Body composition and bone health in adolescents after Roux-en-Y gastric bypass for severe obesity.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGB) causes changes in body composition and bone metabolism, yet little is known about effects in adolescents. OBJECTIVES: The objective of this study was to report dual-energy X-ray absorptiometry measures and serum bone markers, hypothesizing that bone turnover increases after surgery. METHODS: Inclusion criteria included the following: age 13-18 years and body mass index (BMI) >35 kg/m2 . Seventy-two adolescents (22 boys; mean age 16.5 years; BMI 44.8 kg/m2 ) undergoing RYGB underwent dual-energy X-ray absorptiometry and serum bone marker analyses preoperatively and annually for 2 years. RESULTS: Mean BMI reduction at 2 years was 15.1 kg/m2 . Body composition changes included a reduction in fat mass (51.8% to 39.6%, p < 0.001) and relative increase in lean mass (47.0% to 58.1%, p < 0.001). In contrast to previous studies in adults, adolescent boys lost a greater percentage of their body fat than girls (-17.3% vs. -9.5%, p < 0.001). Individual bone mineral density Z-scores (BMD-Z) at baseline were within or above the normal range. The mean (SD) BMD-Z was 2.02 (1.2) at baseline, decreasing to 0.52 (1.19) at 2 years. Higher concentrations of serum CTX (p < 0.001) and osteocalcin (p < 0.001) were observed in boys throughout the study period. Levels rose in the first year, before decreasing modestly in the second. Levels of serum markers of bone synthesis and resorption were higher in boys, whose skeletal maturity occurs later than girls'. CONCLUSIONS: Differences in body fat and lean mass proportions were observed according to sex following RYGB. Bone turnover increased, and BMD decreased to levels approaching a norm for age. Long-term outcome will determine the clinical relevance.

Safety and immunogenicity of a glycoprotein D genital herpes vaccine in healthy girls 10-17 years of age: results from a randomised, controlled, double-blind trial.

OBJECTIVE: The investigational AS04-adjuvanted herpes simplex virus type 2 (HSV-2) glycoprotein D (gD2) subunit prophylactic vaccine ('HSV vaccine'; GlaxoSmithKline Vaccines) has been shown to be well tolerated in adults, but limited data exist for pre-teen and adolescent girls, a likely target population. The primary objective of this study was to compare the occurrence of serious adverse events (SAEs) over 12 months between HSV vaccine recipients and saline recipients (placebo control group) in pre-teen and adolescent girls. The immunogenicity of the HSV vaccine was also assessed. METHODS: Healthy girls aged 10-17 years, stratified by age (10-15 years; 16-17 years), were randomised 2:1:1 to receive the HSV vaccine, a hepatitis A vaccine (Havrix™; HAV control) or placebo (saline) according to a 0-, 1-, 6-month schedule. Participants and study personnel not involved in the preparation or administration of vaccines were blinded to treatment. Safety and immunogenicity analyses were performed overall and by age (10-15 years; 16-17 years) and HSV serostatus. RESULTS: No statistically significant difference in the percentage of subjects with SAEs was observed between the HSV and saline group, or between the HSV and pooled control (HAV and saline) groups. The HSV vaccine was well tolerated, although a higher incidence of solicited local symptoms was observed in the HSV group than in the control group. Neither age nor HSV serostatus at the time of study entry had an impact on the safety profile of this vaccine. The HSV vaccine was immunogenic regardless of pre-vaccination HSV serostatus. Higher anti-gD geometric mean concentrations were observed in HSV-1 seropositive participants than in HSV-1 seronegative participants. CONCLUSION: The HSV vaccine had an acceptable safety profile, and was well tolerated and immunogenic when administered to girls aged 10-17 years regardless of age or HSV pre-vaccination serostatus.

Laser beam measurement of abdominal sagittal diameter in obese children: a validation study.

OBJECTIVES: Sagittal diameter (SAD) has been reported to correlate to visceral fat and cardiovascular risk factors. SAD is measured with the individual lying down, halfway between the lower rib margin and the iliac crest; it represents the mid-height of the abdomen. The aim of this study was to validate SAD measured using a recently-developed laser beam device (SAD(LDB) ) against SAD measured using MRI (SAD(MRI)). METHODS: Of 48 obese children (25 boys, 23 girls) aged 9-11 years on the waiting list for obesity treatment, 34 agreed to a baseline measurement, which was followed by repeated measurements 6 and 12 months later in 31 and 22 children respectively. MRI was used to examine SAD(MRI) at 5 cm above (SAD(MRI,cra) ) and below (SAD(MRI,cau)) the mid plane of the L4-5 intervertebral disc. RESULTS: Each of the differences SAD(LBD) - SAD(MRI, cau) and SAD(LBD) - SAD(MRI,cra) was subjected to a repeated-measurements ANOVA; the visit did not have a statistically significant effect in either case (p = 0.19 and p = 0.72, respectively). The difference SAD(LBD) - SAD(MRI, cau) was 1.50 on average (p < 0.0001; CI 1.26-1.74) while the corresponding figure for SAD(LBD) -SAD(MRI, cra) was 1.26 (p < 0.0001; CI 1.04-1.49). Regression of the difference on the mean gave slopes of -0.09 (p = 0.25) and -0.04 (p = 0.57) respectively. Prediction of SAD(MRI) from SAD(LDB) can be performed in different ways: by means of linear regression or by means of an additive correction. CONCLUSIONS: Thus, this laser device can be used instead of MRI to estimate SAD by using a simple correction.

Two-year outcome of laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity: results from a Swedish Nationwide Study (AMOS).

CONTEXT: The prevalence of obesity among adolescents has increased and we lack effective treatments. OBJECTIVE: To determine if gastric bypass is safe and effective for an unselected cohort of adolescents with morbid obesity in specialized health care. DESIGN, SETTING AND PATIENTS: Intervention study for 81 adolescents (13-18 years) with a body mass index (BMI) range 36-69 kg m(-2) undergoing laparoscopic gastric bypass surgery in a university hospital setting in Sweden between April 2006 and May 2009. For weight change comparisons, we identified an adult group undergoing gastric bypass surgery (n=81) and an adolescent group (n=81) receiving conventional care. MAIN OUTCOME MEASUREMENTS: Two-year outcome regarding BMI in all groups, and metabolic risk factors and quality of life in the adolescent surgery group. RESULTS: Two-year follow-up rate was 100% in both surgery groups and 73% in the adolescent comparison group. In adolescents undergoing surgery, BMI was 45.5 ± 6.1 (mean ± s.d.) at baseline and 30.2 (confidence interval 29.1-31.3) after 2 years (P<0.001) corresponding to a 32% weight loss and a 76% loss of excess BMI. The 2-year weight loss was 31% in adult surgery patients, whereas 3% weight gain was seen in conventionally treated adolescents. At baseline, hyperinsulinemia (>20 mU l(-1)) was present in 70% of the adolescent surgery patients, which was reduced to 0% at 1 year and 3% at 2 years. Other cardiovascular risk factors were also improved. Two-thirds of adolescents undergoing surgery had a history of psychopathology. Nevertheless, the treatment was generally well tolerated and, overall, quality of life increased significantly. Adverse events were seen in 33% of patients. CONCLUSIONS: Adolescents with severe obesity demonstrated similar weight loss as adults following gastric bypass surgery yet demonstrating high prevalence of psychopathology at baseline. There were associated benefits for health and quality of life. Surgical and psychological challenges during follow-up require careful attention.

Self-esteem in a clinical sample of morbidly obese children and adolescents.

AIM: To study self-esteem in clinical sample of obese children and adolescents. METHODS: Obese children and adolescents aged 8-19 years (n = 107, mean age 13.2 years, mean BMI 32.5 [range 22.3-50.6], mean BMI z-score 3.22 [range 2.19-4.79]; 50 boys and 57 girls) were referred for treatment of primary obesity. Self-esteem was measured with a validated psychological test with five subscales: physical characteristics, talents and skills, psychological well-being, relations with the family and relations with others. A linear mixed effect model used the factors gender and adolescence group, and the continuous covariates: BMI z-scores, and BMI for the parents as fixed effects and subjects as random effects. RESULTS: Age and gender, but neither the child's BMI z-score nor the BMI of the parents were significant covariates. Self-esteem decreased (p < 0.01) with age on the global scale as well as on the subscales, and was below the normal level in higher ages in both genders. Girls had significantly lower self-esteem on the global scale (p = 0.04) and on the two subscales physical characteristics (p < 0.01) and psychological well-being (p < 0.01). CONCLUSION: Self-esteem is lower in girls and decreases with age. In treatment settings special attention should be paid to adolescent girls.

Metabolic risk-factor clustering estimation in children: to draw a line across pediatric metabolic syndrome.

BACKGROUND: The diagnostic criteria of the metabolic syndrome (MS) have been applied in studies of obese adults to estimate the metabolic risk-associated with obesity, even though no general consensus exists concerning its definition and clinical value. We reviewed the current literature on the MS, focusing on those studies that used the MS diagnostic criteria to analyze children, and we observed extreme heterogeneity for the sets of variables and cutoff values chosen. OBJECTIVES: To discuss concerns regarding the use of the existing definition of the MS (as defined in adults) in children and adolescents, analyzing the scientific evidence needed to detect a clustering of cardiovascular risk-factors. Finally, we propose a new methodological approach for estimating metabolic risk-factor clustering in children and adolescents. RESULTS: Major concerns were the lack of information on the background derived from a child's family and personal history; the lack of consensus on insulin levels, lipid parameters, markers of inflammation or steato-hepatitis; the lack of an additive relevant effect of the MS definition to obesity per se. We propose the adoption of 10 evidence-based items from which to quantify metabolic risk-factor clustering, collected in a multilevel Metabolic Individual Risk-factor And CLustering Estimation (MIRACLE) approach, and thus avoiding the use of the current MS term in children. CONCLUSION: Pediatricians should consider a novel and specific approach to assessing children/adolescents and should not simply derive or adapt definitions from adults. Evaluation of insulin and lipid levels should be included only when specific references for the relation of age, gender, pubertal status and ethnic origin to health risk become available. This new approach could be useful for improving the overall quality of patient evaluation and for optimizing the use of the limited resources available facing to the obesity epidemic.

Physical activity-key issues in treatment of childhood obesity.

Changes in physical activity with the aim of increasing energy expenditure are usually an important component of childhood obesity treatment. Physical activity also has several other aspects that are positive for the obese child's health, such as improving the metabolic profile and psychological well being. The aim of this paper is to give a short review of what we know about physical activity in paediatric obesity treatment. In addition, practical recommendations will be presented which a health care provider can suggest to obese children and their families with a special focus on daily activity, participation in physical education classes and sports, sedentary behaviours, active commuting to school and how to get family and friends involved in supporting the child.

Interventions to prevent obesity in children and adolescents: a systematic literature review.

OBJECTIVE: Preventive measures to contain the epidemic of obesity have become a major focus of attention. This report reviews the scientific evidence for medical interventions aimed at preventing obesity during childhood and adolescence. DESIGN: A systematic literature review involving selection of primary research and other systematic reviews. Articles published until 2004 were added to an earlier (2002) review by the Swedish Council on Technology Assessment in Health Care. METHODS: Inclusion criteria required controlled studies with follow-up of at least 12 months and results measured as body mass index, skinfold thickness or the percentage of overweight/obesity. Children could be recruited from normal or high-risk populations. RESULTS: Combining the new data with the previous review resulted in an evaluation of 24 studies involving 25 896 children. Of these, eight reported that prevention had a statistically significant positive effect on obesity, 16 reported neutral results and none reported a negative result (sign test; P=0.0078). Adding the studies included in five other systematic reviews yielded, in total, 15 studies with positive, 24 with neutral and none with negative results. Thus, 41% of the studies, including 40% of the 33 852 children studied, showed a positive effect from prevention. These results are unlikely to be a random chance phenomenon (P=0.000061). CONCLUSION: Evidence shows that it is possible to prevent obesity in children and adolescents through limited, school-based programs that combine the promotion of healthy dietary habits and physical activity.

From birth to adolescence: Vienna 2005 European Childhood Obesity Group International Workshop.

BACKGROUND: In the last 15 y there has been a tremendous increase in the number of studies on pediatric obesity looking at epidemiology, health-related risks, etiology, methodology and treatment. During the early 1990s, the European Childhood Obesity Group (ECOG) was born as a group of scientists' expert in the field of pediatric obesity. ECOG this year celebrates the approach to early maturity with an excited and omni-comprehensive program developing through eight different tracks. METHODS: Comments on different 'key' papers in each of the eight tracks. RESULTS: The eight tracks were (1) Nutrition requirements and food habits, (2) physical activity, (3) prevention and political actions/strategies, (4) diabetes, (5) metabolism, (6) psychology, (7) pathology, and (8) treatment with emphasis on drugs. CONCLUSION: Looking at the overall picture of the ECOG workshop we could conclude that despite the fact that childhood obesity is a crisis facing worldwide youth, it is necessary that action to control it must be taken now. All the six relevant levels (ie, family, schools, health professionals, government, industry and media) could be involved in prevention of child and adolescent obesity.

The happy obese child.

OBJECTIVE: Firstly, is the negative psychological effect of obesity also present in the whole population of obese and overweight children? Secondly, what tools could be recommended to measure the psychological effects of obesity? DESIGN: Review. METHODS: Quality of life or self-esteem is often used in evaluating the psychological effects of obesity. Test instruments used have been instruments for measuring quality of life such as the pediatric quality of life inventory (PedsQL) or the KINDL instrument, and measurements of self-esteem, such as 'ITIA' ('I think I am) and the Self-Perception Profile for Children. RESULTS: The obese child studied in community samples has better quality of life and self-esteem than obese children from clinical samples. CONCLUSION: Psychosocial factors seem to be more important than the functional limitations of obesity itself. This means that we might help the obese child better by social support to a minor part of the population than to focus on the child's obesity as a cause of psychological problems. A happy obese child might have greater resources to cope with the problem than previously thought.

Reactogenicity and immunogenicity profile of a two-dose combined hepatitis A and B vaccine in 1-11-year-old children.

This study was conducted to compare the reactogenicity, immunogenicity and safety of a combined two-dose (0, 6 months) hepatitis A and B vaccine (720ELU HAV, 20 mcg HBsAg) with the established three-dose (0, 1 and 6 months) hepatitis A and B vaccine (360ELU HAV, 10 mcg HBsAg). A total of 511 children aged 1-11 years who had not previously received a hepatitis A or B vaccine were enrolled in the study. Both vaccines were well tolerated, and were shown to be safe and immunogenic. The analysis, stratified according to two age groups (1-5 year and 6-11-year-old children) demonstrated that the reactogenicity profile of the two-dose schedule was at least as good as that of the established schedule. Both vaccines and schedules provided at least 98% seroprotection against hepatitis B and 100% seroconversion against hepatitis A, 1 month after the end of the vaccination course (Month 7).

New insights into the field of children and adolescents' obesity: the European perspective.

EDITOR'S NOTE: The problem of childhood obesity is accelerating throughout the world. The following is a position paper from The European Childhood Obesity Group (ECOG) that outlines the nature of the problem of childhood obesity along with treatment and prevention methods available today. The paucity of literature on prevention and treatment of obesity in children as documented in this paper points out the need for much additional research on obesity in children. OBJECTIVES: The awareness of childhood obesity as a major health problem and an uncontrolled worldwide epidemic has to be increased in the society. DESIGN: In order to improve the quality of the health care and to minimize the cost it is important to investigate and standardize pediatric obesity prevention and treatment and to adapt to social and cultural aspects. RESULTS: Obesity is the result of excess body fat. The different norms and definitions in Europe and the US is described and clarified. However, the available methods for the direct measurement of body fat are not easily used in daily practice. For this reason, obesity is often assessed by means of indirect estimates of body fat, that is, anthropometrics. There are essentially six relevant levels, which could be involved in prevention of child and adolescent obesity: family (child, parents, siblings, etc), schools, health professionals, government, industry and media. Evidence-based health promotion programs has to be given a high priority. Government should encourage media increase information about healthy nutrition and to avoid the marketing of unhealthy foods including sweet drinks, for example, in TV. Many different approaches of treatments of obesity have been investigated, including diet, exercise, behavioral therapy, surgery, and medication. None have been found to be effective enough as sole tools in children. This has led to focus on multidisciplinary programs especially involving families. Behavioral cognitive therapy is effective in treating childhood obesity as is family therapy. Surgery and drug treatment cannot be recommended without additional research. Clinicians should consider the various factors that can influence body composition. CONCLUSION: It is important to know and to follow nutritional factors, energy intake and composition of the diet, nutrition and hormonal status, food preferences and behavior, and the influence of non-nutritional factors. We recommend that obesity should be the major priority both in the health care system, on the scientific level and for future political actions.

Calculation of resting energy expenditure in obese children.

UNLABELLED: For the calculation of resting energy expenditure, which is the main part of total energy expenditure in children with low physical activity, Fusch et al. have developed an equation. CONCLUSION: This equation might be useful for research but not in daily work with obese patients.

[Family therapy appropriate even in somatic care. Study review of medically oriented family therapy]. / Familjeterapi tillämplig även i somatiska vården. Studieöversikt över medicinskt orienterad familjeterapi.

By observing and analyzing the influence of the therapist on the family as well as interactions between family members, the encounter with a family in a medical setting can serve to improve the health of its members, by improving their ability to use their own resources. This method of focusing on the interaction between individuals in a family or other systems has been a valuable addition to medical treatment of chronic disease. Family therapy has been shown to effectively improve treatment of diabetes, asthma and obesity. A review of the literature is presented.

Hereditary dyslipidemias and combined risk factors in children with a family history of premature coronary artery disease.

AIM: Schoolchildren aged 10-11 with a family history of premature coronary artery disease (CAD), were examined in order to identify children with genetically determined dyslipidemias and a combination of risk factors. METHODS: A total of 4000 questionnaires were distributed by the school; 55% of the families answered and returned the questionnaire. Blood lipids, apolipoprotein B, and Lp(a) lipoprotein were analysed in high risk children and their parents. RESULTS: A family history of premature CAD in parents or grandparents was identified in 208 families; 175 agreed to take part in a clinical examination and laboratory tests. Normal blood lipid tests were found in 89 children. Another 48 had an isolated increase of Lp(a) lipoprotein of minor clinical importance. Of the remaining 38 children, 23 had non-hereditary abnormalities of low (LDL) or high density lipoprotein (HDL) cholesterol or apolipoprotein B. Fifteen children were suspected to have genetically determined dyslipidemias or a combination of risk factors: in four, possible familial hypercholesterolaemia (FH); in five, possible familial combined hyperlipidaemia; in three, hereditary low HDL cholesterol; and in three a combination of high LDL cholesterol and Lp(a) lipoprotein concentrations. In addition, possible FH was detected in eight of the parents. CONCLUSION: It is worthwhile asking parents about the occurrence of premature CAD among their child's closest relatives.

Ultrasound measurements of subcutaneous adipose tissue in infants are reproducible.

BACKGROUND: The purpose of this study was to evaluate the ultrasound technique for measuring subcutaneous adipose tissue in infants. METHODS: Twenty infants were investigated at 3, 6, and 12 months of age. All measurements were made by the same investigator in triplicate on the left side of the body at the triceps and subscapular anatomic landmarks and at the abdomen and thigh. An ultrasound system equipped with a linear 7.0-MHz transducer was used. RESULTS: The intraclass correlation coefficients were 0.88 to 0.99. Random errors ranged from 0.01 to 0.19 mm. For log-transformed values, the random error ranged from 2.4% to 5.7%. CONCLUSIONS: Measurements of subcutaneous fat in infants using ultrasound are reproducible when performed by the same observer.

The influence of dietary nucleotides on erythrocyte membrane fatty acids and plasma lipids in preterm infants.

OBJECTIVE: The objective of this study was to evaluate whether a regular formula for premature infants supplemented with nucleotides has any influence on plasma lipids and erythrocyte membrane fatty acids. METHODS: Preterm infants fed either human milk supplemented with human milk protein (HM, n = 14), nucleotide-supplemented preterm formula (NF, n = 13), or a regular preterm formula (F, n = 13) were included in the study. The NF was supplemented with 18.2 mg cytidine monophosphate/l (CMP), 7.0 mg uridine monophosphate/l (UMP), 6.4 mg adenosine monophosphate/l (AMP), 3.0 mg inosine monophosphate/l (IMP) and 3.0 mg guanosine monophosphate/l (GMP). RESULTS: There were significantly higher concentrations of triglycerides (TG) in infants fed NF compared to those fed F (191.42 +/- 79.58 vs 108.21 +/- 43.73, p < 0.001, mean +/- SD lipid concentrations, mg/100 ml plasma). Infants fed F had significantly lower concentrations of total cholesterol (94.34 +/- 11.71 vs 115.69 +/- 39.29, p < 0.01) and TG in plasma (108.21 +/- 43.73 vs 172.27 +/- 68.19, p < 0.001, mean +/- SD lipid concentrations, mg/100 ml plasma) when compared to HM-fed infants. There were no significant differences in any of the erythrocyte membrane fatty acids and total long-chain polyunsaturated fatty acids (LC-PUFA) between NF and F during the study period (6 weeks). Furthermore, total LC-PUFA and docosahexaenoic acid (DHA) concentrations in red blood cell were not significantly different when infants fed NF were compared to those fed HM. In contrast, however, infants fed F had significantly lower concentrations of total n-3 LC-PUFA (p < 0.01) and DHA (p < 0.01) than those found in HM-fed infants. CONCLUSIONS: These results do not suggest an effect of nucleotides on the red blood cell LC-PUFA profile in preterm infants. However, the nucleotides may increase the concentrations of triglycerides in plasma.