From biology to behavior: a cross-disciplinary seminar series surrounding added sugar and low-calorie sweetener consumption.

INTRODUCTION: This report presents a synopsis of a three-part, cross-sector, seminar series held at the George Washington University (GWU) in Washington, DC from February-April, 2018. The overarching goal of the seminar series was to provide a neutral forum for diverse stakeholders to discuss and critically evaluate approaches to address added sugar intake, with a key focus on the role of low-calorie sweeteners (LCS). METHODS: During three seminars, twelve speakers from academic institutions, federal agencies, non-profit organizations, and the food and beverage industries participated in six interactive panel discussions to address: 1) Do Farm Bill Policies Impact Population Sugar Intake? 2) What is the Impact of Sugar-sweetened Beverage (SSB) Taxes on Health and Business? 3) Is Sugar Addictive? 4) Product Reformulation Efforts: Progress, Challenges, and Concerns? 5) Low-calorie Sweeteners: Helpful or Harmful, and 6) Are Novel Sweeteners a Plausible Solution? Discussion of each topic involved brief 15-minute presentations from the speakers, which were followed by a 25-minute panel discussion moderated by GWU faculty members and addressed questions generated by the audience. Sessions were designed to represent opposing views and stimulate meaningful debate. Given the provocative nature of the seminar series, attendee questions were gathered anonymously using Pigeonhole™, an interactive, online, question and answer platform. RESULTS: This report summarizes each presentation and recapitulates key perspectives offered by the speakers and moderators. CONCLUSIONS: The seminar series set the foundation for robust cross-sector dialogue necessary to inform meaningful future research, and ultimately, effective policies for lowering added sugar intakes.

Current practices of obesity pharmacotherapy, bariatric surgery referral and coding for counselling by healthcare professionals.

INTRODUCTION: Rates of obesity pharmacotherapy use, bariatric surgery and intensive behavioural counselling have been extremely low. OBJECTIVES: The primary objective of this study was to survey healthcare provider beliefs, practice and knowledge regarding obesity management. METHODS: Primary care physicians (PCPs), OB-GYN physicians and nurse practitioners (NPs) responded to a web-based survey related to drug therapy practice, bariatric surgery referral and reimbursement coding practice. RESULTS: Rates of reported use of obesity pharmacotherapy appear to be increasing among PCPs, which is likely related to the approval of four new obesity pharmacotherapy agents since 2012. Rates of pharmacotherapy use among OB-GYNs and NPs appear much lower. Similarly, few PCPs are averse to recommending bariatric surgery, but aversion among OB-GYNs and NPs is significantly higher. CONCLUSION: Together, these observations suggest that OB-GYN and NP populations are important targets for education about obesity management. Very few PCPs, OB-GYNs or NPs use behavioural counselling coding for obesity. Better understanding of why this benefit is not being fully used could inform outreach to improve counselling rates.

The association between childhood sexual and physical abuse with incident adult severe obesity across 13 years of the National Longitudinal Study of Adolescent Health.

BACKGROUND: Severe obesity has increased, yet childhood antecedents of adult severe obesity are not well understood. OBJECTIVE: Estimate adult-onset severe obesity risk in individuals with history of childhood physical and/or sexual abuse compared with those who did not report abuse. METHODS: Longitudinal analysis of participants from the US National Longitudinal Study of Adolescent Health (n = 10,774) wave II (1996; aged 12-22 years) followed through wave IV (2008-2009; aged 24-34 years). New cases of adult-onset severe obesity (body mass index [BMI] ≥ 40 kg/m2 using measured height and weight) in individuals followed over 13 years who were not severely obese during adolescence (BMI <120% of 95th percentile Centers for Disease Control and Prevention National Center for Health Statistics growth curves). RESULTS: The combined occurrence of self-reported sexual and physical abuse during childhood was associated with an increased risk of incident severe obesity in adulthood in non-minority females (hazard ratio [HR; 95% Confidence Interval] = 2.5; 1.3, 4.8) and males (HR = 3.6; 1.5, 8.5) compared with individuals with no history of abuse. CONCLUSION: In addition to other social and emotional risks, exposure to sexual and physical abuse during childhood may increase risk of severe obesity later in life. Consideration of the confluence of childhood abuse might be considered as part of preventive and therapeutic approaches to address severe obesity.

Change in leptin, body composition and other hormones around menarche--a visual representation.

AIM: To present a visual representation of changes in body composition, leptin, insulin, estradiol and follicular stimulating hormone (FSH) levels in relation to menarche in girls. METHODS: Participants were a subset of healthy girls (n = 108) enrolled in a longitudinal study of growth and development conducted at the General Clinical Research Center at the Massachusetts Institute of Technology (MIT). Participants were seen annually from before menarche until 4 years postmenarche for measures of body composition and serum levels of leptin, insulin, estradiol and FSH. Body composition was determined by bioelectrical impedance. Standardized body composition and hormone levels were smoothed and plotted relative to menarche to visualize patterns of change. RESULTS: At menarche, the mean percentage body fat (%BF) of girls was 24.6% (SD = 4.1%) after menarche %BF was approximately 27%. Leptin levels averaged 8.4 ng/mL (SD = 4.6) at menarche and were approximately 12 ng/mL after menarche. Changes in leptin levels closely paralleled changes in %BF. Insulin, estradiol and FSH levels followed expected patterns relative to menarche. Leptin began rising closer to menarche than did insulin or the other sex hormones. CONCLUSION: We provide a visual presentation of hormonal and body composition changes occurring throughout the pubertal period in girls which may be useful in generating new hypotheses related to the timing of menarche.

Dietary pattern as a predictor of change in BMI z-score among girls.

OBJECTIVES: To describe child and adolescent dietary patterns and to determine associations between childhood dietary pattern and longitudinal change in body mass index (BMI) z-score among girls. POPULATION AND METHODS: Healthy girls (n = 101) aged 8-12 years at baseline and 11-19 years at follow-up participated in a longitudinal study of growth and development. Participants kept 7-day dietary records at two points in time. We incorporated time of day, frequency, and amount of energy consumed (defined as percentage of total energy consumed per dietary event) when characterizing dietary patterns. RESULTS: Girls ate an average of 4-5 times per day and consumed most energy in the afternoon and in the evening/night, rather than in the morning. After controlling for baseline BMI, the mean percentage of daily energy consumed in the evening/night was positively associated with change in BMI z-score (P = 0.039). Eating between 4.0 and 5.9 times per day overall and no more than 1.9 times in the evening/night daily were negatively associated with change in BMI z-score (P = 0.002 and 0.047, respectively), after controlling for baseline BMI z-score. DISCUSSION: Recommendations to decrease the percentage of energy coming from the evening/night meal and the number of dietary events to no more than six times per day and two times in the evening/night should be evaluated in future longitudinal investigations.

Relation of BMI to fat and fat-free mass among children and adolescents.

OBJECTIVE: Although the body mass index (BMI, kg/m2) is widely used as a surrogate measure of adiposity, it is a measure of excess weight, rather than excess body fat, relative to height. We examined the relation of BMI to levels of fat mass and fat-free mass among healthy 5- to 18-y-olds. METHODS AND PROCEDURES: Dual-energy X-ray absorptiometry was used to measure fat and fat-free mass among 1196 subjects. These measures were standardized for height by calculating the fat mass index (FMI, fat mass/ht2) and the fat-free mass index (FFMI, fat-free mass/ht2). RESULTS: The variability in FFMI was about 50% of that in FMI, and the accuracy of BMI as a measure of adiposity varied greatly according to the degree of fatness. Among children with a BMI-for-age > or =85th P, BMI levels were strongly associated with FMI (r=0.85-0.96 across sex-age categories). In contrast, among children with a BMI-for-age <50th P, levels of BMI were more strongly associated with FFMI (r=0.56-0.83) than with FMI (r=0.22-0.65). The relation of BMI to fat mass was markedly nonlinear, and substantial differences in fat mass were seen only at BMI levels > or =85th P. DISCUSSION: BMI levels among children should be interpreted with caution. Although a high BMI-for-age is a good indicator of excess fat mass, BMI differences among thinner children can be largely due to fat-free mass.

Inter-relationships among childhood BMI, childhood height, and adult obesity: the Bogalusa Heart Study.

OBJECTIVE: Although the body mass index (BMI, mass index, kg/m2) is widely used as a surrogate measure of adiposity, it is moderately associated (r approximately 0.3) with height among children. We examined whether the resulting preferential classification of taller children as overweight is appropriate. DESIGN: Cross-sectional analyses of children (ages, 3-17 y) examined the relation of height to adiposity (as assessed by BMI and skinfold thicknesses) and fasting levels of insulin. Longitudinal analyses examined the relation of childhood height and weight-height indices to adult (mean age, 25 y) levels of adiposity and fasting insulin. SUBJECTS: Children (n=11,406) and adults (n=2911) who had participated in the Bogalusa Heart Study. MEASUREMENTS: We constructed three weight-height indices: BMI, W/H3, and W/Hp. The triceps and subscapular skinfolds, as well as fasting levels of insulin, were also measured. RESULTS: The classification of children as overweight (BMI-for-age > or =95th percentile) varied markedly by height, with a 10-fold difference in the prevalence of overweight across quintiles of height between the ages of 3 and 10 y. Childhood height, however, was also related to skinfold thicknesses and insulin levels, and all associations were modified in a similar manner by age. Furthermore, childhood height was related to adult adiposity, and of the three childhood weight-height indices, BMI showed the strongest associations with adult adiposity. CONCLUSIONS: Because BMI reflects the positive association between height and adiposity among children, it is a better weight-height index than is either W/H3 or W/Hp.

Food purchased away from home as a predictor of change in BMI z-score among girls.

OBJECTIVES: To assess the relationship between eating food purchased away from home (FAH) and longitudinal change in body mass index (BMI) z-score among girls, and to assess the longitudinal tracking of eating FAH from childhood through adolescence. DESIGN: Participants kept 7-day dietary records at two points in time. The records included the place and time for all foods consumed. We recorded how often participants ate FAH, calculated the percent of total energy derived from FAH, and classified foods as quick-service food, coffee-shop food, or restaurant food. PARTICIPANTS: Healthy girls (n=101) between the ages of 8 and 12 y at baseline and 11 and 19 y at follow-up participated in a longitudinal study of growth and development at the Massachusetts Institute of Technology. STATISTICAL ANALYSES: Analysis of variance was used to assess the relationship between change in BMI z-score and both the frequency of eating FAH and energy derived from eating FAH. The participants' baseline BMI z-score was a significant covariate and was controlled for in both models. We used the kappa coefficient to assess FAH tracking from childhood through adolescence. RESULTS: The frequency of eating quick-service food at baseline was positively associated with change in BMI z-score (F=6.49, P<0.01). Participants who ate quick-service food twice a week or more at baseline had the greatest mean increase in BMI z-score compared to those who ate quick-service food once a week or not at all. Quick-service food eating tracked slightly from childhood through adolescence (k=0.17, P<0.05). DISCUSSION: Adolescent girls who eat quick-service food twice a week or more are likely to increase their relative BMI over time.

Relationship between temperament, nonresting energy expenditure, body composition, and physical activity in girls.

OBJECTIVES: To assess the extent that predilection for movement, as measured by a temperament questionnaire (activity temperament), contributes to nonresting energy expenditure and body composition in girls. DESIGN, SETTING, AND PARTICIPANTS: Baseline data for 196 premenarcheal non-obese girls aged 8-12 y were obtained from a longitudinal study of growth and development. The association of activity temperament with nonresting energy expenditure in girls with low and high levels of physical activity was evaluated, as was the association of activity temperament with body composition. MEASURES: Maternal reports of child activity temperament were obtained by questionnaire. Nonresting energy expenditure was calculated as total energy expenditure (measured by doubly labeled water) minus resting energy expenditure (obtained by indirect calorimetry). Body composition was estimated by total body water. Questionnaires and activity diaries were used to assess physical activity and sedentary behavior. RESULTS: Higher activity temperament was associated with higher nonresting energy expenditure after multivariate control for weight, vigorous activity, walking and light activity, and television viewing, although activity temperament did not account for a large percentage of the variability in nonresting energy expenditure (partial squared correlation coefficient=0.03). In girls with physical activity levels below the median, high activity temperament was associated with a mean+/-s.d., nonresting energy expenditure of 310+/-138 kJ (74+/-33 kcal) above that of girls with a low activity temperament. Girls with a high activity temperament had less body fat than did girls with a low activity temperament (21.6 vs 24.5%, a difference of 2.9 percentage points; 95% confidence interval, 1.3-4.4 percentage points). CONCLUSION: Predilection for movement, as measured by a temperament questionnaire, contributes to nonresting energy expenditure and may be useful in capturing an aspect of energy expenditure in population studies. The cross-sectional observation that girls with a high activity temperament were leaner than girls with a low activity temperament suggests that a constitutional predilection for movement may play a role in the development of obesity.

The relation of obesity throughout life to carotid intima-media thickness in adulthood: the Bogalusa Heart Study.

OBJECTIVE: Although obese children are at increased risk for coronary heart disease in later life, it is not clear if this association results from the persistence of childhood obesity into adulthood. We examined the relation of adiposity at various ages to the carotid intima-media thickness (IMT) at age 35 y. DESIGN: Prior to the determination of IMT by B-mode ultrasound, subjects (203 men, 310 women) had, on average, six measurements of body mass index (BMI) and triceps skinfold thickness (TSF) between the ages of 4 and 35 y. Mixed regression models for longitudinal data were used to assess the relation of these characteristics to adult IMT. RESULTS: Overall, adult IMT was associated with levels of both BMI and TSF (P<0.001), with the magnitudes of the associations with childhood adiposity comparable to those with adult levels of BMI and TSF. Furthermore, adult obesity modified the association between childhood adiposity and IMT: high IMT levels were seen only among overweight (BMI > or =95th percentile) children who became obese (BMI > or =30 kg/m2) adults (P<0.01 for linear trend). In contrast, IMT levels were not elevated among (1) overweight children who were not obese in adulthood, or among (2) thinner children who became obese adults. CONCLUSIONS: These results emphasize the adverse, cumulative effects of childhood-onset obesity that persists into adulthood. Since many overweight children become obese adults, the prevention of childhood obesity should be emphasized.

Energy cost of physical activities in 12-y-old girls: MET values and the influence of body weight.

BACKGROUND: Few data exist on the energy cost of specific activities in children. The influence of body weight on the energy cost of activity when expressed as metabolic equivalents (METs) has not been vigorously explored. OBJECTIVE: To provide MET data on five specific activities in 12-y-old girls and to test the hypothesis that measured MET values are independent of body weight. SUBJECTS AND METHODS: In 17 12-y-old girls, resting metabolic rate (RMR) and the energy expended while sitting, standing, walking on a flat treadmill at 3.2 and at 4.8 km/h, and walking on a treadmill at a 10% incline at 4.8 km/h were measured using indirect calorimetry. MET values were calculated by dividing the energy expenditure of an activity by the subject's RMR. The influence of body weight was assessed using simple linear regression. RESULTS: The observed METs were more consistent with published values for similar activities in adults than those offered for children. Body weight was a statistically significant predictor of the MET of all three walking activities, but not the MET of sitting or standing. Body weight explained 25% of the variance in the MET value for walking at 3.2 km/h, 39% for walking at 4.8 km/h, and 63% for walking at a 10% incline at 4.8 km/h. CONCLUSION: METs for the three walking activities were not independent of body weight. The use of average MET values to estimate the energy cost of these three activities would result in an underestimation of their energy cost in heavier girls and an overestimation in lighter girls. These results suggest that the estimation of total energy expenditure from activity diary, recall, and direct observation data using average MET values may be biased by body weight.

Body weight and obesity in adults and self-reported abuse in childhood.

BACKGROUND: Little is known about childhood factors and adult obesity. A previous study found a strong association between childhood neglect and obesity in young adults. OBJECTIVE: To estimate associations between self-reported abuse in childhood (sexual, verbal, fear of physical abuse and physical) adult body weight, and risk of obesity. DESIGN: Retrospective cohort study with surveys during 1995-1997. PATIENTS: A total of 13,177 members of California health maintenance organization aged 19-92 y. MEASUREMENTS: Body weight measured during clinical examination, followed by mailed survey to recall experiences during first 18 y of life. Estimates adjusted for adult demographic factors and health practices, and characteristics of the childhood household. RESULTS: Some 66% of participants reported one or more type of abuse. Physical abuse and verbal abuse were most strongly associated with body weight and obesity. Compared with no physical abuse (55%), being 'often hit and injured' (2.5%) had a 4.0 kg (95% confidence interval: 2.4-5.6 kg) higher weight and a 1.4 (1.2-1.6) relative risk (RR) of body mass index (BMI) > or = 30. Compared with no verbal abuse (53%), being 'often verbally abused' (9.5%) had an RR of 1.9 (1.3-2.7) for BMI > or = 40. The abuse associations were not mutually independent, however, because the abuse types strongly co-occurred. Obesity risk increased with number and severity of each type of abuse. The population attributable fraction for 'any mention' of abuse (67%) was 8% (3.4-12.3%) for BMI > or = 30 and 17.3% (-1.0-32.4%) for BMI > or = 40. CONCLUSIONS: Abuse in childhood is associated with adult obesity. If causal, preventing child abuse may modestly decrease adult obesity. Treatment of obese adults abused as children may benefit from identification of mechanisms that lead to maintenance of adult obesity.

Relationship of childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa Heart Study.

BACKGROUND: Childhood obesity is related to adult levels of lipids, lipoproteins, blood pressure, and insulin and to morbidity from coronary heart disease (CHD). However, the importance of the age at which obesity develops in these associations remains uncertain. OBJECTIVE AND DESIGN: We assessed the longitudinal relationship of childhood body mass index (BMI, kg/m(2)) to adult levels of lipids, insulin, and blood pressure among 2617 participants. All participants were initially examined at ages 2 to 17 years and were reexamined at ages 18 to 37 years; the mean follow-up was 17 years. RESULTS: Of the overweight children (BMI >/=95th percentile), 77% remained obese (>/=30 kg/m(2)) as adults. Childhood overweight was related to adverse risk factor levels among adults, but associations were weak (r ~ 0.1-0.3) and were attributable to the strong persistence of weight status between childhood and adulthood. Although obese adults had adverse levels of lipids, insulin, and blood pressure, levels of these risk factors did not vary with childhood weight status or with the age (/=18 years) of obesity onset. CONCLUSIONS: Additional data are needed to assess the independent relationship of childhood weight status to CHD morbidity. Because normal-weight children who become obese adults have adverse risk factor levels and probably will be at increased risk for adult morbidity, our results emphasize the need for both primary and secondary prevention.

Impact of overweight on the risk of developing common chronic diseases during a 10-year period.

BACKGROUND: Overweight adults are at an increased risk of developing numerous chronic diseases. METHODS: Ten-year follow-up (1986-1996) of middle-aged women in the Nurses' Health Study and men in the Health Professionals Follow-up Study to assess the health risks associated with overweight. RESULTS: The risk of developing diabetes, gallstones, hypertension, heart disease, and stroke increased with severity of overweight among both women and men. Compared with their same-sex peers with a body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) between 18.5 and 24.9, those with BMI of 35.0 or more were approximately 20 times more likely to develop diabetes (relative risk [RR], 17.0; 95% confidence interval [CI], 14.2-20.5 for women; RR, 23.4; 95% CI, 19.4-33.2 for men). Women who were overweight but not obese (ie, BMI between 25.0 and 29.9) were also significantly more likely than their leaner peers to develop gallstones (RR, 1.9), hypertension (RR, 1.7), high cholesterol level (RR, 1.1), and heart disease (RR, 1.4). The results were similar in men. CONCLUSIONS: During 10 years of follow-up, the incidence of diabetes, gallstones, hypertension, heart disease, colon cancer, and stroke (men only) increased with degree of overweight in both men and women. Adults who were overweight but not obese (ie, 25.0 < or = BMI < or = 29.9) were at significantly increased risk of developing numerous health conditions. Moreover, the dose-response relationship between BMI and the risk of developing chronic diseases was evident even among adults in the upper half of the healthy weight range (ie, BMI of 22.0-24.9), suggesting that adults should try to maintain a BMI between 18.5 and 21.9 to minimize their risk of disease.

Nutritional rickets in Georgia.

Opinions expressed in commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees. Commentaries are not peer-reviewed.

Obesity in women of childbearing age: risks, prevention, and treatment.

This article reviews the health burden of obesity, its treatment and prevention, and potential barriers to care with special emphasis on adult women of childbearing age. From 1988 to 1994, 22% of nonpregnant women 18-49 years old in the United States were overweight (body mass index [BMI] >/= 25-29.9), and 22% were obese (BMI >/= 30). Both conditions increase the risk of chronic disease and mortality, and among women of childbearing age, overweight and obesity also increase the risk of infertility and adverse pregnancy outcomes.The three main strategies for preventing obesity are weight maintenance, weight loss for overweight and obese persons, and physical activity for all. More than 44% of nonpregnant women of childbearing age are trying to lose weight, and more than 33% are trying to maintain weight, but less than 21% of women of childbearing age use the recommended combination of physical activity and caloric restriction to try to lose or maintain weight. Pregnant women should try to gain no more than the recommended weight gain range for their prepregnancy BMI, yet about one third gain more weight.Although research has shown that advice from physicians can have an impact on their patients' eating habits and physical activity, many health professionals either provide no such advice or give inappropriate advice to women of childbearing age. Barriers may include inadequate reimbursement, time constraints, and lack of professional training. Frequent contact with women of childbearing age provides obstetricians and gynecologists and nurse specialists an opportunity to prevent and treat obesity successfully.