Transition to adult care in adolescent obesity: a systematic review and why it is a neglected topic.

Transition in pediatric health care involves the purposeful, planned movement of patients from pediatric to adult services. Following the significant increases in long-term survival of chronic childhood diseases in the 1980s, transition has taken on an increasing importance in the management of these chronic diseases. In Australia, there is a conspicuous lack of programs/guidelines for transitioning adolescents with obesity. The authors sought to determine if this is an international phenomenon that should be addressed. This study aimed to identify what formal transition services or guidelines exist internationally for adolescents with overweight/obesity. Two systematic reviews of the published and 'gray' literature were implemented via searches of relevant databases, search engines and websites. The primary review eligibility criteria were documents published between 1982 and 2012 including any aspect of transitioning adolescents with overweight/obesity from pediatric to adult weight management services. The secondary review included current clinical practice guidelines/statements on pediatric obesity management published between 1992 and 2012, and transition recommendations contained within. Non-English language documents were excluded. Relevant text from eligible documents was systematically identified and extracted, and a qualitative synthesis of the data was prepared. Overall, 2272 unique records were identified from the literature searches. Three eligible articles were identified by the primary review. The secondary review identified 24 eligible guidelines/statements. In total, six of the identified documents contained information on transition in adolescent obesity-the most detailed documents provided only a brief statement recommending that transition from pediatric to adult weight management services should take place. In conclusion, internationally there is an absence of published intervention programs/policies, and brevity of clinical guidance and expert opinion, on the transition of adolescents with obesity making this a priority research area. Consideration is given to the reasons why transition in adolescent obesity is a neglected topic.

Two-year outcomes of an adjunctive telephone coaching and electronic contact intervention for adolescent weight-loss maintenance: the Loozit randomized controlled trial.

This paper reports the final 24-month outcomes of a randomized controlled trial evaluating the effect of additional therapeutic contact (ATC) as an adjunct to a community-based weight-management program for overweight and obese 13-16-year-olds. ATC involved telephone coaching or short-message-service and/or email communication once per fortnight. Adolescents were randomized to receive the Loozit group program-a two-phase behavioral lifestyle intervention with (n=73), or without (n=78), ATC in Phase 2. Adolescents/parents separately attended seven weekly group sessions (Phase 1), followed by quarterly adolescent sessions (Phase 2). Assessor-blinded, 24-month changes in anthropometry and metabolic health included primary outcomes body mass index (BMI) z-score and waist:height ratio (WHtR). Secondary outcomes were self-reported psychosocial and lifestyle changes. By 24 months, 17 adolescents had formally withdrawn. Relative to the Loozit program alone, ATC largely had no impact on outcomes. Secondary pre-post assessment of the Loozit group program showed mean (95% CI) reductions in BMI z-score (-0.13 (-0.20, -0.06)) and WHtR (-0.02 (-0.03, -0.01)) in both arms, with several metabolic and psychosocial improvements. Adjunctive ATC did not provide further benefits to the Loozit group program. We recommend that further work is needed to optimize technological support for adolescents in weight-loss maintenance. Australian New Zealand Clinical Trials Registry Number ACTRNO12606000175572.

Higher protein diet for weight management in young overweight women: a 12-month randomized controlled trial.

UNLABELLED: Clinical research on weight management in young women is limited. This randomized controlled trial compared the efficacy of two iso-energetically restricted (5600 kJ) diets [higher protein (HP): 32% protein, 41% carbohydrate, 25% fat or higher carbohydrate (HC): 20, 58, 21%, respectively] in 71 (HP: n = 36; HC: n = 35) young healthy women (18-25 years; body mass index ≥ 27.5 kg/m2) for weight (kg; percent weight loss), body composition, metabolic and iron changes assessed at baseline, 6 and 12 months. DATA: mean (95% CI). In HP completers at 6 months, percent weight loss was higher [HP: 9.3 (5.6-13.1); HC: 5.1 (2.3-7.9)%; p = 0.06]; although, this did not reach statistical significance. Absolute weight [HP: 8.9 (5.3-12.5); HC: 4.6 (2.2-7.0) kg; p = 0.034] and fat loss [HP: 8.0 (4.4-11.5); HC: 3.4 (1.3-5.6) kg; p = 0.022] were significantly greater. No significant between-diet differences were observed at 12 months. Biochemistry remained within normal ranges with HP showing superior preservation of ferritin at 6 months [HP: 53 (40-66); HC: 46 (30-61) µg/l; p = 0.029]. Both diets supported clinically meaningful weight loss with HP tending to be more effective in the medium-term.

The use of motivational enhancement strategies for the maintenance of weight loss among obese individuals: a preliminary investigation.

AIM: To investigate the efficacy of motivational enhancement strategies integrated within a standard lifestyle modification program for the maintenance of weight loss and improved psychosocial functioning of obese adults. METHODS: Twenty-two obese adults completed 20 sessions of a motivationally informed cognitive behavioural treatment for weight loss and maintenance. Treatment outcome measures included anthropometrics, obesity-specific quality of life, impulsive eating tendencies, body dissatisfaction, mood disturbance and maladaptive cognitions. RESULTS: At post-treatment, there was a significant decrease in body weight (123.04 +/- 22.06 vs. 116.84 +/- 23.53, p < 0.001) with no significant change by the 12-month follow-up. Patients also reported significant improvements in obesity-related quality of life, impulsive eating tendencies, body dissatisfaction and maladaptive cognitions at post-treatment that were maintained at the 1-year follow-up. CONCLUSIONS: The implementation of motivational enhancement strategies within a cognitive behavioural program results in sustained weight loss that compares favourably to previous lifestyle modification programs.

Hypoglycaemia in cystic fibrosis in the absence of diabetes: A systematic review.

BACKGROUND: Hypoglycaemia in CF in the absence of diabetes or glucose lowering therapies is a phenomenon that is receiving growing attention in the literature. These episodes are sometimes symptomatic and likely have variable aetiologies. Our first aim was to conduct a systematic review of the literature to determine what is known about hypoglycaemia in CF. Our second aim was to assess evidence based guidelines for management strategies. METHODS: A comprehensive search of databases and guideline compiler entities was performed. Inclusion criteria were primary research articles and evidence based guidelines that referred to hypoglycaemia in CF in the absence of insulin treatment or other glucose lowering therapies. RESULTS: A total of 11 studies (four manuscripts and seven abstracts) and five evidence-based guidelines met the inclusion criteria. Prevalence rates of hypoglycaemia unrelated to diabetes varied between studies (7-69%). Hypoglycaemia was diagnosed during oral glucose tolerance testing or continuous glucose monitoring (CGM). Associations between hypoglycaemia and clinical parameters of BMI, lung function, liver disease and pancreatic insufficiency were measured in some studies. There was no unifying definition of hypoglycaemia in the absence of diabetes. Only two evidence based guidelines reported possible management strategies. CONCLUSION: The systematic review found limited data on this clinical problem and supports the need for high quality methodological studies that are able to describe the experience and the aetiology(ies) of hypoglycaemia in CF.

Reduced adrenal androgens in patients with myotonic dystrophy.

Endocrine disturbances associated with myotonic dystrophy (MD) include testicular atrophy, hyperinsulinemic glucose intolerance, thyroid abnormalities, and low or low normal urinary 17-ketosteroid (17-KS) excretion. Since the major circulating precursors of urinary 17-KS are dehydroepiandrosterone sulfate (DHAS) and dehydroepiandrosterone (DHA), a decrease in adrenal androgen production has been suggested. This possibility was studied in 19 MD patients and 19 age- and sex-matched normal subjects. Each patient had a 24-h urine collection for 17-KS and cortisol determinations, a 4-h iv infusion of 25 micrograms tetracosactrin with serial measurements of serum DHAS, DHA, and cortisol, and an insulin-induced hypoglycemia test. Sixteen patients had 0800 and 2400 h serum collections for cortisol estimations. Serum DHAS [1.0 +/- 0.5 (+/- SD) vs. 3.9 +/- 1.9 mumol/liter; P less than 0.0005] and DHA (5.9 +/- 2.7 vs. 11.0 +/- 7.1 nmol/liter; P less than 0.005) levels were significantly lower in MD patients than in normal subjects; cortisol levels were higher (540 +/- 222 vs. 394 +/- 128 nmol/liter; P less than 0.01), almost certainly a reflection of stress. A normal diurnal cortisol rhythm was found in all 16 subjects. Cortisol responses to insulin-induced hypoglycemia were normal, increasing from 345 +/- 243 nmol/liter to a maximum of 831 +/- 282 nmol/liter. Urinary 17-KS excretion was low or low normal, while urinary cortisol levels were normal in 18 and mildly elevated in 1 patient. There was a significant correlation between 17-KS and DHAS levels (r = 0.46; P less than 0.05). DHAS, DHA, and cortisol responses to tetracosactrin infusion were similar in patients and normal subjects. It is concluded that 1) in MD patients, serum DHAS and DHA concentrations are significantly lower than those in normal subjects, explaining the frequent reports of low or low normal 17-KS excretion; 2) the reduced DHAS and DHA concentrations are most likely due to decreased production rather than increased clearance; and 3) glucocorticoid production is normal.

The importance of physical activity in the prevention of overweight and obesity in childhood: a review and an opinion.

The prevalence of childhood obesity is increasing and there are a number of theoretical reasons as to why intervention may be more effective in childhood. There are certain risk times for the development of obesity in childhood, which provide a basis for targeted intervention. In addition, tracking data supports the persistence of obesity, at least in later childhood, as well as cardiovascular risk factors. Physical activity is the discretionary component of energy expenditure and there is evidence that falling levels of physical activity are contributing to the obesity epidemic. Physical activity in children is related to developmental stage, is reduced with increasing age and is influenced by parental physical activity. While there is debate about the immediate health benefits of physical activity to children, there are data to support that lower physical activity levels and sedentary behaviours are associated with a higher prevalence of obesity in children. Physical activity is an accepted strategy in the treatment of established obesity (tertiary prevention). The role of physical activity in the prevention of obesity (primary and secondary prevention) is less clear. However a number of recent school-based interventions directed at either increasing physical activity and/or decreasing sedentary behaviours, have shown encouraging results. On balance, increasing physical activity in children is an attractive and non-restrictive approach to obesity prevention. To adopt this approach requires the support and involvement of many community sectors other than health.

Total energy expenditure, body fatness, and physical activity in children aged 6-9 y.

BACKGROUND: The recent worldwide increase in the prevalence of childhood obesity may be due in part to a decrease in children's physical activity levels. OBJECTIVE: The current study of children in the years just before puberty aimed to 1) measure total energy expenditure (TEE) by use of the doubly labeled water (DLW) method, 2) determine the proportion of TEE related to physical activity, 3) investigate the relations between measures of physical activity and body fatness, and 4) investigate possible sex differences in these relations. DESIGN: The DLW technique was used to measure TEE over 10 d in 106 healthy children (52 boys) aged 7.8 +/- 0.9 y (x +/- SD). Fat-free mass, and hence fat mass, was derived from the (18)O dilution space. Resting energy expenditure (REE) was calculated with use of the Schofield equations. Physical activity level was calculated as TEE/REE. RESULTS: Mean TEE in both boys (7871 +/- 1135 kJ/d) and girls (7512 +/- 1195 kJ/d) was significantly different (P < 0.0001) from FAO/WHO/UNU recommendations (13% and 9% lower, respectively). There was no significant difference in physical activity level between boys (1.69 +/- 0.22) and girls (1.71 +/- 0.23). In boys but not girls, physical activity level was inversely correlated with BMI (r = -0.37, P < 0.01), fat mass (r = -0.46, P < 0.005), and percentage of body fat (r = -0.50, P < 0.0001). CONCLUSIONS: In boys but not girls, percentage of body fat is inversely associated with physical activity level. Physical activity is one factor contributing to body fatness in boys, but additional factors may influence the size of the fat stores in girls.

Comparison of total energy expenditure and energy intake in children aged 6-9 y.

BACKGROUND: The accurate measurement of food intake in children is important for assessing nutritional status. OBJECTIVE: We sought to both compare measurements of energy intake (EI) from diet records and of total energy expenditure (TEE) by the doubly labeled water (DLW) method and to investigate misreporting of EI. DESIGN: Forty-seven children (22 boys and 25 girls) aged 7.4 +/- 0.8 y ( +/- SD) were recruited from 25 schools in western Sydney. TEE was measured by DLW over 10 d and EI by use of 3-d food records. Misreporting was defined as [(EI - TEE)/TEE] x 100%. RESULTS: Girls had a higher (P = 0.02) percentage of body fat (28.2 +/- 7.0%) than did boys (22.9 +/- 8.0%); otherwise there were no differences among sex. Although mean (+/-SD) values for EI (7514 +/- 1260 kJ/d) and TEE (7396 +/- 1281 kJ/d) were not significantly different, there was no significant correlation between EI and TEE. EI and TEE were 9% and 11% lower, respectively, than current World Health Organization recommendations for EI. The relative bias (mean difference, EI - TEE) was low at 118 kJ/d, but the limits of agreement (bias +/- 2 SD of the difference) were wide at 118 +/- 3345 kJ/d. Although the mean percentage of misreporting was low (4 +/- 23%), the high SD indicates large intraindividual differences between EI and TEE. The most significant predictor of misreporting was dietary fat intake (r(2) = 0.45, P < 0.0001). Misreporting was not associated with sex or body composition. CONCLUSIONS: In this age group, reported EI is not representative of TEE at the individual level. However, at the population level, 3-d food records may be used for surveys of EI by 6-9-y-old children.

Very low calorie diet (VLCD): a useful alternative in the treatment of the obese NIDDM patient.

Conventional treatment of obese noninsulin dependent diabetes mellitus (NIDDM) patients is often unsatisfactory. In this study the efficacy of Modifast, a commercial very low calorie diet (VLCD), was evaluated in a population of obese poorly controlled NIDDM patients. The mechanisms of action of VLCD in these patients were also studied by comparing: (i) Plasma insulin and glucose profiles after a VLCD and an isocaloric mixed meal and (ii) plasma amino acid levels, both at baseline and after four weeks of VLCD treatment. A total of 14 obese NIDDM patients (M/F 7/7. median body mass index (BMI) 38.7 kg-2, interquartile range (IQ) 34.7-46.5 kg-2, waist circumference 116 cm, IQ 106-139 cm, insulin treated 7/14) with poor diabetic control (HbA1c 8.6%, IQ 7.8-10%) were studied. Patients were given a VLCD (425 kcal/day) for 12 weeks. At baseline, VLCD and isocaloric meal tests were performed on consecutive mornings. Fasting plasma amino acid levels were also determined at baseline and after 4 weeks of VLCD treatment. Weight, waist circumference, HbA1c, blood pressure, fasting plasma insulin, total cholesterol and triglyceride levels all fell significantly following VLCD treatment. Insulin therapy was able to be ceased in the seven insulin treated patients. Oral hypoglycaemic agent dosage fell from a median of eight (IQ 6-12) to two (IQ 0-8) tablets per day (P = 0.03) in patients initially on this form of therapy. Insulin secretion was higher after VLCD than isocaloric meal (P = 0.04). Fasting plasma alanine level fell from 512.0 (IQ 412.0-563.0) to 374.0 (IQ 342-472.0) mumol/l (P = 0.04) following VLCD treatment. In conclusion, the short term use of a VLCD is very effective in rapidly improving glycaemic control and promoting substantial weight loss in obese NIDDM patients. Moreover, a VLCD diet increases insulin secretion and reduces substrate for gluconeogenesis. Thus, VLCD treatment may improve glycaemic control by factors more than caloric restriction alone.

Food, activity and family--environmental vs biochemical predictors of weight gain in children.

OBJECTIVE: To identify whether measures of energy intake and expenditure predict excessive weight gain over time in children and to describe how these measures relate to similar measures in parents. DESIGN: Prospective, descriptive study over 12 months with no intervention. SETTING: University teaching hospital. SUBJECTS: Children aged between 6.0 and 9.0 y. Recruitment was through advertisement. A total of 59 children (30 F), 41 mothers and 29 fathers. In all, 41 (69%) of the children were reviewed at 12 months (20 F). RESULTS: No significant correlations were identified between body mass index (BMI) z-score change in children over 12 months for any dietary variable or for any measures of energy expenditure, including hours of television viewing or percent time spent in low-, moderate- or high-intensity activity. The BMI z-score change over 12 months was significantly correlated with LDL cholesterol and Apo B/ApoA-1 ratio, independent of percent body fat (r=0.45, P=0.01; r=0.37, P=0.03). A significant positive correlation was found for mothers and girls for percent time in moderate to high activity (r=0.44, P=0.03) and between fathers and children for percent time spent in low activity (r=0.43, P=0.005). CONCLUSIONS: The study has been unable to identify environmental predictors that indicate propensity to faster weight gain over time in this cohort of children, but has extended the evidence on lifestyle-influenced biochemical predictors that do. An overall lack of vigorous activity in this age group, and correlations between parental and child activity and inactivity have been identified.

Coronary heart disease risk factors in male adolescents, with particular reference to smoking and blood lipids.

PURPOSE: To examine coronary heart disease (CHD) risk factors, particularly blood lipids and smoking, in adolescent boys in the Sydney Metropolitan area, and to investigate possible differences between boys from English-speaking (ESB) and non-English-speaking backgrounds (NESBs). METHODS: Male volunteers aged 15-18 years were recruited from the senior years of four secondary schools in different geographical areas of Sydney. Body mass index (BMI), waist-hip ratio (WHR), blood lipids, and percent body fat were measured. Behavioral variables were estimated by questionnaire. RESULTS: A total of 110 boys were recruited; 74% were from an ESB. Mean WHR (0.836 +/- 0.045), waist circumference (80.6 +/- 9.4 cm), and percent body fat (21.0 +/- 6.3) were similar across age groups. Atherogenicity of the lipid profile, as measured by the ratio of total cholesterol to high-density lipoprotein cholesterol (TC:HDL-C), was lower in boys aged 15 years than in any other age group (p < .05). TC:HDL-C was strongly associated with BMI (r = .57; p < .0001) and WHR (r = .35; p < .01). Smokers had higher BMI, were less active and had lower HDL-C (p < .001) and higher TC:HDL-C (p < .0001) than nonsmokers. Smoking, even of short duration, and quite moderate consumption of cigarettes (6/day) were associated with a deterioration of the lipid profile. Boys from NESBs had a higher degree of risk in all of the factors examined. CONCLUSIONS: Regular smoking of short duration has an appreciable impact on lipid and lipoprotein concentrations in this sample of Australian adolescent boys. Boys from an NESB appear to be at greater risk of developing CHD in later life.

A candidate gene approach for identifying differential iron responses in young overweight women to an energy-restricted haem iron-rich diet.

Although iron deficiency is common in women especially during dieting, weight management trials rarely examine the longitudinal impact of genetics on iron. This study examined the associations between the TMPRSS6 rs855791 polymorphism and iron indices at baseline and after a 12-month trial comparing two weight loss diets (higher-protein, higher-haem iron (HPHI) vs lower-protein, lower-haem iron (LPLI)). A total of 76 young overweight women (18-25y; BMI⩾27.5 kg/m(2)) were included at baseline, with 27 (HPHI: n=15; LPLI: n=12) completing the 12-month trial. At baseline, C allele homozygotes exhibited higher serum iron (P=0.047) and lower hepcidin (P=0.023) compared with T allele carriers. After 12 months, no genotypic differences were observed for ferritin and soluble transferrin receptor, although C homozygotes on HPHI showed higher serum iron and transferrin saturation (P<0.05). Results indicate that rs855791 can influence iron metabolism to some extent, but its impact on storage and functional iron status is small relative to dietary protein/iron manipulation.

The role of parents in pre-adolescent and adolescent overweight and obesity treatment: a systematic review of clinical recommendations.

The study aims to describe clinical recommendations (i) on the role of parents in both pre-adolescent and adolescent overweight and obesity treatment; (ii) to health professionals on how to involve parents in paediatric overweight and obesity treatment and (iii) to identify deficiencies in the associated literature. A systematic literature review was conducted in March 2010 to identify clinical practice guidelines, position or consensus statements on clinical management of paediatric overweight or obesity, developed by a national or international health professional association or government agency, and endorsed for current use. Relevant clinical recommendations in these documents were identified via a screen for the words 'parent', 'family' and synonyms. Twenty documents were included. Most documents emphasized the importance of involving parents or the family in paediatric overweight and obesity treatment with approximately a third of documents providing separate recommendations on the role of parents/family for pre-adolescents and adolescents. The documents varied markedly with regard to the presence of recommendations on parent/family involvement in the various components of lifestyle interventions or bariatric surgery. Almost half of the documents contained recommendations to health professionals regarding interactions with parents. High-quality research is needed on age-specific techniques to optimize the involvement of parents and family members in paediatric overweight and obesity treatment.

Comparison of metabolic syndrome prevalence using six different definitions in overweight pre-pubertal children enrolled in a weight management study.

OBJECTIVES: To assess the implications of variation in Metabolic Syndrome (MS) definition (biochemical and anthropometric indicators) on MS prevalence estimates in a population of overweight and mildly obese children. DESIGN: Cross-sectional study. SUBJECTS: Ninety-nine (64 girls) overweight or mildly obese, but otherwise healthy, pre-pubertal 6-9-year olds recruited for a randomized controlled trial of weight management. MEASURES: Height, weight and waist circumference were measured with BMI and waist z-scores calculated. Fasting cholesterol and fractions, glucose and insulin were measured, together with systolic and diastolic blood pressure (BP). Anthropometric and metabolic indicators were classified as normal or elevated using adult- or child-specific cut points with clustering of MS indicators also assessed using two adult and three child-specific definitions. RESULTS: A total of 0-4% of subjects were classified with MS when adult definitions were applied. This increased to between 39 and 60% using child-specific definitions, varying according to whether hyperinsulinaemia was central to the MS classification. Systolic BP, triglycerides, total cholesterol, high-density lipoprotein cholesterol and waist z-score increased across insulin quartiles (P<0.05). The use of body mass index and waist circumference in the MS definition classified the same subjects. CONCLUSIONS: The classification of MS in children depends strongly on the definition chosen, with MS prevalence estimates higher if insulin is part of the definition and child-specific cut points for metabolic indicators are used. Hyperinsulinaemia and MS are common consequences of childhood obesity but they are not commonly part of the assessment or management plan for weight management in children. There is a need for the establishment of normal insulin ranges and consistent definition of MS in childhood and adolescence.

A proposed protocol for the development of a register of trials of weight management of childhood overweight and obesity.

INTRODUCTION: Currently, there is no international co-ordinated approach to research into childhood obesity. This is despite much research activity in this area and the universality of the condition. METHOD: This proposal involves the development of an international register of randomized controlled trials of weight management in overweight and obese children. The primary purpose of the register will be to generate and perform important, focussed prospective meta-analysis of data from trials using the conventional weight management strategies. Prospective meta-analysis is an emerging methodology and has some methodological advantages over retrospective meta-analysis. PROPOSAL: The fundamental initial tasks will be to create scientific interest in the proposal, to identify and co-ordinate Management and Advisory Committees with international membership, to determine and define inclusion and exclusion criteria for trial registration, to define the questions that need to be addressed by prospective meta-analysis and finally to engage investigators to register.

Thyroid abnormalities in patients with myotonic dystrophy.

Myotonic dystrophy (MD) is a systemic genetic disorder predominantly affecting musculature. Although endocrine disturbances have been described, data relating to thyroid gland involvement are sparse and conflicting. To further investigate this aspect, twenty MD patients and twenty age-and sex-matched controls were studied. All were clinically euthyroid and there were no significant differences between circulating levels (mean +/- SD) of T4 (101 . 5 +/- 28.2 v. 103 . 8 +/- 27 . 7 nmol/l), T3 (1 . 86 +/- 0 . 57 v. 2 . 15 +/- 0 . 47 nmol/l), rT3 (0 . 39 +/- 0 . 14 v. 0 . 42 +/- 0 . 09) nmol/l) or TSH (2 . 6 +/- 0 . 5 v. 2 . 4 +/- 0 . 8 mu/l) or between T3 resin uptakes (97 +/- 8 v. 98 +/- 11%). TSH responses following TRH stimulation were significantly less in the MD patients (323 +/- 141 v. 529 +/- 240%; P less than 0.0025). The mean maximum TSH levels achieved were 6 . 7 +/- 3 . 6 mu/l (MD) and 17 . 1 +/- 7 . 2 mu/l (controls); P less than 0.005. Two patients had multinodular goitres (MNG) and one a single thyroid nodule. Thyroid scans were normal except for patchy uptake in the two MNG patients. There was no abnormal incidence of circulating thyroid microsomal or thyroglobulin antibodies, and thyrotrophin binding inhibitory immunoglobulin levels were normal in four patients. It is concluded that in MD: 1 palpable thyroid gland abnormalities occur with increased frequency, 15% (three/twenty) in the present study and 20% (twenty/102 case reports) from a review of the literature; 2 TSH responses to TRH are significantly reduced; 3 circulating thyroid hormone levels are usually normal.

Severe obesity: the use of very low energy diets or standard kilojoule restriction diets.

OBJECTIVES: To determine the efficacy of two dietary therapies in both the short term (hospitalisation) and the longer term treatment of severe obesity. DESIGN: A descriptive study of two patient groups with obesity defined by a body mass index of greater than 30 kg/m2. SETTING: A multidisciplinary weight control program in a tertiary care hospital. PATIENTS: All admissions to hospital of patients on the weight control program for initiation of weight loss during a period of 48 months. INTERVENTION: A standard kilojoule reduction regimen or the use of complete, followed by partial, long term meal substitution with a very low energy liquid diet (VLED), coupled with an exercise and a behavioural modification program. OUTCOME MEASURES: Weight loss during and after hospitalisation was measured in both dietary regimen groups. RESULTS: Both diets induced weight loss in hospital. Men prescribed VLED lost significantly more weight, 8.3 +/- 0.8 kg (mean +/- SEM) than women prescribed this diet (5.5 +/- 0.5 kg) or standard kilojoule restriction (5.1 +/- 0.8 kg). CONCLUSIONS: VLED and standard kilojoule restriction are both effective for the treatment of severe obesity, particularly in a controlled environment (hospitalisation). In the longer term, VLED is an effective method of maintaining weight loss. Lack of continuing weight loss may reflect the patients who were initially placed on this regimen--small eaters with a presumed high metabolic efficiency.

Tissue [1-14C] 2-deoxyglucose metabolism in the gold thioglucose obese mouse: effects of 'dieting'.

Glucose uptake into heart and skeletal muscle and white and brown adipose tissue is reduced in mice with gold thioglucose-induced obesity. After acute dieting (40% of lean control uptake) for 18 days, glucose uptake into tissues remains low despite consistently elevated serum insulin levels. This reduced glucose uptake may be a consequence of the raised serum fatty acid levels produced by dieting. When the reduced weight obese mice are pair-fed with lean controls, they gain weight. Glucose uptake into both muscle and adipose tissues is markedly increased, and the insulin resistance of both previous obesity and recent relative starvation is rapidly overcome at the level of the glucose uptake, but serum insulin levels and insulin secretion from islets of Langerhans isolated from these animals remain high. To maintain reduced weight, previously obese animals were fed 80% of lean control intake. In this situation, glucose uptake into the four tissues studied remained reduced (compared to lean controls), consistent with relative starvation. While tissue glucose uptake increases after dieting and re-feeding of obese animals, serum insulin levels remain high, indicating persistence of a degree of insulin resistance. Reduced-weight obese animals are energy-efficient in that they gain excess weight on the control intake.

The effect of an individual versus group program on weight loss.

The therapy of obesity is difficult and success rates are low. Because of these observations many different therapeutic modalities have been advocated. In this study the short term weight loss results using individual and group approaches are described. For both approaches changes in lifestyle and behaviours were emphasised. The major finding of the study was that while patient retention rates were better in the group approach, weight loss was greater in those patients who were seen individually. The reasons for these findings are discussed and some suggestions are made as to how the group approach, which has the significant advantage of making more efficient use of health professionals' time, might be made more therapeutically effective.