Influence of adiposity on insulin resistance and glycemia markers among U.K. Children of South Asian, black African-Caribbean, and white European origin: child heart and health study in England

The Role of Prenatal Psychosocial Stress in the Associations of a Proinflammatory Diet in Pregnancy With Child Adiposity and Growth Trajectories

Importance

Prenatal psychosocial stress and nutrition may each program offspring adiposity, an important predictor of lifelong cardiometabolic health. Although increased stress and poor nutrition have been found to co-occur in pregnancy, little is known about their combined longitudinal associations in the offspring.

Objective

To investigate whether the associations of the Dietary Inflammatory Index (DII) with offspring adiposity differ by prenatal stress levels and whether these associations change with age.

Design, Setting, and Participants

Project Viva, a prospective prebirth cohort study of mother-child dyads in Massachusetts, included singleton children of mothers enrolled between April 1999 and July 2002, with follow-up visits at early childhood, midchildhood, and early adolescence. Data analysis was performed from October 31, 2020, to October 31, 2022.

Exposures

Food frequency-derived DII score in pregnancy was the exposure. Effect modifiers included stress-related measures in pregnancy; depressive symptoms assessed using the Edinburgh Postnatal Depression Scale (EPDS), dichotomized at scores greater than or equal to 13 vs less than 13; and census tract-level social vulnerability (overall Social Vulnerability Index and its 4 main subindices), dichotomized at the 75th percentile.

Main Outcomes and Measures

Overall adiposity, comprising sex- and age-standardized body mass index (BMI z), sum of subscapular and triceps skinfolds, fat mass index (FMI), and body fat percentage estimated using bioelectrical impedance analysis (BIA) and dual x-ray absorptiometry (DXA); and central adiposity, comprising waist circumference, ratio of subscapular to triceps skinfolds, and DXA-derived trunk FMI.

Results

Among 1060 mother-child dyads, mean (SD) maternal age was 32.6 (4.6) years, and 811 (77%) mothers were non-Hispanic White. Mean (SD) DII score was -2.7 (1.3) units, Social Vulnerability Index level was 38th (27th) percentile, and 8% of mothers had depressive symptoms. Mean (SD) age of the children was 3.3 (0.3) years at the early childhood visit, 7.9 (0.8) years at the midchildhood visit, and 13.2 (0.9) years at the early adolescence visit. In adjusted analyses, children born to mothers in the highest (vs lowest) quartile of DII had slower decrease in BMI z scores (β, 0.03 SD units/y; 95% CI, 0.01-0.05 SD units/y), and faster adiposity gain (eg, BIA total FMI β, 0.11 kg/m2/y; 95% CI, 0.03-0.19 kg/m2/y) over time. Associations of prenatal DII quartiles with childhood adiposity were stronger (eg, BIA total FMI quartile 4 vs quartile 1 change in β, 1.40 kg/m2; 95% CI, 0.21-2.59 kg/m2) among children of mothers with high vs low EPDS scores in pregnancy, although EPDS scores did not modify the change over time. Associations of prenatal DII with adiposity change over time, however, were greater among children whose mothers lived in neighborhoods with a high (BIA percentage body fat: β, 0.55% per year; 95% CI, 0.04%-1.07% per year) vs low (β, 0.13% per year; 95% CI, -0.20 to 0.46% per year), percentage of racial and ethnic minorities, and residents with limited English-language proficiency.

Conclusions and Relevance

The findings of this cohort study suggest that it may be useful to simultaneously evaluate prenatal diet and psychosocial stress in women as targets for interventions intended to prevent excess childhood adiposity.

Towards standardised and valid anthropometric indicators of nutritional status in middle childhood and adolescence

Recognition of the importance of nutrition during middle childhood (age 5-9 years) and adolescence (age 10-19 years) is increasing, particularly in the context of global food insecurity and rising overweight and obesity rates. Until now, policy makers have been slow to respond to rapidly changing patterns of malnutrition across these age groups. One barrier has been a scarcity of consistent and regular nutrition surveillance systems for these age groups. What should be measured, and how best to operationalise anthropometric indicators that have been the cornerstone of nutrition surveillance in younger children and in adults, has been the topic of ongoing debate. Even with consensus on the importance of a given anthropometric indicator, difficulties arise in interpreting trends over time and between countries owing to the use of different terminologies, reference data, and cutoff points. In this Viewpoint we highlight the need to revisit anthropometric indicators across middle childhood and adolescence, a process that will require WHO and UNICEF coordination, the engagement of national implementors and policy makers, and partnership with research communities and donors.

External validation of a prediction model for estimating fat mass in children and adolescents in 19 countries: individual participant data meta-analysis

OBJECTIVE

To evaluate the performance of a UK based prediction model for estimating fat-free mass (and indirectly fat mass) in children and adolescents in non-UK settings.

DESIGN

Individual participant data meta-analysis.

SETTING

19 countries.

PARTICIPANTS

5693 children and adolescents (49.7% boys) aged 4 to 15 years with complete data on the predictors included in the UK based model (weight, height, age, sex, and ethnicity) and on the independently assessed outcome measure (fat-free mass determined by deuterium dilution assessment).

MAIN OUTCOME MEASURES

The outcome of the UK based prediction model was natural log transformed fat-free mass (lnFFM). Predictive performance statistics of R², calibration slope, calibration-in-the-large, and root mean square error were assessed in each of the 19 countries and then pooled through random effects meta-analysis. Calibration plots were also derived for each country, including flexible calibration curves.

RESULTS

The model showed good predictive ability in non-UK populations of children and adolescents, providing R² values of >75% in all countries and >90% in 11 of the 19 countries, and with good calibration (ie, agreement) of observed and predicted values. Root mean square error values (on fat-free mass scale) were <4 kg in 17 of the 19 settings. Pooled values (95% confidence intervals) of R², calibration slope, and calibration-in-the-large were 88.7% (85.9% to 91.4%), 0.98 (0.97 to 1.00), and 0.01 (-0.02 to 0.04), respectively. Heterogeneity was evident in the R² and calibration-in-the-large values across settings, but not in the calibration slope. Model performance did not vary markedly between boys and girls, age, ethnicity, and national income groups. To further improve the accuracy of the predictions, the model equation was recalibrated for the intercept in each setting so that country specific equations are available for future use.

CONCLUSION

The UK based prediction model, which is based on readily available measures, provides predictions of childhood fat-free mass, and hence fat mass, in a range of non-UK settings that explain a large proportion of the variability in observed fat-free mass, and exhibit good calibration performance, especially after recalibration of the intercept for each population. The model demonstrates good generalisability in both low-middle income and high income populations of healthy children and adolescents aged 4-15 years.

Sexual dimorphism of leptin and adiposity in children between 0 and 10 years: a systematic review and meta-analysis

Background

Differences in adolescents and adults by sex in blood levels of leptin and adiposity have been described; however, it is not yet clear if these differences arise from the prepubertal stage in subjects with a normal-weight. Therefore, we examine whether there are differences by sex in levels of blood leptin and adiposity in children with a normal-weight between 0 and 10 years old.

Methods

Search strategy: eligible studies were obtained from three electronic databases (Ovid, Embase and LILACS) and contact with experts. Selection criteria: healthy children up to 10 years of age with normal-weight according to age.

Data collection and analyses: data were extracted by four independent reviewers using a predesigned data collection form. For the analysis, we stratified according to age groups (newborns, 0.25–0.5 years, 3–5.9 years, 6–7.9 years, 8–10 years). The statistical analysis was performed in the R program.

Results

Of the initially identified 13,712 records, 21 were selected in the systematic review and meta-analysis. The sex was associated with the overall effect on blood leptin (pooled MD = 1.72 ng/mL, 95% CI: 1.25–2.19) and body fat percentage (pooled MD = 3.43%, 95% CI: 2.53–4.33), being both higher in girls. This finding was consistent in the majority of age groups.

Conclusion

The results of our meta-analyses support the sexual dimorphism in circulating blood leptin and body fat percentage between girls and boys with normal-weight from prepuberty.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13293-022-00454-y.

Differences by sex in blood leptin and body fat percentage in children are present before 10 years old

Girls have higher circulating leptin and body fat percentage than boys

The sex differences in blood leptin and adiposity in children increase progressively with the age

Are children with obesity at school entry more likely to have a diagnosis of a musculoskeletal condition? Findings from a systematic review

BACKGROUND

Children with obesity at school entry are at increased risk of persistent obesity throughout childhood and adulthood. Little is known about associations with adverse health outcomes with onset during childhood including those affecting the musculoskeletal system. We examined the association between obesity present at school entry and adverse musculoskeletal diagnoses with onset during childhood.

METHODS

We searched three electronic databases to identify longitudinal studies published in English between January 2000 and June 2022 assessing associations between obesity measured at school entry (around age 5 years) and musculoskeletal diagnoses made before age 20 years. Two reviewers screened titles, abstracts and full-text using EPPI-Reviewer software. Bias and quality of eligible studies were appraised using The Quality Assessment tool for Observational Cohort and Cross-sectional studies and findings synthesised.

RESULTS

We identified four eligible studies from 291 unique records, three conducted in Spain and one in Scotland. These studies reported on 1 232 895 children (available data: 51.4% boys; none reported ethnic distribution) with study sample sizes ranging from <2000 to 600 000 and length of follow-up from 2 to 13 years. Quantitative synthesis of findings across these four studies was not possible due to differences in outcomes and effect sizes reported. Children with obesity at school entry were more likely to receive diagnoses of slipped capital femoral epiphysis, back pain, fractures and musculoskeletal complaints made in primary care settings. Included studies were assessed as of 'fair' to 'good' quality.

CONCLUSION

There is good to fair evidence to suggest children with obesity at school entry are more likely to receive a diagnosis of a musculoskeletal condition during childhood. Further research is needed to replicate these findings in ethnically diverse populations and to investigate whether these are causal associations. The implications of this for children's mobility and quality of life and future musculoskeletal health warrants further assessment.

Drawing on Cultural Traditions to Improve Cardiorespiratory Fitness with South Asian Children: A Feasibility Study

Background: South Asian children have a higher prevalence of cardiovascular disease risk factors compared with children of other ethnic backgrounds. Our objective was to explore the feasibility, acceptability, and potential fitness-related impact of a 7-month afterschool Bhangra dance intervention for South Asian children. Methods: We recruited 172 children grades 3 through 6 across 4 elementary schools for an intervention involving twice weekly Bhangra sessions in the school setting. Feasibility and acceptability were defined by recruitment, attendance, and retention metrics. The primary fitness outcome was cardiorespiratory fitness (CRF), measured via shuttle run laps and VO₂ max. Secondary fitness outcomes included musculoskeletal (vertical jump height) and morphological fitness (waist circumference and BMI). Results: Sample size ranged from 28 to 54 participants per school (n = 172); mean attendance rate was 74%; and retention rate was 87%. VO₂ max and shuttle laps increased by 1.4 mL·kg/min [95% confidence interval (CI): 0.93 to 1.84] and by 7.6 (95% CI: 6.11 to 9.08), respectively. Both these improvements remained significant after controlling for sex and age (VO₂ max) and sex and baseline weight (shuttle laps). Musculoskeletal and morphological fitness indices also improved. Conclusions: Findings suggest that an afterschool Bhangra dance intervention is feasible, acceptable, and associated with CRF improvements as well as other indices of physical fitness.

The Relationship between Fat Mass Percentage and Glucose Metabolism in Children and Adolescents: A Systematic Review and Meta-Analysis

To assess the relationship between fat mass percentage (FMP) and glucose metabolism in children aged 0−18 years we performed a systematic review of the literature on Medline/PubMed, SinoMed, Embase and Cochrane Library using the PRISMA 2020 guidelines up to 12 October 2021 for observational studies that assessed the relationship of FMP and glucose metabolism. Twenty studies with 18,576 individuals were included in the meta-analysis. The results showed that FMP was significantly associated with fasting plasma glucose (FPG) (r = 0.08, 95% confidence interval (CI): 0.04−0.13, p < 0.001), fasting plasma insulin (INS) (r = 0.48, 95% CI: 0.37−0.57, p < 0.001), and homeostasis model assessment (HOMA)- insulin resistance (IR) (r = 0.44, 95% CI: 0.33−0.53, p < 0.001). The subgroup analysis according to country or overweight and obesity indicated that these associations remained significant between FMP and INS or HOMA-IR. Our results demonstrated that there is a positive relationship between FMP and FPG. Moreover, subgroup analysis according to country or overweight and obesity indicated that FMP is significantly associated with INS and HOMA-IR. This is the first known systematic review and meta-analysis to determine the associations of FMP with glucose metabolism in children and adolescents.

Differences in total and regional body fat and their association with BMI in UK-born White and South Asian children: findings from the Born in Bradford birth cohort

Background: Body mass index (BMI) is commonly used as a proxy to determine excess adiposity, though this may underestimate fat mass (FM) in individuals of South Asian (SA) heritage. SA tend to have greater central adiposity than white people, which is associated with a higher risk of cardiometabolic disease. In this cross-sectional study, we aimed to determine the differences in total and regional FM using Dual-energy X-ray absorptiometry (DXA), and to see if any differences in FM varied by BMI category in UK-born white and SA children aged ~9 years. Methods: Anthropometric measurements and DXA scans were undertaken from 225 white and 269 SA children from the Born in Bradford cohort study. Linear regression was used to assess ethnic differences in total body fat percent and total and regional FM. Results: Although mean BMI was similar, compared to white children, the proportion of SA children who were overweight or obese was ~10% higher, and the proportion with > 35% total body fat (TBF) was 22% and 16% higher in boys and girls respectively. Mean TBF% was greater in SA children compared to white children in the same BMI category. Fat mass index (FMI) was higher in all body regions in SA children in all BMI categories; as was total and truncal FMI in healthy and overweight, but not obese, SA children. Conclusions: Greater TBF% and total and regional FM in SA children suggests they may be at greater risk of future cardiometabolic disease at a BMI level below the obesity threshold. However, our sample size was small, and results may be influenced by selection bias and confounding; our findings need to be replicated in a larger study.

Indian Phenotype Characteristics Among Patients with Type 2 Diabetes Mellitus: Insights from a Non-interventional Nationwide Registry in India

Background: Indian patients with type 2 diabetes mellitus (T2D) constitute one-sixth of affected adults globally. Here, we evaluate the association of body mass index (BMI) with body fat percentage (BF%) and glycated haemoglobin (HbA1c) levels among patients with T2D in India. Method: This was a cross-sectional Indian registry study across 845 geographically diverse zones between December 2017 and August 2019. Results: Of 37,927 patients, 55.6% were men, with a mean ± standard deviation age of 54.2 ± 11.5 years and HbA1c of 8.3 ± 1.71%. Mean ± standard deviation BMI and BF% were 27.0 ± 4.6 kg/m2 and 32.0 ± 8.0%, respectively. Overall, 15.4% of patients were overweight, and 25.0% were obese. Despite fewer males (20.7%) having BMI-based obesity than females (31.2%), around three-quarters of both sexes had BF%-defined obesity (males 77.2%; females 71.2%). One-third of males (34.6%) and 41.9% of females had BF%-defined obesity despite normal BMI. The association was substantiated by a moderately significant correlation (r=0.51) between BMI and BF% in the overall population (p<0.0001). Conclusion: This pan-India registry presents a real-world reflection of the Asian Indian phenotype: high BF% despite lower BMI in people with T2D. This highlights the importance of primordial and primary prevention, and may guide decisions on the choice of agents for glycaemic control, with a preference for drugs that promote weight loss or are weight neutral.

A Mini-Review of Pediatric Anthropometrics as Predictors of Future Insulin Resistance

The impact of rising rates of childhood obesity is far reaching. Metabolic syndrome in children is increasing, yet for most children the consequences of excess adiposity will manifest in adulthood. Excess early fat accrual is a risk factor for future insulin resistance. However, certain types of fat and patterns of fat distribution are more relevant than others to metabolic risk. Therefore, adiposity measures are important. The link between childhood obesity and future insulin resistance was initially established with body mass index (BMI), but BMI is an in imperfect measure of adiposity. It is worthwhile to evaluate other anthropometrics as they may more accurately capture metabolic risk. While measures such as waist to height ratio are established as superior screening measures in adulthood - the findings are not as robust in pediatrics. Emerging evidence suggests that alternative anthropometrics may be slightly superior to BMI in identifying those youth most at risk of developing insulin resistance, but the clinical significance of that superiority appears limited. Increasing study is needed in longitudinal and varied cohorts to identify which pediatric anthropometric best predicts adult insulin resistance. We review alternative anthropometrics as predictors of future insulin resistance and identify current gaps in knowledge and potential future directions of inquiry.

The Relationship Between Fat-Free Mass and Glucose Metabolism in Children and Adolescents: A Systematic Review and Meta-Analysis

PURPOSE

To assess the relationship between fat-free mass (FFM) and glucose metabolism in children 0-18 years of age.

METHODS

We performed a systematic review of the literature on Medline/PubMed, SinoMed, Embase, and the Cochrane Library using the PRISMA 2020 guidelines to 12 October 2021; this encompassed observational studies in which the relationship between FFM and glucose metabolism was assessed. Correlation coefficient (r), regression coefficient (β), and odds ratio (OR) values in the studies were extracted and recorded as the primary data. "Agency for Healthcare Research and Quality" quality-assessment forms recommended for cross-sectional/prevalence studies were applied to evaluate the quality of the selected studies, and we executed R software to combine the pooled data.

RESULTS

We included eight studies comprising 13,282 individuals, five of which involved the assessment of the relationship between FFM and blood glucose, and four on the relationship between FFM and insulin resistance (IR). Our results showed that FFM was significantly associated with fasting plasma insulin levels (r = 0.34, 95% CI: 0.30-0.39, P < 0.001). Due to high heterogeneity or insufficient quantity of data, the studies of the relationship between FFM and fasting plasma glucose, HOMA-IR, or HbA1c were not congruent, and were therefore not suitable for meta-analysis.

CONCLUSION

Our results indicated that FFM was significantly associated with fasting plasma insulin levels. As far as we have determined, this is the first-ever systematic review and meta-analysis of the associations between FFM and glucose metabolism in children and adolescents; and our results thus provide novel information to fill a gap in the literature in this area.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020150320, PROSPERO CRD42020150320.

Unequal burden of equal risk factors of diabetes between different gender in India: a cross-sectional analysis

Many studies have supported that the burden of diabetes is shared differently by different genders due to various factors associated with it. This study aims at capturing whether women and men with a similar background, dietary and smoking habits, and biological conditions (blood pressure and body mass index (BMI)) are being affected equally or differently by diabetes. We have used cross-sectional data of NFHS-4 by covering the age group 15-49 years. Association between socio-economic background, dietary habits, biological conditions, and diabetes has been estimated using two separate multivariate logistic regression models. Results show that the overall prevalence of diabetes is higher among men (2.63%) than women (2.35%). Whereas, women belonging to urban areas (3.53%), Christian category (3.92%), richer section (3.22%), women with no schooling (2.51%), those reported never to consume pulses (2.66%) and green vegetables (2.40%) and daily consuming eggs (3.66%) and chicken or meat (3.54%) are more affected by diabetes than their men counterparts. Whereas men residing in rural areas (2.30%), belonging to the general category (3.12%), SCs (2.37%) and STs (1.72%) are more affected than their women counterparts. Results have also shown a higher prevalence of diabetes among obese men (11.46%), non-vegetarian (2.71%) and those who watch television almost every day (3.03%) as compared to their women counterparts. Regression analyses show that the richest, hypertensive, and obese women and men are significantly more likely to suffer from diabetes. This study concludes that women and men with similar socio-economic status, biological conditions, dietary and smoking habits are being affected differently by diabetes. Thus, there is a need for gender dimension in research to understand and validate the differences in the needed interventions for diabetes control in India.

Differences in total and regional body fat and their association with BMI in UK-born White and South Asian children: findings from the Born in Bradford birth cohort

Background: Body mass index (BMI) is commonly used as a proxy to determine excess adiposity, though this may underestimate fat mass (FM) in individuals of South Asian (SA) heritage. SA tend to have greater central adiposity than white people, which is associated with a higher risk of cardiometabolic disease. In this cross-sectional study, we aimed to determine the differences in total and regional FM using Dual-energy X-ray absorptiometry (DXA), and to see if any differences in FM varied by BMI category in UK-born white and SA children aged ~9 years. Methods: Anthropometric measurements and DXA scans were undertaken from 225 white and 269 SA children from the Born in Bradford cohort study. Linear regression was used to assess ethnic differences in total body fat percent and total and regional FM. Results: Although mean BMI was similar, compared to white children, the proportion of SA children who were overweight or obese was ~20% higher, and the proportion with > 35% total body fat (TBF) was 22% and 16% higher in boys and girls respectively. Mean TBF% was greater in SA children compared to white children in the same BMI category. Fat mass index (FMI) was higher in all body regions in SA children in all BMI categories; as was total and truncal FMI in healthy and overweight, but not obese, SA children.. Conclusions: Greater TBF% and total and regional FM in SA children suggests they may be at greater risk of future cardiometabolic disease at a BMI level below the obesity threshold. However, our sample size was small, and results may be influenced by selection bias and confounding; our findings need to be replicated in a larger study.

Completeness and representativeness of body mass index in children's electronic general practice records: Linked cross-sectional study in an ethnically-diverse urban population in the United Kingdom

OBJECTIVE

To assess completeness and accuracy of children's body mass index (BMI) recorded in general practice electronic health records (GP-EHRs).

METHODS

We linked National Child Measurement Programme (NCMP) records from 29 839 5-year-olds and 26 660 11-year-olds attending state schools in inner London to GP-EHRs (95% linked; 49.1% girls). We estimated adjusted odds (aOR) of at least one GP-BMI record by sex, ethnic background, area-level deprivation, weight-status and long-term conditions. We examined within-child BMI differences and compared obesity prevalence from these sources.

RESULTS

10.5% (2964/28330) and 26.0% (6598/25365) of 5- and 11-year-olds respectively had at least one GP-BMI record. Underweight (aOR;95% CI:1.71;1.34,2.19), obesity (1.45;1.27,1.65), South Asian background (1.55;1.38,1.74), presence of a long-term condition (8.15;7.31,9.10), and residence in deprived areas (Wald statistic 38.73; P-value<0.0001) were independently associated with at least one GP-BMI record. NCMP-BMI and GP-BMI differed by +0.45(95% Limits of Agreement -1.60,+2.51) and + 0.16(-2.86,+3.18) in 5- and 11-year-olds, respectively. The prevalence of obesity based on GP-BMI was 18.2%(16.1,20.5) and 35.9%(33.9,38.0) in 5- and 11-year-olds respectively, compared to 12.9%(12.5,13.3) and 26.9%(26.4,27.4) based on NCMP-BMI.

CONCLUSION

Child BMI is not comprehensively recorded in urban general practice. Linkage to school measurement records is feasible and enables assessment of health outcomes of obesity.

Is child weight status correctly reported to parents? Cross-sectional analysis of National Child Measurement Programme data using ethnic-specific BMI adjustments

Background

BMI underestimates and overestimates body fat in children from South Asian and Black ethnic groups, respectively.

Methods

We used cross-sectional NCMP data (2015–17) for 38 270 children in three inner-London local authorities: City & Hackney, Newham and Tower Hamlets (41% South Asian, 18.8% Black): 20 439 4–5 year-olds (48.9% girls) and 17 831 10–11 year-olds (49.1% girls). We estimated the proportion of parents who would have received different information about their child’s weight status, and the area-level prevalence of obesity—defined as ≥98th centile—had ethnic-specific BMI adjustments been employed in the English National Child Measurement Programme (NCMP).

Results

Had ethnic-specific adjustment been employed, 19.7% (3112/15 830) of parents of children from South Asian backgrounds would have been informed that their child was in a heavier weight category, and 19.1% (1381/7217) of parents of children from Black backgrounds would have been informed that their child was in a lighter weight category. Ethnic-specific adjustment increased obesity prevalence from 7.9% (95% CI: 7.6, 8.3) to 9.1% (8.7, 9.5) amongst 4–5 year-olds and from 17.5% (16.9, 18.1) to 18.8% (18.2, 19.4) amongst 10–11 year-olds.

Conclusions

Ethnic-specific adjustment in the NCMP would ensure equitable categorization of weight status, provide correct information to parents and support local service provision for families.

Prevalence of increased transaminases and its association with sex, age, and metabolic parameters in children and adolescents with obesity - a nationwide cross-sectional cohort study

Background

Childhood obesity increases the risk of non-alcoholic fatty liver disease marked by elevated alanine aminotransferase (ALT). This study investigated the prevalence of increased ALT in children and adolescents with obesity, and its associations with sex, age, degree of obesity, and metabolic parameters.

Methods

Individuals between 5 and 17.99 years of age enrolled in the Swedish Childhood Obesity Treatment Register (BORIS) before March 2020 were included. Mildly increased ALT was defined by ALT 27–51 U/L (males) and 23–43 U/L (females), while markedly increased ALT by levels above. Multiple logistic regression models were used for statistical analysis.

Results

Among 11,776 individuals (age 11.0 ± 3.3 years, 53.5% males), the prevalence of mildly and markedly increased ALT were 37.9 and 10.6%, respectively. A sex-age interaction was found, where increasing age strengthened the odds of markedly increased ALT in males (OR, 99% CI: 1.34, 1.29–1.4 for each year) while the corresponding pattern in females with was minuscule (1.09, 1.02–1.10). Compared to class I obesity, class II and III obesity had greater odds ratios for mildly increased ALT (class II obesity OR, 99% CI: 1.51, 1.35–1.70; class III obesity OR, 99% CI: 2.17, 1.66–2.61) and for markedly increased ALT (class II obesity OR, 99% CI: 1.82, 1.51–2.20; class III obesity OR, 99% CI 3.38, 2.71–4.23). Dyslipidemia was associated with both mildly and markedly increased ALT, all p < 0.001. Prevalence of impaired fasting glucose was 19.1% in normal ALT group, 20.4% in mildly increased ALT group, and 29.0% in markedly increased ALT group.

Conclusions

The risk of markedly increased ALT increased exponentially with age among boys, but not among girls. Higher degree of obesity was observed in individuals with mildly and markedly increased ALT. Further, metabolic derangements were more prevalent among individuals with mildly and markedly increased ALT.

Obesity cardiomyopathy: evidence, mechanisms, and therapeutic implications

The prevalence of heart failure is on the rise and imposes a major health threat, in part, due to the rapidly increased prevalence of overweight and obesity. To this point, epidemiological, clinical, and experimental evidence supports the existence of a unique disease entity termed “obesity cardiomyopathy,” which develops independent of hypertension, coronary heart disease, and other heart diseases. Our contemporary review evaluates the evidence for this pathological condition, examines putative responsible mechanisms, and discusses therapeutic options for this disorder. Clinical findings have consolidated the presence of left ventricular dysfunction in obesity. Experimental investigations have uncovered pathophysiological changes in myocardial structure and function in genetically predisposed and diet-induced obesity. Indeed, contemporary evidence consolidates a wide array of cellular and molecular mechanisms underlying the etiology of obesity cardiomyopathy including adipose tissue dysfunction, systemic inflammation, metabolic disturbances (insulin resistance, abnormal glucose transport, spillover of free fatty acids, lipotoxicity, and amino acid derangement), altered intracellular especially mitochondrial Ca²⁺ homeostasis, oxidative stress, autophagy/mitophagy defect, myocardial fibrosis, dampened coronary flow reserve, coronary microvascular disease (microangiopathy), and endothelial impairment. Given the important role of obesity in the increased risk of heart failure, especially that with preserved systolic function and the recent rises in COVID-19-associated cardiovascular mortality, this review should provide compelling evidence for the presence of obesity cardiomyopathy, independent of various comorbid conditions, underlying mechanisms, and offer new insights into potential therapeutic approaches (pharmacological and lifestyle modification) for the clinical management of obesity cardiomyopathy.

Association of Childhood Fat Mass and Weight With Adult-Onset Type 2 Diabetes in Denmark

IMPORTANCE

Childhood obesity, defined by cutoffs based on the weight-based marker of body mass index, is associated with adult type 2 diabetes (T2D) risk. Whether childhood fat mass (FM) is the driver of these associations is currently unknown.

OBJECTIVE

To quantify and compare height-independent associations between childhood FM and weight with adult T2D risk in a historic Danish cohort.

DESIGN, SETTING, AND PARTICIPANTS

This population-based retrospective cohort study included schoolchildren from The Copenhagen School Health Records Register born between January 1930 and December 1985 with follow-up to adulthood through December 31, 2015. Analyses were based on 269 913 schoolchildren aged 10 years with 21 896 established adult T2D cases and 261 192 children aged 13 years with 21 530 established adult T2D cases for whom childhood height and weight measurements, as well as predicted FM, were available. Statistical analyses were performed between April 2019 to August 2020.

EXPOSURES

Childhood FM and weight at ages 10 and 13 years.

MAIN OUTCOMES AND MEASURES

Diagnoses of T2D were established by linkage to national disease registers for adults aged at least 30 years. Sex-specific Cox regression quantified associations, adjusted for childhood height, which were evaluated within 5 birth-cohort groups. Group-specific results were pooled using random-effects meta-analyses accounting for heterogeneity across group-specific associations.

RESULTS

This cohort study analyzed data from 269 913 children aged 10 years (135 940 boys [50.4%]) with 21 896 established adult T2D cases and 261 192 children aged 13 years (131 025 boys [50.2%]) with 21 530 established adult T2D cases. After adjusting for childhood height, increases in FM and weight (per kilogram) among boys aged 10 years were associated with elevated T2D risks at age 50 years of 12% (hazard ratio [HR], 1.12; 95% CI, 1.10-1.14) and 7% (HR, 1.07; 95% CI, 1.05-1.09), respectively, and among girls aged 10 years of 15% (HR, 1.15; 95% CI, 1.13-1.17) and 10% (HR, 1.10; 95% CI, 1.08-1.11), respectively. Among children aged 13 years, increases in FM and weight (per kilogram) were associated with increased T2D risks at age 50 years of 10% (HR, 1.10; 95% CI, 1.09-1.10) and 6% (HR, 1.06; 95% CI, 1.05-1.07) for boys, respectively, and of 10% (HR, 1.10; 95% CI, 1.10-1.11) and 7% (HR, 1.07; 95% CI, 1.06-1.08), respectively, for girls.

CONCLUSIONS AND RELEVANCE

This cohort study found that a 1-kg increase in childhood FM was more strongly associated with increased adult T2D risk than a 1-kg increase in weight, independent of childhood height. Information on FM, rather than weight-based measures, focuses on a modifiable component of weight that may be associated with adult T2D risk. These findings support the assessment of childhood FM in adiposity surveillance initiatives in an effort to reduce long-term T2D risk.

Differences in total and regional body fat and their association with BMI in UK-born White and South Asian children: findings from the Born in Bradford birth cohort

Background: Body mass index (BMI) is commonly used as a proxy to determine excess adiposity, though this may underestimate fat mass (FM) in individuals of South Asian (SA) heritage. SA tend to have greater central adiposity than white people, which is associated with a higher risk of cardiometabolic disease. In this cross-sectional study, we aimed to determine the differences in total and regional FM using Dual-energy X-ray absorptiometry (DXA), and to see if any differences in FM varied by BMI category in UK-born white and SA children aged ~9 years. Methods: Anthropometric measurements and DXA scans were undertaken from 225 white and 269 SA children from the Born in Bradford cohort study. Linear regression was used to assess ethnic differences in total body fat percent and total and regional FM. Results: Although the mean BMI was similar, compared to white children, the proportion of SA children who were overweight or obese was ~20% higher, they had a median of 2kg more total FM, and the proportion with > 35% total body fat (TBF) was 22% and 16% higher in boys and girls respectively. Mean TBF% was greater in each BMI category, as was truncal, android and gynoid FM, with the greatest differences between ethnic groups observed in the healthy and overweight categories. Conclusions: Greater TBF% and total and regional FM in the healthy- and overweight BMI categories observed in SA children suggests they may be at greater risk of future cardiometabolic disease at a BMI level below obesity threshold. However, our sample size was small, and results may be influenced by selection bias and confounding; our findings need to be replicated in a larger study.

Obesity and Diabetes: A Sword of Damocles for Future Generations

Childhood obesity is one of the most challenging problem of the 21st century. The prevalence has increased, reaching an alarming rate. Furthermore, the problem is global and is also affecting low- and middle-income countries. This global obesity epidemic explains how the roots of cardiovascular disease, the most common cause of mortality among adults, begin in childhood. Overweight and obese children are likely to stay obese into adulthood and to develop noncommunicable diseases such as diabetes and cardiovascular diseases at a younger age. Thus, prevention should be the major goal and should start early in life. The aim of this review is to present an updated framework of the current understanding of the cardiovascular and metabolic risks in obese children and adolescents and to discuss the available therapeutic options.

Obesity and insulin resistance in children

PURPOSE OF REVIEW

It is well known that obesity represents the main modifiable risk factor for insulin resistance in children and adolescents; obesity-induced insulin resistance in children is the most important risk factor for developing cardiovascular diseases and type 2 diabetes in adulthood. The mechanisms through which obesity causes insulin resistance are complex and not completely known to date.

RECENT FINDINGS

In children, global adiposity is the main factor determining insulin resistance. Excessive fatty acids play a determinant role in the pathogenesis of insulin resistance in obese children, inducing an increased production of acetyl-CoA in the liver and enhancing inflammation in adipose tissue. The aetiology of insulin resistance in polycystic ovary syndrome is multifactorial and still debated.

SUMMARY

The aim of this review is to present an updated frame and new insights of the numerous pathways involved in the development of insulin resistance in obese patients, focusing on the peculiarities of children and adolescents. Improving the knowledge of mechanisms through which obesity leads to insulin resistance is fundamental in order to recommend particular follow-up and possible treatment to specific categories of obese children and adolescents.

Changes in Free-Living Glycemic Profiles after 12 Months of Lifestyle Intervention in Children with Overweight and with Obesity

Previous studies demonstrated that hyperglycemic glucose concentrations are observed in children that are overweight or have obesity. The aim of this study was to evaluate the effect of a 12 month lifestyle intervention on free-living glycemic profiles in children that were overweight or had obesity, and the association of the alterations with changes in cardiovascular risk parameters. BMI z-score, free-living glycemic profiles, continuous overlapping net glycemic action (CONGA), and cardiovascular parameters were evaluated before and after a multidisciplinary lifestyle intervention, in 33 non-diabetic children that were overweight or had obesity. In children with a decrease in BMI z-score, the duration which glucose concentrations were above the high-normal threshold (6.7 mmol/L) and the glycemic variability decreased significantly. In these children, a decrease in median sensor glucose was associated with decreases in LDL-cholesterol, and systolic and diastolic blood pressure z-score. A decrease in BMI z-score was associated with a decrease in CONGA1, 2, and 4. In conclusion, the glycemic profiles in free-living conditions in children that were overweight improved in children with a decrease in BMI z-score after lifestyle intervention. In those children, changes in median sensor glucose concentrations were associated with changes in LDL-cholesterol and blood pressure z-scores. These results suggest that glucose homeostasis can improve after one year of lifestyle intervention and that these improvements are associated with improvements in cardiovascular health parameters.

Glucose metabolism among obese and non-obese children of mothers with gestational diabetes

OBJECTIVES

Abdominal obesity is more closely associated with diabetes than general obesity in adults, however, it is unknown which kind of obesity is more closely associated with abnormal glucose metabolism in children.

RESEARCH DESIGN AND METHODS

We recruited 973 children (aged 3.08±1.06) of mothers with prior gestational diabetes mellitus (GDM). Children's height, weight, waist circumstance, fasting glucose and insulin were measured using standardized methods. Logistic regression models were used to assess the single and joint associations of general and abdominal obesity with the risks of hyperglycemia (the upper quartile of fasting glucose), insulin resistance (the upper quartile of homeostatic model assessment of insulin resistance (HOMA-IR)), and β-cell dysfunction (the lower quartile of HOMA-%β).

RESULTS

Compared with normal weight children, children with general overweight/obesity had higher levels of HOMA-IR and HOMA-%β, higher ORs for hyperglycemia (1.56, 95% CI 1.06 to 2.30) and insulin resistance (3.44, 95% CI 2.32 to 5.09), but a lower OR for β-cell dysfunction (0.65, 95% CI 0.41 to 1.04). Children with abdominal obesity had an increased risk of insulin resistance (2.54, 95% CI 1.71 to 3.76) but not hyperglycemia and β-cell dysfunction compared with children with normal waist circumstance. In the joint analyses, general overweight children with and without abdominal obesity had an increased risk of hyperglycemia and insulin resistance compared with normal weight children.

CONCLUSIONS

General obesity was more closely associated with abnormal glucose metabolism than abdominal obesity in children of mothers with GDM.

The double burden of malnutrition: aetiological pathways and consequences for health

Malnutrition has historically been researched and addressed within two distinct silos, focusing either on undernutrition, food insecurity, and micronutrient deficiencies, or on overweight, obesity, and dietary excess. However, through rapid global nutrition transition, an increasing proportion of individuals are exposed to different forms of malnutrition during the life course and have the double burden of malnutrition (DBM) directly. Long-lasting effects of malnutrition in early life can be attributed to interconnected biological pathways, involving imbalance of the gut microbiome, inflammation, metabolic dysregulation, and impaired insulin signalling. Life-course exposure to early undernutrition followed by later overweight increases the risk of non-communicable disease, by imposing a high metabolic load on a depleted capacity for homoeostasis, and in women increases the risk of childbirth complications. These life-course trajectories are shaped both by societal driving factors-ie, rapidly changing diets, norms of eating, and physical activity patterns-and by broader ecological factors such as pathogen burden and extrinsic mortality risk. Mitigation of the DBM will require major societal shifts regarding nutrition and public health, to implement comprehensive change that is sustained over decades, and scaled up into the entire global food system.

Phenotyping diabetic cardiomyopathy in Europeans and South Asians

Background

The pathogenesis and cardiovascular impact of type 2 diabetes (T2D) may be different in South Asians compared with other ethnic groups. The phenotypic characterization of diabetic cardiomyopathy remains debated and little is known regarding differences in T2D-related cardiovascular remodeling across ethnicities. We aimed to characterize the differences in left ventricular (LV) diastolic and systolic function, LV structure, myocardial tissue characteristics and aortic stiffness between T2D patients and controls and to assess the differences in T2D-related cardiovascular remodeling between South Asians and Europeans.

Methods

T2D patients and controls of South Asian and European descent underwent 3 Tesla cardiovascular magnetic resonance imaging (CMR) and cardiac proton-magnetic resonance spectroscopy (¹H-MRS). Differences in cardiovascular parameters between T2D patients and controls were examined using ANCOVA and were reported as mean (95% CI). Ethnic group comparisons in the association of T2D with cardiovascular remodeling were made by adding the interaction term between ethnicity and diabetes status to the model.

Results

A total of 131 individuals were included (54 South Asians [50.1 ± 8.7 years, 33% men, 33 patients vs. 21 controls) and 77 Europeans (58.8 ± 7.0 years, 56% men, 48 patients vs. 29 controls)]. The ratio of the transmitral early and late peak filling rate (E/A) was lower in T2D patients compared with controls, in South Asians [− 0.20 (− 0.36; − 0.03), P = 0.021] and Europeans [− 0.20 (− 0.36; − 0.04), P = 0.017], whereas global longitudinal strain and aortic pulse wave velocity were similar. South Asian T2D patients had a higher LV mass [+ 22 g (15; 30), P < 0.001] (P for interaction by ethnicity = 0.005) with a lower extracellular volume fraction [− 1.9% (− 3.4; − 0.4), P = 0.013] (P for interaction = 0.114), whilst European T2D patients had a higher myocardial triglyceride content [+ 0.59% (0.35; 0.84), P = 0.001] (P for interaction = 0.002) than their control group.

Conclusions

Diabetic cardiomyopathy was characterized by impaired LV diastolic function in South Asians and Europeans. Increased LV mass was solely observed among South Asian T2D patients, whereas differences in myocardial triglyceride content between T2D patients and controls were only present in the European cohort. The diabetic cardiomyopathy phenotype may differ between subsets of T2D patients, for example across ethnicities, and tailored strategies for T2D management may be required.

The diabesity epidemic in the light of evolution: insights from the capacity-load model

The global nutrition transition, which embraces major changes in how food is produced, distributed and consumed, is associated with rapid increases in the prevalence of obesity, but the implications for diabetes differ between populations. A simple conceptual model treats diabetes risk as the function of two interacting traits: 'metabolic capacity,' which promotes glucose homeostasis, and 'metabolic load', which challenges glucose homoeostasis. Population variability in diabetes prevalence is consistent with this conceptual model, indicating that the effect of obesity varies by ethnicity. Evolutionary life history theory can help explain why variability in metabolic capacity and metabolic load emerges. At the species level (hominin evolution), across human populations and within individual life courses, phenotypic variability emerges under selective pressure to maximise reproductive fitness rather than metabolic health. Those exposed to adverse environments may express or develop several metabolic traits that are individually beneficial for reproductive fitness, but which cumulatively increase diabetes risk. Public health interventions can help promote metabolic capacity, but there are limits to the benefits that can emerge within a single generation. This means that efforts to curb metabolic load (obesity, unhealthy lifestyles) must remain at the forefront of diabetes prevention. Such efforts should go beyond individuals and target the broader food system and socioeconomic factors, in order to maximise their efficacy.

Does parental concern about their child's future risk of overweight vary by their ethnic background? Cross-sectional analysis of a national cohort study

OBJECTIVES

Children from South Asian ethnic backgrounds are at increased risk of obesity and its associated future health risks; however, evidence is lacking as to whether parental concern about their child's future overweight risk varies by ethnic background. We hypothesised that parents of 5-year-old children from South Asian backgrounds would be more likely to express such concerns.

DESIGN

Cross-sectional.

SETTING

UK.

PARTICIPANTS

15 039 singleton 5-year-old Millennium Cohort Study participants (48.9% girls; 86.7% White).

PRIMARY OUTCOME MEASURE

Parent-reported concern (some/none) about future overweight risk.

METHODS

We estimated the adjusted ORs (aORs) of some parental concern (ranging from a little to very concerned) by child's ethnic background (reference group: White), adjusted for parent and child weight status, and child sex.

RESULTS

Parents of girls from Pakistani (aOR 0.4; 95% CI 0.2 to 0.5), Bangladeshi (0.3; 0.2 to 0.5), Black African (0.5; 0.3 to 0.7) and Mixed (0.7; 0.5 to 0.99) ethnic backgrounds and of boys from Pakistani ethnic backgrounds (0.6; 0.4 to 0.9) were less likely to report concern about their child's future overweight risk than parents of White girls and boys, respectively. Overweight (2.5; 2.2 to 2.8) and obesity (6.7; 5.7 to 7.9) in children, and overweight (1.4; 1.2 to 1.5) and obesity (1.9; 1.7 to 2.2) in parents, were associated with increased likelihood of concern.

CONCLUSIONS

Parents of children from South Asian ethnic backgrounds express less concern about their child's future overweight risk. Qualitative studies are needed to understand the concerns of parents from different ethnic backgrounds to inform weight-management interventions in ethnically diverse populations.

Coffee consumption and all-cause and cause-specific mortality: a meta-analysis by potential modifiers

Coffee consumption has been associated with decreased mortality in previous studies. As aging, obesity, and lifestyle factors affect the risk of mortality, the association between coffee and mortality needs to be examined in various subpopulations by characteristics of subjects. To quantitatively assess this association, we conducted an updated meta-analysis including stratified analyses by potential modifiers. We searched in the PubMed and Web of Science databases through March 8, 2019, and conducted meta-analysis including linear and non-linear dose-response analyses. We identified 40 studies including 3,852,651 subjects and 450,256 all-cause and cause-specific deaths. Non-linear inverse associations between coffee consumption and mortality from all-causes, cardiovascular disease (CVD), and cancers were found. The lowest relative risk (RR) was at intakes of 3.5 cups/day for all-cause mortality (RR = 0.85, 95% CI 0.82-0.89), 2.5 cups/day for CVD mortality (RR = 0.83, 95% CI 0.80-0.87), and 2 cups/day for cancer mortality (RR = 0.96, 95% CI 0.94-0.99), while additional intakes were not associated with further lower mortality. An inverse association between coffee consumption and all-cause mortality was maintained irrespective of age, overweight status, alcohol drinking, smoking status, and caffeine content of coffee. By region, Europe and Asia showed stronger inverse associations than US. A non-linear inverse association was found for mortality from respiratory disease and diabetes, while linear inverse association was found for mortality from non-CVD, non-cancer causes. Moderate coffee consumption (e.g. 2-4 cups/day) was associated with reduced all-cause and cause-specific mortality, compared to no coffee consumption. The inverse association between coffee and all-cause mortality was consistent by potential modifiers except region.

The TyG index cutoff point and its association with body adiposity and lifestyle in children

OBJECTIVE

To investigate the factors associated with insulin resistance in children aged 4-7 years, and to identify the cutoff point of the triglyceride-glucose index for the prediction of insulin resistance in this population.

METHODS

A cross-sectional study was conducted with 403 children from a retrospective cohort. Insulin resistance was also evaluated in a sub-sample using the HOMA index. Four indicators of body adiposity were assessed: body mass index, waist-to-height ratio, and the percentages of total and central body fat. Food habits were evaluated by the identification of dietary patterns, using principal component analysis. Information was also collected on lifestyle, socioeconomic status, and breastfeeding time.

RESULTS

The median index observed in the sample was 7.77, which did not differ between the genders. The shorter the time spent in active activities, the higher the triglyceride-glucose value; and increase in the values of body adiposity indicators was positively associated with triglyceride-glucose. The cutoff point with the best balance between sensitivity and specificity values was 7.88 (AUC=0.63, 95% CI: 0.51-0.74).

CONCLUSION

The present study identified that total and central body adiposity and shorter time spent in lively activities was positively associated with insulin resistance, evaluated through the triglyceride-glucose index. The cutoff point of 7.88 may be used in this population for insulin resistance risk screening, but caution is required when using it in other populations.

Association Between Early Life Weight Gain and Abdominal Fat Partitioning at 4.5 Years is Sex, Ethnicity, and Age Dependent

OBJECTIVE

The aim of this study was to investigate the independent associations between age-specific annual weight gain from birth to age 4 years and fat deposition in metabolically distinct compartments at age 4.5 years in a South Asian longitudinal birth cohort.

METHODS

Volumetric abdominal magnetic resonance imaging with comprehensive segmentation of deep and superficial subcutaneous adipose tissue (SAT) and visceral adipose tissues (VAT) was performed in 316 children (150 boys and 166 girls in three ethnic groups; 158 Chinese, 94 Malay, and 64 Indian) aged 4.5 years. Associations between fat volumes and annual relative weight gain conditional on past growth were assessed overall and stratified by sex and ethnicity.

RESULTS

Conditional relative weight gain had stronger associations with greater SAT and VAT at age 4.5 years in girls than boys and in Indians compared with Malay and Chinese. Overall, the magnitude of association was the largest during 2 to 3 years for SAT and 1 to 2 years for VAT. Despite similar body weight, Indian children and girls had the highest deep and superficial SAT volumes at age 4.5 years (all interactions P < 0.05). No significant sex or ethnic differences were observed in VAT. With increasing BMI, Indian children had the highest tendency to accumulate VAT, and girls accumulated more fat than boys in all depots (all interactions P < 0.001).

CONCLUSIONS

Indian ethnicity and female sex predisposed children to accumulate more fat in the VAT depot with increasing conditional relative weight gain in the second year of life. Thus, 1 to 2 years of age may be a critical window for interventions to reduce visceral fat accumulation.

The contribution of physical fitness to individual and ethnic differences in risk markers for type 2 diabetes in children: The Child Heart and Health Study in England (CHASE)

BACKGROUND

The relationship between physical fitness and risk markers for type 2 diabetes (T2D) in children and the contribution to ethnic differences in these risk markers have been little studied. We examined associations between physical fitness and early risk markers for T2D and cardiovascular disease in 9- to 10-year-old UK children.

METHODS

Cross-sectional study of 1445 9- to 10-year-old UK children of South Asian, black African-Caribbean and white European origin. A fasting blood sample was used for measurement of insulin, glucose (from which homeostasis model assessment [HOMA]-insulin resistance [IR] was derived), glycated hemoglobin (HbA1c), urate, C-reactive protein (CRP), and lipids. Measurements of blood pressure (BP) and fat mass index (FMI) were made; physical activity was measured by accelerometry. Estimated VO_{2 max} was derived from a submaximal fitness step test. Associations were estimated using multilevel linear regression.

RESULTS

Higher VO_{2 max} was associated with lower FMI, insulin, HOMA-IR, HbA1c, glucose, urate, CRP, triglycerides, LDL-cholesterol, BP and higher HDL-cholesterol. Associations were reduced by adjustment for FMI, but those for insulin, HOMA-IR, glucose, urate, CRP, triglycerides and BP remained statistically significant. Higher levels of insulin and HOMA-IR in South Asian children were partially explained by lower levels of VO_2max compared to white Europeans, accounting for 11% of the difference.

CONCLUSIONS

Physical fitness is associated with risk markers for T2D and CVD in children, which persist after adjustment for adiposity. Higher levels of IR in South Asians are partially explained by lower physical fitness levels compared to white Europeans. Improving physical fitness may provide scope for reducing risks of T2D.

The capacity-load model of non-communicable disease risk: understanding the effects of child malnutrition, ethnicity and the social determinants of health

The capacity-load model is a conceptual model developed to improve understanding of the life-course aetiology of non-communicable diseases (NCDs) and their ecological and societal risk factors. The model addresses continuous associations of both (a) nutrition and growth patterns in early life and (b) lifestyle factors at older ages with NCD risk. Metabolic capacity refers to physiological traits strongly contingent on early nutrition and growth during the first 1000 days, which promote the long-term capacity for homeostasis in the context of fuel metabolism and cardiovascular health. Metabolic load refers to components of nutritional status and lifestyle that challenge homeostasis. The higher the load, and the lower the capacity, the greater the NCD risk. The model therefore helps understand dose-response associations of both early development and later phenotype with NCD risk. Infancy represents a critical developmental period, during which slow growth can constrain metabolic capacity, whereas rapid weight gain may elevate metabolic load. Severe acute malnutrition in early childhood (stunting, wasting) may continue to deplete metabolic capacity, and confer elevated susceptibility to NCDs in the long term. The model can be applied to associations of NCD risk with socio-economic position (SEP): lower SEP is generally associated with lower capacity but often also with elevated load. The model can also help explain ethnic differences in NCD risk, as both early growth patterns and later body composition differ systematically between ethnic groups. Recent work has begun to clarify the role of organ development in metabolic capacity, which may further contribute to ethnic differences in NCD risk.

Risk of Type 2 Diabetes Mellitus Development in the Native Population of Low- and High-Altitude Regions of Kyrgyzstan: Finnish Diabetes Risc Score Questionnaire Results

Moldobaeva, Marina S., Anastasiya V. Vinogradova, and Marina K. Esenamanova. Risk of type 2 diabetes mellitus development in the native population of low- and high-altitude regions of Kyrgyzstan: Finnish Diabetes Risc Score questionnaire results. High Alt Med Biol. 18:428-435, 2017.

OBJECTIVE

The number of patients with diabetes is steadily growing, but likely only half of all cases are ever identified. The Kyrgyz, native inhabitants of Central Asia, live in the mountainous area and have a particular lifestyle and nutrition. However, the risk of type 2 diabetes mellitus (T2DM) in our population is not well defined. Therefore, we aimed at determining the risk of T2DM development in the Kyrgyz population residing in low- and high-altitude (HAlt) regions by using the Finnish Diabetes Risc Score (FINDRISC) questionnaire.

METHODS

We included in the study 3190 randomly selected participants, including 1780 low-altitude (LAlt) residents (Chu region, 500-1200 m) and 1410 HAlt residents (Naryn region, 2000-4500 m), among whom there were 1207 men and 1983 women. Assessment of T2DM development was conducted by using the FINDRISC questionnaire and risk stratification was performed by region of residency, gender, and age.

RESULTS

An irregular intake of vegetables and fruits, increased waist circumference (WC), and increased body mass index (BMI) were identified as leading risk factors of T2DM development in native residents of Chu and Naryn regions of Kyrgyzstan. The 10-year risk stratification of T2DM development revealed the absence of a very high-risk group; high-risk status was more frequently identified among residents of the LAlt Chu district (4.7% of women and 2.1% of men), as compared with the HAlt population (1.9% of women and 1% of men) (p = 0.0018 for women and p = 0.09 for men).

CONCLUSIONS

In the Kyrgyz population, a 10-year high risk of T2DM development is greater among residents of LAlts as compared with HAlts, irrespective of gender. No very high-risk group was detected in residents of low or HAlts. The leading composites of FINDRISC score are increased WC and BMI, possibly due to irregular intake of vegetables and fruits that are dependent on the altitude of residence and age.

Using a co-production prioritization exercise involving South Asian children, young people and their families to identify health priorities requiring further research and public awareness

OBJECTIVES

To facilitate South Asian (SA) families and health-care professionals (HCPs) participation in a prioritization exercise to co-produce child health research and public awareness agendas.

DESIGN

A three-stage process was adopted involving the following: (i) systematic literature review, (ii) HCP scoping survey and (iii) focus groups of SA adolescents and families. A Punjabi- and Urdu-speaking community facilitator moderated focus groups. A British Sign Language interpreter assisted in the hard of hearing group. Concordant and discordant themes between HCPs and SAs were identified.

SETTING

National survey of HCPs. Leicestershire for SA families.

PARTICIPANTS

A total of 27 HCPs and 35 SAs. SAs varied by descent, age (16-74), UK stay length (3-57 years) religion and disability.

RESULTS

Ranked by submission frequency in the survey, HCPs prioritized (i) public awareness on obesity, mental health, health-care access, vitamin D and routine health checks and (ii) research on nutrition, diabetes, health education and parenting methods.

DISCUSSION

South Asians prioritized research into the effectiveness of alternative medicines, a theme not identified by HCPs. Both HCPs and SAs prioritized increased research or public awareness on mental health illness, blood and organ donation, obesity and diet. Whilst HCPs identified diabetes, vitamin D and rickets together with parenting methods were important priorities requiring increased public awareness, and these views were not shared by SAs.

CONCLUSIONS

Minority groups are not always included in priority setting exercises due to concerns about language and perceived difficulty with accessing communities. Through this co-production exercise, we showed that it is possible and essential.

Increase of body mass index (BMI) from 1.5 to 3 years of age augments the degree of insulin resistance corresponding to BMI at 12 years of age

To elucidate the effect of early growth patterns on the metabolic sensitivity to adiposity, we examined the relationship between the homeostatic model assessment of insulin resistance (HOMA-IR) and body mass index (BMI) levels at 12 years of age in 101 boys and 91 girls in a birth cohort. Children with an increase in BMI from the ages of 1.5 to 3 years exhibited a greater increase of HOMA-IR per BMI increase at 12 years of age compared to those with a decrease in BMI or stable BMI from 1.5 to 3 years. This suggests that children who show an increase in BMI from 1.5 to 3 years, a period normally characterized by a decreased or stable BMI, are more prone to developing insulin resistance at 12 years of age.

Body composition and susceptibility to type 2 diabetes: an evolutionary perspective

Type 2 diabetes is rapidly increasing in prevalence worldwide, in concert with epidemics of obesity and sedentary behavior that are themselves tracking economic development. Within this broad pattern, susceptibility to diabetes varies substantially in association with ethnicity and nutritional exposures through the life-course. An evolutionary perspective may help understand why humans are so prone to this condition in modern environments, and why this risk is unequally distributed. A simple conceptual model treats diabetes risk as the function of two interacting traits, namely 'metabolic capacity' which promotes glucose homeostasis, and 'metabolic load' which challenges glucose homoeostasis. This conceptual model helps understand how long-term and more recent trends in body composition can be considered to have shaped variability in diabetes risk. Hominin evolution appears to have continued a broader trend evident in primates, towards lower levels of muscularity. In addition, hominins developed higher levels of body fatness, especially in females in relative terms. These traits most likely evolved as part of a broader reorganization of human life history traits in response to growing levels of ecological instability, enabling both survival during tough periods and reproduction during bountiful periods. Since the emergence of Homo sapiens, populations have diverged in body composition in association with geographical setting and local ecological stresses. These long-term trends in both metabolic capacity and adiposity help explain the overall susceptibility of humans to diabetes in ways that are similar to, and exacerbated by, the effects of nutritional exposures during the life-course.

Body mass index adjustments to increase the validity of body fatness assessment in UK Black African and South Asian children

Background/Objectives:

Body mass index (BMI) (weight per height²) is the most widely used marker of childhood obesity and total body fatness (BF). However, its validity is limited, especially in children of South Asian and Black African origins. We aimed to quantify BMI adjustments needed for UK children of Black African and South Asian origins so that adjusted BMI related to BF in the same way as for White European children.

Methods:

We used data from four recent UK studies that made deuterium dilution BF measurements in UK children of White European, South Asian and Black African origins. A height-standardized fat mass index (FMI) was derived to represent BF. Linear regression models were then fitted, separately for boys and girls, to quantify ethnic differences in BMI–FMI relationships and to provide ethnic-specific BMI adjustments.

Results:

We restricted analyses to 4–12 year olds, to whom a single consistent FMI (fat mass per height⁵) could be applied. BMI consistently underestimated BF in South Asians, requiring positive BMI adjustments of +1.12 kg m⁻² (95% confidence interval (CI): 0.83, 1.41 kg m⁻²; P<0.0001) for boys and +1.07 kg m⁻² (95% CI: 0.74, 1.39 kg m⁻²; P<0.0001) for girls of all age groups and FMI levels. BMI overestimated BF in Black Africans, requiring negative BMI adjustments for Black African children. However, these were complex because there were statistically significant interactions between Black African ethnicity and FMI (P=0.004 boys; P=0.003 girls) and also between FMI and age group (P<0.0001 for boys and girls). BMI adjustments therefore varied by age group and FMI level (and indirectly BMI); the largest adjustments were in younger children with higher unadjusted BMI and the smallest in older children with lower unadjusted BMI.

Conclusions:

BMI underestimated BF in South Asians and overestimated BF in Black Africans. Ethnic-specific adjustments, increasing BMI in South Asians and reducing BMI in Black Africans, can improve the accuracy of BF assessment in these children.

Sex Differences in Associations of Adiposity Measures and Insulin Resistance in US Hispanic/Latino Youth: The Hispanic Community Children's Health Study/Study of Latino Youth (SOL Youth)

CONTEXT

US Hispanic/Latino youth are disproportionally affected by the obesity and diabetes.

OBJECTIVE

We examined associations of adiposity measures with insulin resistance (IR) and hyperglycemia and the influences of sex and pubertal development on these associations.

DESIGN, SETTING, AND PARTICIPANTS

We performed a cross-sectional analysis of 1223 8- to 16-year-old Hispanic/Latino youth from a community-based study in the United States (SOL Youth).

MAIN OUTCOME MEASURES

We measured IR (≥75th percentile of sex-specific Homeostatic Model Assessment of Insulin Resistance) and hyperglycemia (fasting glucose ≥100 mg/dL or hemoglobin a1c ≥5.7%).

RESULTS

In boys, body mass index (BMI) showed the strongest association with IR [prevalence ratio (PR), 2.10; 95% confidence interval (CI), 1.87 to 2.36 per standard deviation], which was not statistically different compared with body fat percentage (%BF) (PR, 2.03; 95% CI, 1.81 to 2.29) and waist circumference (WC) (PR, 1.89; 95% CI, 1.67 to 2.13) but was significantly stronger compared with fat mass index (FMI) (PR, 1.79; 95% CI, 1.63 to 1.96), waist-to-hip ratio (WHR) (PR, 1.32; 95% CI, 1.21 to 1.44), and waist-to-height ratio (WHtR) (PR, 1.76; 95% CI, 1.54 to 2.01) (P for difference, <0.05). In girls, %BF (PR, 2.73; 95% CI, 2.34 to 3.20) showed a significantly stronger association with IR compared with BMI (PR, 1.48; 95% CI, 1.29 to 1.70), FMI (PR, 1.71; 95% CI, 1.49 to 1.95), WC (PR, 1.96; 95% CI, 1.70 to 2.27), WHR (PR, 1.95; 95% CI, 1.70 to 2.23), and WHtR (PR, 1.79; 95% CI, 1.53 to 2.09) (P for difference, <0.003). Associations between adiposity measures and IR were generally stronger among children in puberty versus those who had completed puberty, with significant interactions for WC and WHtR in boys and for BMI in girls (P for interaction, <0.01). Adiposity measures were modestly associated with hyperglycemia (PR, 1.14 to 1.25), with no interactions with sex or pubertal status.

CONCLUSIONS

Sex and puberty may influence associations between adiposity measures and IR in US Hispanic/Latino youth. Multiple adiposity measures are needed to better assess IR risk between boys and girls according to pubertal status.

Body composition and the monitoring of non-communicable chronic disease risk

There is a need for simple proxies of health status, in order to improve monitoring of chronic disease risk within and between populations, and to assess the efficacy of public health interventions as well as clinical management. This review discusses how, building on recent research findings, body composition outcomes may contribute to this effort. Traditionally, body mass index has been widely used as the primary index of nutritional status in children and adults, but it has several limitations. We propose that combining information on two generic traits, indexing both the ‘metabolic load’ that increases chronic non-communicable disease risk, and the homeostatic ‘metabolic capacity’ that protects against these diseases, offers a new opportunity to improve assessment of disease risk. Importantly, this approach may improve the ability to take into account ethnic variability in chronic disease risk. This approach could be applied using simple measurements readily carried out in the home or community, making it ideal for M-health and E-health monitoring strategies.

The Elevated Susceptibility to Diabetes in India: An Evolutionary Perspective

India has rapidly become a "diabetes capital" of the world, despite maintaining high rates of under-nutrition. Indians develop diabetes at younger age and at lower body weights than other populations. Here, we interpret these characteristics in terms of a "capacity-load" model of glucose homeostasis. Specifically, we assume that glycemic control depends on whether the body's "metabolic capacity," referring to traits, such as pancreatic insulin production and muscle glucose clearance, is able to resolve the "metabolic load" generated by high levels of body fat, high dietary glycemic load, and sedentary behavior. We employ data from modern cohorts to support the model and the interpretation that elevated diabetic risk among Indian populations results from the high metabolic load imposed by westernized lifestyles acting on a baseline of low metabolic capacity. We attribute this low metabolic capacity to the low birth weight characteristic of Indian populations, which is associated with short stature and low lean mass in adult life. Using stature as a marker of metabolic capacity, we review archeological and historical evidence to highlight long-term declines in Indian stature associated with adaptation to several ecological stresses. Underlying causes may include increasing population density following the emergence of agriculture, the spread of vegetarian diets, regular famines induced by monsoon failure, and the undermining of agricultural security during the colonial period. The reduced growth and thin physique that characterize Indian populations elevate susceptibility to truncal obesity, and increase the metabolic penalties arising from sedentary behavior and high glycemic diets. Improving metabolic capacity may require multiple generations; in the meantime, efforts to reduce the metabolic load will help ameliorate the situation.

Cardiometabolic risk: leg fat is protective during childhood

BACKGROUND

Childhood obesity is associated with early cardiometabolic risk (CMR), increased risk of adulthood obesity, and worse health outcomes. Leg fat mass (LFM) is protective beyond total fat mass (TFM) in adults. However, the limited evidence in children remains controversial.

OBJECTIVE

We investigated the relationship between LFM and CMR factors in youth.

SUBJECTS

A total of 203 overweight/obese children, 7-17-yr-old, followed in the Pediatric Clinic, Luxembourg.

METHODS

TFM and LFM by dual energy x-ray absorptiometry and a detailed set of CMR markers were analyzed.

RESULTS

After TFM, age, sex, body mass index (BMI) Z-score, sexual maturity status, and physical activity adjustments, negative significant partial correlations were shown between LFM and homeostasis model assessment of insulin resistance (HOMA) (variance explained: 6.05% by LFM*; 7.18% by TFM**), fasting insulin (variance explained: 5.71% by LFM*; 6.97% by TFM**), triglycerides (variance explained: 3.96% by LFM*; 2.76% by TFM*), systolic blood pressure (variance explained: 2.68% by LFM*; 4.33% by TFM*), C-reactive protein (variance explained: 2.31% by LFM*; 4.28% by TFM*), and resistin (variance explained: 2.16% by LFM*; 3.57% by TFM*). Significant positive partial correlations were observed between LFM and high-density lipoprotein (HDL) cholesterol (variance explained: 4.16% by LFM*) and adiponectin (variance explained: 3.09% by LFM*) (*p-value < 0.05 and **p-value < 0.001). In order to adjust for multiple testing, Benjamini-Hochberg method was applied and the adjusted significance level was determined for each analysis. LFM remained significant in the aforementioned models predicting HOMA, fasting insulin, triglycerides, and HDL cholesterol (Benjamini and Hochberg corrected p-value < 0.01).

CONCLUSIONS

LFM is protective against CMR in children, at least in terms of insulin resistance and adverse blood lipid profiles.

Maternal investment, life-history strategy of the offspring and adult chronic disease risk in South Asian women in the UK

BACKGROUND AND OBJECTIVES

Patterns of development predict cardiovascular disease (CVD) risk, and ethnic differences therein, but it remains unclear why apparently 'adaptive plasticity' in early life should generate health costs in later life. We hypothesized that offspring receiving low maternal investment during fetal life, the primary period of organogenesis, should predict a shorter reproductive career and develop a fast life-history strategy, prioritizing reproduction over growth and homeostatic maintenance.

METHODOLOGY

We studied 58 young adult South Asian women living in the UK, a group with high susceptibility to CVD. We obtained gestational age, birth weight (BW) and menarcheal age by recall and measured anthropometry, body composition, resting metabolic rate (RMR) and blood pressure (BP).

RESULTS

BW and gestational age were inversely associated with menarcheal age, indicating that lower maternal investment is associated with faster maturation. Menarcheal age was positively associated with height but inversely with adiposity, indicating that rapid maturation prioritizes lipid stores over somatic growth. BW was inversely associated with BP, whereas adiposity was positively associated, indicating that lower maternal investment reduces BP homeostasis. BW was positively associated with RMR, whereas menarche was inversely associated, indicating that maternal investment influences adult metabolism.

CONCLUSIONS AND IMPLICATIONS

Supporting our hypothesis, low maternal investment promoted faster life histories, demonstrated by earlier menarche, reduced growth and elevated adiposity. These traits were associated with poorer BP regulation. This is the first study demonstrating strategic adjustment of the balance between reproduction and metabolic health in response to the level of maternal investment during fetal life.

A clinical perspective of obesity, metabolic syndrome and cardiovascular disease

The metabolic syndrome is a condition characterized by a special constellation of reversible major risk factors for cardiovascular disease and type 2 diabetes. The main, diagnostic, components are reduced HDL-cholesterol, raised triglycerides, blood pressure and fasting plasma glucose, all of which are related to weight gain, specifically intra-abdominal/ectopic fat accumulation and a large waist circumference. Using internationally adopted arbitrary cut-off values for waist circumference, having metabolic syndrome doubles the risk of cardiovascular disease, but offers an effective treatment approach through weight management. Metabolic syndrome now affects 30-40% of people by age 65, driven mainly by adult weight gain, and by a genetic or epigenetic predisposition to intra-abdominal/ectopic fat accumulation related to poor intra-uterine growth. Metabolic syndrome is also promoted by a lack of subcutaneous adipose tissue, low skeletal muscle mass and anti-retroviral drugs. Reducing weight by 5-10%, by diet and exercise, with or without, anti-obesity drugs, substantially lowers all metabolic syndrome components, and risk of type 2 diabetes and cardiovascular disease. Other cardiovascular disease risk factors such as smoking should be corrected as a priority. Anti-diabetic agents which improve insulin resistance and reduce blood pressure, lipids and weight should be preferred for diabetic patients with metabolic syndrome. Bariatric surgery offers an alternative treatment for those with BMI ≥ 40 or 35-40 kg/m(2) with other significant co-morbidity. The prevalence of the metabolic syndrome and cardiovascular disease is expected to rise along with the global obesity epidemic: greater emphasis should be given to effective early weight-management to reduce risk in pre-symptomatic individuals with large waists.

Differential impact of maternal and paternal ethnicity on the pattern of fat distribution in infants at age 3 months

BACKGROUND

As ethnicity is typically recorded as a single demographic variable in clinical studies, little is known about the relative impact of maternal vs. paternal ethnicity on fat distribution.

OBJECTIVES

The objective of this study was to determine whether there is a differential impact of maternal and paternal ethnicity on infant adiposity.

METHODS

Three hundred fifty-five infants underwent anthropometric assessment at age 3 months, including skin-fold thickness (SFT) measurement at subscapular, suprailiac and triceps. Maternal (M) and paternal (P) ethnicity were classified as white (M = 241, P = 252), Asian (M = 50, P = 42) or other (M = 64, P = 61).

RESULTS

Infants with either Asian mother (compared with white) or Asian father (compared with white) had increased subscapular, suprailiac and triceps SFT (all P < 0.05). On logistic regression analysis, however, only maternal Asian ethnicity (compared with white) independently predicted the likelihood of an infant being in the highest tertile for SFT at subscapular (odds ratio [OR] = 2.72, 95% confidence interval 1.17-6.34, P = 0.02), suprailiac (OR = 3.56, 1.51-8.42, P = 0.004) and triceps (OR = 3.26, 1.40-7.55, P = 0.005). In contrast, paternal Asian ethnicity was independently associated with sum of SFT only (OR = 2.46, 1.02-5.97, P = 0.04).

CONCLUSION

Maternal and paternal Asian ethnicity have differential effects on infant fat distribution. Future clinical studies on obesity and fat composition should consider the distinct contributions of both parents to the ethnic classification of participants.

Differences in the associations of anthropometric measures with insulin resistance and type 2 diabetes mellitus between Korean and US populations: Comparisons of representative nationwide sample data

BACKGROUNDS

Variation among ethnic groups in the association between obesity and insulin resistance (IR)/diabetes has been suggested, but studies reported inconsistent results. We evaluated ethnic differences in the association between obesity and insulin resistance (IR)/diabetes.

METHODS

We conducted a cross-sectional analysis using Korea (n=18,845) and the USA (n=4657) National Health and Nutrition Examination Survey(NHANES) 2007-2010. We performed statistical comparisons of AUC-ROC (area under the curve in a receiver operating characteristic curve) values for body mass index (BMI), waist circumference (WC) and homeostasis model assessment of insulin resistance (HOMA-IR) to predict IR or diabetes among different ethnic groups.

RESULTS

AUC-ROC values for BMI and WC for predicting IR were highest in Whites (0.8324 and 0.8468) and lowest in Koreans (0.7422 and 0.7367). Whites showed the highest AUC-ROC values for BMI (0.6869) and WC (0.7421) for predicting diabetes, while the AUC-ROC for HOMA-IR was highest in Koreans (0.8861). Linear regression showed significant interactions between ethnicity and the main effects (all P<0.0001). Increases in BMI were associated with a larger increase in HOMA-IR in Whites (β=0.0719) and WC in Hispanics (β=0.0324), while BMI was associated with a larger increase in fasting glucose in Koreans (β=0.8279) and WC in Blacks (β=0.4037). In addition, the slope for fasting glucose with increasing HOMA-IR was steeper in Koreans (β=16.5952, P<0.001) than in other groups.

CONCLUSION

The ability of BMI and WC to predict IR and diabetes was highest in Whites, while the ability of HOMA-IR to predict diabetes was highest in Koreans.

Beyond height and weight: a programme of school nurse assessed skinfold measurements from white British and South Asian origin children aged 4-5 years within the Born in Bradford cohort study

OBJECTIVE

To describe the feasibility, reliability and additional information gained from collecting additional body fatness measures (beyond height and weight) from UK reception year children.

DESIGN

Prospective cohort study.

SETTING

Bradford, UK.

PARTICIPANTS

2458 reception year children participating in the Born in Bradford (BiB) cohort study.

MAIN OUTCOME MEASURES

The feasibility and reliability of subscapular and triceps skinfold measurements and differences in adiposity between ethnic groups.

RESULTS

Of those children who were matched to their school, 91% had a subscapular skinfold measurement and 92% had a triceps skinfold measurement recorded. Reliability was generally over 90% for all measurers and both measurements. Pakistani children were slightly taller but weighed less and had lower triceps skinfold thickness (mean difference -1.8 mm, 95% CI -2.1 to -1.4 mm) but higher subscapular (mean difference 0.1 mm, 95% CI -0.1 to 0.4 mm) than white British children.

CONCLUSIONS

We have shown that it is feasible for school nurses to collect skinfold measurements in a similar way to the height and weight measurements collected from reception year children for the National Child Measurement Programme (NCMP), and that these measurements are reliable. It is important for healthcare practice to acknowledge ethnic-specific risk and these additional measurements can provide important information to examine population-level risk in populations with large proportions of South Asian children.