Inflammatory bowel disease (IBD) patients with impaired quality of life on biologic therapy benefit from the support of an IBD nurse specialist: Results of a randomised controlled trial in Germany (IBDBIO-ASSIST study)

BACKGROUND

IBDBIO-ASSIST was a randomised controlled trial assessing the efficacy of care provided by IBD nurse specialists in Germany in improving health-related quality of life (QoL) in IBD patients on biologic therapy.

AIM

To evaluate patient-related outcomes and economic consequences associated with integrating IBD nurses into usual care.

METHODS

We randomly assigned 1086 patients with IBD on biologic therapy to a control group (CG) receiving usual care or an intervention group (IG) receiving additional care from an IBD nurse specialist. The primary outcome was disease-specific QoL (sIBDQ) assessed at 6, 12 and 18 months.

RESULTS

At baseline, patients in both groups were highly satisfied with their treatment situation and had relatively high sIBDQ values (range: 1-7; CG: 5.12; IG: 4.92). In the intention-to-treat (ITT) analysis of the overall sample, there was no significant difference in sIBDQ between groups at the assessment time points. However, a per-protocol analysis of patients with impaired QoL at baseline (EQ-VAS < 75 [median]), showed improvement in sIBDQ over 6 months that became significant at month 12 and remained significant through month 18 (baseline: IG 4.24; CG 4.31; 18 months: IG 5.02; CG 4.76; p = 0.017).

CONCLUSION

High baseline satisfaction of IBD patients with treatment and the relatively high baseline sIBDQ values may have contributed to the lack of significant difference in sIBDQ scores for the overall sample. However, patients with impaired QoL derived significant benefit from additional care provided by an IBD nurse specialist, leading to meaningful improvements in sIBDQ over the long term.

Letter: Comparing first-line infliximab and vedolizumab for ulcerative colitis-it depends on how you use the drug. Authors' reply

This article is linked to Bokemeyer et al papers. To view these articles, visit https://doi.org/10.1111/apt.17616 and https://doi.org/10.1111/apt.17770

Real-world Comparative Effectiveness of Ustekinumab vs Anti-TNF in Crohn's Disease With Propensity Score Adjustment: Induction Phase Results From the Prospective, Observational RUN-CD Study

BACKGROUND

In addition to randomized controlled trials (RCTs), real-world studies on the effectiveness of ustekinumab (UST) in Crohn's disease (CD) are required inasmuch as RCTs are usually confined to selected patients, which may not represent everyday clinical practice. Within the framework of the prospective real-world RUN-CD registry, a total of approximately 900 CD patients from 44 inflammatory bowel disease centers from all over Germany starting a new therapy with UST or other biologics were screened for a real-world evidence (RWE) comparison of CD patients with UST vs antitumor necrosis factor (TNF).

METHODS

A total of 618 CD patients with a nonrandomized biological therapy were qualified for this induction phase effectiveness RUN-CD study of UST vs anti-TNF. To reduce selection bias in estimations of treatment effects, the propensity score with inverse probability of treatment weighting was implemented. The results were reported as odds ratio (OR) and 95% confidence interval (CI).

RESULTS

A total of 339 UST and 279 anti-TNF patients were analyzed. The effectiveness of UST vs anti-TNF in terms of clinical remission (UST 65.4% vs anti-TNF 63.0%; OR, 1.11; 95% CI, 0.71-1.74) and steroid-free remission (UST 51.0% vs anti-TNF 53.8%; OR, 0.94; 95% CI, 0.60-1.47) was comparable at the end of induction therapy. Similar results were observed in the bio-naïve and bio-experienced UST vs anti-TNF groups. For both, the remission rates were higher in the bio-naïve than in the bio-experienced groups (P < .05).

CONCLUSIONS

In this prospective, observational RUN-CD study, the RWE head-to-head comparison of UST vs anti-TNF showed similar induction effectiveness in both groups, remarkably higher than those found in prior RCTs.

Real-world effectiveness of vedolizumab compared to anti-TNF agents in biologic-naïve patients with ulcerative colitis: A two-year propensity-score-adjusted analysis from the prospective, observational VEDOIBD -study

BACKGROUND

This observational real-world evidence (RWE) study is based on prospectively collected data from the VEDOIBD registry study.

AIM

To compare the effectiveness of vedolizumab and anti-TNF agents in biologic-naïve patients with ulcerative colitis (UC) at the end of induction and during maintenance treatment.

METHODS

Between 2017 and 2020, we enrolled 512 patients with UC starting therapy with vedolizumab or an anti-TNF agent in 45 IBD centres across Germany. We excluded biologic-experienced patients and those with missing partial Mayo (pMayo) outcomes; this resulted in a final sample of 314 (182 on vedolizumab and 132 on an anti-TNF agent). The primary outcome was clinical remission measured using pMayo score; any switch to a different biologic agent was considered an outcome failure (modified ITT analysis). We used propensity score adjustment with inverse probability of treatment weighting to correct for confounding.

RESULTS

During induction therapy, clinical remission was relatively low and similar in vedolizumab- and anti-TNF-treated patients (23% vs. 30.4%, p = 0.204). However, clinical remission rates after two years were significantly higher for vedolizumab-treated patients than those treated with an anti-TNF agent (43.2% vs. 25.8%, p < 0.011). Among patients treated with vedolzumab, 29% switched to other biologics, versus 54% who had received an anti-TNF agent.

CONCLUSION

After two years of treatment, vedolizumab resulted in higher remission rates than anti-TNF agents.

Real-World Effectiveness of Vedolizumab vs Anti-TNF in Biologic-naïve Crohn's Disease Patients: A 2-year Propensity-score-adjusted Analysis from the VEDOIBD-Study

BACKGROUND

The aim of this observational, real-world evidence, modified intention-to-treat (mITT) study based on prospectively collected data from the VEDOIBD registry was to compare the effectiveness of vedolizumab (VEDO) vs antitumor necrosis factor (anti-TNF) in biologic-naïve Crohn's disease (CD) patients.

METHODS

Between 2017 and 2020, 557 CD patients starting therapy with VEDO or anti-TNF were consecutively enrolled in 45 IBD centers across Germany. Per study protocol, the analysis excluded biologic-experienced patients and those with a missing Harvey-Bradshaw Index score, resulting in a final sample of 327 biologic-naïve CD patients. Clinical remission was measured using the Harvey-Bradshaw Index at the end of induction therapy and after 1 and 2 years. Switching to a different therapy was considered an outcome failure. Propensity score adjustment with inverse probability of treatment weighting was used to correct for confounding.

RESULTS

The effectiveness of both VEDO (n = 86) and anti-TNF (n = 241) was remarkably high for induction treatment, but VEDO performed significantly less well than anti-TNF (clinical remission: 56.3% vs 73.9%, P < .05). In contrast, clinical remission after 2 years was significantly better for VEDO compared with anti-TNF (74.2% vs 44.7%; P < .05; odds ratio, 0.45; 95% CI, 0.22-0.94). Remarkably, only 17% of patients switched from VEDO to another biologic vs 44% who received anti-TNF.

CONCLUSIONS

The results of this prospective, 2-year, real-world evidence study suggest that the choice of VEDO led to higher remission rates after 2 years compared with anti-TNF. This could support the role of VEDO as a first-line biologic therapy in CD.

Health Status, Quality of Life, Psychosocial Well-being, and Wearables Data of Patients With Active Ulcerative Colitis Receiving Filgotinib Therapy (FilgoColitis Study): Protocol for a Real-world Observational Study

BACKGROUND

Filgotinib was approved in Germany for treating patients with moderate to severe active ulcerative colitis in November 2021. It represents a preferential Janus kinase 1 inhibitor. The FilgoColitis study began recruiting immediately after approval and aims to assess filgotinib effectiveness under real-world conditions with a particular focus on patient-reported outcomes (PROs). The novelty of the study design is the optional inclusion of 2 innovative wearables, which could provide a new layer of patient-derived data.

OBJECTIVE

The study investigates quality of life (QoL) and psychosocial well-being of patients with active ulcerative colitis during long-term exposure to filgotinib. PROs related to QoL and psychometric profiles (fatigue and depression) are collected alongside with disease activity symptom scores. We aim to evaluate physical activity patterns collected by wearables as an addition to traditional PROs, patient-reported health status, and QoL in different phases of disease activity.

METHODS

This is a prospective, single-arm, multicentric, noninterventional, observational study with a sample size of 250 patients. QoL is assessed with validated questionnaires: the Short Inflammatory Bowel Disease Questionnaire (sIBDQ) for the disease-specific QoL, the EQ-5D for the general QoL, and the fatigue questionnaire (Inflammatory Bowel Disease-Fatigue [IBD-F]). Physical activity data are collected from patients using wearables (SENS motion leg sensor [accelerometry] and smartwatch, GARMIN vívosmart 4).

RESULTS

The enrollment started in December 2021 and was still open at the date of submission. After 6 months of study initiation, 69 patients were enrolled. The study is expected to be completed in June 2026.

CONCLUSIONS

Real-world data for novel drugs are important to assess effectiveness outside of highly selected populations represented by randomized controlled trials. We examine whether patients' QoL and other PROs can be supplemented with physical activity patterns measured objectively. Use of wearables with newly defined outcomes represents an additional observational tool for monitoring disease activity in patients with inflammatory bowel disease.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00027327; https://drks.de/search/en/trial/DRKS00027327.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42574.

Evaluation of a downstaging, bidirectional version of the Montreal classification of Crohn's disease: Analysis of 5-year follow-up data from the prospective BioCrohn study

OBJECTIVE

Under the assumption of irreversibility, the Montreal classification provides a unidirectional assessment of the complications and behaviour of Crohn's disease (CD) that does not allow for downstaging. We examined the use of a bidirectional Montreal classification system that can capture disease regression.

DESIGN

From the BioCrohn Registry, an inception cohort of patients with CD for ≤12 months duration was defined and followed up for 5-years. Cumulative probabilities for developing complications were estimated using the Kaplan-Meier method. Potential associations of explanatory variables with disease progression were estimated with Cox regression.

RESULTS

Among 393 incident CD patients (of whom 255 completed the entire follow-up), the 5-year cumulative probability of developing complications was 41.5% (15.6% and 25.9% for stricturing and penetrating complications respectively). Perianal disease (hazard ratio [95% confidence interval]: 8.45 [4.74-15.07]) and surgical resection of the intestine (2.71 [1.50-4.92]) in the very early phase of the disease were associated with a higher risk of developing a penetrating complication within the 5-year follow-up. The use of a bidirectional Montreal classification system which can account for disease regression demonstrated that 90% of patients exhibited inflammatory disease behaviour at 5 years, in contrast to 58%, if the hierarchical, unidirectional Montreal classification system was used.

CONCLUSION

An additional bidirectional disease behaviour assessment capturing reversed or fully controlled complications may provide a more realistic appraisal of the complexity and unmet needs of patients treated with advanced therapies.

Early MOnitoring of REsponse (MORE) to Golimumab Therapy: Results of a Multicentre, Prospective Observational Trial

BACKGROUND

The therapeutic goal of clinical remission in patients with moderate to severe ulcerative colitis (UC) is achieved after biological therapy only in 16-39%. Individualization of therapeutic intervention would benefit from prediction of early response.

STUDY OBJECTIVE

The primary objective of our study was to assess golimumab (GLM) trough serum level of ≥2.5 μg/mL in combination with a reduction of faecal calprotectin (FC) of ≥50% at week 6 compared to baseline to predict clinical response at week 26 after regular GLM intake.

METHODS

Patients with moderate to severe active UC and planned GLM treatment were recruited for a prospective, multicentre, observational study in Germany. Prediction of clinical response was assessed by FC and GLM trough level. Missing data were imputed as therapy failure according to the last observation carried forward method.

RESULTS

Fifty nine patients have been enrolled. 54% of patients were anti-TNF naïve. Clinical response at week 6 was a significant predictor for achieving clinical response at week 26 (odds ratio [OR] 10.97, confidence interval [CI], 2.96-40.68; p < 0.001). Moreover, patients with a GLM trough level of ≥2.5 μg/mL and a ≥50% reduction of FC at week 6 had an OR of 5.33 (95% CI, 0.59-47.84) to achieve clinical response at week 26.

CONCLUSION

Clinical response at week 6 is the best predictive marker for achieving clinical response at week 26. Consideration of significant reduction of FC and trough GLM serum levels could improve prediction of response.

Prevalence of Itch in German Schoolchildren: A Population-based Study

Itch is a common symptom, but there is limited evidence on the prevalence of itch in children. The aim of this study was to assess the prevalence of itch in schoolchildren. A questionnaire was developed by experts in the field and based on a literature search. The questionnaire was applied in a pilot study of 25 consecutively selected paediatric patients and their parents. It confirmed the high content validity of the questionnaire, and the questionnaire was comparable to hospital records regarding chronic itch (n = 19, mean consistency 89.47%). The questionnaire was distributed among German schoolchildren in 9/12 randomly selected primary schools in Kiel, Germany. Of 1,722 invited students, 443 schoolchildren aged 6–10 years participated, and 26.2% (n = 116) reported itch. The prevalence of acute itch was 20.0% (n = 87), and 14.7% (n = 65) reported chronic itch. Reduced sleep and mood were often related to chronic itch. This study demonstrated that itch is a common symptom in German schoolchildren.

Relationship between Birth Weight, Early Growth Rate, and Body Composition in 5- to 7-Year-Old Children

BACKGROUND

Programing of body composition during intrauterine growth may contribute to the higher risk for cardio-metabolic disease in individuals born small or large for gestational age (SGA, LGA). Compensations of intrauterine growth by catch-up or catch-down postnatal growth may lead to adverse consequences like a thin-fat phenotype.

METHODS

The impact of (i) birth weight as well as (ii) the interaction between birth weight and catch-up or catch-down growth during the first 2 years of life on fat-free mass index (FFMI) and fat mass index (FMI) in 3,204 5-7-year-old children were investigated using Hattori's body composition chart. Body composition results were compared to appropriate for gestational age (AGA) birth weight with the same body mass index (BMI).

RESULTS

In total, 299 children at age 5-7 years were categorized as SGA, 2,583 as AGA, and 322 as LGA. When compared to AGA-children, BMI at 5-7 years of age was higher in LGA-children (15.5 vs. 16.2 kg/m2; p < 0.001) but not different in SGA-children. Compared to AGA with the same BMI, LGA was associated with higher FMI and a lower FFMI in 5-7-year-old girls. This phenotype was also seen for both sexes with catch-down growth during the first 2 years of life whereas catch-up growth prevented the higher FMI and lower FFMI per BMI. By contrast, SGA was associated with a higher FFMI and lower FMI in 5-7-year-old boys compared to AGA boys with the same BMI. This phenotype was also seen with catch-down growth in both genders whereas catch-up growth in girls led to more gain in FMI per BMI.

CONCLUSION

LGA with a compensatory catch-down postnatal growth may be a risk factor for the development of disproportionate gain in fat over lean mass whereas SGA with a catch-down postnatal growth seems to favor the subsequent accretion of lean over fat mass. A higher propensity of lean mass accretion during postnatal growth in boys compared to girls explains sex differences in these phenotypes.

Profile of patients with inflammatory bowel disease in conjunction with unmet needs and decision-making for choosing a new biologic therapy: a baseline analysis of the VEDOIBD-Study

PURPOSE

We characterized the profile of Crohn's disease (CD) or ulcerative colitis (UC) biologic-naïve patients (starting a new therapy with vedolizumab or TNFα-antagonists), their baseline disease activity predictors, and their perception of the quality of life (HRQoL).

METHODS

The VEDO_IBD-Study is a real-world study on the effectiveness of vedolizumab vs other biologics as induction and maintenance therapy for CD and UC. A total of 627 CD and 546 UC patients were enrolled from IBD-experienced centers across Germany. In both biologic-naïve vedolizumab (n=397) and anti-TNF (n=359) patients, CD and UC disease severity and HRQoL predictors were analyzed with logistic regression. The results were reported as odds ratio (OR) and 95% confidence interval (CI).

RESULTS

When compared to biologic-naïve anti-TNF patients, a first biological therapy with vedolizumab was considered for older CD patients, with a less complicated though longer disease course, and with a history of comorbidities. No differences in (unmet) needs were observed among patients with UC. The presence of extra-intestinal manifestations in biologic-naïve anti-TNF patients with CD (OR (95% CI): 3.83 (1.69-8.68)) and, in both biologic-naïve groups of patients with UC, stool frequency (2.00 (1.25-3.19); 1.82 (1.10-3.02), respectively) and rectal bleeding (2.24 (1.20-4.18); 1.92 (1.19-3.11), respectively) emerged as the most important predictors of disease severity, which in turn were also significantly associated with a worse HRQoL.

CONCLUSION

This study highlights the existence of unmet medical needs of patients with CD or UC, for whom a new biological therapy is planned as part of the VEDO_IBD-Study, which considerably impacts their HRQoL.

Body Composition Characteristics of a Load-Capacity Model: Age-Dependent and Sex-Specific Percentiles in 5- to 17-Year-Old Children

INTRODUCTION

Body composition assessment is superior to the use of body mass index (BMI) to characterize the nutritional status in pediatric populations. For data interpretation, suitable reference data are needed; hence, we aimed to generate age-dependent and sex-specific body composition reference data in a larger population of children and adolescents in Germany.

METHODS

This is a cross-sectional study on a representative group of 15,392 5- to 17-year-old children and adolescents. Body composition was assessed by bioelectrical impedance analysis using a population-specific algorithm validated against air displacement plethysmography. Age- and sex-specific percentiles for BMI, fat mass index (FMI), fat-free mass index (FFMI), and a "load-capacity model" (characterized by the ratios of fat mass [FM]/ fatt-free mass [FFM] and FM/FFM2) were modeled using the LMS method.

RESULTS

BMI, FMI, FFMI, FM/FFM, and FM/FFM2 curves showed similar shapes between boys and girls with steady increases in BMI, FMI, and FFMI, while FM/FFM2-centiles decreased during early childhood and adolescence. Sex differences were observed in FMI and FM/FFM percentiles with increases in FMI up to age 9 years followed by a steady decrease in FM/FFM during and after puberty with a fast-growing FFMI up to age 17 in boys. The prevalence of low FFM relative to FM reached more than 60% in overweight children and adolescents.

CONCLUSION

These pediatric body composition reference data enable physicians and public health scientists to monitor body composition during growth and development and to interpret individual data. The data point out to an early risk of sarcopenia in overweight children and adolescents.

Family and Lifestyle Factors Mediate the Relationship between Socioeconomic Status and Fat Mass in Children and Adolescents

Socioeconomic status (SES) is strongly associated with childhood overweight. The underlying mechanism and the role of family and lifestyle factors as potential mediators of this relationship remain, however, unclear. Cross-sectional data of 4,772 girls and boys aged 5-16 years from the Kiel Obesity Prevention Study were considered in mediation analyses. Fat mass (FM) was assessed by bioelectrical impedance analysis and converted into a percent FM SD score (FM%-SDS). SES was defined by the parental educational level, classified as low, middle, or high. Characteristics of family and lifestyle factors were obtained via validated questionnaires and considered as mediators. In 3 different age groups, the product-of-coefficients method was used to examine age-specific mediator effects on the relationship between SES and FM%-SDS (c = total effects) and their ratio to total effects, adjusted for age, sex, puberty, and nationality. The prevalence of overweight was 6.9%. In all age groups, SES was inversely associated with FM%-SDS as follows: 5-7 years, c1 = -0.11 (95% CI -0.19 to -0.03); 9-11 years, c2 = -0.21 (95% CI -0.27 to -0.14); and 13-16 years, c3 = -0.23 (95% CI -0.28 to -0.17). The relationship between SES and FM%-SDS was fully (5-7 and 9-11 years) and partly (13-16 years) mediated by similar and age-specific mediators, including parental BMI, parental smoking habits, media consumption, physical activity, and shared meals. Overall, these variables resulted in a total mediating effect of 77.8% (5-7 years), 82.4% (9-11 years), and 70.6% (13-16 years). Consistent for both sexes, the relationship between SES and FM%-SDS was therefore mediated by parental weight status, risk-related behavior within families, and children's and adolescents' lifestyle factors. Strategies for obesity prevention, which are predominantly targeted at socially disadvantaged groups, should therefore address the family environment and lifestyle factors.

Dietary Patterns in Primary School are of Prospective Relevance for the Development of Body Composition in Two German Pediatric Populations

This study performed comparative analyses in two pediatric cohorts to identify dietary patterns during primary school years and examined their relevance to body composition development. Nutritional and anthropometric data at the beginning of primary school and two or four years later were available from 298 and 372 participants of IDEFICS-Germany (Identification and prevention of Dietary-induced and lifestyle-induced health Effects In Children and infants Study) and the KOPS (Kiel Obesity Prevention Study) cohort, respectively. Principal component analyses (PCA) and reduced rank regression (RRR) were used to identify dietary patterns at baseline and patterns of change in food group intake during primary school years. RRR extracted patterns explaining variations in changes in body mass index (BMI), fat mass index (FMI), and waist-to-height-ratio (WtHR). Associations between pattern adherence and excess gain in BMI, FMI, or WtHR (>75th percentile) during primary school years were examined using logistic regression. Among PCA patterns, only a change towards a more Mediterranean food choice during primary school years were associated with a favorable body composition development in IDEFICS-Germany (p < 0.05). In KOPS, RRR patterns characterized by a frequent consumption of fast foods or starchy carbohydrate foods were consistently associated with an excess gain in BMI and WtHR (all p < 0.005). In IDEFICS-Germany, excess gain in BMI, FMI, and WtHR were predicted by a frequent consumption of nuts, meat, and pizza at baseline and a decrease in the consumption frequency of protein sources and snack carbohydrates during primary school years (all p < 0.01). The study confirms an adverse impact of fast food consumption on body composition during primary school years. Combinations of protein and carbohydrate sources deserve further investigation.

Postdiagnostic physical activity, sleep duration, and TV watching and all-cause mortality among long-term colorectal cancer survivors: a prospective cohort study

BACKGROUND

Lifestyle recommendations for cancer survivors are warranted to improve survival. In this study, we aimed to examine the association of total physical activity, different types of physical activity, hours of sleeping at day and night, and hours spent watching television (TV) with all-cause mortality in long-term colorectal cancer (CRC) survivors.

METHODS

We assessed physical activity in 1376 CRC survivors (44% women; median age, 69 years) at median 6 years after CRC diagnosis using a validated questionnaire. Multivariable-adjusted Cox regression models were used to estimate hazard ratios (HRs) for all-cause mortality according to categories of physical activities, sleep duration, and TV watching.

RESULTS

During a median follow-up time of 7 years, 200 participants had died. Higher total physical activity was significantly associated with lower all-cause mortality (HR: 0.53; 95% CI: 0.36-0.80, 4th vs. 1st quartile). Specifically, sports, walking, and gardening showed a significant inverse association with all-cause mortality (HR: 0.34; 95% CI: 0.20-0.59, HR: 0.65; 95% CI: 0.43-1.00, and HR: 0.62; 95% CI: 0.42-0.91, respectively for highest versus lowest category). Individuals with ≥2 h of sleep during the day had a significantly increased risk of all-cause mortality compared to individuals with no sleep at day (HR: 2.22; 95% CI: 1.43-3.44). TV viewing of ≥4 h per day displayed a significant 45% (95% CI: 1.02-2.06) higher risk of dying compared to ≤2 h per day of watching TV.

CONCLUSIONS

Physical activity was inversely related to all-cause mortality; specific activity types might be primarily responsible for this association. More hours of sleep during the day and a higher amount of TV viewing were each associated with higher all-cause mortality. Based on available evidence, it is reasonable to recommend CRC survivors to engage in regular physical activity.

Association of Vitamin E Levels with Metabolic Syndrome, and MRI-Derived Body Fat Volumes and Liver Fat Content

We aimed to relate circulating α- and γ-tocopherol levels to a broad spectrum of adiposity-related traits in a cross-sectional Northern German study. Anthropometric measures were obtained, and adipose tissue volumes and liver fat were quantified by magnetic resonance imaging in 641 individuals (mean age 61 years; 40.6% women). Concentrations of α- and γ-tocopherol were measured using high performance liquid chromatography. Multivariable-adjusted linear and logistic regression were used to assess associations of circulating α- and γ-tocopherol/cholesterol ratio levels with visceral (VAT) and subcutaneous adipose tissue (SAT), liver signal intensity (LSI), fatty liver disease (FLD), metabolic syndrome (MetS), and its individual components. The α-tocopherol/cholesterol ratio was positively associated with VAT (β scaled by interquartile range (IQR): 0.036; 95%Confidence Interval (CI): 0.0003; 0.071) and MetS (Odds Ratio (OR): 1.83; 95% CI: 1.21–2.76 for 3rd vs. 1st tertile), and the γ-tocopherol/cholesterol ratio was positively associated with VAT (β scaled by IQR: 0.066; 95% CI: 0.027; 0.104), SAT (β scaled by IQR: 0.048; 95% CI: 0.010; 0.087) and MetS (OR: 1.87; 95% CI: 1.23–2.84 for 3rd vs. 1st tertile). α- and γ-tocopherol levels were positively associated with high triglycerides and low high density lipoprotein cholesterol levels (all P_trend < 0.05). No association of α- and γ-tocopherol/cholesterol ratio with LSI/FLD was observed. Circulating vitamin E levels displayed strong associations with VAT and MetS. These observations lay the ground for further investigation in longitudinal studies.

Postdiagnostic Mediterranean and Healthy Nordic Dietary Patterns Are Inversely Associated with All-Cause Mortality in Long-Term Colorectal Cancer Survivors

Background: Dietary factors are known to affect the risk of new-onset colorectal cancer (CRC), but information on the extent to which postdiagnostic diet affects mortality in long-term CRC survivors is scarce.Objective: We investigated the association of 2 a priori-defined postdiagnostic dietary patterns [Modified Mediterranean Diet Score (MMDS) and healthy Nordic Food Index (HNFI)] with all-cause mortality in long-term CRC survivors.Methods: Diet was assessed at a median time of 6 y after cancer diagnosis in 1404 CRC survivors (median age: 69 y; 56% men) in a prospective cohort study in Northern Germany by using a semiquantitative food-frequency questionnaire. Cox proportional hazard models, adjusting for clinical and sociodemographic characteristics, were used to assess associations of the MMDS and the HNFI with all-cause mortality.Results: A total of 204 patients died during a median follow-up time of 7 y after diet assessment. In multivariable-adjusted models, higher adherence to the modified Mediterranean diet was significantly associated with lower all-cause mortality (HR: 0.48; 95% CI: 0.32, 0.74 for highest compared with lowest score quartile and HR: 0.88; 95% CI: 0.81, 0.96 per 1-point increment in pattern score). Similarly, the HNFI was inversely associated with all-cause mortality when the highest was compared with the lowest index quartile (HR: 0.63; 95% CI: 0.39, 1.04) and when modeled as a continuous trait (HR: 0.90; 95% CI: 0.82, 0.99 per 1-point increment in the score).Conclusions: Our results suggest that higher adherences to the Mediterranean diet and to the healthy Nordic diet after CRC diagnosis are associated with better overall survival in long-term CRC survivors.

[Required Effekt Sizes of Preventive Measures for Overweight in Children and Adolescents]

BACKGROUND AND AIM OF THE STUDY

Successful preventive measures can stop a further increase in the prevalence of overweight in children and adolescents. However, up to now, the required effect sizes of interventions for reducing childhood overweight remain unclear. The calculation of the energy gap (excess calories consumed over calories expended) offers the possibility to estimate the required effect sizes. In this work 2 approaches to calculate the energy gap will be compared.

METHODS

Longitudinal data of 1690 children and adolescents of the Kiel Obesity Prevention Study (KOPS) on measured height, weight, fat mass and fat-free mass (using bioelectrical impedance analysis) at age 6 and 10 years will be used to calculate energy gap with 2 different approaches: (i) using age-independent changes in fat mass and fat-free mass (old approach) and (ii) using a mathematic model of weight dynamic (new approach).

RESULTS

Energy gap according to the old approach was 140 kcal/day; by contrast, new modeling resulted in an energy gap between 270 and 370 kcal/day. Both, BMI and fat mass were suitable to calculate energy gap and led to nearly same results. Exceeding the 90(th) percentile of BMI or fat mass (incidence approach) as well as large changes within the normal range (i.e. between the 10(th) and the 90(th) percentile) led to large energy gaps. Thus, all children with large energy gaps have to be characterized as at risk for overweight.

CONCLUSION

The new approach seems to be convincing because it considered the additional energy expenditure for building fat-free mass due to increasing age and weight.Calculating energy gap offers a new approach for prevention of overweight. It shows that the required effect sizes of prevention measures have to be in a region of 140 to 400 kcal/day. This differs clearly from energy reduction of diets in the therapy of obesity.

Differences in BMI z-scores between offspring of smoking and nonsmoking mothers: a longitudinal study of German children from birth through 14 years of age

BACKGROUND

Children of mothers who smoked during pregnancy have a lower birth weight but have a higher chance to become overweight during childhood.

OBJECTIVES

We followed children longitudinally to assess the age when higher body mass index (BMI) z-scores became evident in the children of mothers who smoked during pregnancy, and to evaluate the trajectory of changes until adolescence.

METHODS

We pooled data from two German cohort studies that included repeated anthropometric measurements until 14 years of age and information on smoking during pregnancy and other risk factors for overweight. We used longitudinal quantile regression to estimate age- and sex-specific associations between maternal smoking and the 10th, 25th, 50th, 75th, and 90th quantiles of the BMI z-score distribution in study participants from birth through 14 years of age, adjusted for potential confounders. We used additive mixed models to estimate associations with mean BMI z-scores.

RESULTS

Mean and median (50th quantile) BMI z-scores at birth were smaller in the children of mothers who smoked during pregnancy compared with children of nonsmoking mothers, but BMI z-scores were significantly associated with maternal smoking beginning at the age of 4-5 years, and differences increased over time. For example, the difference in the median BMI z-score between the daughters of smokers versus nonsmokers was 0.12 (95% CI: 0.01, 0.21) at 5 years, and 0.30 (95% CI: 0.08, 0.39) at 14 years of age. For lower BMI z-score quantiles, the association with smoking was more pronounced in girls, whereas in boys the association was more pronounced for higher BMI z-score quantiles.

CONCLUSIONS

A clear difference in BMI z-score (mean and median) between children of smoking and nonsmoking mothers emerged at 4-5 years of age. The shape and size of age-specific effect estimates for maternal smoking during pregnancy varied by age and sex across the BMI z-score distribution.

Overweight in adolescence can be predicted at age 6 years: a CART analysis in German cohorts

OBJECTIVE

To examine, whether overweight in adolescents can be predicted from the body mass index (BMI) category, at the age of 6, the mother's education level and mother's obesity and to quantify the proportion of overweight at the age of 14 that can be explained by these predictors.

METHOD

Pooled data from three German cohorts providing anthropometric and other relevant data to a total of 1 287 children. We used a classification and regression tree (CART) approach to identify the contribution of BMI category at the age of 6 (obese: BMI > 97th percentile (P97); overweight: P90 < BMI ≤ P97; high normal weight: P75P90) at the age of 14.

RESULTS

While 4.8% [95%CI: 3.2;7.0] of 651 boys and 4.1% [95%CI: 2.6;6.2] of 636 girls with a BMIP97 (similar results for girls). BM I ≥ P75 at the age of 6 explained 63.5% [95%CI: 51.1;74.5]) and 72.0% [95%CI: 60.4;81.8] of overweight/obesity at the age of 14 in boys and girls, respectively.

CONCLUSIONS

Overweight/obesity in adolescence can be predicted by BMI category at the age of 6 allowing for parent counselling or risk guided interventions in children with BMI ≥ P75, who accounted for >2/3 of overweight/obesity in adolescents.

Attributable risks for childhood overweight: evidence for limited effectiveness of prevention

OBJECTIVE

Calculation of attributable risks (ARs) of childhood overweight to estimate effectiveness of prevention strategies.

METHODS

We used pooled data of 4 population-based German studies including 34240 children and adolescents aged 3 to 18 years to calculate the impact of familial, social, "early life", and lifestyle factors on overweight. ARs (joint for all determinants as well as partial risks) were calculated.

RESULTS

The prevalence of childhood overweight was 13.4%. Successfully tackling all determinants can reduce overweight by 77.7% (ie, from 13.4% to 3.0%; = joint AR) with partial effects of treating parental overweight (42.5%); improving social status (14.3%); reducing media time to <1 hour per day (11.4%); and not smoking during pregnancy, low weight gain during pregnancy, and breastfeeding (together 9.5%), respectively. Improving all preventable risk factors (ie, early life factors and lifestyle) the effect is 9.2%. Media time has the strongest effect.

CONCLUSIONS

The determinants identified explained 78% of the prevalence of overweight. Taking into account the partial ARs, the effectiveness of lifestyle interventions to prevent overweight in children is limited. Our data argue in favor of interventions aimed at families and social environments, with a major focus on promoting a lower screen time and computer use in children.

Gestational weight gain and body mass index in children: results from three german cohort studies

Introduction

Previous studies suggested potential priming effects of gestational weight gain (GWG) on offspring’s body composition in later life. However, consistency of these effects in normal weight, overweight and obese mothers is less clear.

Methods

We combined the individual data of three German cohorts and assessed associations of total and excessive GWG (as defined by criteria of the Institute of Medicine) with offspring’s mean body mass index (BMI) standard deviation scores (SDS) and overweight at the age of 5–6 years (total: n = 6,254). Quantile regression was used to examine potentially different effects on different parts of the BMI SDS distribution. All models were adjusted for birth weight, maternal age and maternal smoking during pregnancy and stratified by maternal pre-pregnancy weight status.

Results

In adjusted models, positive associations of total and excessive GWG with mean BMI SDS and overweight were observed only in children of non- overweight mothers. For example, excessive GWG was associated with a mean increase of 0.08 (95% CI: 0.01, 0.15) units of BMI SDS (0.13 (0.02, 0.24) kg/m² of ‘real’ BMI) in children of normal-weight mothers. The effects of total and excessive GWG on BMI SDS increased for higher- BMI children of normal-weight mothers.

Discussion

Increased GWG is likely to be associated with overweight in offspring of non-overweight mothers.

Body fat percentiles for German children and adolescents

OBJECTIVE

The aim of this study was to define body fat percentiles for German children and adolescents aged 3-16 years using the largest German database.

METHODS

The study population included 11,632 girls and 11,604 boys. Data were pooled from: i) Kiel Obesity Prevention Study (KOPS), acquisition period: 1996-2008, n = 12,237; ii) 'Better diet. More exercise. KINDERLEICHT-REGIONS', acquisition period: 2007, n = 9,405; and iii) examination of Jena schoolchildren, acquisition period: 2005, n = 1,594. Body fat mass was measured by bioelectrical impedance analysis using a population-specific algorithm. Data were weighted to achieve a representative sample for Germany. Percentile curves were constructed by the LMS method and proved by Worm plots and Q-statistic.

RESULTS

In both genders, the higher body fat percentile curves sloped downwards to age 7 years, whereas the lower percentiles declined up to 8.5 years. Thereafter fat mass remained nearly constant with age in boys and increased in girls. The 10th percentile achieved a minimum of 10-11% body fat in both genders, whereas the 90th percentile curve fluctuated between 29 and 44% in boys or 30-43% in girls. The association between fat mass and blood pressure was too weak to define disease-related cut-offs.

CONCLUSION

These body fat percentiles are suitable reference values for German children and adolescents.

Eight-year follow-up of school-based intervention on childhood overweight--the Kiel Obesity Prevention Study

OBJECTIVE

The aim of this study was to evaluate the 8-year outcome of school-based intervention on weight status, lifestyle and blood pressure (BP) as part of the Kiel Obesity Prevention Study (KOPS).

METHODS

Within a quasi-randomized controlled trial, 240 intervention (I) and 952 non-intervention (NI) students at age 6 and 14 years were assessed in schools. Six nutrition units followed by 20-min running games were performed within the first year at school. Primary outcome was the 8-year change in body mass index standard deviation score (BMI-SDS) according to German references. Effective intervention was tested using multilevel linear regression analysis.

RESULTS

Eight-year changes in BMISDS were +0.18 and +0.22 with increases in prevalence of overweight from 8.3 to 10.4% and 7.0 to 11.2% in I and NI students, respectively. Cumulative 8-year incidence of overweight was 5.9% and 7.1% in I and NI students, respectively. There was no overall effect of intervention, but a significant interaction was shown between the intervention and the socio-economic status (SES), which demonstrated that in high SES, the 8-year change in BMI-SDS was in favour of I (-0.17 in I and +0.17 in NI; p < 0.01). Intervention had no measurable effects on lifestyle and BP.

CONCLUSIONS

School-based health promotion has some favourable and sustained effects on 8-year changes in BMI-SDS, which are most pronounced in students of high SES families. The data argue in favour of further preventive measures.

[Social inequality, migration, and healthy environments as determinants of overweight of children and adolescents. Results of the Kiel Obesity Prevention Study (KOPS)]

This study aimed at studying the relationships between different social determinants, overweight, migration background, lifestyle factors, and neighborhood characteristics in children and adolescents aged 6-14 years. Data were collected within the Kiel Obesity Prevention Study (KOPS). The lower the social status, the higher the prevalence of overweight (e.g., parental education low/middle/high,%: 18.4/13.6/7.9). Non-German children are twice as often overweight as German children (20.2% versus 11.7%) with a social gradient in overweight (%: 26.0/28.2/17.2). There are social differences in health-related behavior between the social groups and also between German and non-German children of the same social group. The social gradient in overweight is, in part, independent of lifestyle factors. Neighborhood characteristics like high food supply and traffic density add to the development of overweight. To summarize, overweight is a social issue; direct prevention has to address the social determinants of health as well as families with migration background. In addition, the development of "healthy" neighborhoods may support the prevention of overweight.

Health-related behaviour, knowledge, attitudes, communication and social status in school children in Eastern Germany

Enhancing health literacy is a keystone in health promotion. Yet, most studies on health literacy are limited to functional literacy levels. Furthermore, little evidence is available from children. Based on Nutbeam's outcome model for health promotion, this study aims (i) to elaborate a set of short scales to measure important health literacy domains in children and (ii) to analyse their associations among each other, with health behaviour as an intermediate health outcome, subjective health, social status and gender. The sample comprised 852 school children in fifth grade, aged 9-13 years, in Western Pomerania, Germany. Items were taken from the child's questionnaire to form short scales for health-related knowledge, attitudes, communication and behaviour. The internal consistencies of the communication and attitude scales were 0.73 and 0.57, respectively. Unidimensional scalability of the knowledge and behaviour scales was supported by item response models. Associations between health scales were modest. In regression analyses, social status and gender predicted only health knowledge and communication but not health behaviours, attitudes and self-efficacy. Health knowledge was not associated with any other scale. Our results suggest that targeting one specific component of health literacy in children is likely to exert only small effects on health status and health behaviour.

Long-term effects of rapid weight gain in children, adolescents and young adults with appropriate birth weight for gestational age: the Kiel Obesity Prevention Study

AIM

This study investigates the effect of rapid weight gain in term children, adolescents and young adults born appropriate for gestational age.

METHODS

In all, 173 girls and 178 boys aged 6.1-19.9 (12.5 +/- 3.1)years participated. Rapid weight gain (group 1) was defined as a change in weight-SDS (standard deviation score) from birth till two years >0.67, 'no change' as > or =-0.67 and < or =0.67 (group 2) vs 'slow weight gain' as <-0.67 (group 3). BMI-SDS, waist circumference (WC) z-score, fat mass (FM)/fat free mass (FFM; Air-Displacement-Plethysmography), resting energy expenditure (REE; ventilated hood system), cardio-metabolic risk factors, serum leptin and adiponectin were assessed. >90th age-/sex-specific BMI-percentile was defined as overweight. Parental BMI, socio-economic status and lifestyle were assessed as confounders.

RESULTS

A total of 22.8% gained weight rapidly, and 15.7% was overweight. Group 1 compared with group 2 and 3 subjects was taller, heavier and had a higher prevalence of overweight (girls/boys: 26.2%/28.9% vs 11.6%/19.0% vs 2.8%/5.0%; p < 0.01/p < 0.05). Concomitantly, a higher WC, %FM and FFM were observed. Rapid weight gain was positively associated with REE (adjusted for FFM) in boys (r = 0.26; p < 0.01), but not with cardio-metabolic risk factors.

CONCLUSION

Rapid weight gain was related to increases in height, weight, a higher prevalence of overweight and central fat distribution. In addition, rapid weight gain was related to a higher REE in boys, but not to cardio-metabolic risk factors.

Energy gain and energy gap in normal-weight children: longitudinal data of the KOPS

Population-based prevention of overweight needs evidence-based goals consistent with our present knowledge about energy gap (i.e., daily imbalance between energy intake and energy expenditure resulting in overweight). Longitudinal data of normal-weight children (1,029 girls and 1,028 boys; Kiel Obesity Prevention Study, KOPS) were used to calculate energy gain (i.e., increase in fat mass (FM) and fat-free mass (FFM)) in normal-weight children staying normal weight (persistent children) or becoming overweight (incident children). Taking into account weight gain in proportion to height gain (normal development) energy gap was calculated from increases in FM and FFM exceeding normal development. Children were divided into two groups and were followed from age 6 to 10 (group A) and 10 to 14 years (group B). FM and FFM were measured. Medians of 4-year BMI- (kg/m(2))/weight changes (kg) were +1.8/+13.2 (A) and +3.0/+18.7 (B) in girls, and +1.6/+12.8 (A) and +2.6/21.7 (B) in boys. Corresponding data for FM/FFM (kg) were +3.1/+10.2 (A) and +5.1/12.7 (B) in girls, and +2.3/10.8 (A) and +3.0/18.6 (B) in boys. The 4-year-incidence of overweight (%) were 9.4 (A) and 5.4 (B) in girls, and 11.0 (A) and 3.8 (B) in boys, respectively. Mean energy gains (kcal/day) were 26.8 (A) and 46.4 (B) in girls, and 22.1 (A) and 32.5 (B) in boys. The 90th percentile of energy gap (kcal/day) in incident children were 58.1 (A) and 72.0 (B) in girls and 46.0 (A) and 53.2 (B) in boys. To prevent overweight in children energy gap should not exceed 46-72 kcal/day.

Assessment of representativity of a study population - experience of the Kiel Obesity Prevention Study (KOPS)

OBJECTIVE

Exemplified by data of the Kiel Obesity Prevention Study (KOPS), different methods to control for response bias and to assess representativity were compared.

METHODS

4,997 cross-sectional data of 5- to 7-year-old German children (main cohort) were investigated between 1996 and 2001 within school entry examination. A subgroup responded to a questionnaire to socio-demographic and lifestyle factors (responders, n = 2,631). Representativity of the main cohort was tested in comparison to the total population. To control for response bias within the responders a non-response analysis as well as an analysis of missing values were performed.

RESULTS

The comparison with the total population showed a higher prevalence of obese boys and girls from families of low socio-economic status (SES) within the main cohort. The responders were less frequently obese and overweight and more rarely belonged to low SES families when compared with non-responders. Analysis of missing values did not detect any further biases. According to an epidemiological assessment of differences the main cohort of KOPS is suggested to be representative for all 5- to 7-year-old children in Kiel, whereas the responders can be at best called 'relatively' representative.

CONCLUSION

The analysis of non-response is the most sensitive method to detect group differences, but a comparison with the total population can also be used to control for biases. In addition representativity has to be proven not only for the main cohort but also for the subgroup of responders with which data analysis will be done.

Four-year follow-up of school-based intervention on overweight children: the KOPS study

OBJECTIVE

To evaluate the 4-year outcome of a school-based health promotion on weight status as part of the Kiel Obesity Prevention Study (KOPS).

RESEARCH METHODS AND PROCEDURES

Within a cluster-sampled quasi-randomized controlled trial, 1764 children at 6 and 10 years of age were assessed between 1996 and 2005 in 32 primary schools in Kiel, North Germany. Six nutrition units followed by 20-minute running games were performed within the first year at school. Prevalence, incidence, and remission of overweight were main outcome measures.

RESULTS

The 4-year change in BMI was +11.6%, with increases in prevalence of overweight and obesity from 5.2% to 11.1% and 3.9% to 5.1%, respectively. Cumulative 4-year incidence of overweight and obesity was 9.2% and 3.1%, respectively. Intervention had no effect on mean BMI. The effect on prevalence was significant in children from families with high socioeconomic status [odds ratio (OR), 0.35; 95% confidence interval (CI), 0.14 to 0.91] and marginally significant in children of normal-weight mothers (OR, 0.57; 95% CI, 0.33 to 1.00). Cumulative 4-year incidence of overweight was lower only in intervention children from families with high socioeconomic status (OR, 0.26; 95% CI, 0.07 to 0.87). Remission of overweight was most pronounced in children of normal-weight mothers (OR, 5.43; 95% CI, 1.28 to 23.01). Prevalence of underweight was unchanged. The intervention had minor but favorable effects on lifestyle.

DISCUSSION

A school-based health promotion has sustainable effects on remission and incidence of overweight; it was most pronounced in children of normal-weight mothers and children from families with high socioeconomic status. There was no effect on obesity. The data argue in favor of additional measures of prevention.

Associations between active commuting to school, fat mass and lifestyle factors in adolescents: the Kiel Obesity Prevention Study (KOPS)

OBJECTIVE

To examine possible associations between active commuting (walking or cycling) to school, parameters of adiposity and lifestyle factors in 14-year-old adolescents of the Kiel Obesity Prevention Study.

SUBJECTS

A total of 626 14-year-old adolescents.

METHODS

Measured body mass index (BMI), fat mass (FM), distance to school as well as self-reported modes and duration of commuting to school, time spent in structured and unstructured physical activities (PAs), media use, nutrition, alcohol consumption and smoking.

RESULTS

Parameters of adiposity did not differ between different commuting modes after stratifying by gender. Active commuters reported higher overall PA, which was caused by commuting activity and time spent in unstructured PA in girls and just by commuting activity in boys. In active commuters, 28.4% of overall PA was explained by commuting activity. Additionally, TV viewing was lower in active commuters. Compared to their inactively commuting counterparts, actively commuting boys were less likely to smoke. After controlling for potential confounders the interaction term 'active commuting by distance to school' and 'time spent in structured PA' were independent predictors of FM, whereas active commuting by itself showed no effect.

CONCLUSION

The present data suggest that active commuting to school per se does not affect FM or BMI until considering distance to school. Increasing walking or cycling distance results in decreasing FM. However, the everyday need to get to and from school may enhance adolescents' overall PA.