Severe obesity and global developmental delay in preschool children: Findings from a Canadian Paediatric Surveillance Program study.

Background: The co-presentation of severe obesity (SO) and global developmental delay (GDD) in Canadian preschool children has not been examined. However, SO and GDD may require syndromic diagnoses and unique management considerations. Objectives: To determine (1) minimum incidence; (2) age of onset and risk factors; and (3) health care utilization for co-presenting SO and GDD. Methods: Through the Canadian Paediatric Surveillance Program (CPSP), a monthly form was distributed to participants from February 2018 to January 2020 asking for reports of new cases of SO and GDD among children ≤5 years of age. We performed descriptive statistics for quantitative questions and qualitative content analysis for open-ended questions. Results: Forty-seven cases (64% male; 51% white; mean age: 3.5 ± 1.2 years) were included. Age of first weight concern was 2.5 ± 1.3 years and age of GDD diagnosis was 2.7 ± 1.4 years. Minimum incidence of SO and GDD was 3.3 cases per 100,000 for ≤5 years of age per year. Identified problems included school and/or behavioural problems (n = 17; 36%), snoring (n = 14; 30%), and asthma/recurrent wheeze (n = 10; 21%). Mothers of 32% of cases (n = 15) had obesity and 21% of cases (n = 10) received neonatal intensive care. Microarray was ordered for 57% (n = 27) of children. A variety of clinicians and services were accessed. As reported by CPSP participants, challenges faced by families and health service access were barriers to care. Conclusion: Children with SO and GDD have multiple comorbidities, and require early identification and referral to appropriate services. These cases may also benefit from additional testing to rule out known genetic obesity syndromes.

Tenorio syndrome: Description of 14 novel cases and review of the clinical and molecular features.

Tenorio syndrome (TNORS) (OMIM #616260) is a relatively recent disorder with very few cases described so far. Clinical features included macrocephaly, intellectual disability, hypotonia, enlarged ventricles and autoimmune diseases. Molecular underlying mechanism demonstrated missense variants and a large deletion encompassing RNF125, a gene that encodes for an U3 ubiquitin ligase protein. Since the initial description of the disorder in six patients from four families, several new patients were diagnosed, adding more evidence to the clinical spectrum. In this article, we described 14 additional cases with deep phenotyping and make an overall review of all the cases with pathogenic variants in RNF125. Not all patients presented with overgrowth, but instead, most patients showed a common pattern of neurodevelopmental disease, macrocephaly and/or large forehead. Segregation analysis showed that, though the variant was inherited in some patients from an apparently asymptomatic parent, deep phenotyping suggested a mild form of the disease in some of them. The mechanism underlying the development of this disease is not well understood yet and the report of further cases will help to a better understanding and clinical characterization of the syndrome.

Binge eating and social anxiety in treatment-seeking adolescents with eating disorders or severe obesity.

PURPOSE: Binge eating is a common behavior in children and adolescents who suffer from either eating disorders (EDs) or from severe obesity. The purpose of the current study was to explore the association between social anxiety and binge eating and compare prevalence rates of social anxiety between youth with severe obesity or EDs who did or did not engage in binge eating. METHODS: Retrospective data on treatment-seeking youth's (n = 490) eating behaviors and social anxiety at assessment were analyzed. RESULTS: Results indicate that those who engage in binge eating have higher rates of social anxiety; frequency of binges does not predict severity of social anxiety, though social anxiety predicts presence of binge eating. Adolescents with EDs had higher rates of social anxiety than those with obesity, and for both groups, rates of social anxiety were highest in those who binge. CONCLUSIONS: Clinicians who treat youth with EDs and with obesity should be aware of the relationship between binge eating and social anxiety and of the need for treatment to address both these disorders. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

Bingeing, Purging, and Suicidal Ideation in Clinical and Non-Clinical Samples of Youth.

Suicidal ideation is a serious mental health concern reported by adolescents. Despite understanding of increased suicidal ideation in patients with eating disorders (EDs) and obesity, few studies have compared how disordered eating (bingeing, vomiting and over exercising) is associated with suicidal ideation in clinical and non-clinical samples of youth across the ED and weight spectrum. The present study aimed to 1) comparatively examine rates of suicidal ideation and disordered eating behaviors in clinical samples of youth with EDs, complex obesity, or from the community, and 2) examine whether disordered eating was associated with suicidal ideation above and beyond age, body mass index, diagnosis, treatment-seeking status, and depressive symptoms in large samples of males vs. females in an attempt to understand whether these behaviors should lead to concern regarding suicidal ideation. Data from charts on treatment-seeking adolescents diagnosed with either an ED (N = 315), severe complex obesity (N = 212), and from the community (N = 3036) were pooled together for comparative purposes. Results showed that suicidal ideation was higher in youth seeking treatment for an ED (50.2%) and obesity (23.7%) as compared to youth from the community (13%). Binary logistic regression analyses revealed that vomiting (OR = 1.73 for females, 8.17 for males) and over-exercising (OR = 1.47 for females, 1.68 for males) was significantly associated with suicidal ideation in both males and females. Findings underscore the importance of screening for suicidal ideation in youth who report vomiting or over-exercising despite diagnostic presentation, age, weight, or treatment setting.

Health trajectories of children with severe obesity attending a weight management program.

PURPOSE: The objective of the present study is to examine physical and mental health trajectories of change in youth with severe obesity attending a tertiary care weight management program. It was predicted that younger children would show favourable changes in body mass index (BMI), markers of cardiovascular health, quality of life, and mental health. METHODS: This 2-year longitudinal study examined health trajectories of children referred to a weight management program at a Canadian paediatric tertiary care centre from November 2010 to December 2013. Participants were 209 of 217 consecutive referred paediatric patients (families) aged 3 to 17 years who met criteria for severe obesity and consented to participate. To maximize generalizability of results, there were no exclusion criteria. Primary outcomes were children's quality of life and BMI. Secondary outcomes included anxiety, depression, and non-high-density lipoprotein cholesterol levels. RESULTS: The findings suggest an improvement in mental health, quality of life, and cardiometabolic health of children and adolescents of all ages over the 2 years of programming. These positive findings were consistent across gender, age, and distance to the program. BMI trajectory changes varied across age cohorts such that younger children showed more favourable outcomes. The retention rate over the 2 years was high at 82.9%. CONCLUSIONS: This is the first study to show improvements in both physical and mental health outcomes beyond 1 year in a tertiary care setting with a high-risk population of children and youth with severe obesity. Findings highlight the need to examine both mental and physical health outcomes beyond 1 year.

Development of the Ottawa Disordered Eating Screen for Youth: The ODES-Y.

OBJECTIVE: To develop a concise screening tool that allows for early identification of disordered eating in youth. STUDY DESIGN: In this 2-step classification accuracy study, questions for the Ottawa Disordered Eating Screen-Youth, a 2-question screening tool (index test), were conceptualized by clinician-scientists from tertiary care pediatric eating disorder and weight-related clinics, and was validated using retrospective data (2004-2010) from a community-based study, the Research on Eating and Adolescent Lifestyles (REAL) study. RESULTS: Analyses of contrast between the index test and the reference standard using data from 2892 (1714 females) students between grade 7 and grade 12 revealed classification statistics of 67.1% for sensitivity, 85.9% for specificity, 4.7 for positive likelihood ratio, 0.38 for negative likelihood ratio, 50.6% for positive predictive value, and 92.4% for negative predictive value for females and 61.1% for sensitivity, 93.9% for specificity, and 9.9 for positive likelihood ratio, 0.41 for negative likelihood ratio, 32.3% for positive predictive value, and 98.0% for negative predictive value for males. CONCLUSIONS: Our findings suggest that the index test has utility as a short and accurate screening tool for earlier detection of disordered eating thoughts and behaviors in youth. Additional research is needed to best determine how the index test can be administered to youth across various health care, school, public health, and surveillance settings in clinically sensitive pragmatic ways.

Changes in the Brain-Derived Neurotrophic Factor Are Associated with Improvements in Diabetes Risk Factors after Exercise Training in Adolescents with Obesity: The HEARTY Randomized Controlled Trial.

Obesity in youth increases the risk of type 2 diabetes (T2D), and both are risk factors for neurocognitive deficits. Exercise attenuates the risk of obesity and T2D while improving cognitive function. In adults, these benefits are associated with the actions of the brain-derived neurotrophic factor (BDNF), a protein critical in modulating neuroplasticity, glucose regulation, fat oxidation, and appetite regulation in adults. However, little research exists in youth. This study examined the associations between changes in diabetes risk factors and changes in BDNF levels after 6 months of exercise training in adolescents with obesity. The sample consisted of 202 postpubertal adolescents with obesity (70% females) aged 14-18 years who were randomized to 6 months of aerobic and/or resistance training or nonexercise control. All participants received a healthy eating plan designed to induce a 250/kcal deficit per day. Resting serum BDNF levels and diabetes risk factors, such as fasting glucose, insulin, homeostasis model assessment (HOMA-B-beta cell insulin secretory capacity) and (HOMA-IS-insulin sensitivity), and hemoglobin A1c (HbA1c), were measured after an overnight fast at baseline and 6 months. There were no significant intergroup differences on changes in BDNF or diabetes risk factors. In the exercise group, increases in BDNF were associated with reductions in fasting glucose (ß = -6.57, SE = 3.37, p = 0.05) and increases in HOMA-B (ß = 0.093, SE = 0.03, p = 0.004) after controlling for confounders. No associations were found between changes in diabetes risk factors and BDNF in controls. In conclusion, exercise-induced reductions in some diabetes risk factors were associated with increases in BDNF in adolescents with obesity, suggesting that exercise training may be an effective strategy to promote metabolic health and increases in BDNF, a protein favoring neuroplasticity. This trial is registered with ClinicalTrials.gov NCT00195858, September 12, 2005 (funded by the Canadian Institutes of Health Research).

Prevalence and risk factors for non-alcoholic fatty liver in children and youth with obesity.

BACKGROUND: Non- Alcoholic Fatty Liver (NAFL) is a spectrum of liver diseases (LD) that ranges from benign fatty infiltration of the liver to cirrhosis and hepatic failure. Hepatic ultrasound (US) and serum alanine aminotransferase (ALT) are often used as markers of NAFL. Our aim is to describe prevalence of NAFL and associated findings on ultrasound (US) and biochemical parameters in a population of children and adolescents with obesity at the Children's Hospital of Eastern Ontario. METHODS: Children with Obesity (BMI >95th percentile) ages 8-17 years presenting to the Endocrinology and Gastroenterology clinics, without underlying LD were prospectively recruited from 2009 to 2012. Fasting lipid profile, HOMA IR) and serum adiponectin levels were measured. NAFL was defined as ALT > 25 and >22 IU/mL (males and females respectively) and/or evidence of fatty infiltration by US. Logistic regression was performed to assess associations. RESULTS: 97 children with obesity included in the study (Male 43%). Mean age was 12.9 ± 3.2 years (84% were older than 10 y). Mean BMI-Z score was 3.8 ± 1.4. NAFL was identified in 85%(82/97) of participants. ALT was elevated in 61% of patients. Median triglyceride (TG) level was higher in children with NAFL(1.5 ± 0.9 vs. 1.1 ± 0.5 mmol/L, p = 0.01). Total cholesterol, HDL, LDL and Non HDL cholesterol were similar in both groups(p = 0.63, p = 0.98, p = 0.72 and p = 0.37 respectively). HOMA IR was ≥3.16 in 53% of children(55% in those with NAFL and 40% in those without NAFL). Median serum adiponectin was 11.2 µg/ml(IQR 7.3-18.3) in children with NAFL vs. 16.1 µg/ml(IQR 9.0-21.9) in those without NAFL(p = 0.23). Liver US was reported as normal in 30%, mild fatty infiltration in 38%, moderate in 20% and severe in 12%. TG were significantly higher(1.5 mmol/L vs. 1.0 mmol/L, p < 0.01) and HDL-C was lower(1.0 mmol/L vs. 1.1 mmol/L, p = 0.05) in children with moderate and severe NAFL by US. BMI-Z score, HOMA IR, serum adiponectin and HDL levels were not associated with NAFL, however TG were significantly associated(OR = 3.22 (95% CI: 1.01-10.25, p = 0.04)). CONCLUSION: NAFL is highly prevalent in obese children and youth. Elevated TG levels are associated with NAFL; these findings may serve as a noninvasive screening tool to help clinicians identify children with obesity needing liver biopsy and/or more aggressive therapeutic interventions.

Persistent Albuminuria in Children with Type 2 Diabetes: A Canadian Paediatric Surveillance Program Study.

OBJECTIVE: To determine the prevalence and the clinical features associated with persistent albuminuria in Canadian children aged <18 years with type 2 diabetes. STUDY DESIGN: This national prospective surveillance study involved a network of pediatricians and pediatric endocrinologists. Cases of persistent albuminuria in children with type 2 diabetes were reported during a 24-month period from 2010 to 2012. Persistent albuminuria was defined as an elevated albumin-to-creatinine ratio in a minimum of 2 out of 3 urine samples obtained at least 1 month apart over 3-6 months and confirmed with a first morning sample. Descriptive statistics were used to illustrate demographic and clinical features of the population. The prevalence of persistent albumuria was estimated using data from a previous national surveillence study of type 2 diabetes in children. RESULTS: Fifty cases were reported over the 24-month study period. The estimated prevalence of persistent albuminuria in children with type 2 diabetes in Canada was 5.1%. The median duration of diabetes at the time of diagnosis of albuminuria was 21 days (IQR, 0-241 days). Almost two-thirds (64%) were female, 80% were of Canadian First Nations heritage, and 76% were from Manitoba. Exposure to gestational or pregestational diabetes in utero occurred in 65%, and 48% had a family history of diabetes-related renal disease. Structural anomalies of the kidney were found in 37%. CONCLUSION: Persistent albuminuria occurs in youths with type 2 diabetes in the first year after diagnosis, demonstrates regional variation, and is associated with First Nations heritage and exposure to maternal diabetes during pregnancy.

Screen time is associated with depressive symptomatology among obese adolescents: a HEARTY study.

UNLABELLED: Obese adolescents spend a disproportionate time in screen-based activities and are at higher risk for clinical depression compared to their normal-weight peers. While screen time is associated with obesity and cardiometabolic risk factors, little is known about the relationship between screen time and mental health. This cross-sectional study examines the association between duration and types of screen time and depressive symptomatology (subclinical symptoms) in a sample of 358 (261 female; 97 male) overweight and obese adolescents aged 14-18 years. Self-report measures assessed depressive symptoms and time spent in different types of screen behavior (TV, recreational computer use, and video games). After controlling for age, ethnicity, sex, parental education, body mass index (BMI), physical activity, caloric intake, carbohydrate intake, and intake of sugar-sweetened beverages, total screen time was significantly associated with more severe depressive symptomatology (ß = 0.21, p = 0.001). After adjustment, time spent playing video games (ß = 0.13, p = 0.05) and recreational computer time (ß = 0.18, p = 0.006) was associated with depressive symptoms, but TV viewing was not. CONCLUSIONS: Screen time may represent a risk factor or marker of depressive symptomatology in obese adolescents. Future intervention research should evaluate whether reducing screen exposure reduces depressive symptoms in obese youth, a population at increased risk for psychological disorders. WHAT IS KNOWN: • Screen time is associated with an increased risk of obesity in youth. • Screen time is associated with an adverse cardio-metabolic profile in youth. What is New: • Screen time is associated with more severe depressive symptoms in overweight and obese adolescents. • Time spent in recreational computer use and playing video games, but not TV viewing, was associated with more severe depressive symptoms in overweight and obese adolescents.

The Edmonton Obesity Staging System for Pediatrics: A proposed clinical staging system for paediatric obesity.

Traditionally, clinical recommendations for assessing and managing paediatric obesity have relied on anthropometric measures, such as body mass index (BMI), BMI percentile and/or BMI z-score, to monitor health risks and determine weight management success. However, anthropometric measures do not always accurately and reliably identify children and youth with obesity-related health risks or comorbidities. The authors propose a new clinical staging system (the Edmonton Obesity Staging System for Pediatrics, EOSS-P), adapted from the adult-oriented EOSS. The EOSS-P is used to stratify patients according to severity of obesity-related comorbidities and barriers to weight management into four graded categories (0 to 3) within four main health domains: metabolic, mechanical, mental health and social milieu (the 4Ms). The EOSS-P is based on common clinical assessments that are widely available and routinely completed by clinicians, and has the potential to provide clinical and prognostic information to help evaluate and inform the management of paediatric obesity.

D'ordinaire, les recommandations cliniques pour évaluer et prendre en charge l'obésité juvénile reposent sur des mesures anthropométriques, telles que l'indice de masse corporelle (IMC), le percentile d'IMC ou l'écart réduit de l'IMC, pour surveiller les risques sur la santé et déterminer la bonne gestion du poids. Cependant, les mesures anthropométriques ne permettent pas toujours de déterminer avec précision et fiabilité les enfants et les adolescents présentant des risques de santé ou des comorbidités liés à l'obésité. Les auteurs proposent un nouveau système clinique d'établissement du stade de l'obésité (le système d'Edmonton pour évaluer le stade de l'obésité, ou EOSS-P), adapté de l'EOSS destiné aux adultes. L'EOSS-P est utilisé pour stratifier les patients selon la gravité des comorbidités liées à l'obésité et les obstacles à la gestion du poids en quatre catégories (0 à 3) tirées de quatre grands domaines de santé : métabolique, mécanique, santé mentale et milieu social (les 4M). L'EOSS-P, qui repose sur des évaluations cliniques courantes généralisées souvent remplies par les cliniciens, peut fournir de l'information clinique et pronostique pour contribuer à évaluer et étayer la prise en charge de l'obésité juvénile.

Physical activity and sedentary behavior in obese youth.

OBJECTIVE: To determine whether directly measured physical activity and sedentary behavior patterns of obese children presenting to a weight-management clinic differs from nationally representative samples of obese and normal-weight children. STUDY DESIGN: A cross-sectional comparison study of 3 groups of boys and girls between 8 and 18 years (mean, 13.4 years) was performed. A clinical group (n=56) seeking specialized care for obesity was compared with 2 nationally representative samples of children from the Canadian Health Measures Survey (CHMS): (1) body mass index>95th percentile (n=143); and (2) body mass index<85th percentile (n=958). RESULTS: Obese clinical and obese CHMS boys did not differ in daily moderate-to-vigorous physical activity (MVPA). Both obese groups engaged in less MVPA than normal-weight boys in the CHMS (P<.0006). Compared with normal-weight boys, obese boys had fewer days in which they accrued 60 or 30 minutes of MVPA (P=.006 and .01, respectively). Daily MVPA did not differ among the 3 groups of girls. Light activity in clinical boys was lower than in the normal weight CHMS boys, whereas clinical girls engaged in less light activity than both CHMS comparators. No differences were observed between groups for sedentary behavior. CONCLUSIONS: Obese youth, whether in clinic or the community, were not more sedentary than their normal-weight CHMS comparators. Although obese youth were less active, overall MVPA was low in all groups. This finding highlights the need for health professionals to target both physical activity and sedentary behavior in all children, rather than focusing on only children with obesity.

LMS tables for waist-circumference and waist-height ratio Z-scores in children aged 5-19 y in NHANES III: association with cardio-metabolic risks.

BACKGROUND: In adults, anthropometric measures of central adiposity, such as waist-height ratio (WHtR) and waist circumference (WC), are more strongly associated with cardio-metabolic risks than BMI. METHODS: To provide similar quantitative tools for North American children, we created smoothed centile charts and LMS tables for WHtR and WC based on data from the US National Health and Nutrition Survey, cycle III (NHANES III, N = 11,930 aged 2-24 y 1988-1994). RESULTS: Applying these reference charts to subsequent NHANES survey cycles, 1999-2012) demonstrated a significant mean increase in both Z-scores of approximately 0.30 SD. In measuring the strength of the association between anthropometric measures and cardio-metabolic risk factors, a unit change in Z-scores for WHtR, WC, and BMI significantly increased the odds of an adverse outcome in all cases (1.18-2.03, P < 0.0001). Z-scores for both measures of central adiposity were significantly more strongly associated with cardio-metabolic comorbidities than BMI-Z. CONCLUSION: Since Z-scores permit standardized comparisons across ages and genders, they are useful measures of central adiposity in both clinical or research settings. By providing LMS tables for children and adolescents based on North American reference data, we hope to provide quantitative tools for the study of obesity and its complications.

Screen time is independently associated with health-related quality of life in overweight and obese adolescents.

AIM: Excessive screen time and diminished health-related quality of life (HRQoL) are greater problems for obese than nonobese adolescents, but no research has examined the relationship between these two variables. This study examined the association between screen time and HRQoL in overweight and obese adolescents. METHODS: A sample of 358 overweight and obese adolescents aged 14-18 years were assessed at baseline between 2005 and 2010 as part of the Canadian Healthy Eating, Aerobic and Resistance Training in Youth (HEARTY) trial. We used the Pediatric Quality of Life (PEDS-QL) and other self-report measures to assess HRQoL and screen time, defined as how long the 261 females and 97 males spent viewing TV, using the computer and playing video games. RESULTS: After adjusting for socio-demographic variables, adiposity, physical activity and diet, screen time duration was associated with reduced overall HRQoL (adjusted r = -0.16, ß = -0.16, p = 0.009) and psychosocial HRQoL (adjusted r = -0.16, ß = -0.18, p = 0.004), but not physical HRQoL. No differences were found between males and females. CONCLUSION: Screen time was associated with reduced overall and psychosocial HRQoL in overweight and obese adolescents. Future research should determine whether reducing screen time improves overall and psychosocial HRQoL in obese adolescents.

Behavioral and emotional characteristics of Canadian children with obesity and moderate-severe sleep-disordered breathing treated with positive airway pressure: longitudinal changes and associations with adherence.

STUDY OBJECTIVES: Behavioral characteristics and outcomes of positive airway pressure (PAP) therapy in children with obesity and moderate-severe sleep-disordered breathing (SDB) have not been reported. Our aims were to 1) determine baseline behavioral/emotional symptoms of this population and characterize changes over time with PAP, and 2) examine associations between baseline behavioral/emotional symptoms and PAP adherence. METHODS: This multicenter prospective cohort study of children with obesity prescribed PAP for moderate-severe SDB assessed PAP adherence (≥ 4 h/night, >50% of nights, usage diaries, downloads) and compared behavioral/emotional characteristics with parent- and child-reported Conners Rating Scale (Conners) and the Child Behavior Checklist (CBCL) at baseline and 1 year after PAP prescription between adherent and nonadherent participants; scores at baseline were compared retrospectively between adherence groups. RESULTS: Twenty-four children were included (median 14.1 years [IQR:12.4,16.0]; 87.5% males). Baseline Conners and CBCL scores were elevated (parent- and child-reported Conners inattention and hyperactivity subscales and CBCL subscales [total, internalizing, externalizing]). Baseline parent-reported Conners scores were significantly more elevated in the nonadherent than adherent group (inattention: 73.3 ± 8.5 vs 60.5 ± 14.6, P = .01; hyperactivity: 70.9 ± 11.1 vs 59.1 ± 16.0, P = .05). This difference was present 1 year later for inattention (P = .01) but not for hyperactivity (P = .09). Parent-reported CBCL scores improved over 1 year in adherent but not nonadherent participants. CONCLUSIONS: We found that children with obesity and moderate-severe SDB have elevated symptoms of behavioral/emotional concerns on standardized testing. Parent-reported emotional characteristics improved in the adherent but not in the nonadherent group. Children with greater inattention/hyperactivity at baseline were less adherent to PAP, suggesting this may contribute to PAP nonadherence. CITATION: Constantin E, MacLean JE, Barrowman N, et al. Behavioral and emotional characteristics of Canadian children with obesity and moderate-severe sleep-disordered breathing treated with positive airway pressure: longitudinal changes and associations with adherence. J Clin Sleep Med. 2023;19(3):555-562.

Effects of the HEARTY exercise randomized controlled trial on eating behaviors in adolescents with obesity.

Background: There are well-recognized benefits of behavioral interventions that include exercise for children and adolescents with obesity. However, such behavioral weight management programs may precipitate unintended consequences. It is unclear if different exercise modalities impact eating behaviors differently in youth with obesity. Objectives: The purpose of this study was to examine the effects of aerobic, resistance, and combined aerobic and resistance exercise training on eating attitudes and behaviors (uncontrolled eating, restrained eating, emotional eating, external eating and food craving) among adolescents with overweight and obesity. Methods: N = 304 (70% female) adolescents with overweight and obesity participated in the 6-month Healthy Eating Aerobic and Resistance Training in Youth (HEARTY) randomized controlled trial. All participants were inactive post-pubertal adolescents (15.6 ± 1.4 years) with a mean BMI = 34.6 ± 4.5 kg/m2. The Food Craving Inventory (food cravings), Dutch Eating Behavior Questionnaire (restrained eating, emotional eating, external eating), and the Three-Factor Eating Questionnaire (uncontrolled eating) were used to assess eating attitudes and behaviors. Results: All exercise groups showed within-group decreases in external eating and food cravings. Participants randomized to the Combined training group and were more adherent showed the greatest improvements in eating behaviors and cravings. Conclusions: A 6-month exercise intervention produced improvements in disordered eating behaviors and food cravings, but effects may be gender and modality-specific. Findings highlight the need to tailor exercise intervention to participant characteristics for the promotion of healthier eating and weight management outcomes in youth with obesity.Clinical Trial Registration # and Date: ClinicalTrials.Gov NCT00195858, September 12, 2005.

Sleep and insulin sensitivity in adolescents at risk of type 2 diabetes: the Sleep Manipulation in Adolescents at Risk of Type 2 Diabetes (SMART2D)randomized crossover study.

STUDY OBJECTIVES: To investigate the effect of increasing sleep duration for 1 week, compared to a week of habitual and decreased sleep, on insulin sensitivity(IS) in adolescents at risk for type 2 diabetes(T2D). METHODS: Adolescents, 13-18y old, at risk for T2D, with obesity and other risk factors, were recruited for a randomized(1:1), open-label, sex-stratified crossover study, that manipulated time-in-bed to modify sleep duration (measured by actigraphy). Following a week of habitual(HB) sleep, time-in-bed was increased(IN) and decreased(DE) by 1h30min/night for 1 week, counterbalanced across participants(HBINDE or HBDEIN), and separated by a week of washout sleep. The main outcome measure was IS, obtained via 2-h oral-glucose-tolerance-test conducted after each sleep week. RESULTS: Of the 43 participants recruited, 36(84%) completed all sleep interventions (52.8% female, age=15.1y, body-mass-index=99.9th percentile, order: HBINDE=18 and HBDEIN=18). On average, during the HB week, participants slept 7h31min/night; sleep duration was 1h02min/night higher during the IN week and 1h19min/night lower during the DE week. We found a significant effect of sleep week on IS with a large effect size. Following the IN sleep week, IS was 20% higher compared to after the HB and DE sleep weeks, but there was no significant difference in IS following HB versus DE sleep weeks. CONCLUSION: Whenever possible, clinicians should empower youth at risk of T2D to improve their sleep duration, since even a modest increase in sleep duration of 1h/night for one-week can have a positive impact on IS in this population.

The Resistance Exercise in Already Active Diabetic Individuals (READI) Randomized Clinical Trial.

CONTEXT: Resistance exercise training (strength training) and aerobic exercise training are both recommended for people with type 1 diabetes, but it is unknown whether adding resistance exercise provides incremental benefits in people with this condition who already perform aerobic exercise regularly. OBJECTIVE: This work aimed to evaluate the incremental effect of resistance training on glycated hemoglobin A1c (HbA1c), fitness, body composition, and cardiometabolic risk factors in aerobically active people with type 1 diabetes. METHODS: The Resistance Exercise in Already-active Diabetic Individuals (READI) trial (NCT00410436) was a 4-center, randomized, parallel-group trial. After a 5-week run-in period with diabetes management optimization, 131 aerobically active individuals with type 1 diabetes were randomly assigned to resistance exercise (n = 71, intervention-INT) or control (n = 60, CON) for 22 additional weeks. Both groups maintained their aerobic activities and were provided dietary counseling throughout. Exercise training was 3 times per week at community-based facilities. The primary outcome was HbA1c, and secondary outcomes included fitness (peak oxygen consumption, muscle strength), body composition (anthropometrics, dual-energy x-ray absorptiometry, computed tomography), and cardiometabolic risk markers (lipids, apolipoproteins). Assessors were blinded to group allocation. RESULTS: There were no significant differences in HbA1c change between INT and CON. Declines in HbA1c (INT: 7.75 ± 0.10% [61.2 ± 1.1 mmol/mol] to 7.55 ± 0.10% [59 ± 1.1 mmol/mol]; CON: 7.70 ± 0.11% [60.7 ± 1.2 mmol/mol] to 7.57 ± 0.11% [59.6 ± 1.3 mmol/mol]; intergroup difference in change -0.07 [95% CI, -0.31 to 0.18]). Waist circumference decreased more in INT than CON after 6 months (P = .02). Muscular strength increased more in INT than in CON (P < .001). There were no intergroup differences in hypoglycemia or any other variables. CONCLUSION: Adding resistance training did not affect glycemia, but it increased strength and reduced waist circumference, in aerobically active individuals with type 1 diabetes.

Differing clinical features in Aboriginal vs. non-Aboriginal children presenting with type 2 diabetes.

OBJECTIVES: Childhood type 2 diabetes (T2D) is increasing and may present differently across various populations. This study compares clinical features of T2D at diagnosis in Aboriginal children with Caucasian children and children from other high-risk ethnic groups. PATIENTS AND METHODS: This retrospective observational study used data from a Canadian surveillance study where newly diagnosed cases of childhood T2D were reported (n = 227). Using descriptive statistics, clinical features at diagnosis of T2D were compared across different ethnic groups including Aboriginal (n = 100), Caucasian (n = 57), and other high-risk ethnic groups (n = 64). Comparisons were made between Aboriginal children living in central Canada (Manitoba/northwestern Ontario) (n = 74) and Aboriginal children from other regions of Canada (n = 26). RESULTS: Aboriginal children were younger, less obese, and less likely to have polycystic ovarian syndrome and dyslipidemia when compared to Caucasian children and children from other high-risk ethnic groups (p < 0.05). Aboriginal children from central Canada vs. those from other regions of Canada did not differ in age, body mass index z-score, family history of T2D, or presence of acanthosis nigricans. Those from central Canada had lower hemoglobin A1c levels (p < 0.05) and were less likely to have dyslipidemia than Aboriginal children from other regions (p < 0.05). CONCLUSIONS: Clinical features and rates of comorbidity in children with newly diagnosed T2D differ across various populations (Caucasian, Aboriginal, and children who belong to other high-risk ethnic groups) and across distinct Aboriginal populations (those living in central Canada vs. those living in other regions of Canada). Future research should determine specific genetic and environmental factors that contribute to these differences.

Hyperglycemic hyperosmolar syndrome at the onset of type 2 diabetes mellitus in an adolescent male.

Hyperglycemic hyperosmolar state (HHS) is rare in the paediatric population. The diagnosis and management of HHS presents a challenge in paediatric patients who may present with a mixed picture of HHS and diabetic ketoacidosis (DKA).A 15-year-old obese African American male was brought to the emergency department following a two-day history of feeling unwell. The patient was obtunded, hypotensive and tachypneic. Initial investigations revealed the following: pH 6.97 (normal 7.35 to 7.41), HCO(3) (-) 5 mEq/L (normal 20 mEq/L to 25 mEq/L), glucose 90.9 mmol/L (normal 3.4 mmol/L to 6.3 mmol/L), serum osmolality 454 mOsm/kg (normal 275 mOsm/kg to 295 mOsm/kg), Na(+) 141 mEq/L (normal 135 mEq/L to 145 mEq/L), corrected Na(+) 165 mEq/L, K(+) 8.4 mEq/L (normal 3.5 mEq/L to 5.0 mEq/L), urinalysis revealed 1+ ketones and 4+ glucose. The patient's clinical course was complicated by severe hyperkalemia, acute renal failure, refractory status epilepticus, rhabdomyolysis, pancreatitis and hypertension.The present case emphasizes the complexity of managing patients with a mixed DKA/HHS presentation and associated morbidities. It is very important to disseminate and implement screening guidelines for type 2 diabetes mellitus, so as to prevent this potentially devastating complication.