Effects of multidisciplinary interventions on weight loss and health outcomes in children and adolescents with morbid obesity.

OBJECTIVE: Morbid obesity is the fastest growing subcategory of childhood obesity, associated with an increased health risk that persists into adulthood. There is an urgent need to develop multifaceted interventions that target initial and long-term lifestyle changes. This review investigates the effects of multidisciplinary interventions on weight loss and health outcomes in children and adolescents with morbid obesity. The influence of age, gender and family participation on health outcomes and intensive treatment alternatives are explored. METHODS: The review includes 16 studies conducted between 1995 and 2017. Studies examined youth with morbid obesity, 4-18 years old, undergoing multidisciplinary treatment. RESULTS: All studies found a reduction in body mass index (BMI or z-score) and if measured, cardiovascular risk factors. Physical activity, nutrition education, behavioural modification and family involvement are commonly included treatment components and have improved weight loss and health-related outcomes. However, initial weight loss was often not sustainable, despite the favourable interventional effect on cardiometabolic risk markers. Weight loss was prolonged in younger children and among the male sex. CONCLUSIONS: There is not a 'one-size-fits-all' treatment approach, and matched care to personal needs is preferable. The integration of a chronic care approach is critical for the successful adaption of sustainable health behaviours.

Predictors of Retention among African Americans in a Randomized Controlled Trial to Test the Healthy Eating and Active Living in the Spirit (HEALS) Intervention.

INTRODUCTION: Retention of racial/ethnic minority groups into research trials is necessary to fully understand and address health disparities. This study was conducted to identify participants' characteristics associated with retention of African Americans (AAs) in a randomized controlled trial (RCT) of a behavioral intervention. METHODS: Using data from an RCT conducted from 2009 to 2012 among AAs, participant-level factors were examined for associations with retention between three measurement points (ie, baseline, 3-month, and 12-month). Chi-square tests and logistic regression analyses were conducted to compare retained participants to those who were not retained in order to identify important predictors of retention. RESULTS: About 57% of participants (n=238) were retained at 12 months. Baseline characteristics that showed a statistically significant association with retention status were age, marital status, body mass index (BMI), intervention group, enrollment of a partner in the study, and perceived stress score (PSS). Multivariable logistic regression that adjusted for age, BMI, and PSS showed the odds of being retained among participants who enrolled with a partner was 2.95 (95% CI: 1.87-4.65) compared with participants who had no study partner enrolled. The odds of being retained among participants who were obese and morbidly obese were .32 and .27 (95% CI: .14-.74 and .11-.69), respectively, compared with participants who had normal weight. CONCLUSION: Having a partner enrolled in behavioral interventions may improve retention of study participants. Researchers also need to be cognizant of participants' obesity status and potentially target retention efforts toward these individuals.

Fracaso dietético, oscilaciones de peso y motivo de la cirugía en pacientes bariátricos / Dietary failure, weight oscillations and reason for surgery in bariatric patients

Fundamentos: Analizar la relación entre las oscilaciones de peso y el IMC preoperatorio de 307 pacientes bariátricos. Conocer la causa fundamental del abandono de tratamientos dietéticos y la motivación principal para acudir a una Unidad de Cirugía Bariátrica (UCB). Métodos: Se recogieron prospectivamente en 307 casos las siguientes variables: edad, sexo, IMC máximo alcanzado, ratio 'oscilación máxima peso/peso máximo', motivo de la consulta y del fracaso de los tratamientos anteriores. Se estudió la relación entre el grado de obesidad y las variables mediante el test X2. Resultados: La 'oscilación máxima peso/peso máximo' no se asoció al grado de obesidad (correlación/Pearson -0,79). El 58,9% de los pacientes acudieron a una UCB motivados por el deseo de mejorar su calidad de vida, y un 26,1% para cambiar su imagen corporal. Los pacientes abandonaban las dietas por ser monótonas, poco realistas y por estancamiento en la pérdida de peso. Conclusiones: Los pacientes que acuden a una UCB presentan una mayor preocupación por la calidad de vida como motivo de consulta y refieren haber fracasado con las dietas como causa fundamental por la monotonía de éstas. Las oscilaciones de peso no se asocian al grado de obesidad (AU)

Background: To analyze the relationship between variations in weight and preoperative BMI of 307 bariatric patients. To know what is the principal cause of the abandonment of dietary treatments. To know what is the main motivation for attending a Bariatric Surgery Clinic (BSC). Methods: Age, sex, reached maximum BMI, ratio 'maximum weight fluctuations/maximum weight', reason for consultation and the failure of previous treatments. The following variables were collected retrospectively in 307 cases. We have studied the relationship between obesity and the variables by X2 test. Results: The 'maximum weight fluctuations/maximum weight' is not associated with the degree of obesity (Pearson correlation -0.79). 58.9% of patients come to a BSC motivated by a desire to improve their quality of life, and 26.1% do so to change their body image. Patients leave for being monotonous diets, unrealistic and stagnant in weight loss. Conclusions: Patients who come to a BSC have greater concern for quality of life as the reason for consultation and have failed with diets as a root cause for the monotony of these. Fluctuations in weight are not associated with the degree of obesity (AU)

Obesity Severity, Dietary Behaviors, and Lifestyle Risks Vary by Race/Ethnicity and Age in a Northern California Cohort of Children with Obesity.

Identification of modifiable behaviors is important for pediatric weight management and obesity prevention programs. This study examined obesogenic behaviors in children with obesity in a Northern California obesity intervention program using data from a parent/teen-completed intake questionnaire covering dietary and lifestyle behaviors (frequency of breakfast, family meals, unhealthy snacking and beverages, fruit/vegetable intake, sleep, screen time, and exercise). Among 7956 children with BMI ≥ 95th percentile, 45.5% were females and 14.2% were 3-5, 44.2% were 6-11, and 41.6% were 12-17 years old. One-quarter (24.9%) were non-Hispanic white, 11.3% were black, 43.5% were Hispanic, and 12.0% were Asian/Pacific Islander. Severe obesity was prevalent (37.4%), especially among blacks, Hispanics, and older children, and was associated with less frequent breakfast and exercise and excess screen time, and in young children it was associated with consumption of sweetened beverages or juice. Unhealthy dietary behaviors, screen time, limited exercise, and sleep were more prevalent in older children and in selected black, Hispanic, and Asian subgroups, where consumption of sweetened beverages or juice was especially high. Overall, obesity severity and obesogenic behaviors increased with age and varied by gender and race/ethnicity. We identified several key prevalent modifiable behaviors that can be targeted by healthcare professionals to reduce obesity when counseling children with obesity and their parents.

An Integrated Framework For The Prevention And Treatment Of Obesity And Its Related Chronic Diseases.

Improved patient experience, population health, and reduced cost of care for patients with obesity and other chronic diseases will not be achieved by clinical interventions alone. We offer here a new iteration of the Chronic Care Model that integrates clinical and community systems to address chronic diseases. Obesity contributes substantially to cardiovascular disease, type 2 diabetes mellitus, and cancer. Dietary and physical activity interventions will prevent, mitigate, and treat obesity and its related diseases. Challenges with the implementation of this model include provider training, the need to provide incentives for health systems to move beyond clinical care to link with community systems, and addressing the multiple elements necessary for integration within clinical care and with social systems. The Affordable Care Act, with its emphasis on prevention and new systems for care delivery, provides support for innovative strategies such as those proposed here.

Feasibility and Impact of a Combined Supervised Exercise and Nutritional-Behavioral Intervention following Bariatric Surgery: A Pilot Study.

BACKGROUND: Lifestyle intervention programs after bariatric surgery have been suggested to maximise health outcomes. This pilot study aimed to investigate the feasibility and impact of an 8-week combined supervised exercise with nutritional-behavioral intervention following Roux-en-Y gastric bypass and sleeve gastrectomy. METHODS: Eight female patients (44 ± 8 years old, BMI = 38.5 ± 7.2 kg m(-2)) completed the program. Before and after intervention, anthropometric measures, six-minute walk test (6MWT), physical activity level, eating behavior, and quality of life (QoL) were assessed. Percentage weight loss (%WL) outcomes were compared with a historical matched control group. RESULTS: The program significantly improved functional capacity (mean increment in 6MWT was 127 ± 107 meters, p = 0.043), increased strenuous intensity exercise (44 ± 49 min/week, p = 0.043), increased consumption of fruits and vegetables (p = 0.034), reduced consumption of ready meals (p = 0.034), and improved "Change in Health" in QoL domain (p = 0.039). The intervention group exhibited greater %WL in the 3-12-month postsurgery period compared to historical controls, 12.2 ± 7.5% versus 5.1 ± 5.4%, respectively (p = 0.027). CONCLUSIONS: Lifestyle intervention program following bariatric surgery is feasible and resulted in several beneficial outcomes. A large randomised control trial is now warranted.

Can medical therapy mimic the clinical efficacy or physiological effects of bariatric surgery?

The number of bariatric surgical procedures performed has increased dramatically. This review discusses the clinical and physiological changes, and in particular, the mechanisms behind weight loss and glycaemic improvements, observed following the gastric bypass, sleeve gastrectomy and gastric banding bariatric procedures. The review then examines how close we are to mimicking the clinical or physiological effects of surgery through less invasive and safer modern interventions that are currently available for clinical use. These include dietary interventions, orlistat, lorcaserin, phentermine/topiramate, glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, pramlintide, dapagliflozin, the duodenal-jejunal bypass liner, gastric pacemakers and gastric balloons. We conclude that, based on the most recent trials, we cannot fully mimic the clinical or physiological effects of surgery; however, we are getting closer. A 'medical bypass' may not be as far in the future as we previously thought, as the physician's armamentarium against obesity and type 2 diabetes has recently got stronger through the use of specific dietary modifications, novel medical devices and pharmacotherapy. Novel therapeutic targets include not only appetite but also taste/food preferences, energy expenditure, gut microbiota, bile acid signalling, inflammation, preservation of ß-cell function and hepatic glucose output, among others. Although there are no magic bullets, an integrated multimodal approach may yield success. Non-surgical interventions that mimic the metabolic benefits of bariatric surgery, with a reduced morbidity and mortality burden, remain tenable alternatives for patients and health-care professionals.

El agua: bebida recomendable para una adecuada nutrición en la infancia / Water: recommended drink for an adequate nutrition during childhood

Se revisan las necesidades de agua en la infancia, así como las características de los tipos de agua para el consumo humano. Se indica la concentración ideal de sodio, calcio, nitratos y flúor en las aguas de bebida para los niños según su edad. Se revisa el papel de los zumos y las bebidas de refresco como factores de riesgo de obesidad y sus comorbilidades. Se recuerda que el agua y la leche son las dos bebidas fundamentales de los niños y adolescentes. Finalmente, se revisa la importancia de una buena hidratación en caso de realizar ejercicio físico (AU)

The needs of water in childhood, as well as the characteristics of the types of water for human consumption, are reviewed. The ideal concentration of sodium, calcium, nitrates and fluoride in the water that is drank by children according to their age group. The role of juices and soda drinks is also reviewed as a risk factor of obesity and its comorbidities. It is recalled that water and milk are two fundamental drinks in children and adolescents’. Finally, the importance of a good hydration if doing exercise is recalled (AU)

Pharmacological and surgical intervention for the prevention of diabetes.

The increasing prevalence of diabetes is reaching epidemic proportion worldwide. Because of the associated morbidity and mortality, it is exerting major pressure on the healthcare system. With a better understanding of the pathophysiology of type-2 diabetes, the concept of primary prevention has emerged. A number of studies have confirmed that intensive lifestyle modification was very effective in the prevention of diabetes in the impaired glucose tolerance (IGT) population. However, maintaining long-term lifestyle modification is a major challenge. It is, therefore, important to have other strategies, either pharmacological or surgical, that can be used as an adjunct or alternative to lifestyle modification. The Chinese study showed that metformin and acarbose could reduce the risk of diabetes by 65 and 83%, respectively, in IGT subjects. The efficacy of metformin was confirmed by the Diabetes Prevention Program (31% risk reduction) and that of acarbose by the STOP-NIDDM trial (36% risk reduction) in a similar high-risk population. The TRIPOD study showed that troglitazone could reduce the risk of diabetes by 55% in Hispanic women with a history of gestational diabetes. And more recently, the XENDOS study showed that orlistat could reduced the risk of diabetes by 37% in obese subjects when used as an adjunct to an intensive lifestyle program. Three studies have suggested that bariatric surgery in morbidly obese subjects could reduce the risk of diabetes to near zero. Furthermore, a number of studies have examined the effect of a renin angiotensin aldosterone system inhibitor, as well as statin and hormone replacement therapy on the prevention of type-2 diabetes in high-risk subjects as secondary outcomes and have suggested that they could be of potential benefit. The accumulating evidence is now overwhelming. Yes, diabetes can be prevented or delayed in high-risk populations. With this new information, we need to design new strategies to screen high-risk populations and to implement the new treatments that have proven effective in the prevention of type-2 diabetes.

Physiologic approaches to the control of obesity.

Morbid obesity is a major health problem in this country and throughout the world. In addition to its social stigma (in the western world), obesity exacerbates several disease states such as diabetes, hypertension, cardiac disease and restrictive lung disease. When effective medical treatment of obesity becomes available, it will depend in part upon understanding the physiologic factors that control satiety. This review summarizes the information available on brain and gut control mechanisms of satiety. Brain nuclei located in the lateral hypothalamus, ventromedial hypothalamus, and other paraventricular areas are the sites of action for potent neuropeptides, such as cholecystokinin (CCK) and neuropeptide Y, that appear to regulate feeding. Exogenous CCK has been used clinically to decrease meal size in obese patients. The sites of the satiety cascade that are most often manipulated are the gastric and intestinal phases. Physiologic gastric distension is a potent inhibitor of feeding, whereas the intermeal interval may be regulated by intestinal signals released by food in the gut. Jejunal-ileal bypass has fallen from favor and has been replaced by gastric restrictive procedures that create a small proximal gastric pouch that empties into the small bowel (gastric bypass) or the distal stomach (gastroplasty). These operations rely partially on their ability to produce gastric distension in the proximal gastric pouch at an early stage during a meal. Thus, failure results if the pouch compensates by distending or if the stoma widens with subsequent loss of slow emptying. Improved medical and surgical treatment will be designed to intervene at specific sites of the satiety cascade as knowledge of the physiologic control mechanisms of satiety increases.