WHO European Childhood Obesity Surveillance Initiative 2008: weight, height and body mass index in 6-9-year-old children.

UNLABELLED: What is already known about this subject Overweight and obesity prevalence estimates among children based on International Obesity Task Force definitions are substantially lower than estimates based on World Health Organization definitions. Presence of a north-south gradient with the highest level of overweight found in southern European countries. Intercountry comparisons of overweight and obesity in primary-school children in Europe based on measured data lack a similar data collection protocol. What this study adds Unique dataset on overweight and obesity based on measured weights and heights in 6-9-year-old children from 12 European countries using a harmonized surveillance methodology. Because of the use of a consistent data collection protocol, it is possible to perform valid multiple comparisons between countries. It demonstrates wide variations in overweight and obesity prevalence estimates among primary-school children between European countries and regions. BACKGROUND: Nutritional surveillance in school-age children, using measured weight and height, is not common in the European Region of the World Health Organization (WHO). The WHO Regional Office for Europe has therefore initiated the WHO European Childhood Obesity Surveillance Initiative. OBJECTIVE: To present the anthropometric results of data collected in 2007/2008 and to investigate whether there exist differences across countries and between the sexes. METHODS: Weight and height were measured in 6-9-year-old children in 12 countries. Prevalence of overweight, obesity, stunting, thinness and underweight as well as mean Z-scores of anthropometric indices of height, weight and body mass index were calculated. RESULTS: A total of 168 832 children were included in the analyses and a school participation rate of more than 95% was obtained in 8 out of 12 countries. Stunting, underweight and thinness were rarely prevalent. However, 19.3-49.0% of boys and 18.4-42.5% of girls were overweight (including obesity and based on the 2007 WHO growth reference).The prevalence of obesity ranged from 6.0 to 26.6% among boys and from 4.6 to 17.3% among girls. Multi-country comparisons suggest the presence of a north-south gradient with the highest level of overweight found in southern European countries. CONCLUSIONS: Overweight among 6-9-year-old children is a serious public health concern and its variation across the European Region highly depends on the country. Comparable monitoring of child growth is possible across Europe and should be emphasized in national policies and implemented as part of action plans.

Ontogenesis of laterality in 3- to 10-yr.-old children: increased unimanual independence grounded on improved bimanual motor function.

Underlying sensorimotor factors, such as intermanual coupling, contributing to optimal laterality, long remain immature. Using the handmotor laterality blackboard, developmental change in symmetric bimanual motor function for 413 children in groups of 3 to 10 years of age shows synchronicity increased between groups 3 and 5 years of age; but between groups 5 and 7 years of age, given immature coupling, one hand may still disturb the movements of the other one. Between groups 7 and 9 years of age, the hands gradually stop disturbing each other and move independently and fluently. Changes in intermanual coupling with increasing unimanual independence represent expression of changing interhemispheric integration across groups. This promotes optimal laterality and task distribution between the hands. Maturation of the corpus callosum is inferred to be a factor in these ontogenetic changes which ultimately lead to optimal left hemisphere specialization for actions such as fluent writing.

Ontogenetic trends in gnostic hand function in 3- to 12-yr-old children.

The intimate relation between the sensory and motor functions of the hands during object manipulation and exploratory touch, the well-known improvement in object handling and constructive performance in ontogenesis and the emergent laterality thereof, assume changes in morphognostic capabilities in children. In this study we tried to corroborate the hypothesis of Mesker that mature and lateralized finger-thumb opposition is preceded by a stage of two-sided manual form agnosia in preschool children, followed by acquisition of morphognosis of the fingers and, finally, the thumbs. This study examined the development of gnostic hand function in 290 children from 3 to 11 years of age who drew the outlines of a meaningless wooden object passively felt with each hand without visual control. Analysis showed a clear ontogenetic change across the two age groups of increasing morphognostic function: 48% of the 6-yr.-olds drew correctly what the fingers of both left and right hands had perceived (thumbs, 14%). Of the 11-yr.-olds 91% and 61% performed perfectly with the right and left hands, respectively. The fingers preceded the thumbs in reproduction by most children, and the correct reproduction by the left thumb precedes that of the right thumb. The ontogenesis of bimanual sensorimotor functioning is discussed in the light of cortical and callosal development.

Leptin levels in type 2 diabetes: associations with measures of insulin resistance and insulin secretion.

Interactions between leptin and insulin have been shown previously, in vitro and in vivo. In this study, we evaluate the associations of leptin levels with insulin secretion and insulin sensitivity in type 2 diabetes. Fasting leptin levels, HbA 1c, glucose, insulin, C-peptide, intact and des-31,32-proinsulin were measured in 100 non-insulin-treated type 2 diabetic patients. Glucose, insulin and C-peptide were measured 2 hours after an oral glucose load. Insulin resistance and beta-cell function were calculated using HOMA. Leptin levels were found to be associated with all measures of beta-cell secretion: with fasting and 2 hours insulin and C-peptide, with intact and des-31,32-proinsulin concentrations, and with beta-cell secretion estimated with HOMA. This association was independent of age and body fat in women, but in men, associations with insulin and C-peptide weakened after controlling for fat mass, whereas those with intact and des-31,32-proinsulin disappeared. Fasting insulin and C-peptide levels were also significant in multiple regression analyses, besides gender and fat mass. Insulin resistance, as assessed by HOMA, was strongly correlated with leptin, also after correction for age and fat mass in both genders. We conclude that, besides fat mass and gender - the main determinants for leptin levels in type 2 diabetic subjects as in healthy subjects - insulin secretion and the degree of insulin resistance also seem to contribute significantly to leptin levels.

Visceral fat is a determinant of PAI-1 activity in diabetic and non-diabetic overweight and obese women.

Plasminogen activator inhibitor type 1 (PAI-1), an inhibitor of fibrinolysis and an important and independent cardiovascular risk factor, has been shown to be elevated in obesity and type 2 diabetes. Recent study results have suggested that adipose tissue--visceral fat in particular--could play an important role in the fibrinolytic process.In order to assess the specific role of this fat distribution, we measured PAI-1 activity (AU/ml) and visceral fat (CT-scan at level L4-L5) in 2 groups of 30 overweight and obese diabetic and overweight and obese non-diabetic women. Subjects were matched for age, weight, body mass index, fat mass and total abdominal fat. Visceral adipose tissue and PAI-1 were significantly higher in diabetic women (p = 0.022 and p = 0.004 respectively) than in non-diabetic patients. Visceral fat correlated significantly with PAI-1 activity, even after correction for insulin and triglycerides (r = 0.28, p = 0.034). Stepwise regression analysis showed visceral fat as the most important determinant factor for PAI-1 in the whole group and in the non-diabetic group. In the diabetic group, fasting insulin was the most important determinant. These results show that visceral fat is more important than BMI or total body fat in the determination of PAI-1 levels. Furthermore, the increased amount of visceral fat in type 2 diabetics may contribute to the increase of PAI-1 activity levels and the subsequent increased risk for thrombovascular disease, regardless of BMI and total fatness.

Leptin receptor gene polymorphisms are associated with insulin in obese women with impaired glucose tolerance.

Leptin receptors are present on beta-cells as well as on muscle and fat cells, thus enabling leptin to modulate both insulin secretion and insulin action. Leptin inhibits especially the glucose-stimulated insulin secretion from pancreatic cells. The leptin receptor (LEPR) gene could thus play a role in the regulation of glucose and insulin after an oral glucose load. Therefore, the relationship between LEPR polymorphisms and glucose and insulin response to an oral glucose tolerance test (OGTT) was investigated. Three LEPR polymorphisms (Lys(109)Arg, Gln(223)Arg, and Lys(656)Asn) were typed on genomic DNA of 358 overweight and obese women, aged 18-60 yr. Based on an OGTT, 269 subjects were defined with normal glucose tolerance, and 89 with impaired glucose tolerance (IGT). Associations between genotypes and glucose metabolism were analyzed with a general linear models procedure in pre- and postmenopausal women separately, after adjusting the data for age and fat mass. In postmenopausal women with IGT (n = 24), associations were found with Lys(109)Arg and Lys(656)Asn for fasting insulin (P = 0.05) and with Lys(109)Arg and Gln(223)Arg for the insulin response to an OGTT (P < 0.02). In the same group, trends were found with Lys(656)Asn for fasting glucose as well as in response to the OGTT. In premenopausal women with IGT (n = 65), associations were found with Lys(109)Arg and Lys(656)Asn for overall glucose response to the glucose load. In contrast, no associations with insulin or glucose were found in women with normal glucose tolerance. In conclusion, these data indicate that LEPR polymorphisms are associated with insulin and glucose metabolism in women with impaired glucose homeostasis.

Polymorphisms in the leptin receptor gene, body composition and fat distribution in overweight and obese women.

OBJECTIVE: Leptin is an adipocyte-secreted hormone involved in body weight regulation, acting through the leptin receptor, localised centrally in the hypothalamus as well as peripherally, amongst others on adipose tissue. The aim of this study was to evaluate whether polymorphisms in the leptin receptor (LEPR) gene were related to obesity and body fat distribution phenotypes, such as waist and hip circumferences and the amount of visceral and subcutaneous fat. METHODS: Three known LEPR polymorphisms, Lys109Arg, Gln223Arg and Lys656Asn, were typed on genomic DNA of 280 overweight and obese women (body mass index (BMI)>25), aged 18-60 y. General linear model (GLM) analyses were performed in 198 pre- and 82 postmenopausal women, adjusting the data for age and menopausal state, plus fat mass for the fat distribution phenotypes. RESULTS: No associations were found between the LEPR polymorphisms and BMI or fat mass. In postmenopausal women, carriers of the Asn656 allele had increased hip circumference (P=0.03), total abdominal fat (P=0.03) and subcutaneous fat (P=0.04) measured by CT scan. Total abdominal fat was also higher in Gln223Gln homozygotes (P=0.04). Also in postmenopausal women, leptin levels were higher in Lys109Lys homozygotes (P=0.02). CONCLUSION: In conclusion, polymorphisms in the leptin receptor gene are associated with levels of abdominal fat in postmenopausal overweight women. Since body fat distribution variables were adjusted for fat mass, these results suggest that DNA sequence variations in the leptin receptor gene play a role in fat topography and may be involved in the predisposition to abdominal obesity.

Human leptin: from an adipocyte hormone to an endocrine mediator.

Leptin is a mainly adipocyte-secreted protein that was discovered 5 years ago. Most of the research following this discovery focused on the role of leptin in body weight regulation, aiming to illuminate the pathophysiology of human obesity. However, more and more data are emerging that leptin is not only important in the regulation of food intake and energy balance, but that it also has a function as a metabolic and neuroendocrine hormone. It is now clear that it is especially involved in glucose metabolism, as well as in normal sexual maturation and reproduction. Besides this, interactions with the hypothalamic-pituitary-adrenal, thyroid and GH axes and even with haematopoiesis and the immune system have also been described. It has been shown that leptin secretion by the adipocyte is partly regulated by other hormones, such as insulin, cortisol, and sex steroids, mainly testosterone. Also, other hormones like thyroid hormone and GH are possibly involved in leptin synthesis. Leptin itself exerts effects on different endocrine axes, mainly on the hypothalamic-pituitary-gonadal axis and on insulin metabolism, but also on the hypothalamic-pituitary-adrenal, thyroid and GH axes. Leptin may thus be considered a new endocrine mediator, besides its obvious role in body weight regulation.

Associations of leptin with body fat distribution and metabolic parameters in non-insulin-dependent diabetic patients: no effect of apolipoprotein E polymorphism.

Leptin levels have been shown previously to be associated with anthropometric parameters such as the body mass index (BMI), total body fat, and subcutaneous fat. Since apolipoprotein E (apoE) polymorphism is known to be a genetic marker affecting the relationship between certain anthropometric and metabolic parameters, we evaluated whether the leptin level and/or associations between the leptin level and body composition in non-insulin-dependent diabetic patients could be determined by apoE polymorphism. In 171 type 2 diabetic patients (105 male and 66 female), body composition (BMI, waist to hip ratio [WHR], fat mass, and visceral fat) was measured and fasting blood samples were obtained to determine the apoE genotype, leptin, glucose, and insulin levels, and the lipid profile. The mean leptin level for the whole group was 11.7 +/- 9.3 ng/mL, with a significant difference (P < .001) between men (7.1 +/- 4.9 ng/mL) and women (19.0 +/- 10.1 ng/mL). No difference was found for leptin levels or anthropometric variables between the 3 different apoE genotypes (E3/E3 homozygotes, E2 carriers, and E4 carriers). Only low-density lipoprotein (LDL) cholesterol was significantly different between the 3 apoE subgroups. The correlations of leptin with anthropometric variables, especially visceral fat, tended to be different between the 3 apoE groups, but this was not independent and no effect was found after controlling for the other parameters in the model. A multiple regression model containing gender, subcutaneous fat, fasting glucose, triglycerides, and high-density lipoprotein (HDL) cholesterol explained 81% of the variance in leptin levels. We conclude that apoE polymorphism has no effect on the leptin level or its associations with other anthropometric and metabolic parameters.

Clinical endocrinology of human leptin.

Since the discovery of leptin, a boom of scientific knowledge became available about the OB-protein gene and its role and significance in weight regulation. Both from animal and human research data, serum leptin can probably be considered as one of the best biological markers to reflect total body fat, and this finding is true over a wide range of body mass indexes (BMIs) and in different pathologies: in normal weight, anorexic and obese subjects; in non insulin-dependent diabetes mellitus (NIDDM) patients, PCO women, Prader-Willi children and subjects with hypogonadism and growth hormone deficiency. Gender differences clearly exist, probably related to sex hormone differences, and from fat distribution studies it could be shown that subcutaneous fat is much more related to serum leptin concentrations than visceral fat: also leptin messenger-RNA (m-RNA) expression is significantly higher in subcutaneous fat from human obese subjects. Leptin is not only correlated to a series of endocrine parameters such as insulin, insulin-like growth factor, (IGF) and SHBG, it seems involved as a mediator in some endocrine mechanisms (onset of puberty, insulin secretion, etc) as well. Weight loss will reduce human leptin concentrations, whereas the administration of human recombinant leptin seems to show only limited effects.

Gender differences in leptin levels and physiology: a role for leptin in human reproduction.

Leptin, an adipocyte-derived hormone known to play an important role in body-weight regulation, has been shown to be expressed differentially in men and women. These observations are potentially important for the understanding of differences between men and women in regulation of food intake, weight gain, and body fat distribution. Leptin is also involved in female fertility, especially in pubertal development. It may well be the triggering signal for the onset of puberty in girls. Although the exact mechanisms and interactions with sex steroids are not yet fully established, it is clear that leptin plays a role as an endocrine mediator in sexual development and reproduction.

Sibutramine and fat distribution: is there a role for pharmacotherapy in abdominal/visceral fat reduction?

Visceral adiposity has a strong and independent association with obesity and its related co-morbidities, particularly metabolic complications such as cardiovascular disease and type II diabetes. Waist circumference and waist-to-hip ratio (WHR) are both secondary indicators of visceral obesity. This paper examines the effect of sibutramine, a new serotonin and noradrenaline re-uptake inhibitor, on weight reduction and changes in fat distribution. A meta-analysis of four long-term, placebo-controlled, double-blind studies showed significantly greater mean decreases in waist circumference in sibutramine-treated subjects compared with placebo (P < 0.001). Similar results were seen for WHR, with 15 mg sibutramine daily producing a significant reduction of 0.02 compared with placebo (P < 0.02). Changes in fat distribution have been examined using computerised tomography (CT) scans as part of the Sibutramine Trial of Obesity Reduction and Maintenance (STORM). Preliminary results showed a mean weight loss from baseline of 11.2 +/- 6.3 kg after 6 months of 10 mg sibutramine treatment. Decreases in total abdominal fat (18%), total subcutaneous fat (17%) and total visceral fat (22%) were observed, and there was a significant increase in the subcutaneous-to-visceral fat ratio (P = 0.04). These changes in fat levels and distribution were associated with improvements in related risk factors such as fasting blood glucose and insulin levels, and blood pressure. In conclusion, sibutramine produces statistically and clinically significant decreases in waist circumference and WHR, and preferentially reduces visceral fat levels.

Anti-obesity drugs: what does sibutramine offer? An analysis of its potential contribution to obesity treatment.

Sibutramine is a serotonin and noradrenaline re-uptake inhibitor (SNRI) which induces weight loss via a dual mode of action: enhancing both satiety and energy expenditure. Sibutramine exerts its in vivo effects predominantly via its secondary and primary amine metabolites. Following oral ingestion, sibutramine is well absorbed and undergoes extensive first pass metabolism. Sibutramine produces statistically and clinically significant, dose-related weight loss over the range 5-30 mg once daily; active weight loss occurs for 6 months. Long-term studies of up to 1 year have found that weight loss is maintained with continued sibutramine therapy. Sibutramine-induced weight loss is associated with beneficial changes in obesity-related risk factors, such as serum lipids, uric acid levels, and glycaemic control (in patients with type 2 diabetes). Subcutaneous/visceral fat ratio was found to increase significantly under sibutramine treatment, indicating that relatively more visceral fat than subcutaneous fat is lost. Sibutramine is well tolerated; side-effects are generally mild, non-treatment limiting, and consistent with the known mechanism of action of the drug. Overall, studies have found sibutramine to be an effective weight loss agent with a good safety profile.

Five-year clinical performance of porcelain veneers.

OBJECTIVE: The overall clinical performance of porcelain veneers was evaluated at 5 years. METHOD AND MATERIALS: Porcelain veneers were placed on 87 maxillary anterior teeth in 25 patients (19 to 69 years) by a single operator following a standardized clinical procedure. At the 5-year recall, esthetics, marginal performance, vitality, fracture rate, and patient satisfaction were recorded. RESULTS: At recall, 93% of the veneers were satisfactory without intervention. The remaining 7% presented clinically unacceptable problems such as recurrent caries, porcelain fracture, severe clinical microleakage, or pulpal reaction. The retention rate of the porcelain veneers was 100%, and the maintenance of esthetics was perfect. Only 14% of the veneers presented excellent marginal adaptation over the entire outline of the restoration; however, the impact of the slight marginal defects on the clinical performance was negligible. CONCLUSION: Labial porcelain veneers offer a reliable and effective procedure for the conservative treatment of discolored, malformed, and malaligned anterior teeth.

Are leptin levels dependent on body fat distribution in obese men and women?

Leptin levels are strongly related to total body fat. It is however not yet clear if leptin is also related to visceral fat accumulation or not. In this study, we investigated whether leptin is also associated with body fat distribution and if this association is different in men and women. Leptin was measured in 143 obese subjects (118 women and 25 men) with a body mass index (BMI) greater than 28. Also weight, skinfolds, waist-to-hip ratio (WHR), fat mass by bioimpedance analysis (BIA) were measured, and abdominal visceral and subcutaneous fat were determined by CT scan. Leptin levels were significantly related with BMI, with fat mass (in kg and percentage body fat) as measured by BIA and skinfolds, and with total abdominal fat mass and subcutaneous fat measured by CT scan. No association was found with visceral fat, waist circumference or WHR. In men and women separately, however, a correlation with visceral fat existed. After correction for total body fat, the correlation remained significant only with subcutaneous fat in women. Multiple regression analyses pointed out that percentage body fat was the most important determinant of leptin for all subjects, while for women subcutaneous fat was the most important parameter, and for men alone total abdominal fat. These results suggest that subcutaneous fat seems to be an important factor related to leptin levels.

Effect of one week of fibre supplementation on hunger and satiety ratings and energy intake.

The effect of one week of supplementation with a water-soluble fibre (guar gum) was studied in obese women who had lost weight. In study 1 (N=17; mean+/-SEM: age 38.5+/-2.3 yrs; weight 86.8+/-2.3 kg; BMI 32.2+/-0.9 kg.m-2) energy intake and hunger and satiety scores were assessed under free-living conditions. In study 2 (N=14; age 44. 5+/-1.8 yrs; weight 78.8+/-3.1 kg; BMI 29.0+/-0.9 kg.m-2) energy intake was fixed at 6 MJ.day-1 (their normal energy intake at that time) or 4 MJ.day-1 (low energy intake). In both studies, the effect of one week of fibre supplementation (40 g in study 1 and 20 g in study 2) was compared with no supplementation. In study 1, mean energy intake decreased significantly from 6.7+/-0.4 MJ to 5.4+/-0.2 MJ daily after fibre supplementation, while hunger and satiety scores did not change. At a low energy intake level of 4 MJ given in study 2, hunger scores were significantly decreased after fibre supplementation. No changes were seen in hunger and satiety scores during fibre supplementation at 6 MJ. The reduction in energy intake by soluble fibre under free living conditions and the hunger-reducing effect of fibre at the low energy intake level (4 MJ) suggests that fibre may be useful in the treatment of obesity, by facilitating compliance to low energy intake.

Development, reliability, and validity testing of the Ethical Behavior Test: a measure for nurses' ethical behavior.

The need for reliable and valid measures for ethical behavior of nurses has encouraged the authors to develop a new instrument to measure students' ethical behavior in daily nursing dilemmas. Characteristic of the instrument presented is the inclusion of two fundamental components of ethical behavior: (1) ethical reasoning (and the resulting decision), and (2) the actual implementation of the ethical decision. As for many instruments, Kohlberg's theory of moral development has been used as the conceptual framework. However, Kohlberg's abstract justice orientation was refined by a care perspective and representative nursing dilemmas were used to make the instrument conceptually more appropriate for measuring nurses' ethical behavior. The analysis of the psychometric properties of the instrument has provided several relevant indications for the reliability and validity of the ethical reasoning and implementation scores. The revealed inconsistencies in the Ethical Behavior Test could be satisfactorily interpreted in terms of Kohlberg's theory and related empirical research findings, supporting the reliability of the ethical behavior scores. The content validity rests upon the careful development of the instrument resulting in an optimal mix of dilemmas, arguments and care situations to reveal nurses' ethical behavior and in a substantial degree of correspondence between the concept and operationalization. The congruency between the patterns of ethical behavior and Kohlberg's theoretical insights about ethical reasoning and practice support the construct validity of the instrument.

The beneficial effects of modest weight loss on cardiovascular risk factors.

A range of risk factors affect cardiovascular morbidity and mortality. There is increasing evidence that moderate weight loss, expressed as 5-10% weight loss, has beneficial effects on these cardiovascular risk factors. Such moderate weight loss, combined with exercise, significantly decreases triglyceride levels, while significantly increasing levels of high density lipoprotein (HDL)-cholesterol. Studies also indicate that the oxidizability of lipids and lipoproteins in a given individual is of importance in assessing cardiovascular risk. Preliminary data suggest that moderate weight loss can improve the oxidizability status of obese individuals. Lipoprotein (a) levels, however, are not reduced by modest weight reduction, unless pretreatment values are considered. In addition, there is evidence that limited weight loss (< 7 kg) decreases levels of the haemostatic factors, factor VII and PAI, while increasing the tissue plasminogen activator levels. Fibrinogen levels, however, seem not to benefit from such limited weight loss. Modest weight loss has also been found to cause regression of coronary arterial lesions, and significantly reduce cardiac events, total cardiac mortality, and total mortality. Despite the limited success of long-term weight reduction programmes, it seems worthwhile to motivate overweight people to attempt even a modest amount of weight loss, since this may help to reduce cardiovascular risk factors and total mortality.

Nursing students' responses to ethical dilemmas in nursing practice.

In literature as well as in nursing practice a growing concern about nurses' ethical competence can be observed. Based on the cognitive theory of moral development by Kohlberg, this research examined nursing students' ethical behaviour in five nursing dilemmas. Ethical behaviour refers not only to the ethical reasoning of nursing students but also to the relationship between reasoning and behaviour. Kohlberg's definition of morality was refined by adding a care perspective. The results show that the majority of students can be located in the fourth moral stage according to Kohlberg's theory, that is, the conventional level of moral development. This finding implies that students are still guided by professional rules, norms and duties, and have not (yet) succeeded in making personal ethical decisions on the basis of their own principles and acting according to such decisions.

The surface roughness of enamel-to-enamel contact areas compared with the intrinsic roughness of dental resin composites.

The purpose of this study was to determine the surface roughness of enamel-to-enamel contact areas in order to provide a standard for comparison with surface characteristics of commercially available composite restorative materials. In addition, the inherent surface roughness of resin composites was evaluated profilometrically after a toothbrush abrasion procedure. A one-sided t-test analysis was performed to outline significant differences between the surface roughness value of enamel facets and that of the respective composite samples. A surface roughness of 0.64 +/- 0.25 micron (mean +/- S.D.) was found for the enamel-to-enamel contact areas.