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.

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.

Nutrition policy, food and drinks at school and after school care.

OBJECTIVE: The purpose of the paper is to describe food and drinks available in food stands or cantina at Danish schools and food and drinks provided at after school care institutions in Denmark. MATERIAL AND METHODS: The survey was performed in 1999 and self-administered postal questionnaires were sent to all private and public schools and all after school care institutions in Denmark. The participation rate was 70 at schools and 66 at after school care institutions. RESULTS: In total, 3% of schools and 4% of after school care institutions have a written policy on nutrition. All Danish children have access to milk at school and they can choose between milk with low and high content of fat. Vending machines are rare at schools and are not present at all at after school care institutions. Only 10% of schools offer children sugared carbonated drinks at food stands. Fruit is available daily in 35% of schools, at food stands, and in 18% of the schools, fruit is available on prescription. In after school care institutions, sweets and sugared carbonated drinks are rare. However, juice is served daily in 47% of after school care institutions. Most schools run the food stand at school for profit. CONCLUSION: The paper highlights the important aspects of the institutional level as one of six important levels as regards the prevention of obesity and an important level at which to act to increase nutrition habits in school children.

Overweight and obesity epidemic among children. Answer from European countries.

OBJECTIVE: To investigate the methods and results used and conclusions found in available published papers on childhood overweight and obesity in Europe. SURVEYS: This paper compares the two available published papers on the prevalence of child and adolescent overweight and obesity in Europe. The first paper was published in November 2003 and was based on 20 previously conducted surveys performed from 1992 to 2001. The other paper was published in January 2004 and was based on data from the WHO collaborative survey 'Health Behaviour in School Children', which collected the data in 1997-1998 within a period of 9 months. Height and weight were included as optional questions and 13 European countries, Israel and United States participated. METHODS: In both papers, body mass index (BMI) was used. In the first paper, measured BMI was used and prevalence of overweight was calculated using IOTF cutoff points. In the other paper, overweight and obesity prevalences were calculated from self-reported height and weight using an internal study reference standard. RESULTS: The first paper found a north-south trend in overweight in Europe, whereas the second found a more equal distribution of overweight in European children. Thus, overweight was significantly increased among 13 y olds of both sexes in Finland, Ireland, and Greece, and in Portuguese girls. Among 15 y olds, the prevalence of overweight was significantly increased in Greek boys, and in Danish and Portuguese girls. On the contrary, in Lithuania, there was a significantly low prevalence of overweight among both ages and both sexes. CONCLUSION: Critical reviews of the results of the two published papers show that the year of data collection, methods and use of appropriate statistics are of critical importance for the conclusion drawn from comparative epidemiological surveys on the prevalence of overweight.

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.

Social differences in illness and health-related exclusion from the labour market in Denmark from 1987 to 1994.

OBJECTIVE: The objectives were first to analyse differences in long-standing illness, limiting long-standing illness, and perceived health as below good in relation to different indicators of social class over time; and secondly to analyse the association of long-standing illness, educational level, age, and gender with employment status. SUBJECTS AND METHODS: Self-reported information on illness, educational level, employment status, and occupational class was obtained in two nationally representative Danish health interview surveys in 1987 (n=4753) and 1994 (n=4668). RESULTS: There was a marked increase in long-standing illness from 1987 (33%) to 1994 (38%), especially among women with higher education (13% in 1987 to 26% in 1994). The prevalence of perceived health below good was unchanged (c. 20%) during the same period. Among employed men in 1987 the lowest prevalence of long-standing illness was seen in upper salaried employees (21%) and the highest in skilled workers (35%). In 1994, the difference had diminished and the prevalence rates for the same classes were 28% and 29%, respectively. Among employed women, a similar pattern was seen. The lowest rate in 1987 was seen among self-employed with subordinates (15%) and the highest in self-employed without subordinates (28%). In 1994, the difference was reduced with prevalence rates of 23% and 32%, respectively. In addition, substantial differences in health status between groups with different educational backgrounds were found. The proportion of the population with long-standing illnesses was clearly higher in the group with low education compared with the group with high education. A similar social gradient was found for perceived health as below good. Those with the highest odds ratio of being a disability pensioner are women with long-standing illness, only basic education, and above 55 years of age. CONCLUSION: In conclusion, the study showed that the prevalence of long-standing illness increased from the mid-1980s to the mid-1990s, whereas perceived health below good was unchanged. In 1994, there was a remarkable difference in health between employed and non-employed people, indicating a health-related exclusion from the labour market. This may explain why, in 1994, smaller occupational class differences were found in the prevalence of long-standing illness among employed people compared with the findings in 1987, whereas the health differences remained in the different educational groups. Women above 54 years of age with basic education only and long-standing illness have the highest odds ratio of permanent exclusion from the labour market.

[Small changes in health differences in the Nordic countries during the 1980s and 1990s]. / Liten förändring av hälsoskillnader i Norden under 1980- och 1990-talen.

The study examined changes over time in health inequality in Denmark, Finland, Norway and Sweden. Data derive from comparable interview surveys carried out in 1986/87 and 1994/95. Limiting long-standing illness and perceived ill health were analysed regarding age, gender; educational attainment, and employment status. Age adjusted prevalence rates were calculated. Changes in differences in health were found in education and employment status groups. There was little or no change in the prevalence of ill health during the time period studied. Despite social and economic changes differences in health remained broadly stable in the examined countries.

Parental neglect during childhood and increased risk of obesity in young adulthood.

The association of various features of family life with obesity in childhood is well established, but less is known about the effect of these influences on the risk of later obesity. In this prospective, population-based study, we examined the influence of parental care in childhood on the risk of obesity in the offspring in young adulthood. In 1974, 1258 pupils aged 9-10 years were randomly selected from the third grade of Copenhagen schools. Information on 987 pupils was obtained from the form teachers on family structure and the perceived support from the parents; school medical services reported on the child's general hygiene. 756 (86%) of the 881 eligible participants were followed up 10 years later. The influence of family factors in childhood on the risk of obesity (body-mass index > 95th centile) in young adulthood was estimated by odds ratios with control for age and body-mass index in 1974, sex, and social background. Family structure (biological or other parents and number of siblings) did not significantly affect the risk of adult obesity. Parental neglect greatly increased the risk in comparison with harmonious support (odds ratio 7.1 [95% CI 2.6-19.3]). Dirty and neglected children had a much greater risk of adult obesity than averagely groomed children (9.8 [3.5-28.2]). However, being an only child, receiving overprotective parental support, or being well-groomed had no effect. Parental neglect during childhood predicts a great risk of obesity in young adulthood, independent of age and body-mass index in childhood, sex, and social background.

Maternal attitude to sweet eating habits and risk of overweight in offspring: a ten-year prospective population study.

The possible effect of maternal attitude to sweet eating habits on their offspring's risk of overweight is a common concern. This study addresses the influence of mothers' reports on and attitude to sweet eating habits on the subsequent risk of overweight of their offspring in young adulthood. A study of a randomly selected cohort of 9-10 year old children from schools in the Copenhagen municipality was performed in 1974. A decade later a follow-up was carried out, and 86% of the target population participated. Overweight was defined as the 90th percentile of body mass index distribution (weight/height2 (kg/m2)). The odds ratio of overweight in young adulthood was assessed by logistic regression analysis taking into account body mass index in childhood, gender and social background (both parents' school education, householder's occupational status, and quality of dwellings in childhood rearing areas). The results showed that the risk of overweight was significantly increased if the mother reported lacking knowledge about her offspring's sweet eating habits (OR = 4.5; 95% confidence limits: 1.7-12.1; P = 0.003). The risk was insignificantly increased if the mothers expressed acceptance of sweet eating habits (OR = 1.9; 0.8-4.2; P = 0.1), and if more than an average amount of money was given for sweets (OR = 2.0; 1.0-3.8; P = 0.06). On the other hand, how often the child was actually allowed to eat sweets, and the mother's acceptance of sugary food did not significantly influence the risk.(ABSTRACT TRUNCATED AT 250 WORDS)

School difficulties in childhood and risk of overweight and obesity in young adulthood: a ten year prospective population study.

Cross-sectional studies of adult males have shown that intelligence test score and educational level are inversely correlated to obesity. This study prospectively assessed whether school difficulties in the third school grade are related to the risk of overweight and obesity in young adulthood. In 1974, body weight, height and social background were ascertained in 987 randomly-selected Copenhagen third graders. For each child, information about learning difficulties, scholastic proficiency, special education received, scholarly difficulties, reduced hearing, speech handicap, and speech or hearing education received was obtained. When the subjects were 20-21 years old, they reported their height and weight. The risk of being obese (above the 95th percentile of body mass index distribution) in young adulthood was assessed by logistic regression analysis taking social background, body mass index in childhood, and gender into account. The risk of being obese in young adulthood, measured by the odds ratio (OR), was increased if the child had learning difficulties (OR = 4.2; P = 0.0003), scholastic proficiency below the class average (OR = 2.8; P = 0.006), had received special education (OR = 2.7; P = 0.007), or had scholarly difficulties in childhood (OR = 2.9; P = 0.006). Reduced hearing did not increase the risk (OR = 1.5; P = 0.4). The results of the analysis of being overweight (above the 90th percentile) showed statistically weaker odds ratios around two. None of the individuals either having speech handicap or having received speech or hearing training exceeded the 90th percentile of the body mass index distribution in young adulthood.(ABSTRACT TRUNCATED AT 250 WORDS)

Dental health behaviors and periodontal disease indicators in Danish youths. A 10-year epidemiological follow-up.

The purpose of the present study was to analyse the epidemiologic relationship between dental health behaviors and periodontal disease. Indicators of periodontal disease in terms of bleeding and calculus were measured dichotomously (absence/presence). Periodontal pockets were as follows: normal pockets (0-3 mm), shallow pockets (4-5 mm), and deep pockets (6+ mm). The indicators were measured on 4 surfaces on 6 index teeth (16, 11, 26, 36, 31, 46) in 1984-85. The highest value for each tooth of bleeding (0/1), calculus (0/1) and pockets (0/1/2) was used for calculation of the bleeding index, the calculus index and the pocket index. The participation rate in 1984-85 was 86%, and the study population involved 368 males and 388 females. Information concerning dental health behavior was obtained both in childhood (1974) when the individuals were 9-10 years of age, and in adulthood (1984-85) when the individuals were 20-21 years of age. Information concerning dental health behaviors in adulthood, i.e., regularity of dental visits, frequency of tooth brushing, and regular use of interdental aids, was obtained through a self-administered questionnaire (1984-85). Dental health behaviors in childhood (1974) was operationalized as level of plaque, gingivitis, and dmfs. The results showed that dental health behaviors in childhood and in adulthood were together responsible for 9.4-13.8% of the variance in level of periodontal disease indicators. Determinants of early dental health behaviors in terms of plaque and dmfs at age 9-10 years were significant predictors in pocket index at age 20-21.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of dental services among Danish youths: role of the social environment, the individual, and the delivery system.

The purpose of the present study was to analyze the separate effect and the total effect of the social environment, the individual and the delivery system on frequency of use of dental services among youths. The variables of use were divided into the three main groups according to Coleman (12). Information concerning use of dental services, individual and structural variables was obtained by a self-administered questionnaire to 756 Danes 20-21 yr old in 1984-85. Information concerning social environmental variables was obtained by a postal questionnaire to the mothers of the individuals in 1974 (16). Information from 552 mothers was available. Firstly, the variables concerning the social environment were inserted into a multiple dummy regression analysis as independent variables, and it was found that the following characteristics of the mothers were significant predictors: regularity of dental visits and perceived economic barriers. Secondly, the variables concerning the individual resources were set into a multiple dummy regression model as independent variables. The results showed that the following variables had a significant effect: sex, social conditions, pain tolerance, dental anxiety, and perceived economic barriers. Thirdly, multiple dummy regression analysis showed that among the structural variables general assessment of Child Dental Care compared to Youth Dental Care, and a personality assessment of the general dental practitioner were significant predictors. Finally the predictors from the three main groups all together were inserted as independent dummy variables into a regression model. The results showed that sex, social conditions, pain tolerance, dental anxiety, perceived economic barriers of the youth themselves, general assessment of Child Dental Care compared to Youth Dental Care were significant predictors.(ABSTRACT TRUNCATED AT 250 WORDS)