Laparoscopic gastric bypass versus lifestyle intervention for adolescents with morbid obesity. / Laparoskopisk gastrisk bypassoperasjon versus livsstilsbehandling av unge med sykelig overvekt.

BACKGROUND: There is limited evidence for the effectiveness of bariatric surgery in adolescents, and the associated complications. The main objective of the 4XL study was to clarify whether laparoscopic Roux-en-Y gastric bypass (LGBP) combined with lifestyle intervention is a safe and effective treatment method. MATERIAL AND METHOD: Data were retrieved from an ongoing non-randomised intervention study of adolescents with morbid obesity that is comparing the effects of gastric bypass combined with lifestyle intervention versus lifestyle intervention alone. RESULTS: Altogether 39 patients (64 % girls) treated with a gastric bypass, and 96 patients (57 % girls) treated with lifestyle intervention were examined prior to the start of treatment and one year later. The average age at inclusion (SD) was 16.7 (1.0) years vs. 15.6 (1.3) years, and average BMI was 45.6 (4.4) vs. 43.3 (4.1) kg/m2 in the two groups. Average (95 % CI) percentage weight loss was 30 % (27 %-33 %) after surgery versus weight gain of 1 % (-1 % to 3 %) in the control group. The difference between the groups was 31 % (95 % CI 27 %-34 %, p<0.001). Cardiometabolic risk factors improved only after surgery. After gastric bypass, two early (<6 weeks) minor complications were recorded. One year after surgery, 4 (10 %), 8 (21 %) and 4 (10 %) of patients had anaemia, iron deficiency or low vitamin B12 levels respectively, and 20 of 33 patients (61 %) had low two-hour blood glucose (<2.8 mmol/l) after oral glucose tolerance testing. INTERPRETATION: The results support previous studies showing that gastric bypass is associated with significant weight loss in adolescent patients with morbid obesity. The 4XL study is currently too small and the follow-up time too short to allow the risk of long-term complications to be assessed.

Lifestyle intervention for children and adolescents with severe obesity - results after one year. / Livsstilsbehandling av barn og ungdom med alvorlig fedme ­ resultater etter ett år.

BACKGROUND: Lifestyle interventions for children and adolescents with severe obesity show moderate short-term effects on weight reduction internationally. We evaluated treatment results at two Norwegian specialist outpatient clinics. MATERIAL AND METHOD: We performed a retrospective analysis of data from children and adolescents between 3 and 18 years of age collected in 2012-2016. Children and adolescents with severe obesity who attended their one-year follow-up were included. We included in the analyses the following body weight measures: percentage overweight as defined by the International Obesity Task Force cut-off (% IOTF-25); BMI standard deviation score; waist circumference standard deviation score; and body fat percentage at the start of treatment and at one-year follow-up. RESULTS: Of 568 children and adolescents who started treatment, 416 (73 %) attended the one-year check-up. A total of 271 (65 %) patients achieved a reduction in %IOTF-25, while 228 patients (55 %) reduced their BMI standard deviation score. There was a statistically significant mean reduction of all four registered body weight measurements. Altogether 54 of 325 children (17 %) changed category from severe obesity to obesity, 8 (2 %) went from severe obesity to overweight, and 8 of 91 children (9 %) changed category from obesity to overweight or normal weight. The proportion of participants with a reduction of more than 5 % in %IOTF-25 was 43 % (177/416), and a reduction in BMI standard deviation score of more than 0.25 was observed in 23 % (95/416) of participants. Girls responded on average more poorly to the intervention than boys. There was no clinically significant difference in results between the treatment centres. INTERPRETATION: After one year of treatment of children and adolescents with severe obesity in two specialist healthcare centres, we found a moderate mean reduction in weight, waist circumference and body fat percentage, but with large interindividual variation.

Health-related quality of life after camp-based family obesity treatment: an RCT.

OBJECTIVE: To compare the effects of a 2-year camp-based immersion family treatment for obesity with an outpatient family-based treatment for obesity on health-related quality of life (HRQoL) in two generations. DESIGN: Randomised controlled trial. SETTING: Rehabilitation clinic, tertiary care hospital and primary care. PATIENTS: Families with at least one child (7-12 years) and one parent, both with obesity. INTERVENTIONS: Summer camp for 2 weeks, with four repetition weekends, or lifestyle school, including four outpatient days over 4 weeks. Behavioural techniques to promote a healthier lifestyle. MAIN OUTCOME MEASURES: Children's and parents' HRQoL were assessed using generic and obesity-specific measures. Outcomes were analysed using linear mixed models according to intention to treat, and multiple imputations were used for missing data. RESULTS: Ninety children (50% girls) with a mean (SD) age of 9.7 (1.2) years and body mass index 28.7 (3.9) kg/m2 were included in the analyses. Summer camp children had an estimated mean (95% CI) of 5.3 (0.4 to 10.1) points greater improvement in adiposity-specific HRQoL score at 2 years compared with the lifestyle school children, and this improvement was even larger in the parent proxy-report, where mean difference was 7.3 (95% CI 2.3 to 12.2). Corresponding effect sizes were 0.33 and 0.44. Generic HRQoL questionnaires revealed no significant differences between treatment groups in either children or parents from baseline to 2 years. CONCLUSIONS: A 2-year family camp-based immersion obesity treatment programme had significantly larger effects on obesity-specific HRQoL in children's self-report and parent proxy-reports in children with obesity compared with an outpatient family-based treatment programme. TRIAL REGISTRATION NUMBER: NCT01110096.

Monitoring children and adolescents with severe obesity: body mass index (BMI), BMI z-score or percentage above the International Obesity Task Force overweight cut-off?

AIM: Body mass index (BMI) metrics are widely used as a proxy for adiposity in children with severe obesity. The BMI expressed as the percentage of a cut-off percentile for overweight or obesity has been proposed as a better alternative than BMI z-scores when monitoring children and adolescents with severe obesity. METHODS: Annual changes in BMI, BMI z-score and the percentage above the International Obesity Task Force overweight cut-off (%IOTF-25) were compared with dual-energy X-ray absorptiometry (DXA) derived body fat (%BF-DXA) in 59 children and adolescents with severe obesity. RESULTS: The change in %BF-DXA was correlated with the change in %IOTF-25 (r = 0.68) and BMI (r = 0.70), and somewhat less with the BMI z-score (r = 0.57). Cohen's Kappa statistic to detect an increase or decrease in %BF-DXA was fair for %IOTF-25 (κ = 0.25; p = 0.04) and BMI (κ = 0.33; p = 0.01), but not for the BMI z-score (κ = 0.08; p = 0.5). The change in BMI was positively biased due to a natural increase with age. CONCLUSION: Changes in the BMI metrics included in the study are associated differently with changes in %BF-DXA. The BMI z-score is widely used to monitor changes in adiposity in children and adolescents with severe obesity, but the %IOTF-25 might be a better alternative.

Cardiometabolic risk factors differ among adolescents with obesity in three European countries - a cross-sectional study.

AIM: We aimed to compare modifiable cardiometabolic risk factors among treatment-seeking adolescents with obesity in Italy, Germany and Norway. METHODS: This retrospective, registry-based, cross-sectional cohort study included 2,327 (59% girls) 12-18 year-old adolescents with obesity from three tertiary care outpatient clinics in Europe, between 1999 and 2015. The prevalence of cardiometabolic risk factors was compared between clinics, and multivariate logistic regression models including gender, age, waist circumference and body mass index were used to assess the associations between population and cardiometabolic risk. RESULTS: In total, 1,396 adolescents (60% girls) from Italy, 654 (58% girls) from Germany and 277 (51% girls) from Norway were included. The mean ± SD age was 15.2 ± 1.6 years, body mass index 38.8 ± 6.5 kg/m2 and body mass index standard deviation score 3.21 ± 0.43. The prevalence of elevated nonhigh-density lipoprotein-cholesterol in Norway, Germany and Italy was 60%, 54% and 45%, while the prevalence of high systolic or diastolic blood pressure (≥130 or ≥85 mmHg) were 15%, 46% and 66%, respectively. CONCLUSION: Cardiometabolic risk factors among treatment-seeking adolescents with obesity from Italy, Germany and Norway differed across the populations in this study, which might imply that preventive clinical work should reflect such differences.

Severe obesity is a limitation for the use of body mass index standard deviation scores in children and adolescents.

AIM: We analysed the distribution of the body mass index standard deviation scores (BMI-SDS) in children and adolescents seeking treatment for severe obesity, according to the International Obesity Task Force (IOTF), World Health Organization (WHO) and the national Norwegian Bergen Growth Study (BGS) BMI reference charts and the percentage above the International Obesity Task Force 25 cut-off (IOTF-25). METHODS: This was a cross-sectional study of 396 children aged four to 17 years, who attended a tertiary care obesity centre in Norway from 2009 to 2015. Their BMI was converted to SDS using the three growth references and expressed as the percentage above IOTF-25. The percentage of body fat was assessed by bioelectrical impedance analysis. RESULTS: Regardless of which BMI reference chart was used, the BMI-SDS was significantly different between the age groups, with a wider range of higher values up to 10 years of age and a more narrow range of lower values thereafter. The distributions of the percentage above IOTF-25 and percentage of body fat were more consistent across age groups. CONCLUSIONS: Our findings suggest that it may be more appropriate to use the percentage above a particular BMI cut-off, such as the percentage above IOTF-25, than the IOTF, WHO and BGS BMI-SDS in paediatric patients with severe obesity.

Camp-based family treatment of childhood obesity: randomised controlled trial.

OBJECTIVE: To compare the effectiveness of a 2-year camp-based family treatment programme and an outpatient programme on obesity in two generations. DESIGN: Pragmatic randomised controlled trial. SETTING: Rehabilitation clinic, tertiary care hospital and primary care. PATIENTS: Families with at least one child (7-12 years) and one parent with obesity. INTERVENTIONS: Summer camp for 2 weeks and 4 repetition weekends or lifestyle school including 4 days family education. Behavioural techniques motivating participants to healthier lifestyle. MAIN OUTCOME MEASURES: Children: 2-year changes in body mass index (BMI) SD score (SDS). Parents: 2-year change in BMI. Main analyses: linear mixed models. RESULTS: Ninety children (50% girls) were included. Baseline mean (SD) age was 9.7 (1.2) years, BMI 28.7 (3.9) kg/m2 and BMI SDS 3.46 (0.75). The summer-camp children had a lower adjusted estimated mean (95% CI) increase in BMI (-0.8 (-3.5 to -0.2) kg/m2), but the BMI SDS reductions did not differ significantly (-0.11 (-0.49 to 0.05)). The 2-year baseline adjusted BMI and BMI SDS did not differ significantly between summer-camp and lifestyle-school completers, BMI 29.8 (29.1 to 30.6) vs 30.7 (29.8 to 31.6) kg/m2 and BMI SDS 2.96 (2.85 to 3.08) vs 3.11 (2.97 to 3.24), respectively. The summer-camp parents had a small reduction in BMI (-0.9 (-1.8 to -0.03) vs -0.8 (-2.1 to 0.4) in the lifestyle-school group), but the within-group changes did not differ significantly (0.3 (-1.7 to 2.2)). CONCLUSIONS: A 2-year family camp-based obesity treatment programme had no significant effect on BMI SDS in children with severe obesity compared with an outpatient family-based treatment programme. TRIAL REGISTRATION NUMBER: NCT01110096.