Changes in risk variables of metabolic syndrome since childhood in pre-diabetic and type 2 diabetic subjects: the Bogalusa Heart Study

Prevalence of prediabetes and risk of CVD mortality in individuals with prediabetes alone or plus hypertension in Northeast China: insight from a population based cohort study

BACKGROUND

To evaluate the current prevalence of prediabetes in northeast China, and further determine the association between prediabetes alone or coexistent with hypertension and cardiovascular disease (CVD) mortality.

METHODS

In the prospective study, 15,557 participants without diabetes among aged ≥40 years in northeast China, were followed for a median of 5.5 years. Following the American Diabetes Association, prediabetes was defined as fasting plasma glucose (FPG) range of 5.6-6.9 mmol/L or glycated hemoglobin (HbA1c) range of 5.7-6.4% in people without diabetes.

RESULTS

The prevalence of prediabetes was 44.3% among population aged ≥40 years in northeast China. Prediabetes alone did not promote risk of CVD mortality. However, when the subgroups were stratified by hypertension, the CVD mortality risk in prediabetes plus hypertension subjects increased significantly compared with population without prediabetes and hypertension. Multivariate-adjusted hazard ratios for CVD mortality in prediabetes subgroups plus hypertension were 2.28 (95% CI: 1.50, 3.47) for those diagnosed by FPG < 5.6 mmol/L & HbA1c 5.7-6.4%, 2.18 (95% CI: 1.53, 3.10) for those diagnosed by FPG 5.6-6.0 mmol/L & HbA1c < 6.5% and 2.35 (95% CI: 1.65, 3.35) for those diagnosed by FPG 6.1-6.9 & HbA1c < 6.5% compared with the reference group. Moreover, the percentage of hypertension in prediabetes subjects was high (60.4%), but the awareness, treatment and control rates were far from satisfactory (45.3, 35.1 and 4.8%, respectively).

CONCLUSIONS

The prevalence of prediabetes remains high in northeast China, and the CVD mortality was elevated significantly in prediabetes coexistent with hypertension. Considering the high percentage and low control rate of hypertension in prediabetes, strategies focused on HbA1c screening, FPG lowering and blood pressure management should be emphasized in northeast China.

Urinary epidermal growth factor reflects vascular health in boys with either obesity or type 1 diabetes. A role for renin, or beyond?

An increased blood pressure is a known comorbidity of both type 1 diabetes (T1DM) and obesity in children. Increasing evidence suggests a subtle interplay between epidermal growth factor (EGF) and renin along the juxtaglomerular system, regulating the impact of blood pressure on kidney health and the cardiovascular system. In this study, we investigated the relation between urinary EGF, serum renin and blood pressure in children with obesity or T1DM. 147 non-obese children with T1DM and 126 children with obesity, were included. Blood pressure was measured and mean arterial pressure (MAP) and the pulse pressure (PP) were calculated. Serum renin and urinary EGF levels were determined with a commercial ELISA kit. Partial Spearman rank correlation coefficients and multiple linear regression models were used to study the association between renin, the urinary EGF/urinary creatinine ratio and blood pressure parameters. The urinary EGF/urinary creatinine ratio is correlated with the SBP and the MAP in boys with obesity as well as in boys with T1DM. Multiple regression analysis showed that sex and pulse pressure in male subjects were found to be independently associated with renin. Sex, the presence of diabetes, age, the glomerular filtration rate and both pulse pressure and mean arterial pressure in male subjects were independently associated with urinary EGF/urinary creatinine. In conclusion, in boys with either obesity or diabetes, pulse pressure and mean arterial pressure are negatively associated with the functional integrity of the nephron, which is reflected by a decreased expression of urinary EGF.

Changes in body size phenotypes from childhood to adulthood and the associated cardiometabolic outcomes

AIM

To examine the effects of changes in body size phenotypes between childhood and adulthood on risks of diabetes and left ventricular hypertrophy (LVH) in adulthood.

METHODS

We included 3,351 individuals who participated as both children and adults in the Bogalusa Heart Study.

RESULTS

Compared with participants with persistently metabolically healthy normal weight (MHNW) from childhood to adulthood, MHNW children who became metabolically unhealthy in adulthood had increased diabetes burden and LVH risk in adulthood; Metabolically unhealthy normal weight (MUNW) children who became MHNW or metabolically healthy obese (MHO) as adults and individuals with persistent MHO from childhood to adulthood were not at increased risks of diabetes or LVH. The risks were increased if MHO during childhood transitioned to metabolically unhealthy obesity (MUO) by adulthood or MUO stayed from childhood to adulthood. MUO children who became MHO or MHNW as adults had decreased diabetes burden and LVH risk in adulthood.

CONCLUSIONS

Individuals maintained MHO from childhood to adulthood and MUNW children who became MHO as adults had a diabetes burden and LVH risk similar to individuals with persistent MHNW. Progression to metabolically unhealthy status and maintenance of metabolically unhealthy status, regardless of childhood BMI status, were associated with increased cardiometabolic outcomes.

Acute Response to One Bout of Dynamic Standing Exercise on Blood Glucose and Blood Lactate Among Children and Adolescents With Cerebral Palsy Who are Nonambulant

PURPOSE

To investigate the acute exercise effects of dynamic standing exercise on blood glucose and blood lactate among children and adolescents with cerebral palsy who are nonambulant.

METHODS

Twenty-four participants with cerebral palsy who are nonambulant performed 30 minutes of dynamic standing exercise using a motorized device enabling assisted passive movements in an upright weight-bearing position. Capillary blood samples were taken from the fingertip for measurement of blood glucose and blood lactate at rest and at the end of exercise.

RESULTS

At rest, the participants had hyperlactatemia that was unaffected after exercise, presented as median and interquartile range at rest 1.8 (1.3:2.7) mmol/L, and after exercise 2.0 (1.1:2.5) mmol/L. Children and adolescents with Gross Motor Function Classification System, level V, had higher lactate levels at rest (2.5 [1.8:2.9] vs 1.4 [1.0:2.0]; P = .030) and after exercise (2.3 [2.0:2.6] vs 1.2 [0.9:2.2]; P = .032) compared with children and adolescents with Gross Motor Function Classification System, level IV, respectively. A statistically significant larger decrease in blood lactate levels after exercise was observed in children and adolescents with higher resting blood lactate levels (ρ = .56; P = .004). There were no statistically significant changes in blood glucose.

CONCLUSIONS

Forty percentage of the participants had mild hyperlactatemia at rest and participants with the highest blood lactate levels at rest had the greatest decrease in blood lactate levels after one bout of exercise. Children and adolescents who were classified with the highest level of the Gross Motor Function Classification Scale had higher blood lactate levels. More studies are needed on how to prevent chronically high resting levels of lactate with exercise in children with cerebral palsy who are nonambulant.

Associations of Body Mass Index and Waist Circumference in Young Adulthood with Later Life Incident Diabetes

CONTEXT

The independent contribution of young adult exposure to overweight and obesity to later-life incident diabetes is not well studied.

OBJECTIVE

To assess the associations of exposures to elevated body mass index (BMI) and waist circumference (WC) in young adulthood (ages 18-39 years) with incident diabetes later in life (≥40 years).

DESIGN

Pooled data from 6 US prospective cohorts (Atherosclerosis Risk in Communities Study, Cardiovascular Risk Development in Young Adults Study, Cardiovascular Health Study, (4) Framingham Heart Study Offspring Cohort, (5) Health, Aging and Body Composition Study, and (6) Multi-Ethnic Study of Atherosclerosis.

SETTING

Population-based cohort studies.

PARTICIPANTS

30 780 participants (56.1% female, 69.8% non-Hispanic white) without a diagnosis of diabetes by age 40.

INTERVENTIONS

We imputed BMI and WC trajectories from age 18 for every participant and estimated time-weighted average exposures to BMI or WC during young adulthood and later life.

MAIN OUTCOME MEASURE(S)

Incident diabetes defined as fasting glucose ≥126 mg/dL, nonfasting glucose ≥200 mg/dL, or use of diabetes medications.

RESULTS

During a 9-year median follow-up, 4323 participants developed incident diabetes. Young adult BMI and WC were associated with later-life incident diabetes after controlling for later-life exposures [hazard ratios (HR) 1.99 for BMI ≥ 30 kg/m2 and 2.13 for WC > 88cm (women)/>102cm (men) compared to normal ranges]. Young adult homeostatic model of insulin resistance mediated 49% and 44% of the association between BMI and WC with later-life incident diabetes. High-density lipoproteins and triglycerides mediated a smaller proportion of these associations.

CONCLUSIONS

Elevated BMI and WC during young adulthood were independently associated with later-life incident diabetes. Insulin resistance may be a key mediator.

Novel Insights into the Pathogenesis and Management of the Metabolic Syndrome

The metabolic syndrome, by definition, is not a disease but is a clustering of individual metabolic risk factors including abdominal obesity, hyperglycemia, hypertriglyceridemia, hypertension, and low high-density lipoprotein cholesterol levels. These risk factors could dramatically increase the prevalence of type 2 diabetes and cardiovascular disease. The reported prevalence of the metabolic syndrome varies, greatly depending on the definition used, gender, age, socioeconomic status, and the ethnic background of study cohorts. Clinical and epidemiological studies have clearly demonstrated that the metabolic syndrome starts with central obesity. Because the prevalence of obesity has doubly increased worldwide over the past 30 years, the prevalence of the metabolic syndrome has markedly boosted in parallel. Therefore, obesity has been recognized as the leading cause for the metabolic syndrome since it is strongly associated with all metabolic risk factors. High prevalence of the metabolic syndrome is not unique to the USA and Europe and it is also increasing in most Asian countries. Insulin resistance has elucidated most, if not all, of the pathophysiology of the metabolic syndrome because it contributes to hyperglycemia. Furthermore, a major contributor to the development of insulin resistance is an overabundance of circulating fatty acids. Plasma fatty acids are derived mainly from the triglycerides stored in adipose tissues, which are released through the action of the cyclic AMP-dependent enzyme, hormone sensitive lipase. This review summarizes the latest concepts in the definition, pathogenesis, pathophysiology, and diagnosis of the metabolic syndrome, as well as its preventive measures and therapeutic strategies in children and adolescents.

Variabilities in Childhood Cardiovascular Risk Factors and Incident Diabetes in Adulthood: The Bogalusa Heart Study

OBJECTIVE

Although emerging evidence indicates that increased variability in cardiovascular risk factors (CVRFs) among populations at midlife or later is a reliable predictor of adverse health outcomes, it is unknown whether intraindividual CVRF variability during childhood or adolescence is an independent predictor of later-life diabetes. We aimed to examine the association of CVRF variability during childhood with diabetes in later life.

RESEARCH DESIGN AND METHODS

We included 1,718 participants who participated in the Bogalusa Heart Study and had measures at least four times during childhood (aged 4-19 years). The mean follow-up period was 20.5 years. Intraindividual CVRF variabilities during childhood were calculated using SD, coefficient of variation, deviation from age-predicted values, and residual SD based upon four to eight serial measurements in childhood.

RESULTS

Increased variability in BMI or HDL cholesterol (HDL-C) during childhood, irrespective of the indices used, was significantly positively associated with later-life diabetes risk independent of their respective mean levels in childhood and other possible confounding factors. In combined analysis, the magnitude of the association with diabetes risk was similar for high childhood BMI variability and high childhood HDL-C variability. After adjustments for potential confounding variables, other CVRF variabilities including systolic/diastolic blood pressure, total cholesterol, triglycerides, and LDL cholesterol were not significantly associated with diabetes.

CONCLUSIONS

Increased BMI and HDL-C variabilities during childhood were significant risk factors for the development of diabetes independently of diverse risk factors, which may offer new insights into the childhood origin of adult-onset diabetes.

Glucose metabolism in children and adolescents: Population-based reference values and comparisons to children and adolescents enrolled in obesity treatment

BACKGROUND

Alterations in glucose metabolism that lead to the development of metabolic and cardiovascular disease may begin already in childhood.

OBJECTIVE

This study aims to generate pediatric age and sex-specific reference values for fasting concentrations of glucose, hemoglobin A1c (HbA1c), insulin, C-peptide, and homeostasis model assessment: insulin resistance (HOMA-IR) in Danish/North-European white children and adolescents from a population-based cohort and to compare values from children and adolescents with overweight/obesity with this reference.

METHODS

The population- and obesity clinic-based cohorts consisted of 2451 and 1935 children and adolescents between 6 and 18 years of age. Anthropometric measurements and blood samples were obtained and percentile curves were calculated.

RESULTS

In the population-based cohort, glucose, insulin, and HOMA-IR values increased before the expected onset of puberty (P < .05). Thereafter, all variables decreased in girls (P < .05) and HbA1c decreased in boys (P < .05). Concentrations of all measured markers of glucose metabolism were higher in the obesity clinic-based cohort than the population-based cohort (both sexes P < .001). Specifically, insulin and HOMA-IR continued to increase to 18 years in the clinic-based cohort, particularly among boys.

CONCLUSIONS

Fasting glucose, insulin, and HOMA-IR change during childhood, making pediatric reference values essential for timely identification of derangements in glucose metabolism. Children and adolescents with obesity exhibit increased concentrations of these biomarkers.

Association between Changes in Anthropometric Indices and in Fasting Insulin Levels among Healthy Korean Adolescents: The JS High School Study

BACKGROUND

This study investigated the association between changes in anthropometric indices and fasting insulin levels among healthy adolescents and whether the association differed by baseline obesity status.

METHODS

This analysis was based on data collected for the JS High School study; 884 healthy adolescents aged 15 to 16 years followed up for 24 to 30 months were included. Changes in anthropometric indices and fasting insulin levels were computed as the difference between baseline and follow-up values. Multivariate linear regression models were used to determine the association between changes in anthropometric indices and fasting insulin levels. Based on body mass index (BMI)-for-age and waist circumference (WC)-for-age percentiles, participants were classified as normal weight (<85th percentile), overweight (85th percentile to <95th percentile), or obese (≥95th percentile).

RESULTS

Changes in BMI, WC, waist-hip ratio, and waist-height ratio were significantly associated with changes in fasting insulin levels in both sexes (P<0.05). In analyses stratified by baseline obesity status, the association between change in BMI and change in fasting insulin was significantly stronger in overweight (males: standardized β=1.136; females: standardized β=1.262) and obese (males: standardized β=1.817; females: standardized β=2.290) participants than in those with normal weight (males: standardized β=0.957; females: standardized β=0.976) at baseline. Results were similar for changes in WC.

CONCLUSION

Changes in anthropometric indices were positively associated with fasting insulin level increases. Moreover, those who were overweight or obese at baseline had a higher absolute increase in fasting insulin levels per one standard deviation unit increase in anthropometric indices than adolescents with normal weight.

Trajectories of childhood BMI and adult diabetes: the Bogalusa Heart Study

AIMS/HYPOTHESIS

The aim of this study was to characterise longitudinal profiles of BMI from childhood and to examine the impact of level-independent childhood BMI trajectories on adult type 2 diabetes.

METHODS

The longitudinal cohort consisted of 2449 adults (1613 white and 836 black) who had their BMI measured between four and 15 times from childhood (4-19 years) to adulthood (20-51 years) and fasting glucose measured in adulthood. Model-estimated levels and linear slopes of BMI at childhood age points were calculated in 1-year intervals using growth-curve parameters and their first derivatives, respectively.

RESULTS

BMI from childhood to adulthood fit cubic growth curves; linear and non-linear curve parameters differed significantly between race-sex groups. BMI showed race and sex differences from 15 years onwards. Individuals with hyperglycaemia had higher long-term BMI levels than those who were normoglycaemic in race-sex groups. Linear and non-linear slope parameters of BMI differed consistently and significantly between adult hyperglycaemia groups. The OR of childhood BMI levels for ages 4-19 years was 1.45-1.83 (p < 0.001 for all) for adult hyperglycaemia after adjustment for confounders. Level-adjusted linear slopes of BMI at ages 10-19 years showed significantly positive associations with adult hyperglycaemia (OR 1.17-1.50, p < 0.01 for all). The associations of childhood BMI linear slopes with adult hyperglycaemia were not significant during the age period 5-9 years. The trends in these associations were consistent across race-sex groups.

CONCLUSIONS/INTERPRETATION

These observations indicate that childhood BMI trajectories have a significant impact on adult diabetes, independent of BMI levels. The adolescence age period is a crucial window for the development of diabetes in later life, which has implications for early-life prevention.

DATA AVAILABILITY

All data and materials are publicly available at the National Heart, Lung, and Blood Institute (NHLBI) Biologic Specimen and Data Repository and can be accessed at https://biolincc.nhlbi.nih.gov/studies/bhs .

Impaired fasting glucose and the metabolic profile in Danish children and adolescents with normal weight, overweight, or obesity

OBJECTIVE

Whether the definitions of impaired fasting glucose (IFG) from the American Diabetes Association (ADA) and the World Health Organization (WHO) differentially impact estimates of the metabolic profile and IFG-related comorbidities in Danish children and adolescents is unknown.

METHODS

Two thousand one hundred and fifty four (979 boys) children and adolescents with overweight or obesity (median age 12 years) and 1824 (728 boys) children with normal weight (median age 12 years) from The Danish Childhood Obesity Biobank were studied. Anthropometrics, blood pressure, puberty, and fasting concentrations of glucose, insulin, glycosylated hemoglobin (HbA1c), and lipids were measured.

RESULTS

About 14.1% of participants with overweight or obesity exhibited IFG according to the ADA and 3.5% according to the WHO definition. Among individuals with normal weight, the corresponding prevalences were 4.3% and 0.3%. IFG was associated with a higher systolic blood pressure, higher concentrations of HbA1c, insulin, C-peptide (P < .0001) and triglycerides (P = .03), and lower HOMA2-IS and HOMA2-B (P < .0001) independent of sex, age, puberty, waist-to-height ratio, and degree of obesity. Furthermore, IFG was associated with a higher risk for hypertension (OR = 1.66 [95%CI: 1.21; 2.28], P = .002) and dyslipidemia (OR = 1.90 [95%CI: 1.38; 2.56], P < .0001) compared with the group without IFG independent of age, sex, and puberty.

CONCLUSIONS

The prevalence of IFG, when applying the ADA criterion compared with the WHO criterion, was 4 times higher in individuals with overweight and obesity and 14 times higher in individuals with normal weight in this study sample of children and adolescents. IFG was associated with a higher risk of hypertension and dyslipidemia compared with their normoglycemic peers regardless of the definition applied.

Maternal blood cadmium, lead and arsenic levels, nutrient combinations, and offspring birthweight

Background

Cadmium (Cd), lead (Pb) and arsenic (As) are common environmental contaminants that have been associated with lower birthweight. Although some essential metals may mitigate exposure, data are inconsistent. This study sought to evaluate the relationship between toxic metals, nutrient combinations and birthweight among 275 mother-child pairs.

Methods

Non-essential metals, Cd, Pb, As, and essential metals, iron (Fe), zinc (Zn), selenium (Se), copper (Cu), calcium (Ca), magnesium (Mg), and manganese (Mn) were measured in maternal whole blood obtained during the first trimester using inductively coupled plasma mass spectrometry. Folate concentrations were measured by microbial assay. Birthweight was obtained from medical records. We used quantile regression to evaluate the association between toxic metals and nutrients due to their underlying wedge-shaped relationship. Ordinary linear regression was used to evaluate associations between birth weight and toxic metals.

Results

After multivariate adjustment, the negative association between Pb or Cd and a combination of Fe, Se, Ca and folate was robust, persistent and dose-dependent (p < 0.05). However, a combination of Zn, Cu, Mn and Mg was positively associated with Pb and Cd levels. While prenatal blood Cd and Pb were also associated with lower birthweight. Fe, Se, Ca and folate did not modify these associations.

Conclusion

Small sample size and cross-sectional design notwithstanding, the robust and persistent negative associations between some, but not all, nutrient combinations with these ubiquitous environmental contaminants suggest that only some recommended nutrient combinations may mitigate toxic metal exposure in chronically exposed populations. Larger longitudinal studies are required to confirm these findings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4225-8) contains supplementary material, which is available to authorized users.

Insights for Oxidative Stress and mTOR Signaling in Myocardial Ischemia/Reperfusion Injury under Diabetes

Diabetes mellitus (DM) displays a high morbidity. The diabetic heart is susceptible to myocardial ischemia/reperfusion (MI/R) injury. Impaired activation of prosurvival pathways, endoplasmic reticulum (ER) stress, increased basal oxidative state, and decreased antioxidant defense and autophagy may render diabetic hearts more vulnerable to MI/R injury. Oxidative stress and mTOR signaling crucially regulate cardiometabolism, affecting MI/R injury under diabetes. Producing reactive oxygen species (ROS) and reactive nitrogen species (RNS), uncoupling nitric oxide synthase (NOS), and disturbing the mitochondrial quality control may be three major mechanisms of oxidative stress. mTOR signaling presents both cardioprotective and cardiotoxic effects on the diabetic heart, which interplays with oxidative stress directly or indirectly. Antihyperglycemic agent metformin and newly found free radicals scavengers, Sirt1 and CTRP9, may serve as promising pharmacological therapeutic targets. In this review, we will focus on the role of oxidative stress and mTOR signaling in the pathophysiology of MI/R injury in diabetes and discuss potential mechanisms and their interactions in an effort to provide some evidence for cardiometabolic targeted therapies for ischemic heart disease (IHD).

Metabolic Syndrome: Bridging the Gap from Childhood to Adulthood

Childhood and adolescence are particularly vulnerable periods of life to the effects of cardiometabolic risk and later development of atherosclerosis, hypertension, and diabetes mellitus. Developing countries with limited resources suffer most heavily from the consequences of cardiometabolic risk in children and its future implications to the global health burden. A better understanding of mechanisms leading to cardiometabolic risk in early life may lead to more effective prevention and intervention strategies to reduce metabolic stress in children and later disease. Longitudinal "tracking" studies of cardiometabolic risk in children provide a tremendous global resource to direct prevention strategies for cardiovascular disease. In this review, we will summarize the pathophysiology, existing definitions for cardiometabolic risk components in children. Screening and identifying children and adolescents of high cardiometabolic risk and encouraging them and their families through healthy lifestyle changes should be implemented to as a global public health strategy.

Association between impaired fasting glycaemia in pediatric obesity and type 2 diabetes in young adulthood

Objectives:

In adults, impaired fasting glycemia (IFG) increases the risk for type 2 diabetes mellitus (T2DM). This study aimed to investigate to which extent children with obesity develop T2DM during early adulthood, and to determine whether IFG and elevated hemoglobin A1c (HbA1c) in obese children are risk markers for early development of T2DM.

Methods:

In this prospective cohort study, 1620 subjects from the Swedish Childhood Obesity Treatment Registry – BORIS who were ⩾18 years at follow-up and 8046 individuals in a population-based comparison group, matched on gender age and living area, were included. IFG was defined according to both ADA (cut-off 5.6 mmol l⁻¹) and WHO (6.1 mmol l⁻¹). Elevated HbA1c was defined according to ADA (cut-off 39 mmol l⁻¹). Main outcome was T2DM medication, as a proxy for T2DM. Data on medications were retrieved from a national registry.

Results:

The childhood obesity cohort were 24 times more likely to receive T2DM medications in early adulthood compared with the comparison group (95% confidence interval (CI): 12.52–46). WHO-defined IFG predicted future use of T2DM medication with an adjusted hazard ratio (HR) of 3.73 (95% CI: 1.87–7.45) compared with those who had fasting glucose levels <5.6 mmol l⁻¹. A fasting glucose level of 5.6–6.0 mmol l⁻¹, that is, the IFG-interval added by American Diabetes Association (ADA), did not increase the use of T2DM medication more than pediatric obesity itself, adjusted HR=1.72 (0.84–3.52). Elevated levels of HbA1c resulted in an adjusted HR=3.12 (1.50–6.52). More severe degree of obesity also increased the future T2DM risk.

CONCLUSION:

IFG according to WHO and elevated HbA1c (39–48 mmol l⁻¹), but not the additional fasting glucose interval added by ADA (5.6–6.0 mmol l⁻¹), can be considered as prediabetes in the obese pediatric population in Sweden.

Relation of Cardiometabolic Risk Factors between Parents and Children

OBJECTIVES

To explore the relations of parent-child cardiometabolic risk factors and assess the influence of adiposity on these associations.

STUDY DESIGN

Associations of adiposity, blood pressure (BP), lipids, fasting insulin and glucose, and a risk factor cluster score (CS) were evaluated in a cross-sectional study of 179 parents and their children (6-18 years, N = 255). Insulin resistance was assessed by euglycemic clamp in parents and children aged 10 years or older. Metabolic syndrome in parents was defined by National Cholesterol Education Program's Adult Treatment Panel III criteria. CSs of the risk factors were created based on age-specific z-scores. Analyses included Pearson correlation and linear regression, adjusted for parent and child age, sex, race, and body mass index (BMI), accounting for within-family correlation.

RESULTS

We found positive parent-child correlations for measures of adiposity (BMI, BMI percentile, waist, subcutaneous fat, and visceral fat; r = 0.22-0.34, all P ≤ .003), systolic BP (r = 0.20, P = .002), total cholesterol (r = 0.39, P < .001), low-density lipoprotein cholesterol (r = 0.34, P < .001), high density lipoprotein cholesterol (r = 0.26, P < .001), triglycerides (r = 0.19, P = .01), and insulin sensitivity (r = 0.22, P = .02) as well as CSs (r = 0.15, P = .02). After adjustment for BMI all parent-child correlations, except systolic BP, remained significant.

CONCLUSIONS

Although adiposity is strongly correlated between parents and children, many cardiometabolic risk factors correlate independent of parent and child BMI. Adverse parental cardiometabolic profiles may identify at-risk children independent of the child's adiposity status.

Association between Obesity Indices and Insulin Resistance among Healthy Korean Adolescents: The JS High School Study

Objective

To investigate whether indices of obesity are associated with insulin resistance in Korean adolescents.

Methods

This study was conducted as a cross-sectional analysis of 817 healthy adolescents aged 15–16 years without diabetes. Percentiles group of weight-for-height, body mass index (BMI)-for-age, waist circumference (WC)-for-age, and skin fold thickness (SFT)-for-age were based on the 2007 Korean National Growth Charts. Percentiles of waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), and percent body fat were calculated for the study population. Insulin resistance was estimated by homeostatic model assessment (HOMA-IR). Logistic regression models were used to estimate odds ratio for insulin resistance according to seven obesity indices. Generalized linear models were used to assess the associations between obesity indices and continuous HOMA-IR levels.

Results

Sex and age-adjusted odds ratios (95% confidence interval) for insulin resistance, defined as HOMA-IR>2.50, of the 75–94th and ≥95th percentiles of weight-for-height were 3.87 (2.38–6.30) and 11.37 (5.87–22.02), compared to the <50th percentile. Corresponding odds ratios were 3.27 (2.02–5.28) and 11.72 (6.05–22.73) for BMI-for-age, 4.72 (2.82–7.88) and 13.22 (6.42–27.23) for WC-for-age, 3.67 (2.27–5.94) and 13.58 (6.71–27.48) for WHR, 4.78 (2.99–7.67) and 12.84 (6.23–26.46) for WHtR, 2.62 (1.61–4.26) and 6.68 (3.46–12.90) for SFT-for-age, and 2.29 (1.33–4.26) and 10.06 (4.39–23.06) for body fat. These associations were more prominent when insulin resistance was defined as HOMA-IR>3.16 and were stronger in males than in females. Continuous measure of HOMA-IR was significantly associated with body weight, BMI, WC, WHR, WHtR, and SFT in both sexes (p<0.001), and with percent body fat in males only (p<0.001).

Conclusion

Our findings suggest that obesity indices are positively associated with insulin resistance in apparently healthy adolescents.

Preschoolers in the Playground: a pilot cluster randomised controlled trial of a physical activity intervention for children aged 18 months to 4 years

Background

The preschool years are considered critical for establishing healthy lifestyle behaviours such as physical activity. Levels of physical activity track through childhood into adulthood and establishing habitual physical activity early in life is therefore vital. Time spent outdoors is associated with greater physical activity and playground interventions have been shown to increase physical activity in school-aged children. There are few preschool, playground-based interventions and these have given inconclusive results. A report published by the UK’s Chief Medical Officer (CMO) highlighted the need for new interventions to promote movement in the early years (0–5 years).

Objectives

This study aimed to undertake a pilot cluster randomised controlled trial (RCT) of an outdoor playground-based physical activity intervention for parents and their children aged from 18 months to 4 years (Preschoolers in the Playground or PiP) and to assess the feasibility of conducting a full-scale cluster RCT.

Design

The study was a two-armed pilot cluster RCT with economic and qualitative evaluations. Participants were randomised on a 1 : 1 basis to the PiP intervention (n = 83) or usual practice (control;n = 81).

Setting

Bradford, West Yorkshire, UK.

Participants

Children aged from 18 months to 4 years.

Intervention

The PiP intervention is grounded in behavioural theory (social cognitive theory) and is in accordance with CMO guidance for physical activity in the early years. It is informed by existing literature and data collected from focus groups with parents. The intervention was delivered in primary school playgrounds. Six 30-minute PiP sessions per week were available for 30 weeks; families were encouraged to come to three a week. The 10-week initiation phase was facilitated by a member of school staff and the maintenance phase was unsupervised.

Main outcome measures

Recruitment and retention of schools and families to the trial were the main outcome measures. The acceptability of trial procedures and the intervention, the feasibility of collecting health outcome data and the fidelity of the implementation of the intervention were also evaluated. A preliminary assessment of cost-effectiveness and a sample size calculation for a full trial were conducted.

Results

In total, 37% of schools and 48% of parents approached agreed to take part. Levels of retention were good at 10 and 52 weeks’ follow-up (82.3% and 83.5% respectively). Both the trial procedures and the intervention were acceptable. However, attendance was low during the autumn and winter/spring initiation phases but somewhat better in the summer initiation phase. Attendance was poor throughout all maintenance phases. The accelerometry protocol for measuring physical activity requires modification. The fidelity of intervention implementation was good (81% adherence). The intervention was borderline cost-effective. A sample size of 600 children from 38 schools is required for a full trial.

Conclusion

A full RCT of the PiP intervention is feasible. The PiP intervention requires some modification, for example running the intervention during the summer term only, but was found to be acceptable to schools and families.

Trial registration

Current Controlled Trials ISRCTN54165860.

Funding

This project was funded by the NIHR Public Health Research programme and will be published in full inPublic Health Research; Vol. 3, No. 5. See the NIHR Journals Library website for further project information.

Fibroblast growth factor-21, body composition, and insulin resistance in pre-pubertal and early pubertal males and females

OBJECTIVE

Accumulating evidence derived primarily from animal models suggests that fibroblast growth factor-21 (FGF-21) may affect the musculoskeletal system via effects on the capacity of tissues to respond to insulin. A proportion of musculoskeletal properties and underpinnings of promoting/preventing insulin resistance are established early in the pubertal transition. Thus, the objective of this study was to test the hypothesis that insulin resistance and/or obesity will promote greater FGF-21 concentration which will be inversely associated with musculoskeletal parameters [lean mass and bone mineral content (BMC)] in pre-/early pubertal children. Given the sexual dimorphic nature of musculoskeletal development of fat mass accrual, differences by obesity status and sex were also investigated.

DESIGN

Cross-sectional.

PATIENTS

Children ages 7-12 years (n = 69, 38% male, 48% non-Hispanic black, 45% obese).

MEASUREMENTS

Fasting FGF-21, glucose and insulin measures were obtained. An estimate of insulin resistance was derived using the homoeostatic model assessment of insulin resistance (HOMA-IR). Body composition (BMC, lean mass and fat mass) was assessed by DXA. Multivariate regression analysis was used to evaluate the influence of FGF-21 on BMC, lean mass and HOMA-IR as dependent variables. Obesity status was established based on BMI z-score.

RESULTS

FGF-21 concentrations did not differ by obesity status or by sex. There was an inverse association between FGF-21 and BMC among nonobese individuals (P = 0·01) and an inverse association between FGF-21 and lean mass among females (P = 0·02), which were both independent of fat mass. FGF-21 was inversely associated with HOMA-IR in males, but not females (P = 0·04).

CONCLUSIONS

The existence of relationships of FGF-21 with musculoskeletal parameters and insulin resistance raises the possibility of crosstalk between these systems. These findings suggest that circulating FGF-21 may differ in its association with bone, lean mass and insulin resistance depending on sex and weight status.

Prediabetes and associated disorders

Prediabetes represents an elevation of plasma glucose above the normal range but below that of clinical diabetes. Prediabetes includes individuals with IFG, IGT, IFG with IGT and elevated HbA1c levels. Insulin resistance and β-cell dysfunction are characteristic of this disorder. The diagnosis of prediabetesis is vital as both IFG and IGT are indeed well-known risk factors for type 2 diabetes with a greater risk in the presence of combined IFG and IGT. Furthermore, as will be illustrated in this review, prediabetes is associated with associated disorders typically only considered in with established diabetes. These include cardiovascular disease, periodontal disease, cognitive dysfunction, microvascular disease, blood pressure abnormalities, obstructive sleep apnea, low testosterone, metabolic syndrome, various biomarkers, fatty liver disease, and cancer. As the vast majority of individuals with prediabetes are unaware of their diagnosis, it is therefore vital that the associated conditions are identified, particularly in the presence of mild hyperglycemia, so they may benefit from early intervention.

Early-life risk factors for chronic nonrespiratory diseases

We have witnessed a change in disease patterns contributing to the global burden of disease, with a shift from early childhood deaths due to the classic infectious communicable diseases to years lived with disability from chronic noncommunicable diseases. In both developing and developed countries, the years lived with disability attributable to chronic disease have increased: cardiovascular diseases by 17.7%; chronic respiratory disease by 8.5%; neurological conditions by 12.2%; diabetes by 30.0%; and mental and behavioural disorders by 5.0% over the past 20 years. Recognition of the contribution made by adverse environmental exposures in early life to noncommunicable diseases in later life is increasing. These early-life exposures appear to contribute to both chronic respiratory and chronic nonrespiratory diseases. In this State of the Art article, we aim to examine early-life environmental exposures that have an epidemiological association with chronic nonrespiratory diseases, such as obesity and type II diabetes, cardiovascular disease, and neurocognitive and behavioural problems. We will highlight the potential overlap in environmental risks with respiratory diseases, and point out knowledge gaps and research opportunities.

Neglect: failure to thrive and obesity

Medical providers need to monitor growth at every visit. Weight status is influenced by genetics, medical conditions, socioeconomic status, and family environment. Screening for food security and psychosocial risk factors is an integral tool to identify families at risk for nutritional deficits and child maltreatment. Nutritional rehabilitation is best accomplished in an outpatient, multidisciplinary setting. Medical neglect should be considered in failure to thrive and obesity when there is a serious risk of harm from identified medical complications, additional or worsening medical complications occurring despite a multidisciplinary approach, and/or non-adherence with the treatment plan.

Physical education can improve insulin resistance: the LOOK randomized cluster trial

PURPOSE

As impaired glucose metabolism may arise progressively during childhood, we sought to determine whether the introduction of specialist-taught school physical education (PE) based on sound educational principles could improve insulin resistance (IR) in elementary school children.

METHODS

In this 4-yr cluster-randomized intervention study, participants were 367 boys and 341 girls (mean age = 8.1 yr, SD = 0.35) initially in grade 2 in 29 elementary schools situated in suburbs of similar socioeconomic status. In 13 schools, 100 min·wk-1 of PE, usually conducted by general classroom teachers, was replaced with two classes per week taught by visiting specialist PE teachers; the remaining schools formed the control group. Teacher and pupil behavior were recorded, and measurements in grades 2, 4, and 6 included fasting blood glucose and insulin to calculate the homeostatic model of IR, percent body fat, physical activity, fitness, and pubertal development.

RESULTS

On average, the intervention PE classes included more fitness work than the control PE classes (7 vs 1 min, P < 0.001) and more moderate physical activity (17 vs 10 min, P < 0.001). With no differences at baseline, by grade 6, the intervention had lowered IR by 14% (95% confidence interval = 1%-31%) in the boys and by 9% (95% confidence interval = 5%-26%) in the girls, and the percentage of children with IR greater than 3, a cutoff point for metabolic risk, was lower in the intervention than the control group (combined, 22% vs 31%, P = 0.03; boys, 12% vs 21%, P = 0.06; girls, 32% vs 40%, P = 0.05).

CONCLUSIONS

Specialist-taught primary school PE improved IR in community-based children, thereby offering a primordial preventative strategy that could be coordinated widely although a school-based approach.

Metabolic risk in contemporary children is unrelated to socio-economic status: longitudinal study of a UK urban population (EarlyBird 42)

Lifestyle interventions to improve health in young children tend to target areas of relative deprivation, but the evidence for so doing is largely historical. Accordingly, we have re-examined the link between deprivation, obesity and metabolic risk in contemporary UK children. Using a postcode-based index of multiple deprivation (IMD), we assessed 269 children from the community-based EarlyBird Study, attending 53 schools representing a wide socio-economic range. Annual measures of fatness from 5 to 8 yr included body mass index (BMI), waist circumference (WC), and sum of five skinfolds (SSF). A metabolic risk score, based on blood pressure, lipids and insulin resistance, was derived from annual fasting blood samples. There were no significant associations between deprivation and any measure of adiposity in girls (all p > 0.37). In boys, there was a weak but consistently inverse relationship between deprivation and WC (r = -0.19, p = 0.03) and BMI (r = -0.14, p = 0.09) at 8 yr. Changes in adiposity over 3 yr were unrelated to deprivation in boys. In girls there was a slight but significant increase in SSF only (1 mm/yr per 20 IMD units, p = 0.001). Importantly, in both genders, metabolic risk score was unrelated to deprivation throughout (r values -0.05 to -0.13, all p > 0.12), as was change in metabolic risk (all p > 0.30). Our data do not support the assumption that obesity, metabolic disturbance and thus risk of type 2 diabetes are more prevalent among poorer children. In today's increasingly obesogenic environment, youngsters from all backgrounds appear to be vulnerable, with population-wide implications for public health spending, and the prevention of diabetes in contemporary youth.

Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: a scientific statement from the American Heart Association

Severe obesity afflicts between 4% and 6% of all youth in the United States, and the prevalence is increasing. Despite the serious immediate and long-term cardiovascular, metabolic, and other health consequences of severe pediatric obesity, current treatments are limited in effectiveness and lack widespread availability. Lifestyle modification/behavior-based treatment interventions in youth with severe obesity have demonstrated modest improvement in body mass index status, but participants have generally remained severely obese and often regained weight after the conclusion of the treatment programs. The role of medical management is minimal, because only 1 medication is currently approved for the treatment of obesity in adolescents. Bariatric surgery has generally been effective in reducing body mass index and improving cardiovascular and metabolic risk factors; however, reports of long-term outcomes are few, many youth with severe obesity do not qualify for surgery, and access is limited by lack of insurance coverage. To begin to address these challenges, the purposes of this scientific statement are to (1) provide justification for and recommend a standardized definition of severe obesity in children and adolescents; (2) raise awareness of this serious and growing problem by summarizing the current literature in this area in terms of the epidemiology and trends, associated health risks (immediate and long-term), and challenges and shortcomings of currently available treatment options; and (3) highlight areas in need of future research. Innovative behavior-based treatment, minimally invasive procedures, and medications currently under development all need to be evaluated for their efficacy and safety in this group of patients with high medical and psychosocial risks.

Position of the Academy of Nutrition and Dietetics: the role of nutrition in health promotion and chronic disease prevention

It is the position of the Academy of Nutrition and Dietetics that primary prevention is the most effective and affordable method to prevent chronic disease, and that dietary intervention positively impacts health outcomes across the life span. Registered dietitians and dietetic technicians, registered are critical members of health care teams and are essential to delivering nutrition-focused preventive services in clinical and community settings, advocating for policy and programmatic initiatives, and leading research in disease prevention and health promotion. Health-promotion and disease-prevention strategies are effective at reducing morbidity and mortality and improving quality of life, and have a significant impact on the leading causes of disease. By applying these principles within a social ecological theoretical framework, positive influence can be applied across the spectrum of engagement: at intrapersonal, interpersonal, institutional, community, and public policy levels. Through the application of efficacious and cost-effective interventions, registered dietitians and dietetic technicians, registered, can positively impact public health as well as health outcomes for the individuals that they counsel. This position paper supports the "Practice Paper of the Academy of Nutrition and Dietetics: The Role of Nutrition in Health Promotion and Chronic Disease Prevention" published on the Academy's website at: www.eatright.org/positions.

Insulin sensitivity from preschool to school age in patients with severe obesity

Background

Insulin sensitivity decreases at puberty transition, but little information has been provided on its earlier time-course. Aim of the present study was to describe the time-course of insulin sensitivity in severely obese children at the transition from preschool to school age.

Research design and methods

Retrospective study of a cohort of 47 severely obese [Body Mass Index (BMI) ≥99° percentile] preschoolers evaluated twice, once between 2 and 6 years of age, and once before age 8. Glucose tolerance, Whole Body Insulin Sensitivity Index (WBISI), Insulinogenic Index (IGI); β-cell demand index (BCDI) and Insulin Secretion-Sensitivity Index 2 (ISSI-2) were longitudinally estimated during the oral glucose tolerance test.

Results

After a median follow-up of 2.23 (1–4.52) y, obese patients showed significant decrease in WBISI (p<0.0001), and increase in fasting (p = 0.005) and 2 h glucose (2HG, p = 0.001). One child in preschool age and 4 school age children presented with 2HG between 7.8–11.1 mmol/l. Best predictors of WBISI, 2HG and BCDI in the school age were changes in BMI z-score (R² = 0.309; p = 0.002; β = −0.556), ISSI-2 (R² = 0.465; p<0.0001; β = −0.682), and BMI z-score (R² = 0.246; p = 0.008; 0.496), respectively.

Conclusions

In morbidly obese children, insulin sensitivity seems to decline even before pubertal transition, but changes in total adiposity can only partially explain this variation.

Predicting metabolic syndrome in obese children and adolescents: look, measure and ask

OBJECTIVE

To verify in obese children whether or not the presence of (i) high waist-to-height ratio (WHtR), (ii) family history for type 2 diabetes (T2D) and (iii) acanthosis nigricans (AN), singularly or together, might predict the occurrence of metabolic syndrome or prediabetes.

METHODS

1,080 Italian obese children (567 females) were enrolled. Blood pressure, fasting plasma glucose, insulin, and lipids were measured, and oral glucose tolerance test (OGTT) was performed. The WHtR was calculated, family history for T2D was assessed, and the presence of AN was noticed. The odds ratios for showing metabolic syndrome and/or prediabetes according to the presence of these features were calculated.

RESULTS

The prevalence of metabolic syndrome was 29.2%. AN (OR1.81; p = 0.002) and WHtR higher than 0.60 (OR 2.24; p < 0.0001) were the clinical signs linked to higher risk for showing metabolic syndrome, and the odds raised significantly when these elements occurred simultaneously (OR 3.34; p < 0.0001). T2D family history (OR 2.36; p = 0.01) and WHtR higher than 0.60 (OR 2.32; p = 0.009) were the two features associated with increased odds of showing prediabetes.

CONCLUSIONS

Three simple actions, i.e., looking at the patient, asking about T2D family history, and measuring WHtR, may represent a powerful tool in the hands of pediatricians to identify obese children with high cardiovascular and metabolic risk.

Principal component analysis reveals gender-specific predictors of cardiometabolic risk in 6th graders

Background

The purpose of this study was to determine the sex-specific pattern of pediatric cardiometabolic risk with principal component analysis, using several biological, behavioral and parental variables in a large cohort (n = 2866) of 6th grade students.

Methods

Cardiometabolic risk components included waist circumference, fasting glucose, blood pressure, plasma triglycerides levels and HDL-cholesterol. Principal components analysis was used to determine the pattern of risk clustering and to derive a continuous aggregate score (MetScore). Stratified risk components and MetScore were analyzed for association with age, body mass index (BMI), cardiorespiratory fitness (CRF), physical activity (PA), and parental factors.

Results

In both boys and girls, BMI and CRF were associated with multiple risk components, and overall MetScore. Maternal smoking was associated with multiple risk components in girls and boys, as well as MetScore in boys, even after controlling for children’s BMI. Paternal family history of early cardiovascular disease (CVD) and parental age were associated with increased blood pressure and MetScore for girls. Children’s PA levels, maternal history of early CVD, and paternal BMI were also indicative for various risk components, but not MetScore.

Conclusions

Several biological and behavioral factors were independently associated with children’s cardiometabolic disease risk, and thus represent a unique gender-specific risk profile. These data serve to bolster the independent contribution of CRF, PA, and family-oriented healthy lifestyles for improving children’s health.

The impact of childhood obesity on morbidity and mortality in adulthood: a systematic review

The objective of this study was to evaluate the evidence on whether childhood obesity is a risk factor for adult disease, independent of adult body mass index (BMI). Ovid MEDLINE (1948-May 2011), EMBASE (1980-2011 week 18) and the Cochrane Library (1990-2011) were searched for published studies of BMI from directly measured weight and height in childhood (2-19 years) and disease outcomes in adulthood. Data were synthesized in a narrative fashion. Thirty-nine studies (n 181-1.1 million) were included in the review. There was evidence for associations between childhood BMI and type 2 diabetes, hypertension and coronary heart disease. Few studies examined associations independent of adult BMI; these showed that effect sizes were attenuated after adjustment for adult BMI in standard regression analyses. Although there is a consistent body of evidence for associations between childhood BMI and cardiovascular outcomes, there is a lack of evidence for effects independent of adult BMI. Studies have attempted to examine independent effects using standard adjustment for adult BMI, which is subject to over-adjustment and problems with interpretation. Studies that use more robust designs and analytical techniques are needed to establish whether childhood obesity is an independent risk factor for adult disease.

Risk factors for prediabetes in overweight and obese pre-teens and adolescents

We looked for easy-to-use and predictable tools for identifying early risk ofprediabetes (PD) and preventing the natural course to diabetes in overweight andobese pre-teens and adolescents. In 89 children (9-18 years) family history, bodymass index (BMI), waist circumference (WC), acanthosis nigricans, blood pressure(BP), lipids, HbA1c, fasting glucose and oral glucose tolerance test were determined.We found 69 (77.5%) obese (BMI≥95th percentile) and 20 (22.5%) overweightchildren (BMI 85th-95th percentiles); thirty-six (41.4%) had PD; two had type 2diabetes mellitus; two had metabolic syndrome. PD was associated with obesity (RR5.1), HbA1c>5.5% (RR 2.5), acanthosis nigricans (RR=1.9), malegender (RR = 1.9), total cholesterol ≥170 mg/dL (RR=1.8), high BP (RR=1.7), urbanarea (RR = 1.6). BMI, WC, HbA1c and acanthosis nigricans are the majorpredictors for PD in this population. All blood values are both easy to measure andto accept by children, using finger prick method.

Correlates of age onset of type 2 diabetes among relatively young black and white adults in a community: the Bogalusa Heart Study

OBJECTIVE

The risk factors for middle-age onset of type 2 diabetes are well known. However, information is scant regarding the age onset of type 2 diabetes and its correlates in community-based black and white relatively young adults.

RESEARCH DESIGN AND METHODS

This prospective cohort study consisted of normoglycemic (n = 2,459) and type 2 diabetic (n = 144) adults aged 18-50 years who were followed for an average of 16 years.

RESULTS

The incidence rate of the onset of type 2 diabetes was 1.6, 4.3, 3.9, and 3.4 per 1,000 person-years for age-groups 18-29, 30-39, and 40-50 and total sample, respectively. Incidences of diabetes increased with age by race and sex groups (P for trend ≤ 0.01); higher in black females versus white females and blacks versus whites in total sample (P < 0.05). In a multivariable Cox model, baseline parental diabetes (hazard ratio [HR] 5.24) and plasma insulin were significantly associated with diabetes incidence at the youngest age (18-29 years); black race, BMI, and glucose at age 30-39 years; female sex, parental diabetes (HR 2.44), BMI, ratio of triglycerides and HDL cholesterol (TG/HDL-C ratio), and glucose at age 40-50 years; and black race, parental diabetes (HR 2.44), BMI, TG/HDL-C ratio, and glucose in whole cohort. Further, patients with diabetes, regardless of age onset, displayed a significantly higher prevalence of maternal history of diabetes at baseline (P < 0.01).

CONCLUSIONS

In relatively young adults, predictability of baseline cardiometabolic risk factors along with race, sex, and parental history of diabetes for the onset of type 2 diabetes varied by age-group. These findings have implications for early prevention and intervention in relatively young adults.

Opportunities for using lipoprotein subclass profile by nuclear magnetic resonance spectroscopy in assessing insulin resistance and diabetes prediction

The incidence of type 2 diabetes mellitus (T2DM) has reached epidemic levels, and current trends indicate that its prevalence will continue to rise. The development of T2DM can be delayed by several years, and may even be prevented, by identifying individuals at risk for T2DM and treating them with lifestyle modification and/or pharmacological therapies. There are a number of methods available for assessing the insulin resistance (IR) that characterizes, and is the precursor to, T2DM. However, current clinical methods for assessing IR, based on measures of plasma glucose and/or insulin are either laborious and time-consuming or show a low specificity. IR manifests its earliest measurable abnormalities through changes in lipoproteins, and thus we propose that by examining lipoprotein subclass profile, it may be possible to alert physicians and patients to a heightened risk of developing diabetes. This will allow us to institute appropriate lifestyle changes and treatment potentially to delay the onset or possibly prevent the progression to diabetes.

Race, childhood insulin, childhood caloric intake, and class 3 obesity at age 24: 14-year prospective study of schoolgirls

The prevalence of Class 3 obesity (BMI ≥40 kg/m(2)) has more than doubled in the past 25 years. In a 14-year prospective study from age 10 to 24 of a biracial schoolgirl cohort (293 black, 256 white), we assessed childhood correlates of Class 3 BMI at age 24. Of 42 girls with Class 3 BMI at age 24, 36 (86%) were black. By logistic regression, significant explanatory variables of Class 3 BMI at age 24 included top decile waist circumference at age 11 (odds ratio (OR) 5.7, 95% confidence interval (CI) 2.3-13.9, P = 0.0002), age 10 BMI ≥ the Center for Disease Control (CDC) 2000 top 15% (OR 7.0, 95% CI 2.5-19.3, P = 0.0002), and a three-way interaction between race, childhood insulin, and average caloric intake from age 10 to age 19 (for each unit increase, OR 1.7 95% CI 1.3-2.2, P = 0.0003). Age 10 BMI, age 11 waist circumference, and interaction of race, childhood insulin, and childhood caloric intake predict Class 3 obesity in young adulthood, facilitating childhood identification of girls at high risk for developing Class 3 obesity.

Exenatide as a weight-loss therapy in extreme pediatric obesity: a randomized, controlled pilot study

The objective of this pilot study was to evaluate the effects of exenatide on BMI (primary endpoint) and cardiometabolic risk factors in nondiabetic youth with extreme obesity. Twelve children and adolescents (age 9-16 years old) with extreme obesity (BMI ≥1.2 times the 95th percentile or BMI ≥35 kg/m(2)) were enrolled in a 6-month, randomized, open-label, crossover, clinical trial consisting of two, 3-month phases: (i) a control phase of lifestyle modification and (ii) a drug phase of lifestyle modification plus exenatide. Participants were equally randomized to phase-order (i.e., starting with control or drug therapy) then crossed-over to the other treatment. BMI, body fat percentage, blood pressure, lipids, oral glucose tolerance tests (OGTT), adipokines, plasma biomarkers of endothelial activation, and endothelial function were assessed at baseline, 3-, and 6-months. The mean change over each 3-month phase was compared between treatments. Compared to control, exenatide significantly reduced BMI (-1.7 kg/m(2), 95% confidence interval (CI) (-3.0, -0.4), P = 0.01), body weight (-3.9 kg, 95% CI (-7.11, -0.69), P = 0.02), and fasting insulin (-7.5 mU/l, 95% CI (-13.71, -1.37), P = 0.02). Significant improvements were observed for OGTT-derived insulin sensitivity (P = 0.02) and β-cell function (P = 0.03). Compliance with the injection regimen was excellent (≥94%) and exenatide was generally well-tolerated (the most common adverse event was mild nausea in 36%). These preliminary data suggest that exenatide should be evaluated in larger, well-controlled trials for its ability to reduce BMI and improve cardiometabolic risk factors in youth with extreme obesity.

Prevalence of hyperinsulinemia associated with body mass index, genetic predisposition, and lifestyle in college freshmen students

OBJECTIVE

College lifestyle places an individual at greater risk for the development of insulin resistance (IR) and disease. The aim of this study was to establish a baseline measurement of insulin, and other variables influencing IR in college freshmen.

PARTICIPANTS

Twenty-two men and women, 18 to 19 years of age, during first month of college.

METHODS

Following 12-hour fast, subjects reported to the laboratory for determination of body mass index (BMI) and completion of questionnaire determining ethnicity, family history, and patterns of diet, exercise, and stress. Blood samples were obtained and analyzed for glucose and insulin.

RESULTS

Mean insulin value for men (14.9 ± 1.86 μU/mL) was normal, and that for women (17.3 ± 1.74 μU/mL) was slightly elevated. When subjects were grouped by BMI, genetic predisposition, and summated lifestyle risk, fasting insulin values were significantly different. Eight of 22 subjects were hyperinsulinemic (insulin >19 μU/mL).

CONCLUSION

Hyperinsulinemia is prevalent in this population and merits further investigation and intervention.

The Srb1+1050T allele is associated with metabolic syndrome in children but not with cholesteryl ester plasma concentrations of high-density lipoprotein subclasses

BACKGROUND

Low cholesterol and phospholipid plasma levels of some high-density lipoprotein (HDL) subclasses have been described in children with metabolic syndrome. Scavenger receptor class B type I (SR-BI) has been proposed to be at the origin of such HDL alterations because of its key role on cholesteryl esters-HDL metabolism. However, the possible contribution of SR-BI has not been specifically explored in this kind of patients.

METHODS

Plasma lipid concentrations of HDL subclasses, i.e., triglycerides (TG), phosphatidylcholine (Ph), free cholesterol (FC), and total cholesterol (TC), were determined by enzymatic staining on polyacrylamide gradient gels (PAGE) in 39 pediatric patients with metabolic syndrome and 65 children as controls. Cholesteryl esters were estimated by the difference between TC and FC. Proteins of HDL subclasses were also stained for the assessment of the relative size distribution of HDL. For statistical analysis, the study population was grouped by Srb1 +1050C-->T polymorphism (rs5888) as carriers or noncarriers of the T allele, and data were corrected by metabolic syndrome status.

RESULTS

The Srb1 +1050T allele was associated with metabolic syndrome [odds ratio (OR)=2.18 (1.12-4.22), P=0.02]. Plasma TG corresponding to HDL3a, as well as the relative proportion of this HDL subclass, were slightly higher in carriers of the T allele as compared to CC homozygous subjects. Cholesteryl esters plasma concentrations of all HDL subclasses were comparable between T allele carriers and noncarriers after correction by metabolic syndrome status.

CONCLUSIONS

Srb1 +1050T was associated with metabolic syndrome, but T carrier subjects did not show important differences concerning HDL subclasses as compared to noncarriers.

Tracking blood glucose and predicting prediabetes in Chinese children and adolescents: a prospective twin study

We examined the tracking of blood glucose, the development of prediabetes, and estimated their genetic contributions in a prospective, healthy, rural Chinese twin cohort. This report includes 1,766 subjects (998 males, 768 females) aged 6–21 years at baseline who completed a 6-year follow-up study. Oral glucose tolerance test was performed for all subjects at both baseline and follow-up. We found that subjects with low fasting plasma glucose (FPG) or 2 h post-load glucose (PG) levels at baseline tended to remain at the low level at follow-up. Subjects in the top tertile of baseline plasma glucose tended to have a higher risk of developing prediabetes at follow-up compared to the low tertile: in males, 37.6% vs. 27.6% for FPG and 37.2% vs. 25.7% for 2hPG, respectively; in females, 31.0% vs. 15.4% for FPG and 28.9% vs. 15.1% for 2 h PG, respectively. Genetic factors explained 43% and 41% of the variance of FPG, and 72% and 47% for impaired fasting glucose for males and females, respectively; environmental factors substantially contribute to 2hPG status and impaired glucose tolerance. In conclusion, in this cohort of healthy rural Chinese children and adolescents, we demonstrated that both FPG and 2hPG tracked well and was a strong predictor of prediabetes. The high proportion of children with top tertile of blood glucose progressed to prediabetes, and the incidence of prediabetes has a male predominance. Genetic factors play more important role in fasting than postload status, most of which was explained by unique environmental factors.

Elevated liver function enzymes are related to the development of prediabetes and type 2 diabetes in younger adults: the Bogalusa Heart Study

OBJECTIVE

Elevations in alanine aminotransferase (ALT) and γ-glutamyl transferase (GGT), surrogate markers of liver dysfunction and nonalcoholic fatty liver, are considered as part of metabolic syndrome and related type 2 diabetes. However, information is limited regarding the long-term predictability of ALT and GGT in the development of prediabetes and type 2 diabetes.

RESEARCH DESIGN AND METHODS

In this retrospective cohort study, normoglycemic (n = 874), prediabetic (n = 101), and diabetic (n = 80) adults aged 26-50 years (average age 41.3 years) were followed over an average period of 16 years since their young adulthood (aged 18-38 years, average age 25.1 years), with measurements of cardiometabolic risk factor variables including ALT and GGT.

RESULTS

The follow-up prevalence rate of adult diabetes status by quartiles of baseline ALT and GGT levels showed an adverse trend for both prediabetes (P < 0.05) and diabetes (P < 0.01). In a longitudinal multivariate logistic regression analysis that included anthropometric, hemodynamic, and metabolic variables, as well as alcohol consumption and smoking, individuals with elevated baseline ALT and GGT levels (per 1-SD increment) were 1.16 and 1.20 times, respectively, more likely to develop diabetes (P = 0.05 for ALT and P < 0.01 for GGT); no such associations were noted for prediabetes. Regarding the predictive value of ALT and GGT, the area under the receiver operating curve analysis yielded C values ranging from 0.70 to 0.82, with values significantly higher for diabetes compared with prediabetes.

CONCLUSIONS

These findings in younger adults suggest potential clinical utility of including ALT and GGT as biomarkers in diabetes risk assessment formulations.