[Hypertension, dyslipoproteinemia and BMI-category characterise the cardiovascular risk in overweight or obese children and adolescents: data of the BZgA-observational study (EvAKu-J-project) and the KiGGS-study]. / Hypertonie, Dyslipoproteinämie und BMI-Kategorie charakterisieren das kardiovaskuläre Risiko bei übergewichtigen oder adipösen Kindern und Jugendlichen: Daten der BZgA-Beobachtungsstudie (EvAKuJ-Projekt) und der KiGGS-Studie.

BACKGROUND: The considerable increase of obesity in children and adolescents poses a major challenge to the health care system. METHODS: In an observation study of the Bundeszentrale für gesundheitliche Aufklärung (BZgA) somatic data of 1916 overweight and obese children and adolescents aged 8-17 years were compared to data of 7 451 normal weight children and adolescents (KiGGS). Age, sex, body weight, height, BMI-SDS, blood pressure, and lipids were analyzed. Body weight was assessed using the BMI categories of the Arbeitsgemeinschaft Adipositas im Kindes- und Jugendalter (AGA) guidelines. Blood pressure measurements were given as above 95 (th) percentile and categorized according to the classification of the European Society of Hypertension (ESH). In addition blood pressure in BZgA-patients were estimated as above 95 (th) percentile by age, sex and height in German normal weight children and adolescents. Lipid values were evaluated according to American Heart Association specifications. RESULTS: Out of the participants of BZgA-study 14% were overweight, 48% obese, and 38% extremely obese. Blood pressure values were above the 95 (th) percentile (ESH) in 35%. The blood pressure in normal weight participants of the KiGGS-study were elevated in 5%. Total cholesterol of BZgA-patients was elevated in 13%, LDL-cholesterol was elevated in 13%, HDL-cholesterol was low in 7%, and triglycerides in the fasting state were elevated in 12%. CONCLUSIONS: The rising prevalence of cardiovascular risk factors in children and adolescents with increasing BMI category requires effective strategies for prevention and treatment of obesity.

[Evaluation of obesity treatment in children and adolescents (EvAKuJ Study). Role of therapeutic concept, certification, and quality indicators]. / Evaluation von Therapieangeboten für adipöse Kinder und Jugendliche (EvAKuJ-Projekt). Welche Rolle spielen Behandlungskonzept, AGA-Zertifizierung und initiale Qualitätsangaben?

AIM: Different providers of obesity treatment in children and adolescents in Germany were compared using the following criteria: outpatient/inpatient; with/without AGA certification; good/less good quality. METHODS: A total of 1,916 patients (8-16.9 years) from 48 study centers were examined before (t0), after (t1), and at least 1 year after therapy (t2/3). Body mass index (BMI), blood pressure, blood lipids, and psychosocial data were measured. RESULTS: Patients from inpatient rehabilitation centers were older and more obese. Patients from AGA-certified centers were more obese, and the completeness of comorbidity screening was higher. There were no differences in short- or long-term BMI reduction. "Good" treatment centers (classified after the UKE study 2004) did not differ from those centers not rated as "good" in weight reduction. Patients treated in "good" centers were more obese, and screening for comorbidity was better. No differences in drop out and loss to follow-up were found. CONCLUSION: There were only small differences between the different groups. Pronounced differences were found between the individual treatment centers. In order to improve therapy processes and outcomes, benchmarking and quality management have to be extended.

[Overweight and obesity in childhood and adolescence. Evaluation of inpatient and outpatient care in Germany: the EvAKuJ study]. / Übergewicht und Adipositas in Kindheit und Jugend. Evaluation der ambulanten und stationären Versorgung in Deutschland in der "EvAKuJ-Studie".

Numerous forms of therapy exist for the increasing number of obese children and adolescents in Germany, but these are heterogeneous and have not been evaluated. Access to health care, long- and short-term treatment outcome, as well as factors determining success of therapy were examined for the first time using standardized instruments to measure somatic and psychosocial variables. A total of 1,916 children aged 8-16 years from 48 (5 rehabilitation, 43 outpatient) institutions were examined. Data were collected for height, weight, blood pressure, and lipid status before treatment started (t0), at the end of treatment (t1), and 1 year after completion of treatment (t2). Furthermore, psychosocial variables were documented using questionnaires for parents and children. The mean BMI-SDS (body mass index standard deviation score) reduction at t1 was -0.27 and 1 year later at t2 was -0.23 (per protocol analysis; intention to treat: t1=-0.24; t2=-0.06). Psychological health and quality of life, which were markedly impaired at the beginning, improved. However, physical activity, media consumption, and nutrition remained basically unchanged. A reduction in weight is associated with an improvement in cardiovascular risk profiles, and long-term behavior changes are possible. However, the institutions differed considerably in the percentage of follow-up examinations and in the weight reduction accomplished.

[Treatment of obesity in pediatric patients in Germany: anthropometry, comorbidity and socioeconomic gradients based on the BZgA Observational Study]. / Beobachtungsstudie der BZgA zur Adipositastherapie bei Kindern und Jugendlichen in Deutschland: Anthropometrie, Komorbidität und Sozialstatus.

BACKGROUND: In recent years, the prevalence of overweight and obesity in children and adolescents has markedly increased. Even though numerous treatment options are available for patients, these are heterogeneously structured and insufficiently evaluated. PATIENTS: In this initial report of specific therapy under routine care circumstances, data from 1916 patients aged 8-16.9 years were analyzed. Patients were characterized based on cluster of therapy, sociodemographic, psychosocial and medical features. Furthermore, the quality of care procedures with regard to the diagnosis of comorbidities was analyzed. RESULTS: At initial medical examination mean patient BMI-SDS was +2.43 and mean age was 12.6 years. 43.3% of patients were male. The mean duration of treatment was 6.1 months (55% outpatient, 45% inpatient care setting). 14% of patients were overweight, 48% obese and 37% were extremely obese. In 51% of the patients we could find already comorbidities. Parental BMI was related to patient's BMI. Socioeconomic status was reduced compared to general population. CONCLUSION: In this nationwide, pioneer multicentre observational study initiated by Federal Centre for Health Education (BZgA) in Germany, different therapeutic approaches were compared by examining somatic and psychosocial variables. The short- and long-term effects of different weight reduction programs on BMI-SDS, nutritional- and physical activity habits as well as quality of life and comorbidity will be examined at the end of therapy. Two follow-up assessments are planned for one and two years after the intervention ended.

Medical care of overweight children under real-life conditions: the German BZgA observation study.

OBJECTIVE: Current care for overweight children is controversial, and only few data are available concerning the process of care, as well as the outcome under real-life conditions. METHODS: A nationwide survey of treatment programs for overweight children and adolescents in Germany identified 480 treatment centers. From 135 institutions that had agreed to participate in this study of process of care and outcome, 48 randomly chosen institutions were included in the study. All 1916 overweight children (mean age 12.6 years, 57% female, mean body mass index 30.0 kg/m(2)), who presented at these institutions for lifestyle interventions, were included in this study. Diagnostic procedures according to guidelines and effect of lifestyle interventions on weight status at end of treatment were analyzed. RESULTS: Children treated <3 months were older and more obese, whereas children with >3 months treatment duration demonstrated more cardiovascular risk factors at baseline. On the basis of an intention-to-treat analysis, 75% of the children reduced their overweight. The reduction of overweight varied widely between the treatment institutions (intracluster correlation coefficient 0.15 in the multiple regression model reflecting the intracenter correlation). Screening for hypertension, disturbed glucose metabolism and dyslipidemia was performed in 52% of the children at baseline and in 10% at the end of intervention. CONCLUSION: Overweight reduction is achievable with lifestyle intervention in clinical practice. However, because the clientele, treatment approach and outcome varied widely between different institutions, and screening for comorbidities was seldomly performed as recommended, quality criteria for institutions have to be implemented to improve medical care of overweight children under real-life conditions.

[The combined DAK therapy of obesity for children and adolescents. Evaluation after 1 year]. / Kombinierte stationäre und ambulante Adipositasbehandlung für Kinder und Jugendliche. Evaluation nach einem Jahr.

In 2003, the program "The combined DAK therapy of obesity for children and adolescents", funded and conducted by the Deutsche Angestellten Krankenkasse (DAK) (A German Health Insurance Company), has started. The whole treatment lasts for 1 year including an initial inpatient therapy for 6 weeks followed by an outpatient treatment at home that adresses the overweight patients and their families. The therapy contents are developed according to the recommendations of the "Arbeitsgemeinschaft Adipositas im Kindes- und Jugendalter (AGA)". In a prospective cohort study a sample of 604 subjects was studied in order to examine the achievement of the treatment goals weight reduction, behaviour modification and improvement of quality of life. The development of weight was evaluated using BMI-SDS. 44,1% of children and adolescents had a successful weight reduction, they reduced their weight at least by 0,3 BMI-SDS. Furthermore, significant changes of health behaviour, physical fitness and quality of life were observed. However, during the outpatient treatment an impairment of some behaviour changes were observed. Nevertheless, the study has identified significant, positive effects in weight loss, behaviour modifications, changes in physical fitness and in the development of quality of life as a result of the therapy. It is demonstrated that a relapse in "old behaviour" followed by an increase of weight after the inpatient treatment can be avoided bythe subsequent outpatient therapy.

Severe underreporting of energy intake in normal weight subjects: use of an appropriate standard and relation to restrained eating.

OBJECTIVE: To assess the influence of different standards and restrained eating on underreporting in healthy, non-obese, weight-stable young subjects. DESIGN AND SUBJECTS: Eighty-three young adults (20-38 years, 55 women, 28 men) were assessed under weight-stable conditions with a 7-day dietary record and the three-factor eating questionnaire by Stunkard and Messick. Resting energy expenditure (REE; indirect calorimetry) plus data derived from physical activity records (PA) (Standard 1) or REE times an activity factor (AF) (Standard 2) was used as standard for total energy expenditure (TEE). For comparison, doubly labelled water (DLW) was used to measure TEE in a subgroup of subjects. RESULTS: There was an association between self-reported energy intake and Standard 2 but not with Standard 1. When compared with DLW both calculated standards were inaccurate, but Standard 2 avoided high levels of overreporting. Using Standard 2 to identify 'severe' underreporting (SU; as defined by a deviation of energy intake (EI) and TEE of >20%), SU was seen in 37% of all subjects. It was more frequently found in women than in men (49% of women, 14.3% of men, ). Underreporting subjects had a reduced EI but there were no significant differences in nutritional status (body weight and height, body mass index, fat mass and fat-free mass), energy expenditure and the proportion of energy from macronutrients between normal and underreporting subjects. However, high restraint was associated with a higher degree of underreporting in the total group, whereas disinhibition had an influence only in men. CONCLUSIONS: A high prevalence of SU is seen in non-obese subjects. Characteristics of eating behaviour (restraint and disinhibition) were associated with underreporting but seemed to have a different influence in men and women.

[Self-control, stimulus control, relapse prevention. Behavior therapy helps in weight reduction]. / Selbstbeobachtung, Reizkontrolle, Rückfallprophylaxe. So hilft Verhaltenstherapie beim Abnehmen.

Behavioral therapy is an essential part of the overall strategy for treating obesity. Successes are most evident in short-term treatment, whereas the value of the long-term approach is more difficult to assess due to a lack of adequate data. The aims of behavior-modifying measures are improving eating habits and nutritional awareness, increasing physical activity, and improving strategies for coping with psychological and social consequences. At the focus of behavioral therapeutic techniques aimed at combatting obesity is self-observation supported by stimulus-control techniques, reinforcement techniques, and help with cognitive restructuring. Furthermore, patients learn how to avoid relapse. Success over the long-term can be improved by active follow-up measures and depends, among other things, on adequate quality control. The appropriate approaches to therapeutic programs must be made transparent both to the patient involved and concerned professionals.

Development process of an evidence-based guideline for the treatment of obesity.

OBJECTIVES: To present the development process, summarize the content and discuss the implications of the German evidence-based guideline for the treatment of obesity. DESIGN: The target audience and the development process were defined by a multidisciplinary team of experts. A systematic search of the literature was performed to identify relevant clinical articles. The validity of published studies was systematically evaluated. After developing the draft, an external peer review process was initiated. RESULTS: Three versions of the guideline were published; an expert version, a short version tailored to primary care physicians and a patient version supporting patient participation in the decision-making process. Total development, printing and distribution costs xvere estimated to be 300,000 Euro. CONCLUSIONS: The guideline raises the awareness of obesity and related comorbidities in Germany and may improve the quality of care for obese patients. The development process could serve as an efficient model for other guideline developers.

Functional food science and behaviour and psychological functions.

The impact of ingesting various foods on psychological and behavioural functions is a topic of both interest and concern to the general public. In this article, the scientific literature concerning demonstrated cause-and-effect relationships is reviewed, beginning with methodological considerations specific to the quantification of particular behaviours and psychological events. The essential function of food is to satisfy hunger and the need for essential nutrients. The contributions of macronutrients to appetite and satiety are described, as well as their impact on metabolism and energy balance. Functional properties of macronutrient substitutes (high-intensity sweeteners, fat replacers) and flavour enhancers are examined in relation to their contribution to hunger, satiety, and energy balance. The effects of foods and individual nutrients on the performance of diverse psychomotor tasks are studied with consideration given to the various validated quantitative tools used to assess behaviour. The effects of food components on activation, sedation, and affective states such as dysphoria are also reviewed, with special attention given to brain function and neuroactive substances such as serotonin and the endorphins. The case of hyperactivity in children is given special emphasis with reference to the potential influence of sugar and food additives. Safety issues related to food constituents and additives are discussed. Finally, a set of criteria is proposed for the evaluation and elaboration of studies in the behavioural and psychological fields, along with suggestions for future research.

[Ambulatory, comprehensive, behavior therapy-oriented weight reduction program (Optifast Program). An alternative therapy in obstructive sleep apnea]. / Die ambulante, ganzheitliche, verhaltenstherapeutisch orientierte Gewichtsreduktion (Optifast-Programm). Eine alternative Therapie beim obstruktiven Schlafapnoesyndrom.

We investigated the therapeutic effect of marked body weight reduction on the predominantly obstructive sleep apnea syndrome by the application of an out-patient, behaviour therapy based body weight reduction program (Optifast-program) in five of our obese apnea patients (mean overweight by Broca 53.6 +/- 24.8 kg). Mean body weight reduction was 32.7 +/- 15.8 kg after six months. The mean apnea-index of 34.5 +/- 23.1/h prior to the weight reduction dropped to 7.8 +/- 6.1/h after therapy. The mean apnea-hypopnea-index (so called "respiratory disturbance index", RDI) could be reduced from 45,7 +/- 26.0/h to 14.0 +/- 11.4/h. The best therapeutic effect on the sleep related respiratory parameters was seen in patients who reached their normal weight whereas the absolute weight reduction itself seems to be less important. Our results should encourage this causal therapy in appropriate patients.

[Chronification of sleep disorders. Results of a representative survey in West Germany]. / Chronifizierung von Schlafbeschwerden. Ergebnisse einer Repräsentativumfrage in Westdeutschland.

In a representative selection of German citizens who were older than 13 years of age, 1,997 were asked about their sleep complaints. They were also asked how frequently a physician was consulted and how often sleeping pills were taken. According to our results sleep disturbances are an important health problem in Germany. Every fourth person suffers at least sometimes from difficulties in falling asleep and/or staying asleep, problems which are not due to external influences. Seven percent suffer frequently or always from these complaints; 15% report that they are frequently tired or that they are always tired during the day. Ten percent of all persons suffering from sleep complaints take sleeping pills daily or at least sometimes during the week. Forty-five percent of all persons who take hypnotics daily still frequently or always suffer from difficulties in falling asleep and/or staying asleep. Furthermore, sleep complaints tend to become chronic: 75% of the sleep-disturbed population are chronically ill, having had complaints for more than 2 years of since childhood. They suffer from sleep disturbances and from reduced performance during the following day. Nevertheless, it appears as though neither patients nor physicians take insomnia seriously. This might answer the question of why only 17% of the persons who do not suffer more than 2 years from sleep disturbances and only 49% of the chronically ill population consult a doctor because of their sleep disturbances. The results of this study indicate the importance of informing patients and physicians about insomnia and different ways of treating it.

[Treatment of obstructive sleep apnea syndrome by ambulatory, comprehensive, behavior therapy oriented weight reduction (Optifast program)]. / Die Behandlung des obstruktiven Schlafapnoesyndroms durch eine ambulante, ganzheitliche, verhaltenstherapeutisch orientierte Gewichtsreduktion (Optifast-Programm).

We investigated the therapeutic effect of marked body weight reduction on the predominantly obstructive sleep apnea syndrome by the application of an out-patient, behaviour therapy based body weight reduction program (Optifast-program) in 5 of our obese apnea patients. Mean body weight reduction was 32.7 +/- 15.8 kg after 6 months. The mean apnea-index of 34.5 +/- 23.1/h prior to the weight reduction dropped to 7.8 +/- 6.1/h after therapy. The mean apnea-hypopnea-index could be reduced from 45.7 +/- 25.9/h to 14.0 +/- 11.4/h. The best therapeutic effect on the sleep related respiratory parameters, was seen in patients who reached their normal weight. Our results shows that even severe, predominantly obstructive sleep apnea syndromes could be treated successfully with a marked body weight reduction.

Interaction of vitamins with mental performance.

In the presence of a chronically insufficient vitamin supply which was verified by repeated measurements of the vitamin parameters, many unfavorable psychometric findings in the corresponding deficiency groups are observed for the vitamins C, thiamin, riboflavin, cobalamin and folate, depending on the degree of the insufficient vitamin supply. Vitamin supplementation in cases of initially insufficient vitamin supply indicate some effects in the sense of an improvement of behavior and cognitive functions. Supplemental vitamin intake in physiological dosages in addition to a vitamin-sufficient diet did not lead to an improvement of behavior and mental performance.

Behavioural factors involved in the control of food intake in man.

This paper reviews several psychological models to explain disturbed food intake: the "psychosomatic theory", the "stimulus-binding theory", the "concept of restraint eating", closely related to the "concept of latent obesity", the "set-point-theory" and the "boundary model". All are based on the assumption that there are biological regulating processes of body weight (and with this also of feelings of hunger, appetite and satiation as the determinants of food intake), nevertheless the resulting body weight can be inconsistent with social standards and individual self-concepts. In this case a cognitive control of food intake (dieting behaviour) is activated for weight regulation, which in turn interacts with biological regulatory mechanisms, and as a result leads to specific behavioural dispositions which can be supported by experiments.