health belief model (HBM) as a motivator for behavioral strategies that included modifying diet and participating in physical activity. BMI, health knowledge and behavior for preventing obesity were recorded at baseline and at six months. A multilevel regression model was performed to calculate mean difference between HBMIA and control group.

Findings

The students who participated in the HBMIA showed a decrease in BMI of 1.76 kg/m2, while those who participated in the control showed an increase in BMI of 1.13 kg/m2, with a mean difference of –2.88 kg/m2(95% CI =–3.01 to –2.75), an improvement in health knowledge (mean difference 27.28; 95% CI =26.15–28.41) and an improvement in health behavior (mean difference 23.54; 95% CI =22.60–24.48).

Originality/value

A modified HBM-based intervention to reduce BMI for age is effective in overweight junior high school students.

Energy Management for Personalized Weight Reduction (EMPOWER) Program: Three-Year Outcome Data

BACKGROUND

The current consensus guidelines for management of pediatric obesity recommend clinic-based, family-centered, multi-disciplinary interventions. It is well reported that these programs often only lead to modest improvements in BMI status. The individual factors that differentiate which patient's BMI status will improve vs. worsen remains understudied. A retrospective cohort study was conducted to evaluate the outcomes of EMPOWER clinic and identify the participant specific characteristics that predicted BMI status improvement in this population.

METHODS

Youth who completed at least 6 visits in EMPOWER were included. Paired t-test was utilized to evaluate the mean change in zBMI, modified BMIz and %BMIp95 from baseline to 6th visit, and multivariate mixed effect models were utilized to analyze effect of baseline characteristics on change in BMI status.

RESULTS

92 participants were included in the analysis, 87% with severe obesity and 66% Hispanic. At the 6th visit, there was a significant reduction in zBMI (-0.09 SD, p <0.001) and modified BMIz (-0.0003 SD, p = 0.04) with a small reduction in %BMIp95 (-1.15 %, p = 0.20). Lower BMI status (p < 0.001) and absence of a comorbidity (p < 0.05) at baseline were predictors of BMI status improvement whereas age, gender, ethnicity, family history of obesity and insurance status were not significant predictors.

CONCLUSIONS

Given that implementation of the current guidelines for management of obesity in pediatrics only results in modest BMI status reduction, further investigation is required to understand how the determinants of obesity-related health outcomes can guide development of more innovative, effective interventions for this high risk population.