Childhood obesity in specialist care--searching for a healthy obese child

Predictive markers of metabolically healthy obesity in children and adolescents: can AST/ALT ratio serve as a simple and reliable diagnostic indicator?

This study aimed to estimate the prevalence of metabolically healthy obesity (MHO) according to two different consensus-based criteria and to investigate simple, measurable predictive markers for the diagnosis of MHO. Five hundred and ninety-three obese children and adolescents aged 6-18 years were included in the study. The frequency of MHO was calculated. ROC analysis was used to estimate the predictive value of AST/ALT ratio, waist/hip ratio, MPV, TSH, and Ft4 cut-off value for the diagnosis of MHO. The prevalence of MHO was 21.9% and 10.2% according to 2018 and 2023 consensus-based MHO criteria, respectively. AST/ALT ratio cut-off value for the diagnosis of MHO was calculated as ≥ 1 with 77% sensitivity and 52% specificity using Damanhoury et al.'s criteria (AUC = 0.61, p = 0.02), and 90% sensitivity and 51% specificity using Abiri et al.'s criteria (AUC = 0.70, p = 0.01). Additionally, using binomial regression analysis, only the AST/ALT ratio is independently and significantly associated with the diagnosis of MHO (p = 0.03 for 2018 criteria and p = 0.04 for 2023 criteria).

CONCLUSION

The ALT/AST ratio may be a useful indicator of MHO in children and adolescents.

WHAT IS KNOWN

• Metabolically healthy obesity refers to people who are obese but do not have any of the standard cardio-metabolic risk factors. • Metabolically healthy obesity is not entirely harmless; the metabolic characteristics of individuals with this phenotype are less favorable than those of healthy lean groups. Moreover, it is not a constant state, and there may be a transition to metabolically unhealthy phenotypes over time.

WHAT IS NEW

• The prevalence of MHO is 21.9% and 10.2% according to 2018 and 2023 consensus-based metabolically healthy obesity criteria, respectively. • The ALT/AST ratio may be a useful indicator of metabolically healthy obesity in children and adolescents.

Overweight and Obesity in Finnish Children by Parents' Socioeconomic Position-A Registry-Based Study

Objectives: To examine associations between parents' socioeconomic position (SEP) and child overweight and obesity, using registry data. Methods: Data (final n = 194,423) on children's height, weight and parents' SEP were drawn from the national Register of Primary Health Care Visits (Avohilmo) and Statistics Finland. Risk ratios for bernoulli-distributed overweight (RROW) and obesity (RROB) according to SEP were estimated using generalized linear models and using a log -link. Results: The risk for obesity was lower in boys from high-income families (RROB 0.76), for overweight and obesity was lower in boys (RROW 0.72, RROB 0.58) and girls (RROW 0.72, RROB 0.54) with highly educated fathers, in boys (RROW 0.79, RROB 0.58) and girls (RROW 0.78, RROB 0.56) with high-educated mothers and in boys (RROW 0.85, RROB 0.77) and girls (RROW 0.80, RROB 0.69) living in urban areas, as compared to low-income families, low-educated parents, and rural residence, respectively. Conclusion: The risk of overweight and obesity was increased in children with low SEP or rural residence. Administrative registers are a valid approach to monitor childhood obesity by parents' SEP.

Risk factors, cutoff points, and definition of metabolically healthy/unhealthy obesity in children and adolescents: A scoping review of the literature

Diagnosis of metabolically healthy obesity (MHO) and its definition do not have universal criteria in the pediatric age group. Hence, this scoping review aims to identify the components, the cutoff points, and the definition of MHO in children and adolescents. A comprehensive, systematic search was conducted in PubMed, Scopus, EMBASE, and Google Scholar databases. A consensus-based definition of MHO was developed through a Delphi process involving an international panel of 23 experts. This review included a total of 63 non-randomized studies, published between 2007 and 2022. According to our consensus (≥80% agreement), the proposed definition for MHO included the following components: high-density lipoprotein cholesterol >40 mg/dl (or >1.03 mmol/l), triglycerides ≤150 mg/dl (or ≤1.7 mmol/l), fasting plasma glucose <100 mg/dl (or <5.6 mmol/l), a measure of insulin, and systolic and diastolic blood pressure ≤90th percentile. Therefore, MHO was defined as the absence of the above metabolic risk factors; and those children and adolescents with one or more criteria were considered as metabolically unhealthy. A universal definition of MHO will allow comparisons between studies in the field of childhood obesity and can be useful in clinical practice.

Cross-Sectional Association Between Body Fat Composition and Biomarkers of Inflammation and Endothelial Dysfunction in Children with Overweight/Obesity

BACKGROUND

Childhood obesity is most prevalent nutritional disorder worldwide. Studies on clinical correlations between body fat (BF) composition, lipid profile, inflammatory biomarkers, and endothelial dysfunction (ED) parameters in children from United Arab Emirates (UAE) are limited. Therefore, we aimed to study obesity pattern in children and determine clinical correlations with biomarkers.

METHODS

Children (6-13 years) from different schools were divided into obese, overweight, and normal groups based upon Centers for Disease Control and Prevention weight-for-age centiles study (n=166). Anthropometric, BF composition, lipid profile, inflammatory, and ED biomarkers were determined and analyzed using SPSS software.

RESULTS

The mean age and weight ± SD of participants were 10.6 ± 2.6 years and 48.2 ± 19.5 kg with 65% as overweight or obese. In normal, overweight, and obese group male were 40 (70.2%), 35 (67.3%), and 40 (70.2%) and female were 17 (29.8%), 17 (32.7%) and 17 (29.8%). There was significant difference in age (p<0.01), height (p< 0.01), weight (p< 0.01) among groups. Obesity markers (MCP-1, leptin, adiponectin) showed positive correlation with age, height, weight, WC, BF%, body fat mass (BFM), body muscle mass (BMM). A significant correlation (all p<0.01) of BMM with SBP (r=0.412), DBP (r=0.255), MCP-1 (r=0.558), adiponectin (r=0.635), hs-CRP (r=0.263), IL-6 (r=0.348), TNF-alpha (r=0.370), ICAM-1 (r=0.237), and VCAM-1 (r=0.343). The inflammatory markers (ICAM-1, VCAM-1) showed significant correlations with age, height, weight, WC, BF%, BFM, BMM. Leptin significantly (all p<0.01) correlated with age (r=0.470), height (r=0.423), weight (r=0.677), WC (r=0.606), BF (r=0.700), BFM (r=0.752), and BMM (r=0.524) and negatively correlated with TBW (r=-0.701). Adiponectin also showed a significant (all p<0.01) positive correlation with age, height, weight, WC, BF, BFM, and BMM.

CONCLUSION

A strong association between BF composition, lipid profile, and inflammatory and ED biomarkers was observed in the study. Thus, immediate measures should be implemented to reduce risk of obesity and associated diseases.

Socioeconomic inequalities in overweight and obesity among 6- to 9-year-old children in 24 countries from the World Health Organization European region

Childhood overweight and obesity have significant short- and long-term negative impacts on children's health and well-being. These challenges are unequally distributed according to socioeconomic status (SES); however, previous studies have often lacked standardized and objectively measured data across national contexts to assess these differences. This study provides a cross-sectional picture of the association between SES and childhood overweight and obesity, based on data from 123,487 children aged 6-9 years in 24 countries in the World Health Organization (WHO) European region. Overall, associations were found between overweight/obesity and the three SES indicators used (parental education, parental employment status, and family-perceived wealth). Our results showed an inverse relationship between the prevalence of childhood overweight/obesity and parental education in high-income countries, whereas the opposite relationship was observed in most of the middle-income countries. The same applied to family-perceived wealth, although parental employment status appeared to be less associated with overweight and obesity or not associated at all. This paper highlights the need for close attention to context when designing interventions, as the association between SES and childhood overweight and obesity varies by country economic development. Population-based interventions have an important role to play, but policies that target specific SES groups are also needed to address inequalities.

Microbiome of the first stool and overweight at age 3 years: A prospective cohort study

BACKGROUND

Several reports have revealed that the first-pass meconium hosts a diverse microbiome, but its clinical significance is not known.

OBJECTIVE

We designed a prospective population-based cohort study to evaluate whether the meconium microbiome predicts subsequent growth in children.

METHODS

The study comprised 212 consecutive newborns with a meconium sample and a follow-up sample at 1 year of age. Trained nurses measured the children for weight and length using standardized techniques. We used next-generation sequencing of bacterial 16S rRNA gene and machine-learning approach for the analysis.

RESULTS

The children with overweight at 3 years of age differed in their meconium microbiome from those with normal weight, having a higher proportion of Bacteroidetes phylum (29% vs 15%, P = .013). Using the machine-learning approach, the gut microbiome at birth predicted subsequent overweight with area under the curve 0.70 (SD 0.04). A lower proportion of Staphylococcus at birth was associated with greater length/height at 1 year (ß = -.68, P = .029) and 2 years of age (β = -.74, P = .030).

CONCLUSIONS

The microbiome of the first-pass meconium predicted subsequent overweight at the age of 3 years. The association between the gut microbiome and overweight appears to start already during pregnancy and at birth.

The associations between some biological markers, obesity, and cardiovascular risk in Slovenian children and adolescents

INTRODUCTION

The occurrence of cardiovascular diseases and metabolic disorders steadily increases with the body mass index (BMI). Since the latter is not the best and earliest indicator of obesity and cardiovascular risk, the aim of the study was to evaluate some potential biological markers that would allow us to detect children and adolescents at higher risk at an early stage.

METHODS

A sample of 330 children and adolescents were included in the study and divided into four groups: obese patients with hypertension, normal-weight patients with hypertension, patients with mildly elevated lipids and a control group of healthy children and adolescents. Some clinical parameters (age, body weight, body height, BMI, waist circumference, hip circumference, blood pressure), biochemical parameters (glucose, total cholesterol, triglycerides, HDL, LDL, apolipoprotein A1, homocysteine) and biological markers of obesity (ghrelin, adiponectin, leptin) were evaluated.

RESULTS

Ghrelin and adiponectin were found to have a strong negative statistically significant correlation with BMI in all three observed groups (p < 0.001), but not in the control group (p = 0.053 and p = 0.316, respectively). In addition, leptin had a strong positive statistically significant correlation with BMI in all four groups (p < 0.001 for the research groups, p = 0.009 for the controls). In the group of obese patients with hypertension, statistically significant differences in all three markers of obesity were found in comparison to the control group (p < 0.001 for all markers). In the group of patients with mildly elevated lipids, ghrelin and leptin were significantly different (p = 0.002 and p < 0.001, respectively). In the group of normal-weight hypertensive patients, only values of ghrelin were different compared to the control group (p = 0.001).

CONCLUSION

In the research groups, significant differences were found in clinical, biochemical and biological parameters compared to the control group. The observed biological markers of obesity are useful early markers for identifying groups of patients that are at cardiovascular risk.

Temporal trends in severe obesity prevalence in children and youth from primary care electronic medical records in Ontario: a repeated cross-sectional study

BACKGROUND

There are no current estimates of severe obesity in Canadian children. The objectives of this study were to determine the prevalence of severe obesity in children aged 18 years or less in Ontario and to determine temporal trends from 2004 to 2015.

METHODS

This was a repeated cross-sectional study using height/length and weight of children aged 18 years or less from the Electronic Medical Record Administrative data Linked Database (EMRALD), a database of primary care electronic medical records in Ontario. We calculated body mass index (for age and sex) z-scores (zBMI). Two years of data (2014 and 2015) were used to determine the period prevalence of severe obesity. We used multivariable linear regression generalized estimating equations to estimate the association of calendar year and mean zBMI.

RESULTS

In total, 55 233 children were included. The prevalence of severe obesity (zBMI > 3) increased with increasing age: it was 0.9% (95% confidence interval [CI] 0.7% to 1.0%) among children less than 5 years of age, 2.7% (95% CI 2.3% to 3.1%) among 5- to 9-year-olds, 2.9% (95% CI 2.4% to 3.3%) among 10- to 14-year-olds and 3.7% (95% CI 3.1% to 4.3%) among those aged 15-18. Boys aged 5-9 years had a significantly higher prevalence of severe obesity than their female counterparts (3.5% [95% CI 2.9% to 4.2%] v. 1.7% [95% CI 1.3% to 2.2%]). From 2004 to 2015, the mean zBMI decreased by 0.015 (95% CI -0.018 to -0.012) units per year, with the overall prevalence of severe obesity in all ages highest in 2005 (3%) and a decrease to 2% in 2015.

INTERPRETATION

The prevalence of severe obesity among children and adolescents in Ontario is consistent with that in other developed countries with the exception of the United States. There is evidence of plateauing of estimates and a small decrease in zBMI over time. Further understanding of the impact of prevention efforts on these estimates is an important next step.

Cardiovascular Risk Factors in Children and Adolescents With Obesity: Sex-Related Differences and Effect of Puberty

Objectives: To evaluate the effect of gender and puberty on cardiovascular risk factors (CVRF) in obese children and adolescents. Methods: One thousand four hundred and nine obese patients [age 9.7 (2.2-17.9) y; 646 Male] were studied. Subjects were stratified according to Tanner pubertal staging and age into prepubertal ≤ and >6 ys (G1 and G2), pubertal stage 2-3 (G3), and pubertal stage 4-5 (G4). Waist circumference (WC), systolic and diastolic blood pressure (SP, DP), fasting plasma glucose, insulin, post Oral Glucose Tolerance Test glucose and insulin, and lipids were evaluated. Insulin resistance was evaluated by HOMA index. Patients with no CVRF were considered metabolically healthy (MHO). Results: The percentage of MHO patients was 59.8% in G1 while was consistently around 30% in the other groups. WC was more frequently abnormal in G2 males. Pubertal progression was associated with a decrease in WC abnormalities. SP was more frequently abnormal in G4 males and pubertal progression was associated with higher prevalence of abnormal SP in males. Pubertal progression was associated with an increase in hypertension rate in both sexes. HOMA was more frequently abnormal in G2 and G3 females. HDL, LDL, and TG were more frequently abnormal in G2 females. Dyslipidemia rate was higher in G2 females. Pubertal progression was associated with higher prevalence of abnormal HDL in males. Conclusions: Sex and pubertal status influence the frequency of abnormalities of CVRF in obese children and adolescents. CVRF are already present in prepubertal age. Identifying patients with higher risk of metabolic complications is important to design targeted and effective prevention strategies.

Children With Metabolically Healthy Obesity: A Review

Children with "metabolically healthy obesity" (MHO) are a distinct subgroup of youth with obesity, who are less prone to the clustering of cardiometabolic risk factors. Although this phenotype, frequently defined by the absence of metabolic syndrome components or insulin resistance, was first described during the early 1980s, a consensus-based definition of pediatric MHO was introduced only recently, in 2018. The purpose of this review was to concisely summarize current knowledge regarding the MHO phenomenon in youth. The prevalence of MHO in children varies from 3 to 87%, depending on the definition used and the parameters evaluated, as well as the ethnicity and the pubertal status of the sample. The most consistent predictors of MHO in youth include younger age, lower body mass index, lower waist circumference, and lower body fat measurements. Various hypotheses have been proposed to elucidate the underlying factors maintaining the favorable MHO phenotype. While preserved insulin sensitivity and lack of inflammation were previously considered to be the main etiological factors, the most recent findings have implicated adipokine levels, the number of inflammatory immune cells in the adipose tissue, and the reduction of visceral adiposity due to adipose tissue expandability. Physical activity and genetic factors also contribute to the MHO phenotype. Obesity constitutes a continuum-increased risk for cardiometabolic complications, which is less evident in children with MHO. However, some findings have highlighted the emergence of hepatic steatosis, increased carotid intima-media thickness and inflammatory biomarkers in the MHO group compared to peers without obesity. Screening should be directed at those more likely to develop clustering of cardiometabolic risk factors. Lifestyle modifications should include behavioral changes focusing on sleep duration, screen time, diet, physical activity, and tobacco smoke exposure. Weight loss has also been associated with the improvement of insulin sensitivity and inflammation. Further investigative efforts are needed in order to elucidate the mechanisms which protect against the clustering of cardiometabolic risk factors in pediatric obesity, to provide more efficient, targeted treatment approaches for children with obesity, and to identify the protective factors preserving the MHO profile, avoiding the crossover of MHO to the phenotype with metabolically unhealthy obesity.

Defining metabolically healthy obesity in children: a scoping review

We conducted a scoping review to identify definitions of metabolically healthy obesity (MHO), describe gaps in the literature, and establish a universal definition of MHO in children. We searched electronic databases from January 1980 to June 2017 and grey literature. Experimental, quasi-experimental, or observational studies were eligible for inclusion if they (i) included a definition of MHO that identified risk factors, cut-off values, and the number of criteria used to define MHO, and (ii) classified 2-18 year olds as overweight or obese. Two reviewers independently screened 1,711 papers for relevance and quality; we extracted data from 39 individual reports that met inclusion criteria. Most (31/39; 79%) definitions of MHO included an absence of cardiometabolic risk factors. Heterogeneity across MHO definitions, obesity criteria, and sample sizes/characteristics resulted in variable prevalence estimates (3-80%). Finally, we convened an international panel of 46 experts to complete a 4-round Delphi process to generate a consensus-based definition of MHO. Based on consensus (≥ 80% agreement), our definition of MHO included: high density lipoprotein-cholesterol > 40 mg/dl (or > 1.03 mmol/l), triglycerides ≤ 150 mg/dl (or ≤ 1.7 mmol/l), systolic and diastolic blood pressure ≤ 90th percentile, and a measure of glycemia. This definition of MHO holds potential universal value to enable comparisons between studies and inform clinical decision-making for children with obesity.

Screening and treatment of obesity in school health care - the gap between clinical guidelines and reality

AIMS

School health care offers a natural setting for childhood obesity interventions. Earlier studies reveal inadequate screening and treatment in primary care. However, longitudinal studies in unselected populations are lacking. We aimed to examine how school nurses and physicians identified obesity, diagnosed it and offered interventions over primary school. We compared the results with Finnish recommendations.

METHODS

From our cohort of 2000 primary school sixth graders (aged 12-14), 172 were obese at least once during primary school. We manually collected retrospective electronic health record (EHR) data of these 'ever-obese' children.

RESULTS

Of the ever-obese children, 96% attended annual nurse assessments more than twice. School physicians met 53% of the ever-obese children at health checks at first grade and 93% at fifth grade. Of overweight-related extra visits to school nurses, 94% took place without parents. Parents were present in 48% of extra school physician visits. Only 29% of the 157 who became obese during the first five school grades received an obesity diagnosis. However, school physicians mentioned weight problems in EHR for 90% of the children and, similarly, school nurses for 99%. The majority received a treatment plan at least once. For 78%, at least one plan was made with the parents. Still, 28% missed nutrition plans, 31% exercise plans and 90% lacked recorded weight development targets.

CONCLUSIONS

The gap between clinical guidelines and reality in school health care could be narrowed by improving diagnosing and parent collaboration. Obstacles in parent involvement and work methods in school health care need further study.

Girls and Boys Have a Different Cardiometabolic Response to Obesity Treatment

Background: Childhood obesity exposes individuals to cardiometabolic disturbances. We analyzed how family-based multidisciplinary obesity treatment influenced children's cardiometabolic health. Materials and methods: In this retrospective, two-year, follow-up study of 654 2- to 18-year-old children treated for obesity in three Finnish pediatric clinics in 2005-2012, blood pressure (BP), metabolic parameters, and the influence of sex, puberty and a change in body mass index standard deviation score (BMI SDS) were analyzed. Results: At baseline, at least one cardiovascular risk factor was present in 474 (80%) cases. Boys presented with more significant changes in cardiometabolic parameters than girls during the treatment. Boys' total cholesterol (TC) improved by 12 months (P = 0.009), and their low-density lipoprotein C (LDL-C) and glycosylated hemoglobin ameliorated by 12 months (P = 0.030 and 0.022, respectively) and 24 months (P = 0.043 and 0.025, respectively). Boys' triglycerides, insulin, homeostasis model assessment for insulin resistance (HOMA-IR) and systolic BP deteriorated at 24 months (P < 0.001, 0.004, 0.002, and 0.037, respectively). In all children, the number of acceptable TC, LDL-C, insulin, and HOMA-IR values increased if BMI SDS reduced 0.25 or more by 12 months. Conclusion: Minor cardiometabolic improvements were found during the obesity treatment. These findings indicate the need to assess treatment methods and focus on prevention.

Paediatric obesity treatment had better outcomes when children were younger, well motivated and did not have acanthosis nigricans

AIM

This study evaluated the efficacy of a paediatric obesity treatment programme and explored the factors that contributed to the outcome.

METHODS

We recorded the body mass index standard deviation scores (BMI SDS) of 654 children aged 2-18 years who were treated for obesity in 2005-2012 in three Finnish hospitals, one year before treatment and up to three years after treatment. The family-based multidisciplinary treatment included nutritional advice, exercise and behavioural counselling. The BMI SDS changes, and their contributors, were explored with mixed-model and logistic regression analyses.

RESULTS

BMI SDS increased before baseline and decreased at six, 12 and 24 months (all p < 0.001) and 36 months (p = 0.005). Younger age (p < 0.001), higher BMI SDS at baseline (p = 0.001), motivation (p = 0.013), adherence to the protocol (p = 0.033) and lack of acanthosis nigricans (p < 0.001) improved the outcome. The BMI SDS of children aged 2-6 decreased best from baseline to 12 (-0.35), 24 (-0.58) and 36 months (-0.64) (all p < 0.001).

CONCLUSION

Paediatric obesity treatment was most effective at a younger age. Good motivation and adherence contributed to favourable outcomes, while acanthosis nigricans was associated with a poor outcome.