The role of parents in behavioral treatment for adolescent obesity: design and rationale for the TEENS+ randomized clinical trial

BACKGROUND

There is an urgent need for innovative approaches to adolescent obesity treatment, particularly among individuals from racially and ethnically marginalized backgrounds, who face increased risk of obesity and its associated morbidity and mortality. There is a particular dearth of research on the long-term efficacy of adolescent obesity treatments. Further, research and clinical practice guidelines consistently recommend parents' inclusion in their adolescents' obesity treatment, yet the most effective strategy to engage parents in adolescent obesity treatment remains unclear. Towards that end, this investigation will conduct a fully-powered, randomized clinical trial to examine the efficacy of two distinct approaches to involving parents in their adolescents' obesity treatment.

METHODS

Participants will be 210 12-16 year old adolescents (body mass index [BMI]≥85th percentile) and parents (BMI≥25 kg/m2) with overweight or obesity. Dyads will be randomized to one of two 4-month treatments: 1) TEENS+Parents as Coaches (PAC), engaging parents as helpers in their child's weight management via parent skills training based on authoritative parenting, or 2) TEENS+Parent Weight Loss (PWL), engaging parents in their own behavioral weight management. All adolescents will participate in the TEENS+ protocol, which includes nutrition education with dietary goals, supervised physical activity, and behavioral support, and integrates motivational interviewing to enhance treatment engagement. Assessments of anthropometrics, dietary intake, physical activity, parenting and home environment variables will be completed at 0, 2, 4, 8, and 12 months with the primary endpoint at 12-month follow-up.

DISCUSSION

Results of this investigation have the potential to significantly advance science in this area and ultimately inform clinical practice guidelines related to the role of parents in adolescent obesity treatment.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03851796. Registered: February 22, 2019.

A scalable, virtual weight management program tailored for adults with type 2 diabetes: effects on glycemic control

BACKGROUND

The objective was to test the efficacy of a scalable, virtually delivered, diabetes-tailored weight management program on glycemic control in adults with type 2 diabetes (T2D).

METHODS

This was a single arm, three-site clinical trial. Participants had baseline HbA1c between 7-11% and BMI between 27-50 kg/m². Primary outcome was change in HbA1c at 24 weeks. Secondary outcomes were changes in body weight, waist circumference, the Diabetes Distress Scale (DDS), quality of life (IWQOL-L), and hunger (VAS). Generalized linear effects models were used for statistical analysis.

RESULTS

Participants (n = 136) were 56.8 ± 0.8 y (Mean ± SEM), 36.9 ± 0.5 kg/m², 80.2% female, 62.2% non-Hispanic white. Baseline HbA1c, weight, and total DDS score were 8.0 ± 0.09%, 101.10 ± 1.47 kg, and 2.35 ± 0.08, respectively. At week 24, HbA1c, body weight, and total DDS decreased by 0.75 ± 0.11%, 5.74 ± 0.50%, 0.33 ± 0.10 units, respectively (all p < 0.001). Also, at week 24, quality of life increased by 9.0 ± 1.2 units and hunger decreased by 14.3 ± 2.4 units, (both p < 0.0001).

CONCLUSIONS

The scalable, virtually delivered T2D-tailored weight management program had favorable and clinically meaningful effects on glycemic control, body weight, and psychosocial outcomes.

Effect of a Lifestyle Intervention on Cardiometabolic Health Among Emerging Adults: A Randomized Clinical Trial

IMPORTANCE

The prevalence of obesity has increased substantially among emerging adults, yet no previous large-scale behavioral weight loss trials have been conducted among this age group.

OBJECTIVE

To test the effect of 2 theory-based motivational enhancements on weight loss within a primarily digital lifestyle intervention designed for emerging adults.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial conducted at an academic medical research center, 382 participants aged 18 to 25 years with a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 25 to 45 were enrolled between February 2, 2016, and February 6, 2019. Data collection was completed February 8, 2020. Analysis was performed on an intention-to-treat basis.

INTERVENTIONS

Participants were randomized to 1 of 3 groups: developmentally adapted behavioral weight loss (aBWL), aBWL plus behavioral economics (aBWL + BE), or aBWL plus self-determination theory (aBWL + SDT). All groups received a 6-month intervention with 1 group session, 1 individual session, and a digital platform (digital tools for self-monitoring, weekly lessons, tailored feedback, text messages, and optional social media). The aBWL + BE group received modest financial incentives for self-monitoring and weight loss; the aBWL + SDT group received optional experiential classes. Coaching and message framing varied by group.

MAIN OUTCOMES AND MEASURES

The primary outcome was mean (SE) weight change (in kilograms) at 6 months. Secondary outcomes included proportion of participants achieving weight loss of 5% or more, percentage weight change, waist circumference, body composition, and blood pressure.

RESULTS

Among the 382 participants (mean [SD] age, 21.9 [2.2] years), 316 (82.7%) were female, mean (SD) BMI was 33.5 (4.9), 222 (58.1%) were of underrepresented race and/or ethnicity, and 320 (83.8%) were retained at the primary end point. There was a significant time effect for mean (SE) weight loss (-3.22 [0.55] kg in the aBWL group; -3.47 [0.55] kg in the aBWL + BE group; and -3.40 [0.53] kg in the aBWL + SDT group; all P < .001), but no between-group differences were observed (aBWL vs aBWL + BE: difference, -0.25 kg [95% CI, -1.79 to 1.29 kg]; P = .75; aBWL vs aBWL + SDT: difference, -0.18 kg [95% CI, -1.67 to 1.31 kg]; P = .81; and aBWL + SDT vs aBWL + BE: difference, 0.07 kg [95% CI, -1.45 to 1.59 kg]; P = .93). The proportion of participants achieving a weight loss of 5% or more was 40.0% in the aBWL group (50 of 125), 39.8% in the aBWL + BE group (51 of 128), and 44.2% in the aBWL + SDT group (57 of 129), which was not statistically different across groups (aBWL vs aBWL + BE, P = .89; aBWL vs aBWL + SDT, P = .45; aBWL + SDT vs aBWL + BE, P = .54). Parallel findings were observed for all secondary outcomes-clinically and statistically significant improvements with no differences between groups.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, all interventions produced clinically significant benefit, but neither of the motivational enhancements promoted greater reductions in adiposity compared with the developmentally adapted standard group. Continued efforts are needed to optimize lifestyle interventions for this high-risk population and determine which intervention works best for specific individuals based on sociodemographic and/or psychosocial characteristics.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02736981.

The role of parents in adolescent obesity treatment: Results of the TEENS+ randomized clinical pilot trial

BACKGROUND

The optimal role for involving parents in adolescent obesity treatment is unknown.

OBJECTIVE

To demonstrate that two parent approaches within adolescent obesity treatment are distinct, as evidenced by differential parent outcomes, and determine the preliminary efficacy of each approach on adolescent weight loss.

METHODS

Adolescent/parent dyads (N = 82; mean adolescent age = 13.7 ± 1.2 years) participated in TEENS+, a 4-month behavioural weight loss treatment. Participants were randomized to: (1) TEENS+parents as coaches (PAC; parent skills training), or (2) TEENS+parent weight loss (PWL; adult behavioural weight loss). Assessments occurred at 0, 4 (post-treatment), and 7-months. Within- and between-group repeated measures general linear mixed models examined change in parent weight (∆kg; primary outcome); parenting, feeding, weight control strategies, home environment, and adolescent body mass index (∆BMI; secondary outcomes).

RESULTS

PWL parents had greater 4-month weight losses (∆kg_0-4m  = -5.14 ± 4.87 kg) compared to PAC (-2.07 ± 3.89 kg; between-group p < 0.01). Key constructs differed between groups as expected. Both groups yielded significant within-group adolescent ∆BMI_0-4m (PWL: -0.97 ± 1.38 kg/m² vs. PAC: -0.93 ± 1.42 kg/m² ; ps < 0.01); during maintenance, adolescents in PWL had ∆BMI_4-7m increases (+0.41 ± 1.07 kg/m² ; p = 0.02) while PAC did not (+0.05 ± 1.31 kg/m² ; p = 0.82).

CONCLUSION

Parent treatments were distinct in implementation and both yielded significant 4-month adolescent weight loss. Differential weight patterns were observed during maintenance, favouring PAC, warranting further exploration.

The vaginal microbiome in women of reproductive age with healthy weight versus overweight/obesity

OBJECTIVE

The aim of this study was to evaluate the differences between the vaginal microbiome of reproductive-aged women with overweight and obesity (Ow/Ob) compared with healthy weight (HW).

METHODS

In this case-control study, a cohort of 367 nonpregnant women (18 to 40 years) with Ow/Ob (BMI ≥25 kg/m² ) was case-matched with 367 women with HW (BMI 18.0 to 24.9 kg/m² ). The study was a secondary analysis of 16S rRNA vaginal microbiome surveys through the Vaginal Human Microbiome Study (VaHMP). Groups were matched on age, race/ethnicity, income, and nulliparity status.

RESULTS

Mean age and BMI of Ow/Ob and HW groups were 26.8 versus 26.7 years and 37.0 versus 22.1 kg/m² , respectively. The overall vaginal microbiome composition differed between groups (PERMANOVA, p = 0.035). Women with Ow/Ob had higher alpha diversity compared with women with HW (Wilcoxon test, Shannon index p = 0.025; inverse Simpson index p = 0.026). Lactobacillus dominance (≥30% proportional abundance) was observed in a greater proportion of women with HW (48.7%) compared with Ow/Ob (40.1%; p = 0.026).

CONCLUSIONS

The vaginal microbiome differs in reproductive-aged women with Ow/Ob compared with women with HW, with increased alpha diversity and decreased predominance of Lactobacillus. Observed differences in the vaginal microbiome may partially explain differences in preterm birth and bacterial vaginosis risk between these populations.

Physicians certified by the American Board of Obesity Medicine provide evidence-based care

Our objective was to determine the clinical services offered by American Board of Obesity Medicine (ABOM) Diplomates and whether guideline concordant services varied by clinical practice attributes. We conducted a cross-sectional analysis of the 2019 ABOM Diplomate survey (response rate 19.2%). Respondents (n = 494) self-reported services offered: nutrition, exercise, mental health, minimally invasive bariatric procedures, perioperative bariatric surgical care and FDA-approved anti-obesity medications. We graded concordance of services offered with three evidence-based obesity guidelines, and then conducted bivariate analyses comparing concordance by practice attributes. Most responding ABOM Diplomates offered nutrition (90.1%), exercise (67.8%) and mental health (76.7%). Few offered minimally invasive procedures (24.3%), and most provided perioperative surgical care (63.0%). Most (83.4%) prescribed FDA-approved medications-typically both short- and long-term agents (70.9%). Few Diplomates had low concordance with the American Heart Association/American College of Cardiology/The Obesity Society (AHA/ACC/TOS) guidelines (24.7%). Those who managed more obesity-related conditions and endorsed AHA/ACC/TOS guideline use had higher concordance with these recommendations. No differences in guideline concordance existed by population, clinical effort or location. We found similar findings regarding concordance with ) American Association of Clinical Endocrinologists/American College of Endocrinology and Obesity Medicine Association guidelines. In conclusion, most responding ABOM Diplomates offer evidence-based obesity medicine services. Clinicians may therefore have increased confidence in patient receipt of evidence-based care when referring to an ABOM Diplomate.

Parent Involvement in Adolescent Obesity Treatment: A Systematic Review

CONTEXT

Family-based lifestyle interventions are recommended for adolescent obesity treatment, yet the optimal role of parents in treatment is unclear.

OBJECTIVE

To examine systematically the evidence from prospective randomized controlled and/or clinical trials (RCTs) to identify how parents have been involved in adolescent obesity treatment and to identify the optimal type of parental involvement to improve adolescent weight outcomes.

DATA SOURCES

Data sources included PubMed, PsychINFO, and Medline (inception to July 2019).

STUDY SELECTION

RCTs evaluating adolescent (12-18 years of age) obesity treatment interventions that included parents were reviewed. Studies had to include a weight-related primary outcome (BMI and BMI z score).

DATA EXTRACTION

Eligible studies were identified and reviewed, following the Preferred Reporting for Systematic Review and Meta-Analyses guidelines. Study quality and risk of bias were evaluated by using the Cochrane Collaboration risk of bias tool.

RESULTS

This search identified 32 studies, of which 23 were unique RCTs. Only 5 trials experimentally manipulated the role of parents. There was diversity in the treatment target (parent, adolescent, or both) and format (group sessions, separate sessions, or mixed) of the behavioral weight loss interventions. Many studies lacked detail and/or assessments of parent-related behavioral strategies. In ∼40% of unique trials, no parent-related outcomes were reported, whereas parent weight was reported in 26% and associations between parent and adolescent weight change were examined in 17%.

LIMITATIONS

Only RCTs published in English in peer-reviewed journals were eligible for inclusion.

CONCLUSIONS

Further research, with detailed reporting, is needed to inform clinical guidelines related to optimizing the role of parents in adolescent obesity treatment.

SUCCESSFUL REIMPLEMENTATION OF A VERY LOW CARBOHYDRATE KETOGENIC DIET AFTER SGLT2 INHIBITOR ASSOCIATED EUGLYCEMIC DIABETIC KETOACIDOSIS

Objective

We report a case of a successful reimplementation of a very low carbohydrate ketogenic diet (VLCKD) after a case of euglycemic diabetic ketoacidosis (euDKA).

Methods

A 42-year-old female with a history of type 2 diabetes mellitus on a self-administered VLCKD was prescribed a sodium-glucose co-transporter 2 (SGLT2) inhibitor. Two weeks after initiation, she presented with nausea and vomiting and was found to be in euDKA which was treated with fluid resuscitation, insulin infusion, and cessation of the SGLT2 inhibitor. She was discharged on insulin and instructed not to resume a VLCKD.

Results

After discharge, the patient experienced rapid weight gain and deteriorating glycemic control and desired to resume a VLCKD. She was referred to a university-based medical weight loss clinic that specializes in a VLCKD. The patient was monitored with daily contact via the electronic health record's patient portal and serial laboratory testing while her carbohydrate intake was slowly reduced and her insulin titrated off. She has safely remained in ketosis for 2 years without a further episode of euDKA.

Conclusion

As the clinical use of SGLT2 inhibitors and the VLCKD both become increasingly common, it is vital for practitioners to be aware that the combination can lead to euDKA. We present a case of successfully resuming a VLCKD after recovering from euDKA and cessation of SGLT2 inhibitor therapy.

Impact of motivational interviewing on outcomes of an adolescent obesity treatment: results from the MI Values randomized controlled pilot trial

The aim of this study is to examine outcomes from MI Values, a motivational interviewing (MI) intervention implemented adjunctive to obesity treatment. Adolescents (n = 99; 73% African American; 74% female; mean body mass index [BMI] percentile = 98.9 ± 1.2) were randomized to receive two MI sessions or education control. All adolescents participated in structured behavioural weight management treatment. Baseline, 3- and 6-month assessments of anthropometrics, dietary intake and physical activity were obtained. Both groups had significant reductions in BMI z-scores and energy intake and increased physical activity at 3 and 6 months (P < 0.05). MI participants reported greater reductions in 3-month energy intake compared with controls. Participation in MI is associated with reduction in energy intake, consistent with better adherence to dietitian visits previously reported from MI Values. MI might be an effective adjunct to adolescent obesity treatment; future research is needed to determine if motivational interviewing can enhance BMI outcomes, via greater adherence to behavioural intervention.

Modeling Pediatric Body Mass Index and Neighborhood Environment at Different Spatial Scales

In public health research, it has been well established that geographic location plays an important role in influencing health outcomes. In recent years, there has been an increased emphasis on the impact of neighborhood or contextual factors as potential risk factors for childhood obesity. Some neighborhood factors relevant to childhood obesity include access to food sources, access to recreational facilities, neighborhood safety, and socioeconomic status (SES) variables. It is common for neighborhood or area-level variables to be available at multiple spatial scales (SS) or geographic units, such as the census block group and census tract, and selection of the spatial scale for area-level variables can be considered as a model selection problem. In this paper, we model the variation in body mass index (BMI) in a study of pediatric patients of the Virginia Commonwealth University (VCU) Medical Center, while considering the selection of spatial scale for a set of neighborhood-level variables available at multiple spatial scales using four recently proposed spatial scale selection algorithms: SS forward stepwise regression, SS incremental forward stagewise regression, SS least angle regression (LARS), and SS lasso. For pediatric BMI, we found evidence of significant positive associations with visit age and black race at the individual level, percent Hispanic white at the census block group level, percent Hispanic black at the census tract level, and percent vacant housing at the census tract level. We also found significant negative associations with population density at the census tract level, median household income at the census tract level, percent renter at the census tract level, and exercise equipment expenditures at the census block group level. The SS algorithms selected covariates at different spatial scales, producing better goodness-of-fit in comparison to traditional models, where all area-level covariates were modeled at the same scale. These findings underscore the importance of considering spatial scale when performing model selection.

Insulin sensitizers in adolescents with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common disorder of androgen excess in women of reproductive age. The diagnosis of PCOS can be more challenging in adolescents than in adult women given significant overlap between normal puberty and the signs of PCOS, including acne, menstrual irregularity, and polycystic ovarian morphology. Optimal treatments for adult women with PCOS vary depending on patient risk factors and reproductive goals, but mainly include hormonal contraception and insulin sensitizers. There is continued interest in targeting the intrinsic insulin resistance that contributes to metabolic and hormonal derangements associated with PCOS. The vast majority of published data on insulin sensitizing PCOS treatments are reported in adult women; these have included weight loss, metformin, thiazolidinediones, and the inositols. Furthermore, there is also a small but growing body of evidence in support of the use of insulin sensitizers in adolescents, with or without oral contraceptives. Discussion of the available treatments, including benefits, potential side effects, and incorporation of patient and family preferences is critical in developing a plan of care aimed at achieving patient-important improvements in PCOS signs and symptoms while addressing the longer-term cardiometabolic risks associated with the syndrome.

Thyrotropin Levels Are Associated with Cardiometabolic Risk Factors in Euthyroid Adolescents

BACKGROUND

Increased thyrotropin (TSH) levels and free triiodothyronine to free thyroxine (fT3:fT4) ratios, even within the euthyroid range, have been associated with cardiometabolic risk factors in adults but are less characterized in youth. This study sought to determine relations between TSH, thyroid hormones, and cardiometabolic risk factors in euthyroid adolescents.

METHODS

Data were extracted from the United States National Health and Nutrition Examination Survey, 2007-2010, for univariate and multivariate analyses of TSH, thyroid hormones, body mass index (BMI), blood pressure, lipids, and glucose metabolism. Subjects aged 12-18 years, with normal TSH and antithyroid peroxidase antibody levels, and without a history of thyroid disease, diabetes, or treatment of hypertension/dyslipidemia (n = 1167) were included. TSH and thyroid hormones were assessed for impact on BMI Z-score, systolic blood pressure (SBP) diastolic blood pressure, total cholesterol (TC), high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, apolipoprotein B, triglycerides, and glucose metabolism.

RESULTS

Univariate analyses revealed positive linear relations between TSH and SBP, TC, fasting and two-hour glucose, and homeostasis model assessment of insulin resistance (HOMA-IR). The fT3:fT4 ratio negatively correlated with high-density lipoprotein cholesterol but positively with BMI Z-score, SBP, triglycerides, fasting and two-hour glucose, fasting insulin, and HOMA-IR. In multivariate analyses controlling for age, sex, race/ethnicity, and BMI Z-score, relations between TSH and both TC and fasting glucose remained significant, and the fT3:fT4 ratio was positively associated with fasting glucose and HOMA-IR.

CONCLUSIONS

In an unselected population of euthyroid U.S. adolescents, TSH and thyroid hormones correlate with multiple cardiometabolic risk factors, with age- and sex-independent effects on cholesterol and glucose metabolism.

Evaluation and Treatment of Severe Obesity in Childhood

Pediatric obesity is highly prevalent in developed countries globally (and worsening in developing countries) and threatens to shorten the lifespan of the current generation. At highest risk for weight-related comorbidities including Type 2 diabetes mellitus, non-alcoholic fatty liver disease and dyslipidemia is a sub-set of children with severe obesity, often defined as a body mass index (BMI) percentile ≥99^th percentile for age and sex. The pathophysiology of severe obesity in childhood is complex, resulting from the dynamic interplay of a myriad of individual and societal factors including genetic predisposition and health behaviors contributing to energy imbalance. Approximately 4–6% of children have severe obesity, representing a common scenario encountered by providers, and intervention is critical to halt ongoing weight gain and, when possible, reverse the trend. Clinical approaches promoting behavioral weight loss may result in modest, albeit clinically significant, reductions in BMI; however, such changes are often difficult to maintain long-term. Data regarding the impact of targeted pharmacotherapy including agents such as orlistat are limited in the pediatric population and again only suggest modest results. However, increasing evidence suggest that surgical treatment, as an adjunct to ongoing lifestyle changes, may be a promising option in carefully-screened adolescents with severe obesity and weight-related comorbidities who are motivated to adhere to the long-term treatment needs.

Sympathetic Activity Assessed during Exercise Recovery in Young Obese Females

OBJECTIVE

To evaluate differences in sympathetic activity, as assessed by an exercise recovery index (ERI; heart rate/oxygen consumption [VO2] plateau), between black and white obese female adolescents. An additional aim was to determine the association of ERI with insulin resistance (homeostasis model assessment of insulin resistance [HOMA-IR]), cardiovascular fitness per fat-free mass (VO2 per fat-free mass), systolic blood pressure (SBP), and percent body fat (%FAT) in both black and white obese adolescents.

STUDY DESIGN

Sixty-one females volunteered to participate in this study. HOMA-IR, SBP, and %FAT were assessed during resting conditions in black (n = 49, 13.7 ± 1.6 years, 38.1 ± 6.1 kg/m(2)) and white (n = 12, 13.3 ± 2.2 years, 34.3 ± 4.9 kg/m(2)) obese adolescents. An ERI was calculated during a 5-minute passive recovery period immediately following a graded treadmill exercise test to exhaustion.

RESULTS

The ERI was significantly greater in black compared with white obese adolescent females (29.8 ± 6.4 vs 24.1 ± 3.1 bpm·mLO2(-1)·min(-1), P = .004). Using multiple linear regression modeling, there was a significant independent association between ERI and VO2 per fat-free mass (r = -0.310, P = .027) and %FAT (r = 0.326, P = .020) in black obese adolescents after controlling for HOMA-IR and SBP.

CONCLUSIONS

These results suggest that black obese adolescent females have greater sympathetic activity, as assessed by an ERI, than white obese adolescent females. These findings support the need for weight management efforts aimed at both reducing %FAT and improving fitness in obese adolescents, specifically black females.

TRIAL REGISTRATION

Registered with Clinicaltrials.gov: NCT00562293.

Cardiometabolic and Fitness Improvements in Obese Girls Who Either Gained or Lost Weight during Treatment

OBJECTIVE

To evaluate the quality of weight change (change in fat mass vs fat-free mass [FFM]), changes in cardiorespiratory fitness (CRF), and frequencies of metabolic risk factors in adolescent females with obesity who either lost or gained weight following lifestyle treatment.

STUDY DESIGN

Fifty-eight girls (mean age = 13.0 ± 1.6 years; 77% black; mean body mass index = 36.5 ± 4.5 kg/m(2)) completed a 6-month lifestyle intervention combining dietary and behavioral counseling with aerobic and resistance exercise training. We examined baseline to 6-month differences in weight (kg), body composition, CRF, and frequencies of metabolic risk factors between weight loss and weight gain groups.

RESULTS

In the weight loss group, body weight (-4.50 ± 3.53 kg, P < .001), fat mass (-4.50 ± 2.20 kg, P < .001), and body fat percentage (-2.97% ± 1.45%, P < .001) decreased, and FFM was unchanged at 6 months. In the weight gain group, body weight (4.50 ± 2.20 kg, P < .001), fat mass (1.52 ± 3.16 kg, P < .024), and FFM (2.99 ± 2.45 kg, P < .001) increased, and body fat percentage was unchanged. Both groups improved CRF (P < .05). Frequencies of metabolic risk factors were reduced across all participants after the 6-month treatment.

CONCLUSIONS

Participation in a weight management program might elicit health improvements in obese adolescent females who increase weight and fat mass, provided that FFM gains are sufficient to negate increases in body fat percentage.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00167830.

Motivational interviewing targeting diet and physical activity improves adherence to paediatric obesity treatment: results from the MI Values randomized controlled trial

BACKGROUND

Adherence is a challenge in obesity treatment. Motivational interviewing (MI) may promote patient adherence. MI Values is a randomized controlled trial of MI implemented as an adjunct to an adolescent obesity treatment [Teaching Encouragement Exercise Nutrition Support (T.E.E.N.S.)].

OBJECTIVE

Assess effects of MI Values on T.E.E.N.S. attrition and adherence.

METHODS

Participants were randomized to MI (n = 58) or control (n = 41). At weeks 1 and 10, MI participants had brief MI sessions; controls viewed health education videos. All participants continued with T.E.E.N.S. (biweekly dietitian and behavioural support visits; 3 times per week supervised physical activity). Assessments were repeated at baseline, 3 and 6 months. T-tests and chi-square analyses examined T.E.E.N.S. attrition and adherence by group.

RESULTS

Adolescents (N = 99) were primarily African-American (73%) females (74%); age = 13.8 ± 1.8 years, body mass index percentile = 98.0 ± 1.2. Compared with controls, MI participants had greater 3-month adherence overall (89.2% vs. 81.0%, P = 0.040), and to dietitian (91.3% vs. 84.0%; P = 0.046) and behavioural support (92.9% vs. 85.2%; P = 0.041) visits, and greater 6-month adherence overall (84.4% vs. 76.2%, P = 0.026) and to behavioural support visits (87.5% vs. 78.8%, P = 0.011).

CONCLUSIONS

MI enhanced adherence to this obesity intervention. MI Values is the first study to examine the impact of MI on treatment adherence among obese, primarily African-American adolescents.

Sex differences in pulmonary oxygen uptake kinetics in obese adolescents

OBJECTIVE

To determine whether sex differences exist in the pulmonary oxygen uptake (VO2) uptake on-kinetic response to moderate exercise in obese adolescents. We also examined whether a relationship existed between the VO2 on-transient response to moderate intensity exercise, steady-state VO2, and peak VO2 between obese male and female adolescents.

STUDY DESIGN

Male (n = 12) and female (n = 28) adolescents completed a graded exercise test to exhaustion on a treadmill. Data from the initial 4 minutes of treadmill walking were used to determine the time constant.

RESULTS

The time constant was significantly different (P = .001) between obese male and female adolescents (15.17 ± 8.45 seconds vs 23.07 ± 8.91 seconds, respectively). No significant relationships were observed between the time constant and variables of interest in either sex.

CONCLUSIONS

Sex differences exist in VO2 uptake on-kinetics during moderate exercise in obese adolescents, indicating an enhanced potential for male subjects to deliver and/or use oxygen. It may be advantageous for female subjects to engage in a longer warm-up period before the initiation of an exercise regimen to prevent an early termination of the exercise session.

Pediatric health care provider perceptions of weight loss surgery in adolescents

This study explored pediatric health care providers' obesity treatment practices and perceptions about adolescent weight loss surgery (WLS). Surveys were e-mailed to pediatric listservs. After descriptive analyses, correlations, chi-squares, and one-way analyses of variance compared responses by provider characteristics. Surveys were completed by 109 providers. Almost half do not routinely measure body mass index. Providers typically counsel patients about lifestyle change, with limited perceived benefit; <10% have ever referred patients for WLS, citing cost (20%), risk (49%), or "not indicated in pediatrics" (17%) as reasons. However, when presented with patient scenarios of different ages and comorbidities, likeliness to refer for WLS increased substantially. Surgeons, younger providers and those with fewer years of experience were more likely to refer for WLS (P < .05). Despite expert consensus recommendations supporting WLS as part of a comprehensive obesity treatment plan, significant pediatric provider resistance to refer obese adolescents remains. Improved referral and management practices are needed.

The stress process and eating pathology among racially diverse adolescents seeking treatment for obesity

OBJECTIVE

This study examined the associations of weight-related teasing and daily hassles with eating pathology, as well as potential mediators of these relations, among a racially diverse sample of adolescents.

METHODS

Participants were 92 primarily African American 11-17-year-olds seeking treatment for obesity. Data were collected at baseline.

RESULTS

Both daily hassles and weight-related teasing were significantly correlated with eating pathology at r = .22 and r = .25, respectively. Feeling upset about teasing mediated the associations of daily hassles (PE = .0093, SE = .0054, 95% BCa bootstrap CI of .0001-.0217) and teasing (PE = .0476, SE = .0198, 95% BCa bootstrap CI of .0093-.0873) with eating pathology.

CONCLUSIONS

These results highlight the importance of psychological interventions in the treatment of weight-loss among adolescents, as stressors may impact eating behaviors.

Activation of the LH receptor up regulates the type 2 adiponectin receptor in human granulosa cells

PURPOSE

Adiponectin is a predominantly adipocyte-derived hormone which influences insulin sensitivity and energy homeostasis through at least two receptors, AdipoR1 and AdipoR2. In animal models, adiponectin may regulate ovarian steroidogenesis, folliculogenesis, and ovulation. The receptors AdipoR1 and AdipoR2 are present in the human ovary, but their regulation is unknown. In these studies, we determined the effects of LH receptor activation on the expression and function of the two adiponectin receptors in human granulosa cells.

METHODS

Granulosa cells were obtained at the time of oocyte retrieval in women undergoing in vitro fertilization (IVF). Cells were isolated and cultured for 48 h in DMEM/F12 medium with 5 % FBS and 50 ug/ml gentamicin. Medium was changed to low serum for 12 h and cells were treated with hCG (100 ng/ml), forskolin (30 μMol/L), or FSH (1 IU/ml) for 24 h for mRNA experiments. mRNA was isolated and RT PCR was performed using Taqman assays and quantification with the delta delta CT method. For immunocytochemistry, cells were grown on chamber slides and treated with hCG for 1 to 24 h and fixed with acetone. ICC was performed with polyclonal rabbit primary antibodies followed by alexa fluor goat anti-rabbit antibody and imaging with a fluorescence microscope and Zeiss software analysis. 3β-hydroxysteroid dehydrogenase (3βHSD) enzyme activity was determined by measuring the progesterone produced when cells were provided with an excess of 22-hydroxy-cholesterol as substrate following an incubation with hCG (1 IU/ml) and/or adiponectin (10 ng/ml). Progesterone content in the media was determined by ELISA.

RESULTS

Messenger RNA for the two Adiponectin receptors is differentially regulated by activation of LHR with hCG treatment. AdipoR2 was increased nearly 4-fold (p < 0.05), whereas AdipoR1 expression was not changed by hCG treatment. Treatment with either FSH or forskolin (an activator of cAMP) had similar effects. Basal AdipoR2 protein was fairly low in granulosa cells in culture however treatment of cells with hCG resulted in a discernible increase in immunodetectable cytoplasmic protein as early as 6 h after treatment and was maintained for at least 24 h. The number of cells positive for AdipoR2 at 6 h increased from a basal of 20 % to almost 60 % (p < 0.05). Adiponectin treatment of hCG-primed cells resulted in increased 3βHSD activity by approximately 60 % over hCG alone and more than 3-fold over basal levels.

CONCLUSIONS

AdipoR2 is regulated by the LH receptor function via a cAMP dependant mechanism. Increased expression of adipoR2 prior to and following ovulation may contribute to enhanced 3βHSD activity and increased progesterone secretion by the corpus luteum of the ovary. Dysregulation of adiponectin that may occur with PCOS may impair normal progesterone production.

Tolvaptan for the management of syndrome of inappropriate antidiuretic hormone secretion: lessons learned in titration of dose

OBJECTIVE

To report a patient with idiopathic syndrome of inappropriate antidiuretic hormone secretion (SIADH) who developed profound aquaresis with symptomatic extracellular fluid depletion after initiation of therapy with tolvaptan who was later successfully treated with smaller doses of compounded tolvaptan to prevent rapid correction of serum sodium.

METHODS

Case report and review of the literature.

RESULTS

A 51-year-old woman was diagnosed with SIADH during admission for elective surgery resulting in multiple complications. The patient failed multiple therapies including fluid restriction, salt tablets, and demeclocycline. She was admitted to the hospital for initiation of tolvaptan therapy. After a 15-mg dose of tolvaptan, the patient had rapid increase in urine output and symptomatic hypotension. Sodium levels corrected rapidly overnight from 126 mEq/L to 139 mEq/L. A lower dose of tolvaptan resulted in similar symptoms and sodium correction. Due to continuing symptoms of hyponatremia including headaches, nausea, vomiting, and paresthesias after reinitiation of fluid restriction and salt tablets, tolvaptan was compounded to continue to titrate at lower doses. The patient was then admitted and tolvaptan was initiated at a dose of 1.5 mg with no significant improvement in sodium levels. Tolvaptan was titrated to 3 mg, which resulted in correction of sodium to 129 mEq/L with no associated symptoms of hypovolemia.

CONCLUSIONS

Tolvaptan should be initiated in an inpatient setting with close monitoring of serum sodium levels. In patients who are not able to tolerate recommended dosages, consideration should be given to using a compounded formulation to further titrate to lower doses.

Sex hormone-binding globulin and type 2 diabetes mellitus

Sex hormone-binding globulin (SHBG) has emerged as one of the multiple genetic and environmental factors that potentially contribute to the pathophysiology of type 2 diabetes mellitus (T2DM). In addition to epidemiologic studies demonstrating a consistent relationship between decreased levels of serum SHBG and incident T2DM, recent genetic studies also reveal that transmission of specific polymorphisms in the SHBG gene influence the risk of T2DM. At the molecular level, the multiple interactions between SHBG and its receptors in various target tissues suggest physiologic roles for SHBG that are more complex than the simple transport of sex hormones in serum. Taken together, these data provide support for an expanded role of SHBG in the pathophysiology of insulin resistance and T2DM.

Divergent effects of a combined hormonal oral contraceptive on insulin sensitivity in lean versus obese women

OBJECTIVE

To evaluate the effects of a commonly used combined hormonal oral contraceptive (OC) on carbohydrate metabolism in obese as compared with lean women.

DESIGN

6-month prospective study.

SETTING

Clinical research center at an academic medical center.

PATIENT(S)

Premenopausal nondiabetic women with body mass index <25 kg/m(2) (n = 15) or >30 kg/m(2) (n = 14).

INTERVENTION(S)

Ethinyl estradiol (35 μg) and norgestimate (0.18/0.215/0.25 mg) for 6 cycles.

MAIN OUTCOME MEASURE(S)

Insulin sensitivity by frequent sampling intravenous glucose tolerance test; other indices of insulin sensitivity (homeostatic model assessment of insulin sensitivity index [ISI HOMA], the Matsuda index); fasting lipid panel.

RESULT(S)

Insulin sensitivity changed from 6.62 ± 3.69 min(-1)/mIU/L (baseline) to 8.23 ± 3.30 min(-1)/mIU/L (6 months) in lean women, and from 4.36 ± 2.32 to 3.82 ± 2.32 min(-1)/mIU/L in obese women. Divergent effects on insulin sensitivity were also observed with ISI HOMA and the Matsuda index. Low-density lipoprotein increased by approximately 20 mg/dL in both the lean and obese groups.

CONCLUSION(S)

Lean and obese women exhibit differential changes in insulin sensitivity when given 6 months of a commonly used oral contraceptive. The mechanisms of these differences and whether these divergent effects persist in the long term require further investigation.

Six-month dietary changes in ethnically diverse, obese adolescents participating in a multidisciplinary weight management program

This study's objective was to examine dietary and metabolic changes in obese adolescents who completed 6 months of participation in an outpatient multidisciplinary weight management program (N = 67). Participants (75% African American, 66% female, mean age = 13.7 years) completed 24-hour dietary recalls and underwent measurement of anthropometrics and fasting blood lipid parameters at baseline and after 6 months of participation. General linear models suggested that participants significantly reduced total energy, total fat, saturated fat, carbohydrate, sodium, and sugar intakes, and increased fiber and fruit and vegetable intake (P < .05). Gender-stratified models showed differences in fruit/vegetable intake, percentage calories from fat, sodium, and dietary cholesterol intakes by gender. Significant improvements in body mass index percentile and lipid profiles were also found, lending objective support to the dietary changes participants made. Findings suggest that participation in this multidisciplinary treatment helped participants make behaviorally based dietary changes, which were associated with improved dietary intakes and health status.

Polymorphisms in the SHBG gene influence serum SHBG levels in women with polycystic ovary syndrome

CONTEXT

Single-nucleotide polymorphisms (SNPs) in the SHBG gene are associated with type 2 diabetes mellitus. SHBG has also been proposed as a candidate gene for the polycystic ovary syndrome (PCOS).

OBJECTIVE

The study aims were 1) to determine whether any of four SHBG SNPs (rs1779941, rs6297, rs6259, and rs727428) are associated with PCOS and 2) to determine whether SNP genotype influences SHBG levels in PCOS women.

DESIGN

Using the transmission disequilibrium test, evidence of associations between SHBG SNPs and PCOS were analyzed. Additionally, correlations between SHBG levels and SNP genotype, body mass index, non-SHBG-bound testosterone, and insulin resistance estimated by the homeostasis model were determined.

SETTING

The study was conducted at academic medical centers.

PATIENTS OR OTHER PARTICIPANTS

A total of 430 families having a proband with PCOS were included in the family-based study. Associations between SNP genotypes, SHBG, and metabolic parameters were determined in 758 women with PCOS including probands from the family cohort.

MAIN OUTCOME MEASURES

Primary outcome measures included transmission frequency of SNP alleles and correlation coefficients between SHBG and allele frequency/metabolic parameters.

RESULTS

No evidence of association between SNPs of interest and PCOS was found. However, in multivariate analyses, SHBG levels varied significantly with rs1799941 and rs727428 genotype after controlling for body mass index, non-SHBG-bound testosterone, and homeostasis model for insulin resistance.

CONCLUSIONS

Although SHBG SNPs associated with type 2 diabetes mellitus do not appear to be associated with PCOS status, rs1799941 and rs727428 genotypes are associated with SHBG levels independent of the effects of insulin resistance and obesity.

Total and high-molecular weight adiponectin in women with the polycystic ovary syndrome

Adiponectin, an adipokine with antidiabetic properties, forms multimers; and the high-molecular weight (HMW) form most closely correlates with insulin sensitivity (S(i)). Therefore, we hypothesize that HMW adiponectin levels are decreased in women with polycystic ovary syndrome (PCOS), a condition characterized by insulin resistance, compared with healthy controls and that HMW adiponectin correlates with testosterone and S(i). A cross-sectional study involving 13 women with PCOS and 13 age- and body mass index-matched healthy controls was performed. Waist-to-hip ratios (WHRs), glucose, insulin, sex hormone-binding globulin, total testosterone, and total and HMW adiponectin levels were measured after an overnight fast. Free testosterone was calculated from sex hormone-binding globulin and total testosterone, and S(i) was determined using a frequently sampled intravenous glucose tolerance test. The study's primary outcomes were differences in total and HMW adiponectin between women with PCOS and healthy control women. Total adiponectin (P < .01), HMW adiponectin (P < .01), and the ratio of HMW to total adiponectin (P = .03) were lower in women with PCOS compared with healthy women. Total and HMW adiponectin levels correlated inversely with WHR (P < .01) and free testosterone (P < .01) and positively with S(i) (P < .001). Using forward stepwise multivariate analysis, HMW adiponectin and WHR, but not PCOS status, were independent predictors of S(i). Women with PCOS have lower total and HMW adiponectin levels compared with healthy women. High-molecular weight adiponectin also comprises a smaller proportion of total circulating adiponectin in women with PCOS. Alterations in HMW adiponectin levels in women with PCOS may contribute to the insulin resistance intrinsic to the syndrome.

Sex hormone-binding globulin genetic variation: associations with type 2 diabetes mellitus and polycystic ovary syndrome

Sex hormone-binding globulin (SHBG) is the primary plasma transport protein for sex steroid hormones and regulates the bioavailability of these hormones to target tissues. The gene encoding SHBG is complex and any of several polymorphisms in SHBG have been associated with alterations in circulating SHBG levels. Epidemiological studies have revealed that low plasma SHBG levels are an early indicator of insulin resistance and predict the development of type 2 diabetes mellitus (T2DM) in both men and women. Although associations between low SHBG levels and risk of diabetes could be explained by the observation that elevations in insulin suppress hepatic SHBG production, recent studies documenting that the transmission of SHBG-altering polymorphisms are associated with risk of T2DM suggest that SHBG may have a more direct physiologic role in glucose homeostasis. However, the exact mechanism(s) underlying this association is not known. Non-diabetic women with the polycystic ovary syndrome (PCOS), a common endocrine disorder that is associated with insulin resistance, similarly demonstrate lower levels of SHBG. In light of studies investigating polymorphisms in SHBG and T2DM, our group and others have hypothesized that SHBG may represent a candidate gene for PCOS. In this manuscript, we review studies investigating the association between SHBG polymorphisms and PCOS. In summary, multiple studies in women with PCOS confirm that certain genetic polymorphisms are associated with circulating SHBG levels, but they are not consistently associated with PCOS per se.

Distribution of adiponectin multimeric forms in Chinese women with polycystic ovary syndrome and their relation to insulin resistance

OBJECTIVE

Adiponectin, an abundant adipokine with insulin-sensitizing properties, exists in different multimeric forms, including low-molecular weight, medium-molecular weight, and high-molecular weight (HMW) species. Alterations in the distribution of adiponectin multimers and the relationship between adiponectin multimers and insulin resistance (IR) in women with polycystic ovary syndrome (PCOS) remain unclear. The objective of this study was to compare adiponectin multimerization status and estimate insulin sensitivity in Chinese women with PCOS compared with age- and body mass index (BMI)-matched controls.

METHODS

Cross-sectional study involving 64 Chinese women with PCOS and 59 normal women. Circulating total adiponectin and its multimeric forms were determined by ELISA, and IR was estimated using the homeostasis model assessment IR index (HOMA-IR).

RESULTS

After controlling for BMI status, levels of both total and HMW adiponectin were significantly lower in women with PCOS compared with normal women (P<0.05). Furthermore, HMW adiponectin provided a stronger contribution to models predicting IR than total adiponectin. Lastly, decreased HMW adiponectin was associated with increased HOMA-IR in both normal and PCOS women, and this association was independent of both overall adiposity and visceral adiposity.

CONCLUSION

Levels of both total and HMW adiponectin were decreased in Chinese women with PCOS compared with normal control women, and the differences in HMW adiponectin persisted after controlling for BMI. Furthermore, HMW adiponectin is a stronger predictor of IR than total adiponectin in both women with PCOS and normal women.

Evaluation of a 6-month multi-disciplinary healthy weight management program targeting urban, overweight adolescents: effects on physical fitness, physical activity, and blood lipid profiles

This study evaluated preliminary physical fitness, physical activity, and blood lipid profile data obtained from overweight adolescents upon enrolling in a healthy weight management program and following 6 months of program participation. One hundred and sixty-eight participants (13.4+/-1.8 years, 37.9+/-8.3 kg/m(2), 59.5% female and 76.2% African-American) enrolled in the program. The intervention addressed factors related to nutrition, physical activity, and other behaviors related to weight management. Sixty-four participants (38.1%) completed 6 months of program participation. While there was no significant reduction in body mass or body mass index (BMI), BMI z-score was reduced by 1.2% (p < 0.05), cardiorespiratory fitness was increased by 10.8% (p = 0.001), body fat percentage was reduced by 2.6% (p = 0.001), total cholesterol was reduced by 7.2% (p < 0.001), and low density lipoprotein (LDL-C) was reduced by 8.4% (p < 0.001) at 6 months. Continued development and evaluation of programs designed to prevent and treat child and adolescent overweight is warranted to address this major public health issue.

Prevalence of the metabolic syndrome among obese adolescents enrolled in a multidisciplinary weight management program: clinical correlates and response to treatment

OBJECTIVE

The aim of this study was to determine the prevalence of the metabolic syndrome at baseline and after 6 months of lifestyle modification among obese adolescents referred to a multidisciplinary weight management program.

METHODS

A total of 165 obese adolescents were evaluated at baseline, and measurements were repeated in 57 subjects who completed 6 months of the program. Metabolic syndrome was defined as having three or more of the following: a body mass index (BMI) >97(th) percentile, hypertension, low high-density lipoprotein cholesterol (HDL-C), hypertriglyceridemia, and impaired fasting glucose (IFG).

RESULTS

The prevalence of a BMI >97(th) percentile, hypertension, hypertriglyceridemia, low HDL-C, and IFG was 92.7, 54.5, 29.1, 26.7, and 2.4%, respectively. The prevalence of the metabolic syndrome at baseline was 30.3%. After 6 months of lifestyle modification, BMI z scores, percent body fat, total cholesterol, and low-density lipoprotein cholesterol (LDL-C) decreased significantly from baseline; however, there was no significant change in the number of subjects demonstrating >or=three criteria of the metabolic syndrome.

CONCLUSIONS

Approximately one third of the study subjects met the criteria of the metabolic syndrome, emphasizing the growing concern for the future development of premature cardiovascular disease in this high-risk population. Our data suggest that new strategies for lifestyle modification may be needed to improve cardiovascular risk factors significantly among adolescents with obesity.

Glucose intolerance in polycystic ovary syndrome--a position statement of the Androgen Excess Society

OBJECTIVES

Women with polycystic ovarian syndrome (PCOS) are at increased risk for developing glucose intolerance and type 2 diabetes mellitus (DM). Recommendations for the timing and method of screening have varied. The purpose of this statement is to determine the optimal screening method, timing of screening, and treatment modalities for impaired glucose tolerance (IGT) among women with PCOS.

PARTICIPANTS

The expert panel was appointed by the Androgen Excess Society (AES) to review the literature and make recommendations based on the available evidence. Meetings were open, and there was no funding for the panel.

EVIDENCE

A systematic review was conducted of the published, peer-reviewed medical literature using MEDLINE to identify studies that addressed the prevalence, risk factors, testing, and treatment for IGT in both adults and adolescents with PCOS. Unpublished data were not considered.

CONSENSUS PROCESS

The panel held meetings to review the literature and draft the statement as a committee. The AES board members reviewed and critiqued the manuscript, and changes were made based on their comments.

CONCLUSIONS

The panel recommends that all patients with PCOS be screened for IGT with a 2-h oral glucose tolerance test. A few members of the AES board recommend alternatively screening women with PCOS for IGT and type 2 DM using an oral glucose tolerance test only in patients with a body mass index of 30 kg/m2 or greater or in lean patients with additional risk factors. Patients with normal glucose tolerance should be rescreened at least once every 2 yr, or more frequently if additional risk factors are identified. Those with IGT should be screened annually for development of type 2 DM. PCOS patients with IGT should be treated with intensive lifestyle modification and weight loss and considered for treatment with insulin-sensitizing agents.

Changes in glucose tolerance with metformin treatment in polycystic ovary syndrome: A retrospective analysis

OBJECTIVE

To determine whether treatment with metformin would prevent progression to glucose intolerance and type 2 diabetes in women with polycystic ovary syndrome (PCOS).

METHODS

We conducted a retrospective review of medical records of women treated for PCOS during a 5-year period. Eligibility criteria included exclusion of diabetes at baseline by an oral glucose tolerance test, treatment with metformin, and a repeated oral glucose tolerance test after at least 1 year of metformin therapy. Fifty women with PCOS fulfilled the eligibility criteria.

RESULTS

At baseline, 11 women (22%) had impaired glucose tolerance (IGT), and 39 (78%) had normal glucose tolerance (NGT). After treatment with metformin, IGT persisted in 5 (45%) of the 11 women who had IGT at baseline, whereas 6 (55%) had reversion to NGT. During a mean treatment period of 43.3 months, 2 (5%) of the 39 women with baseline NGT had conversion to IGT, resulting in an annual conversion rate from NGT to IGT of 1.4%. In comparison with the 16% to 19% annual conversion rate reported in the literature, metformin treatment in this study resulted in an 11-fold decrease in the annual conversion rate from NGT to IGT (P = 0.01). None of the 50 women developed diabetes.

CONCLUSION

The findings of this retrospective study suggest that long-term treatment with metformin delays or prevents the development of IGT and type 2 diabetes in women with PCOS.

The metabolic syndrome in polycystic ovary syndrome

Approximately one-third to one-half of all women and adolescent girls with polycystic ovary syndrome (PCOS) has the metabolic syndrome, associated with increased risk for cardiovascular disease and type 2 diabetes. Evidence suggests that insulin resistance is the likely link between PCOS and the metabolic syndrome. Early screening for impaired glucose tolerance, even in adolescents, is recommended. Lifestyle modification with increased physical activity and weight reduction remains first-line therapy. Insulin-sensitizing drugs may also ameliorate features of the metabolic syndrome in PCOS but long-term prospective studies are needed to determine the role of these drugs in the prevention of the metabolic syndrome.

Dermatology of androgen-related disorders

Hyperandrogenism in women can be caused by various conditions, the most prevalent of which is polycystic ovary syndrome. Common dermatologic manifestations of hyperandrogenism include hirsutism, acne, acanthosis nigricans, and androgenic alopecia. Hirsute women often have increased activity of 5 alpha-reductase, the enzyme that converts the androgen testosterone to its active metabolite, in hair follicles. Likewise, androgens affect the formation of acne by increasing sebum production from sebaceous glands in the skin. The diagnosis of polycystic ovary syndrome includes a complete history, physical examination with emphasis on evidence of androgen excess, and appropriate laboratory investigation to exclude other causes of hyperandrogenism. Treatments for the dermatologic conditions of hyperandrogenism include lifestyle modification, oral contraceptives, antiandrogens, and insulin-sensitizing medications.