Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with 'best practice' recommendations.

Childhood obesity is a global epidemic and rising trends in overweight and obesity are apparent in both developed and developing countries. Available estimates for the period between the 1980s and 1990s show the prevalence of overweight and obesity in children increased by a magnitude of two to five times in developed countries (e.g. from 11% to over 30% in boys in Canada), and up to almost four times in developing countries (e.g. from 4% to 14% in Brazil). The goal of this synthesis research study was to develop best practice recommendations based on a systematic approach to finding, selecting and critically appraising programmes addressing prevention and treatment of childhood obesity and related risk of chronic diseases. An international panel of experts in areas of relevance to obesity provided guidance for the study. This synthesis research encompassed a comprehensive search of medical/academic and grey literature and the Internet covering the years 1982-2003. The appraisal approach developed to identify best practice was unique, in that it considered not only methodological rigour, but also population health, immigrant health and programme development/evaluation perspectives in the assessment. Scores were generated based on pre-determined criteria with programmes scoring in the top tertile of the scoring range in any one of the four appraisal categories included for further examination. The synthesis process included identification of gaps and an analysis and summary of programme development and programme effectiveness to enable conclusions to be drawn and recommendations to be made. The results from the library database searches (13,158 hits), the Internet search and key informant surveys were reduced to a review of 982 reports of which 500 were selected for critical appraisal. In total 158 articles, representing 147 programmes, were included for further analysis. The majority of reports were included based on high appraisal scores in programme development and evaluation with limited numbers eligible based on scores in other categories of appraisal. While no single programme emerged as a model of best practice, synthesis of included programmes provided rich information on elements that represent innovative rather than best practice under particular circumstances that are dynamic (changing according to population subgroups, age, ethnicity, setting, leadership, etc.). Thus the findings of this synthesis review identifies areas for action, opportunities for programme development and research priorities to inform the development of best practice recommendations that will reduce obesity and chronic disease risk in children and youth. A lack of programming to address the particular needs of subgroups of children and youth emerged in this review. Although immigrants new to developed countries may be more vulnerable to the obesogenic environment, no programmes were identified that specifically targeted their potentially specialized needs (e.g. different food supply in a new country). Children 0-6 years of age and males represented other population subgroups where obesity prevention programmes and evidence of effectiveness were limited. These gaps are of concern because (i) the pre-school years may be a critical period for obesity prevention as indicated by the association of the adiposity rebound and obesity in later years; and (ii) although the growing prevalence of obesity affects males and females equally; males may be more vulnerable to associated health risks such as cardiovascular disease. Other gaps in knowledge identified during synthesis include a limited number of interventions in home and community settings and a lack of upstream population-based interventions. The shortage of programmes in community and home settings limits our understanding of the effectiveness of interventions in these environments, while the lack of upstream investment indicates an opportunity to develop more upstream and population-focused interventions to balance and extend the current emphasis on individual-based programmes. The evidence reviewed indicates that current programmes lead to short-term improvements in outcomes relating to obesity and chronic disease prevention with no adverse effects noted. This supports the continuation and further development of programmes currently directed at children and youth, as further evidence for best practice accumulates. In this synthesis, schools were found to be a critical setting for programming where health status indicators, such as body composition, chronic disease risk factors and fitness, can all be positively impacted. Engagement in physical activity emerged as a critical intervention in obesity prevention and reduction programmes. While many programmes in the review had the potential to integrate chronic disease prevention, few did; therefore efforts could be directed towards better integration of chronic disease prevention programmes to minimize duplication and optimize resources. Programmes require sustained long-term resources to facilitate comprehensive evaluation that will ascertain if long-term impact such as sustained normal weight is maintained. Furthermore, involving stakeholders in programme design, implementation and evaluation could be crucial to the success of interventions, helping to ensure that needs are met. A number of methodological issues related to the assessment of obesity intervention and prevention programmes were identified and offer insight into how research protocols can be enhanced to strengthen evidence for obesity interventions. Further research is required to understand the merits of the various forms in which interventions (singly and in combination) are delivered and in which circumstances they are effective. There is a critical need for the development of consistent indicators to ensure that comparisons of programme outcomes can be made to better inform best practice.

Development of high-throughput radioligand binding assays for interleukin-1 alpha (IL-1 alpha) and tumor necrosis factor (TNF-alpha) in isolated membrane preparations.

Cytokine binding has been studied in a variety of intact cells, and in isolated receptor preparations. Each approach is associated with limitations with regard to screening large numbers of samples on a repetitive basis. In order to provide a more reproducible system of screening for compounds which modify IL-1 alpha and TNF-alpha binding, we have developed isolated membrane preparations for studying agents which can alter the association of these ligands with their receptors. These results demonstrate IL-1 alpha binding to BALB/c 3T3 cell membranes and TNF-alpha binding to HeLa S3 cell membranes, and indicate that this is a viable approach to high-throughput screening.

IL-1 dependent model of inflammation mediated by neutrophils.

Interleukin-1 (IL-1) mediates a number of immunologic and physiologic responses associated with inflammation. A new model to monitor the primary effects of IL-1 and potential inhibitors on inflammation has been developed, which involves unilateral injection of 300 U of highly purified recombinant human IL-1 in mouse ears. Ear thickness of IL-1 injected ears increased 7-10-fold 24 hr posttreatment, concomitant with a corresponding increase in myeloperoxidase activity, suggesting that neutrophil influx contributes to this response. Administration of nonsteroidal antiinflammatory drugs did not influence the IL-1 effect in vivo. Inhibition of phospholipase A2 activity ameliorated the IL-1 stimulated inflammation; treatment with 10 mg/kg dexamethaxone eliminated approximately 80% of increased myeloperoxidase activity compared to control values. This model provides a well-defined in vivo assay with which to quantify the systemic effects of compounds capable of altering the activity of IL-1, and the data suggest that this mechanism may explain the unique efficacy of steroids as antiinflammatories.

Dapsone inhibits LTB4 binding and bioresponse at the cellular and physiologic levels.

Radioligand binding studies using human neutrophils exposed to 10-100 microM dapsone indicated that this anti-inflammatory compound antagonized association of LTB4 (leukotriene B4) with its specific receptor sites. Binding inhibition was manifested in reduced biologic response of the neutrophils as determined in LTB4-stimulated chemotaxis. In addition, a physiologic model of LTB4-dependent inflammation in mice was antagonized by systemic administration of dapsone. These data suggest that inhibition of LTB4 binding may represent the cellular mechanism of action responsible for the anti-inflammatory effects of dapsone.

Inhibition of LTB4 binding to human neutrophils by nordihydroguaiaretic acid.

Nordihydroguaiaretic acid (NDGA) was investigated for its ability to interact with leukotriene B4 receptors on human polymorphonuclear leukocytes (hPMNs). 3H-LTB4 binding to specific receptors was reduced in a dose-dependent manner with maximal reduction at 100 microM NDGA and an IC50 of about 50 microM. Binding of another inflammatory stimulus. N-formyl-norleucyl-leucyl-phenylalanine (FNLP) was not affected by similar treatment. Chemotaxis and enzyme release stimulated by LTB4 and oligopeptide were inhibited by NDGA. In addition, LTB4-triggered inflammation in vivo in mice was inhibited by systemic administration of NDGA. These data suggest that LTB4 receptor antagonism may contribute to inhibition of inflammation by NDGA.

Physiologic and cellular insulin action in a glucose-intolerant model of type 2 (non-insulin-dependent) diabetes in rats.

A B-cell-deficient model for Type 2 (non-insulin-dependent) diabetes mellitus has been investigated with regard to insulin action at the cellular level. Two-day-old male Sprague Dawley rats were injected with streptozotocin (90 mg/kg) or citrate buffer. At 6 weeks streptozotocin-treated animals were hyperglycaemic and exhibited glucose intolerance, e.g. at 45 min post-glucose (1.5 g/kg) the change in serum glucose level from baseline was 6 +/- 7 mg% in control rats vs. 212 +/- 18 mg% for the streptozotocin-treated rats. Basal activity and insulin action in isolated adipocytes, as estimated by 2-deoxyglucose uptake and glucose metabolism, were not influenced by streptozotocin treatment. For example, uptake of 0.1 mmol/1 2-deoxyglucose at 1000 microU insulin/ml was 58 +/- 8 pmol/10(5) cells min-1 vs 54 +/- 6 pmol for adipocytes isolated from experimental vs. control animals. Although serum insulin levels in streptozotocin-treated rats were significantly decreased (p less than 0.05), there was no difference in insulin receptor number or affinity. Glucose intolerance present in this model is similar to that in Type 2 diabetes. However, concomitant insulin intolerance was not observed. Taken together with our findings of unaltered insulin action at the cellular level, this suggests that the pathogenesis of insulin resistance is not dependent on glucose intolerance. Moreover, this hyperglycaemic model is responsive to oral hypoglycaemic agents and can be used to establish their direct effects on physiologic and cellular insulin action.

Effects of sulfonylureas on the actions of insulin and insulin-mimickers: potentiation of stimulated hexose transport in adipocytes.

The sulfonylurea glyburide, a 'second-generation' oral hypoglycemic compound, was studied in vitro in order to determine its cellular mechanism of action in adipocytes prepared from cultured rat epididymal fat tissue. Glyburide treatment (1 microgram/ml) for 20 h did not alter insulin receptor number or affinity, or down-regulation by insulin. Biologic responses of these cells were measured in the presence of insulin or the oxidants Vitamin K5 and H2O2, which have insulin-like activity, but do not act through the binding portion of the receptor. 2-Deoxyglucose uptake was not significantly changed by exposure to glyburide alone. However, the sulfonylurea increased the insulin-stimulated or insulin-mimicker-activated uptake by approximately 30%. Insulin-stimulated glucose oxidation was also potentiated when glucose transport was rate limiting for metabolism. These findings extend our earlier observation that in adipose tissue the primary cellular mechanism of action of sulfonylureas is to potentiate insulin-stimulated hexose transport, and that this process may account for their hypoglycemic activity.

Sulfonylurea effects on target tissues for insulin.

We have examined the nonpancreatic actions of sulfonylureas on multiple aspects of insulin responsiveness in two target tissues for insulin, liver and fat. In vivo administration of tolazamide and glipizide reduced significantly the postabsorptive serum glucose levels in rats without altering the levels of insulin. This was consistent with extrapancreatic sites of drug action. The number and affinity of hepatic insulin receptors was not different from those of control rats. Using a tissue culture system for rat adipose tissue, a 20-h treatment with sulfonylureas markedly potentiated insulin action in fat cells. The primary augmentation was at the level of insulin-stimulated glucose transport. Again, there was no alteration of the insulin receptors located on the adipose tissue. Furthermore, consistent with the lack of an influence on insulin-induced receptor loss after in vitro treatment with sulfonylureas, the in vivo administration of these agents did not alter the transglutaminase activity in rat hepatic tissue. The data demonstrate that sulfonylureas potentiate the responsiveness of the target tissues for insulin. Thus, these hypoglycemic agents probably act by correcting some of the cellular lesions associated with the insulin resistance in type II diabetes mellitus.

Cellular basis of insulin resistance in chronic uremia.

To define the cellular alterations responsible for insulin resistance during uremia, we studied insulin action in adipocytes isolated from rats 2 wk after 75% partial nephrectomy. Insulin binding to fat cells and purified liver plasma membranes prepared from uremic rats was unaltered. In contrast, hexose transport was significantly decreased, with and without insulin, in the fat cells from the uremic animals. The concentration of insulin that elicited half-maximal response was not altered. Glucose utilization was reduced in the absence or presence of insulin by partial nephrectomy. The stimulation of hexose transport and glucose metabolism by the insulin mimickers, hydrogen peroxide and vitamin K5, were also inhibited. Hexose transport activity in adipocytes obtained from uremic rats was no longer decreased when pieces of fat tissue were cultured for 20 h. Finally, hexose transport was reduced in the cells isolated from normal adipose tissue that was preincubated for 3 h with uremic serum, but insulin binding was not different than control. Thus, insulin resistance associated with uremia may be primarily accounted for by altered postreceptor events that appear to result from a circulating factor(s).

Extrapancreatic effects of sulfonylureas. Potentiation of insulin action through post-binding mechanisms.

Pieces of rat epididymal fat tissue were maintained in a biochemically defined medium for 20 to 44 hours in either the absence or presence of a sulfonylurea at levels known to be effective in humans. Prolonged exposure of adipocytes to sulfonylureas did not influence the number of insulin receptors or their affinity to insulin or the ability of insulin to induce receptor loss (down-regulation). Also, the sulfonylureas did not influence the basal uptake of the D-glucose analogs 2-deoxyglucose and 3-O-methylglucose. However, exposure to these drugs resulted in a potentiation of the stimulatory effects of insulin on hexose transport at submaximal and maximally effective concentrations of insulin. The average potentiation was approximately 30%. In addition, sulfonylureas enhanced stimulation of hexose uptake by the insulin mimickers, hydrogen peroxide and vitamin K5. These oxidants are known to manifest insulin-like actions subsequent to insulin binding. Under conditions in which glucose transport was rate limiting, the conversion of glucose to carbon dioxide and the total lipids mirrored the findings of hexose uptake. However, at a glucose concentration of 50 mM, at which hexose transport is no longer rate limiting, sulfonylureas did not potentiate metabolism in th absence or presence of insulin. These results may help to explain the hypoglycemic action of the drug in view of the recent finding that a postreceptor deficit is present in noninsulin-dependent diabetes mellitus.

In vitro effects of a sulfonylurea on insulin action in adipocytes. Potentiation of insulin-stimulated hexose transport.

The mechanism(s) by which the oral sulfonylurea, tolazamide, exerts its extrapancreatic hypoglycemic effects was studied using rat epididymal adipose tissue maintained 20-44 h in the presence or absence of the drug. Insulin binding, hexose transport and glucose metabolism were compared in adipocytes isolated from the cultured tissue. In contrast to earlier reports that suggested that sulfonylureas alter the binding of insulin, neither receptor number nor affinity were changed by tolazamide treatment. The uptake of the glucose analogs 2-deoxyglucose and 3-0-methylglucose in the absence of insulin (i.e., basal) was also unchanged. However, exposure to tolazamide resulted in a potentiation of the stimulatory effects of insulin by approximately 30% at each hormone concentration assayed (0.4-40 ng/ml). This potentiation was dependent on the tolazamide concentration (0.003-0.30 mg/ml), with a maximal effect observed at therapeutic levels. A tolazamide analog hypoglycemic activity in vivo was found not to enhance either basal or insulin-stimulated uptake in vitro. Conversion of 0.1-5.0 mM glucose to CO2 and total lipids in the presence of insulin was also potentiated by tolazamide treatment. The inability of the drug to directly stimulate basal glucose uptake was paralleled by its lack of effect on glucose metabolism. At 50 mM glucose, where transport is no longer rate-limiting, tolazamide did not potentiate metabolism in the absence or the presence of insulin. These studies demonstrate that tolazamide in vitro alters postreceptor insulin action without influencing the receptor, and suggests insulin-stimulated hexose transport as the cellular process responsible for the hypoglycemic effect of sulfonyureas in adipose tissue.

Use of dyes to estimate the electrical potential of the mitochondrial membrane.

A number of cationic or anionic fluorescent dyes were investigated as possible monitors of the membrane potential of rat liver mitochondria, and giant mitochondria isolated from the liver of mice maintained on a diet containing cuprizone. The fluorescence of four dyes (8-anilino-1-naphthalenesulfonic acid, merocyanine 540, 3,3'-dipropyl-thiocarbocyanine, and bis[1,3-dibutylbarbituric acid-(5)]-pentamethine oxonol) was found to respond appropriately to changes in an apparent K+ diffusion potential. Generally, valinomycin-induced K+ diffusion potentials as calculated using the Nernst equation were used to calibrate the dependence of the fluorescence on the membrane potential. The appropriateness of this approach was verified for two dyes using microelectrodes in giant mitochondria. The apparent membrane potential change induced by the addition of succinate was variable but was very low and generally less than 60 mV in magnitude. The results are consistent with the notion that a large membrane potential is not established upon the initiation of metabolism and that the membrane potential does not play a significant role in the observed ADP phosphorylation.

Assays of the metabolic viability of single giant mitochondria. Experiments with intact and impaled mitochondria.

Single giant mitochondria isolated from mice fed cuprizone were assayed for their metabolic viability. Two tests were devised. One test optically detected the accumulation of calcium phosphate within the mitochondria under massive loading conditions (including the presence of succinate and ATP). The accumulation corresponds to a test of energy coupling from either electron transport or the hydrolysis of ATP since it is blocked by either antimycin A or oligomycin. The other assay tested for the production of ATP from ADP and Pi, using myofibrils. Myofibrils prepared from glycerinated rabbit psoas muscle contract only in the presence of ATP and not in the presence of ADP. Myofibrillar contraction is unaffected by the presence of antimycin A or oligomycin. However, myofibrils in the presence of mitochondria that are phosphorylating ADP to ATP do contract. This contraction is blocked by antimycin A and/or oligomycin. Hence, the ATP which causes myofibrillar contraction is produced by oxidative phosphorylation. At low mitochondrial concentration, only the myofibrils in close proximity with mitochondria contract in the presence of ADP. Therefore the assay can be used to test the viability of individual mitochondria. Individual giant mitochondria were found to be viable, using both of these assays. Comparable results were obtained in mitochondria impaled with microelectrodes. The potentials and resistances were unaffected by concomitant calcium phosphate accumulation or oxidative phosphorylation.

Membrane potentials and resistances of giant mitochondria. Metabolic dependence and the effects of valinomycin.

The membrane potentials and resistances of giant mitochondria from mice fed cuprizone have been studied. They were found to correspond approx. 10-20 mV, positive inside, and 2 M omega, respectively. These properties were found to be independent of the metabolic state. The microelectrodes were in the inner mitochondrial space since (a) the potentials in the presence of valinomycin depended on the K+ concentration of the medium and magnitude of the K+ diffusion potentials was consistent with the presence of a high internal concentration of K+, (b) almost identical results were obtained with mitochondria from which the external membrane had been removed and the cristae were evaginated, and (c) punch-through experiments, in which the microelectrodes were advanced until they emerged through the other side of the mitochondria, showed an identical membrane potential both in the presence and in the absence of valinomycin. The potentials were stable under a variety of conditions and showed no sign of decay of membrane leakiness. Detailed evidence that the impaled mitochondria are metabolically viable will be presented in a separate publication.

Membrane potential of mitochondrial measured with microelectrodes.

The membrane potentials of giant mitochondria from cuprizone-fed mice were found to be independent of metabolic state. Experiments are described in which the presence of the microelectrodes in the inner mitochondrial space, and the metabolic viability of the impaled mitochonidra, are validated.