Relative Body Mass Index Improves the BMI Percentile Performance for Detection and Monitoring of Excess Adiposity in Adolescents.

Obesity is defined as excess adipose tissue; however, commonly used methods may under-detect adiposity in adolescents. This study compared the performance of body mass index percentile (BMI%) and relative body mass index (RBMI) in identifying excess body fat percentage (BF%) and estimated RBMI cut points to better stratify severity of adiposity. In 567 adolescents ages 11-19 year, BF% measured by DXA was used to compare BMI% and RBMI performance at different degrees of adiposity. RBMI cut points for adiposity detection were derived via ROC curve analysis. BF% was strongly correlated with BMI% (r = 0.889, p < 0.001) and RBMI (r = 0.901, p < 0.001). However, RBMI exhibited less dispersion and better discriminated the relationship with BF% independent of age, race, and gender. Both BMI% and RBMI performed similarly for detecting high BF% (≥25 BF% in males; ≥30 BF% in females). Nonetheless, the relationship of BMI% with BF% was diminished among leaner adolescents. RBMI detected overweight in 21.3% more females and 14.2% more males. RBMI improved the detection of excess adiposity in individuals otherwise classified as having normal weight or overweight by BMI%. RBMI is a valuable and accessible tool for earlier detection, intervention, and effective follow-up of excess adiposity in youth at higher risk for complications.

Lifestyle Medicine in Diabetes Care: The Lifedoc Health Model.

Introduction: The relevance of lifestyle medicine in diabetes treatment is now incorporated in clinical practice guidelines but finding an exemplar for the creation of a Lifestyle Medicine Program (LMP) is a difficult task. Aim: To use Lifedoc Health (LDH) as a LMP exemplar by describing their multidisciplinary team (MDT) approach to diabetes care along with tactics to address sustainability challenges. Results: The LDH model facilitates early activation of patients with diabetes and other cardiometabolic risk factors, MDT approaches, and protocols/policies that are able to overcome barriers to equitable healthcare in the community. Specific programmatic targets are clinical outcomes, effective dissemination, economic viability, and sustainability. Infrastructure centers on patient-driven problem-based visits, shared medical appointments, telemedicine, and patient tracking. Further discussions on program conceptualization and operationalization are provided. Conclusion: Even though strategic plans for LMPs that specialize in diabetes care are well represented in the literature, implementation protocols, and performance metrics are lacking. The LDH experience provides a starting point for those healthcare professionals interested in translating ideas into action.

Osteogénesis imperfecta tipo III con presentación inusual / An unusual presentation of osteogenesis imperfecta type III

Introducción: la osteogénesis imperfecta (OI) es el trastorno óseo hereditario más común con incidencia mundial de 1 en 10.000 a 25.000 nacimientos, causado por mutaciones de los genes que codifican las cadenas del colágeno tipo I. La mayoría presenta patrón de herencia autosómico dominante. Las manifestaciones clínicas varían de asintomáticos con mayor predisposición a fracturas, talla normal y sin incidencia en la expectativa de vida, hasta alta letalidad perinatal con deformidades esqueléticas severas, incapacidad motora y talla muy baja. Objetivos: reportar un paciente con presentación inusual de OI tipo III con fracturas in útero para contribuir en la orientación diagnóstica. Caso clínico: recién nacido con sospecha in útero de OI tipo II, nació a término vía cesárea, Ballard de 37 semanas y bajo peso con fracturas múltiples y defectos de osificación (braquicefalia). A los 4 meses con sobrevida mayor a la esperada, presentaba escleróticas grisáceas, braquicefalia, fontanelas amplias, fragilidad ósea generalizada y deformidades angulares en extremidades; confirmándose la OI tipo III mediante secuenciación exómica. Conclusiones: el diagnóstico de la OI se basa en la clínica y las características típicas. La supervivencia, los hallazgos radiográficos y el resultado de los estudios genéticos moleculares permiten la adecuada clasificación.

Introduction: osteogenesis imperfecta (OI) is the most common hereditary bone disorder with a global incidence of 1 in 10,000 to 25,000 births. OI is caused by mutations in the genes encoding the chains of collagen type I and is mostly inherited in an autosomal dominant manner. Clinical manifestations vary from asymptomatic with increased propensity to fractures, normal stature and no impact on life expectancy, to high perinatal lethality, severe skeletal deformities, motor disability and very short stature. Objectives: to report a case of an unusual presentation of OI type III in an infant who had in utero fractures, as a diagnostic resource. Case: a full-term infant born via cesarean section, with suspected in utero OI type II, Ballard score: 37 weeks, low weight and multiple fractures and ossification defects (brachycephaly). At 4 months, a higher survival than the expected, he presented greyish sclerae, brachycephaly, large fontanels, generalized bone fragility and bowing of extremities; OI type III was confirmed by exome sequencing. Conclusions: OI diagnosis is based on the clinical and typical features of the disorder. Survival, radiographic findings and molecular genetic testing allow an adequate classification.

Impact of a Multidisciplinary Approach on Cardiometabolic Risk Reduction in a Multiracial Cohort of Adults: A 1-Year Pilot Study.

Evidence examining specific effects of a multidisciplinary team (MDT) on cardiometabolic risk factors (CMRFs) among multi-ethnic patients in real-world clinical settings is lacking. This one-year retrospective chart review (2018) analyzed 598 adults (African American 59%, Hispanic 35%, and Caucasian 6%) with mean age of 43.8 ± 14.0 years. Qualifying patients with primary inclusion criteria of having body mass indices and blood pressure (BP) measurements in the first and last quarter of the study period were treated under an MDT protocol and compared to those qualifying for MDT but treated solely by a primary care provider (PCP). MDT included endocrinologist-directed visits, lifestyle counseling, and shared medical appointments. MDT patients experienced a greater reduction (ß; 95% CI) in weight (-4.29 kg; -7.62, -0.97), BMI (-1.43 kg/m2; -2.68, -0.18), systolic BP (-2.18 mmHg; -4.09, -0.26), and diastolic BP (-1.97 mmHg; -3.34, -0.60). Additionally, MDT patients had 77%, 83%, and 59% higher odds of reducing ≥5% of initial weight, 1 BMI point, and ≥2 mmHg DBP, respectively. Improvements in hemoglobin A1C measurements were observed in the MDT group (insufficient data to compare with the PCP group). Compared to PCP only, MDT co-management improves CMRF related to adiposity and hypertension in a multiethnic adult cohort in real-world clinical settings. Patient access to best practices in cardiometabolic care is a priority, including the incorporation of culturally adapted evidence-based recommendations translated within a multi-disciplinary infrastructure, where competing co-morbidities are better managed, and associated research and education programs can promote operational sustainability.

Factors Affecting Hemoglobin A1C in the Diagnosis of Diabetes and Prediabetes in Youth.

UNLABELLED: We sought to examine the correlation between variables and A1C levels to determine if prediction modeling could be used in the screening and diagnosis of diabetes and prediabetes in youth. We also sought to test relationships between A1C levels to insulin sensitivity indices and ß-cell function indices. DESIGN AND METHODS: We performed a retrospective review of 904 medical records from youth deemed at-risk for the disease. We performed Pearson correlation, multiple regression, and simple regression testing to determine the relationship between variables and A1C levels. In addition, we performed Pearson correlation testing on insulin sensitivity indices and ß-cell function indices to determine the strength of correlation to A1C levels. RESULTS: Statistical analysis did not show a strong relationship between the variables tested and the A1C. When racial and ethnic groups were tested together, the results from African American participants resulted in bias estimates, and as a result, a statistical model for the entire sample could not be performed. Results indicate that A1C is correlated with all ß-cell function proxy measurements and correlated to the corrected insulin level at 30minutes, but not the fasting insulin or insulinogenic index. DISCUSSION: The results from this study underline the multi-dimensional causes of diabetes and prediabetes and further stress the difficulties in predicting the diseases. The causes of diabetes and prediabetes are multifaceted, often individualized, and often difficult to ascertain. PRACTICE IMPLICATIONS: Clinicians should continue to examine a variety of variables prior to determining the need for diabetes diagnostic testing.

The prevalence of impaired glucose metabolism in Hispanics with two or more risk factors for metabolic syndrome in the primary care setting.

PURPOSE: The purposes of this observational prospective study were (a) to identify the prevalence of undiagnosed impaired glucose metabolism (IGM) including impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and type 2 diabetes mellitus (T2DM) in 55 Hispanic subjects with two or more risk factors for the metabolic syndrome, (b) to examine the association between glucose metabolism and cardiometabolic risk factors (CMRF), including metabolic syndrome components, and (c) to identify predictors of IGM. DATA SOURCES: Subjects underwent a physical examination and a 2-h 75-g oral glucose tolerance test. Data were analyzed using SAS v9.1 with p < or = .05 considered significant. Nonparametric tests were applied including Mann-Whitney-Wilcoxon test and Spearman correlation coefficient. Stepwise logistic multiple regression was used to predict IGM. CONCLUSIONS: Twenty-five patients (46%) had IGM (18% IFG, 15% IGT, and 13%T2DM). Normal fasting glucose was found in 48% of subjects who had IGM. Lipid abnormalities were present in 98% including elevated triglycerides (TG 66%), total cholesterol (48%), low-density lipoprotein (68.8%), and low high-density lipoprotein (67.9%). Twenty-nine percent had body mass index (BMI) >25 kg/m(2) and 62% had BMI >30 kg/m, hypertension (24%), and elevated high-sensitivity C-reactive protein (63%), and mean number of cardiometabolic risk factors (#CMRF) was 4.5. Mean values for each risk factor were no different between groups except for #CMRF (p = .0001) and TG (p = .0001). Total #CMRF was the best predictor of IGM. IMPLICATIONS FOR PRACTICE: The prevalence of IGM is extremely high in Hispanics with metabolic syndrome. Screening for IGM with fasting blood glucose alone underestimates the prevalence of IGM in this population. In subjects with multiple CMRF, screening at lower levels of BMI is warranted.

Biphasic insulin aspart 30 for the treatment of type 1 diabetes mellitus.

BACKGROUND: Type 1 diabetes mellitus is associated with acute and long-term complications, to which pre- and postprandial hyperglycemia are independent contributors. The objective of this review was to evaluate evidence-based information using biphasic insulin aspart 30 in the treatment of type 1 diabetes mellitus. METHODS: The study reviewed the Cochrane Database and scientific literature (PubMed) published until January 2008 using the words biphasic insulin aspart 30 insulin or premixed aspart insulin. CONCLUSIONS: Biphasic insulin aspart 30 is similar in efficacy to biphasic human insulin in improving hemoglobin A(1c) levels, with the advantage of a better postprandial glucose profile. EXPERT OPINION: There is evidence supporting the efficacy and safety of biphasic insulin aspart 30 insulin. However, the need for well-designed clinical trials aimed at understanding the potential differences in safety and efficacy between patients with type 1 and type 2 diabetes is crucial.

Obesity and cardiometabolic syndrome in children.

The cardiometabolic syndrome is highly prevalent among overweight youth. The risk of developing the cardiometabolic syndrome is likely triggered or exacerbated by concurrent obesity, unhealthy lifestyle/eating habits, and hormonal changes (puberty). Current screening recommendations include measurement of blood pressure, fasting insulin and glucose, and total cholesterol. However, limiting assessments to these measures underestimates cardiometabolic risk in overweight youth, particularly minorities. Early identification of cardiometabolic risk in its incipient stages may justify early and more aggressive intervention to prevent progression and complications. This review provides rationale for additional assessments to determine cardiometabolic risk in overweight youth and recommends treatment options.