Behavioral predictors of attrition in adolescents participating in a multidisciplinary obesity treatment program: EVASYON study.

The aims of this study were to identify the cognitive and behavioral predictors of dropping out and to estimate the attrition rate during different phases of an intervention program to treat overweight and obesity in adolescents. Overweight/obese adolescents (n=156, aged: 13-16 years; 71 male and 85 female subjects) were included in a multicomponent (diet, physical activity and psychological support) family-based group treatment program. At baseline and after 2 months (intensive phase) and 13 months (extensive phase) of follow-up, we measured adolescents' cognitive and behavioral dimensions, together with the parents' perception of their child's behavior. Of the 156 adolescents selected, 112 completed the full program (drop-out rate of 28.2%). The risk of dropping out during the extensive phase increased by 20% for each unit increase in the adolescent's social insecurity score (odds ratio=1.20, 95% confidence interval=1.07-1.34, P=0.002). The adolescents who had a high interoceptive awareness showed a significant decrease of 13.0% in the probability of dropping out (odds ratio=0.87, 95% confidence interval=0.77-0.99, P=0.040). Adolescents' social insecurity was the main predictor of drop-out in a multicomponent family-group-based obesity treatment program. To reduce attrition rates in these programs, the individual's social insecurity level needs to be reduced, whereas the family's awareness of eating-related behavior needs adjustment.

Shifts in clostridia, bacteroides and immunoglobulin-coating fecal bacteria associated with weight loss in obese adolescents.

OBJECTIVE: To evaluate the effects of a multidisciplinary obesity treatment programme on fecal microbiota composition and immunoglobulin-coating bacteria in overweight and obese adolescents and their relationship to weight loss. DESIGN: Longitudinal intervention study based on both a calorie-restricted diet (calorie reduction=10-40%) and increased physical activity (calorie expenditure=15-23 kcal/kg body weight per week) for 10 weeks. PARTICIPANTS: Thirty-nine overweight and obese adolescents (BMI mean 33.1 range 23.7-50.4; age mean 14.8 range, 13.0-16.0). MEASUREMENTS: BMI, BMI z-scores and plasma biochemical parameters were measured before and after the intervention. Fecal microbiota was analyzed by fluorescent in situ hybridization. Immunoglobulin-coating bacteria were detected using fluorescent-labelled F(ab')2 antihuman IgA, IgG and IgM. RESULTS: Reductions in Clostridium histolyticum and E. rectale-C. coccoides proportions significantly correlated with weight and BMI z-score reductions in the whole adolescent population. Proportions of C. histolyticum, C. lituseburense and E. rectale-C. coccoides dropped significantly whereas those of the Bacteroides-Prevotella group increased after the intervention in those adolescents who lost more than 4 kg. Total fecal energy was almost significantly reduced in the same group of adolescents but not in the group that lost less than 2.5 kg. IgA-coating bacterial proportions also decreased significantly in participants who lost more than 6 kg after the intervention, paralleled to reductions in C. histolyticum and E. rectale-C. coccoides populations. E. rectale-C. coccoides proportions also correlated with weight loss and BMI z-score reduction in participants whose weight loss exceeded 4 kg. CONCLUSIONS: Specific gut bacteria and an associated IgA response were related to body weight changes in adolescents under lifestyle intervention. These results suggest interactions between diet, gut microbiota and host metabolism and immunity in obesity.

Serum transaminases concentrations in obese children and adolescents.

The aim of the study was to investigate the relationship between liver transaminase levels and metabolic syndrome (MS) features in obese children and adolescents. A total of 132 children and adolescents (73 males and 59 females) aged 8 - 16, participated in the study. All were studied at the department of Paediatrics, University Hospital of Zaragoza (Spain). Inclusion criteria were the existence of obesity as defined by body mass index (BMI) according to Cole cut-off values (when BMI was higher than the age and sex specific equivalent to 30 kg/m2). The definition of metabolic syndrome was according to the International Diabetes Federation criteria. Weight (kg), height (cm), waist circumference (cm), blood pressure and BMI were measured. Laboratory determinations after overnight fasting included: transaminases (ALT, AST, GGT), fasting glucose, insulin, triglycerides and HDL-C. The MS was found in 21.6% of the obese children and adolescents and the prevalence was higher in males (25.9%) than in females (15.9%). Serum transaminases (ALT, AST and GGT) mean concentrations were higher in males than in females, and decreased during pubertal development. The obese children and adolescents with the MS did not show higher transaminases concentrations when compared with those without the MS. Some MS manifestations (mainly waist circumference) showed a correlation with ALT, although all transaminases values were normal according to adult references. Liver transaminases, a surrogate marker of NAFLD, did not show an early and consistent manifestation of abnormalities in the obese children and adolescents studied. In order to define the presence of the disease, it would be necessary to obtain aminotransferase reference standards for children and adolescents, considering pubertal stage and gender.

Metabolic risk-factor clustering estimation in obese children.

The purpose of this study was to apply the new approach for Metabolic Individual Risk-factor And Clustering Estimation (MIRACLE) score in a group of Spanish obese children and adolescents and to describe its relationship with other metabolic risk factors. 153 children with simple obesity were studied: 79 males and 74 females, mean age 11.2 +/- 2.2. Obesity was defined when BMI was higher than the age and sex specific equivalent to 30 kg/m2 in adults. MIRACLE score included: family history (early cardiovascular disease, type 2 diabetes, and hypertension), individual history (small for gestational age and ethnic origin), clinical features (BMI, waist circumference > 90th percentile and blood pressure > 95th percentile) and metabolic abnormalities (glucose intolerance or type 2 diabetes). It was assigned a value of 1 to "presence" and 0 to" absence" in every patient. The children were considered as having metabolic risk when at least 5 items were present. Triglycerides, HDL-cholesterol, apolipoprotein B, apolipoprotein A1, glucose and HOMA index, were measured too. The most frequent clinical features of MIRACLE score were: excess waist circumference (95.4%) and hypertension (41.8%). Family history criteria were frequent (55.3% for type 2 diabetes, 39.1% for hypertension and 31.3% for early cardiovascular disease). Individual risk factors were not frequent. Glucose intolerance was detected in 22.2% of the obese patients. A MIRACLE score > or = 5 was found in 37.4% of the children studied, being associated with a significant risk of dyslipidemia (triglycerides, p = 0.040; HDL-cholesterol, p = 0.006; LDL-cholesterol p = 0.038; apolipoprotein B, p = 0.008) only in females. In conclusion, the MIRACLE score is useful in order to detect metabolic risk in obese children but it seems necessary to improve the score, by including other features of the metabolic syndrome like lipid profile or indirect indicators of insulin resistance.

Diversity of metabolic syndrome risk factors in obese children and adolescents.

The aim of this study was to investigate the frequency of metabolic syndrome (MS) variables in a group of spanish obese children and adolescents, to asses MS prevalence in this population and to describe it's relationship with other metabolic risk factors. 103 children were studied : 54 male and 49 female, mean age 10.08+/-2.3 with exogenous obesity. Obesity was defined when BMI was higher than the age and sex specific equivalent to 30 kg/m(2) in adults. MS variables considered were waist circumference, blood pressure, fasting blood triglycerides, fasting glucose/insulin and HDL-cholesterol. The children were considered as having the MS when three or more characteristics showed abnormal values according to Cook and De Ferranti definitions. HOMA index, ApoB and ApoA1 were studied too. The most frequent features of the metabolic syndrome were excess waist circumference and hypertension. The MS markers with the lowest frequency were dyslipidemia and fasting hyperglicemia. MS prevalence was 29,9% (Cook et al. criteria) and 50% (De Ferranti et al. criteria). Fasting insulin and HOMA index values increased significantly (p < 0.05) when three or more abnormalities of the MS variables were present. Apo B increased significantly only in females (p < 0.05) and Apo Al decreased significantly (p < 0.05) in both sexes when MS was present. Adequate metabolic syndrome risk factors criteria, mainly cut-off values, need to be defined in the European paediatric population.

Homeostatic model assessment (HOMA) index cut-off values to identify the metabolic syndrome in children.

The aim of the study was to establish the best cut-off value for the homeostatic model assessment (HOMA) index in identifying children and adolescents with the metabolic syndrome. The study included 72 non-obese and 68 obese children aged 7 to 16 years. Obesity is defined using the criteria proposed by Cole et al., being included as metabolic syndrome variables waist circumference, systolic blood pressure, diastolic blood pressure and seric values of glucose, uric acid, fasting insulin, leptin, triglycerides and HDL-cholesterol. Children were considered as having the metabolic syndrome when four or more characteristics showed abnormal values. The HOMA index was calculated as the product of the fasting plasma insulin level (microU/mL) and the fasting plasma glucose level (mmol/L), divided by 22.5. HOMA index cut-offs from the 5th to the 95th percentile were used. A receiver operating characteristic (ROC) curve was generated using the different HOMA cut-offs for the screening of the metabolic syndrome. The areas under the ROC curve, 95% confidence intervals, and the point to the ROC curve closest to 1, were calculated. The area under the ROC curve was 0.863 (95% C.I.: 0.797, 0.930). The point closest to 1 corresponds to the 60th percentile of the HOMA index distribution in our sample. HOMA index value at the 60th percentile was 2.28. Cut-off values corresponding to a range of HOMA index from the 50 to the 75 percentile, showed similar distances to 1. HOMA index values for percentiles 50 to 75 ranged from 2.07 to 2.83. In conclusion, HOMA index could be a useful tool to detect children and adolescents with the metabolic syndrome. HOMA cut-off values need to be defined in the paediatric population; however, values near to 3 seem to be adequate.

Early detection of impaired glucose tolerance in patients with cystic fibrosis and predisposition factors.

INTRODUCTION: The number of patients with glucose tolerance alterations associated with cystic fibrosis (CF) has increased, probably due to the greater survival rate among sufferers of this disease. We studied impaired glucose tolerance (IGT) in patients with CF and investigated whether its appearance has any relationship with age, sex, genetic mutation and/or the degree of clinical involvement. We assessed the parameters that might allow early detection. PATIENTS AND METHODS: In 28 patients with CF (14 M, 14 F; aged 22 months to 18 years), sex, genetic mutation, nutritional status and the degree of pancreatic and pulmonary involvement were recorded. The metabolic study included glycosylated hemoglobin (HbA1c) determination, oral glucose tolerance test (OGTT) and intravenous glucose tolerance tests (IVGTT). RESULTS: In the patients with CF, 35.71% showed impaired glucose tolerance (IGT) and 3.57% had diabetes mellitus. The patients with IGT and CF were 3.2 years older than those with normal glucose tolerance (NGT; p<0.05), but no significant differences were found regarding sex, anthropometric measurements, percentage of pulmonary gammagraphic involvement, Shwachman-Kulczycki test or HbA1c. In the OGTT, the patients homozygous for the deltaF508 mutation had higher blood glucose values than the heterozygous group (p=0.03), but these values were not higher than those in patients with other mutations. During the OGTT, blood insulin values at 30' were reduced in patients with IGT compared to patients with NGT (p<0.02) and the insulin peak occurred at 100.9+/-24.3 min compared to 65.3+/-21.8, respectively (p<0.05). In the IVGTT, 82.14% of the patients had reduced insulin levels at 1 and 3 min (I1'+3'). No differences in the blood glucose levels during the OGTT were found between patients with normal I1'+3' values and patients with reduced values. CONCLUSIONS: A high percentage of patients with CF also present with IGT. This increases with age and is more common among patients homozygous for the deltaF508 mutation and is not related to clinical status. Alterations in the kinetics of insulin secretion play an important role in the appearance of IGT and CF. We suggest that the OGTT is a more sensitive method than IVGTT for identifying early alterations in CF-related diabetes mellitus.

Insulin resistance and impaired glucose tolerance in obese children and adolescents.

In developed countries, obesity prevalence has strongly increased in the last decades. This has also been observed in children and adolescents. Until recently, type 2 diabetes mellitus was considered very rare among children and adolescents; however, in the last decades, some cases have been observed mainly in obese adolescents of some minority populations. The aim of our study was to assess the prevalence of type 2 diabetes, impaired glucose tolerance (IGT) and insulin resistance, and the metabolic features, in obese children and adolescents. We have studied 95 obese children and adolescents, 53 males and 42 females, aged 4-16 years. The prevalence of IGT in obese children and adolescents studied was 7.4%; there was not any child with type 2 diabetes. Fasting glucose and insulin serum concentrations did not show significant differences between obese children with or without IGT; however, 120 minutes after an oral glucose tolerance test, glucose and insulin serum concentrations showed statistically significant differences between both groups. Insulin resistance is defined as a HOMA index higher than 4. The prevalence of insulin resistance in obese children studied was 35.8%. Trygliceride serum concentrations were higher and HDL-C serum concentrations were lower in obese children with IGT than in those without IGT, but the differences were not statistically significant. IGT and insulin resistance are frequent in obese children and adolescents; early treatment in obese children and adolescents with IGT constitutes a strategy of reversing progression to beta-cell failure and in preventing type 2 diabetes.

Psyllium fibre and the metabolic control of obese children and adolescents.

In children and adolescents from developed countries, obesity prevalence has strongly increased in the last decades and insulin resistance and impaired glucose tolerance are frequently observed. Some dietary components such as low glycemic index foods and dietary fibre could be used in order to improve glucose homeostasis in these children. Psyllium or ispaghula husk (the husk of the seeds of Plantago ovata) is a mixture of neutral and acid polysaccharides containing galacturonic acid with a ratio of soluble/insoluble fibre of 70/30. Some foods could potentially be enriched with psyllium, like breads, breakfast cereals, pasta and snack foods. The aim of this review was to assess the usefulness of psyllium in the management of obese children and adolescents with abnormalities of carbohydrate and lipid metabolism. After psyllium supplementation, the percentage change in postprandial glucose in type 2 diabetes patients, ranged from -12.2 to -20.2%. In hypercholesterolemic children, the effect of psyllium in LDL-cholesterol serum concentrations ranged from 2.78 to -22.8%; the effect in HDL-cholesterol from -4.16 to 3.05%; and the effect on triglycerides from 8.49 to -19.54%. The reviewed evidence seems to show that psyllium improves glucose homeostasis and the lipid and lipoprotein profile; however, more well controlled trials and further studies are needed to clarify it's effects and the mechanisms involved.

Relationship of body fat distribution to metabolic complications in obese prepubertal girls.

The purpose of this study is to assess the relative effects of body fat distribution and obesity "per se" on serum glucose, insulin, and insulin resistance. Seventeen obese and nine nonobese control prepubertal girls were studied. Biceps, triceps, subscapular, and suprailiac skinfold thickness were measured. Percentage of body fat (% BF) and total body fat (TBF) were calculated. Body fat distribution was assessed by analyzing the central (suprailiac, subscapular)/peripheral (biceps, triceps) ratios. Oral glucose tolerance test was performed. Serum glucose and insulin were measured and insulinogenic index (insulin/glucose) was calculated. Body fat anthropometric data and body fat distribution indexes were significantly higher (p less than 0.001) in the obese group. The obese population presented significantly elevated values of glucose, insulin, and insulinogenic indexes (p less than 0.01-p less than 0.001). In the obese group, insulin showed significant positive correlations (p less than 0.05-p less than 0.001) with biceps, subscapular, and suprailiac skinfolds, % BF and TBF, whereas the insulinogenic index had positive correlations with suprailiac skinfold and TBF (p less than 0.05). Obese girls showed positive correlations between the body fat distribution indexes and insulin or insulinogenic indexes (p less than 0.05-p less than 0.001). In prepubertal girls obesity is of the centripetal (central) type. This pattern has an important role in determining the alterations in the glucose-insulin homeostasis that characterize the childhood nutritional obesity.

[Precocious puberty in girls. Study of 98 cases]. / Les précocités pubertaires des filles. Etude d'une série de 98 cas.

A study of 98 cases of true sexual precocity in girls shows a frequency three times higher between 5 and 7 years than before age 5. Detectable causes (intracranial lesion and Mac Cune-Albright syndrome) were found in 56% of cases before 5 years and only 18% after age 5. The plasma levels of estradiol and gonadotropins and the gonadotropins response to LHRH did not differ significantly from those found at the corresponding stages of normal puberty. Plasma dehydroepiandrosterone was lower. Pelvic ultrasonography sometimes discovered follicular cysts. 44 patients treated with medroxyprogesterone acetate were followed for one or several years. Results on sexual development and plasma estradiol were good in most of them, with individual variations, Improvement in the ratio of bone age as height age and in the expected adult height was obtained but without statistical significance.

Incidence of type I diabetes mellitus in Navarre, Spain (1975-91).

The aim of this study was to ascertain the incidence of Type 1 diabetes mellitus in Navarre, an autonomous community in northern Spain. Subjects were patients who presented with diabetes between 1975 and 1991, age range 0-16 years, resident in Navarre at the onset of symptoms. Endocrinologists in outpatient centres and hospitals (both public and private) in Navarre were the primary source of data, while secondary sources were: independent general practitioners, health centre paediatricians and the Child-Youth Diabetics Parents' Association of Navarre. The degree of ascertainment was 97.8%. Average annual incidence of diabetes detected was 9.54/100000 (95% CI 8.2-11.1) in the 0-14 year-old group. The least incidence was observed in 1976 and highest in 1990. The incidence in males (9.71/100000) was higher than in females (7.83/100000). The highest incidence was observed in the 10-14 year-old group (13.70/100000) when analysed by groups. No seasonal variation in the onset of diabetes was observed. These results suggest a significant increase in the incidence of type 1 diabetes between 1975 and 1991.

Insulin-specific binding to erythrocytes in 6 girls with acanthosis nigricans.

6 girls, aged 4-16 years, with acanthosis nigricans and hirsutism were studied. Fasting and postglucose hyperinsulinism was present in the 5 older girls. In the youngest, a transitory diabetes with hyperinsulinism was induced by a cortisone therapy for hepatitis. Insulin resistance, suggested by the failure to significantly decrease blood glucose after insulin injection (0.1 U/kg), was demonstrated in three steps: (1) Patient plasma failed to bind 125I-insulin after a 5-day incubation followed by precipitation by antihuman globulin serum. (2) Specific 125I-insulin binding to rat liver membranes was identical in the presence of patient plasma and control plasma. (3) Specific 125I-insulin binding to the erythrocytes of the 6 patients (3.5-7.0%) was significantly lower (p less than 0.01) than in controls (4.5-19.5%). Moreover, the significant correlation present in controls between total binding and reticulocyte counts (r = 0.824, p less than 0.001) was absent in the patients. These data demonstrate further that, in the juvenile type of acanthosis nigricans, insulin resistance which may precede hyperinsulinism is not related to anti-insulin antibodies nor to antireceptor antibodies, but results from a primary defect of insulin receptors.

[Tricho-rhino-phalangeal dysplasia type I (Giedion's syndrome) (author's transl)]. / Síndrome trico-rino-falángico tipo I (síndrome de Giedion) Contribución a su conocimiento morfológico y fistiopatológico.

A new case of these rare entity is described. Histopathology and ultrastructure of cartilage is studied pointing out some pathogenics aspects.

Follow-up hormonal controls on a HGH secreting pituitary adenoma. Pre- and postoperative study.

The case of a 12 2/12-year-old boy with an HGH secreting eosinophilic adenoma is presented. The histologic investigation included conventional and ultrastructural techniques. The pre- and postoperative (1, 7, 11, and 20 months) hormonal controls are analyzed, indicating the persistence of HGH anteropituitary activity, even though surgical sectioning of the pituitary stalk was performed and the activities of thyroid, corticoadrenal and gonadotropin functions decreased. It is suggested that the hypothalamo-pituitary relationship may be maintained by extraportal venous circulations.

[Shwachman's syndrome: pancreatic exocrine insufficiency retarded growth, metaphyseal dysostosis and neutropenia (author's transl)]. / Síndrome de Shwachman: insuficiencia pancreática exocrina, neutropenia, disóstosis metafisaria y enanismo.

A boy of 5 8/12 years of age affected with Shwachman's Syndrome is presented. He showed frequent respiratory infections that can be in order with a low account in T-lymphocytes found on immunological study. A cytoplasmic degenerative process was found after microscopical and ultrastructural vision of osteoid tissue, which is compatible with biochemical alterations.

Priming with GHRH (1-29) NH2: an aid in differential diagnosis between hypothalamic and pituitary deficiencies.

More than 80% of children with growth hormone deficiency (GHD) respond with a rise in growth hormone levels when given 1 microgram/kg body weight of growth hormone-releasing hormone (GHRH) in an i.v. bolus. We conducted a study to determine whether the failure of the remaining 20% to respond to GHRH is due to a pituitary deficiency or a secondary effect associated with chronically understimulated somatotrophs. We administered GHRH to "prime" 16 short-statured children (> 2 SD) presenting delayed growth (< 4 cm/year), who had not responded initially when given a single dose of GHRH. Priming consisted of administering GHRH (1-29) NH2 (5 micrograms/kg body weight, s.c.) for six consecutive days. Plasma GH response was studied again after an i.v. injection of 1 microgram/kg body weight of GHRH (1-29) NH2 on the seventh morning. On the basis of these results we were able to separate our patients into two groups: a) responders to priming (n = 8), whose GH responses to pharmacological and acute GHRH tests were < 10 ng/ml, with a 12-hour sleep secretion < 3 ng/ml/min. Priming increased the plasma GH response to acute GHRH in all the children in this group (6.0 +/- 2.1 ng/ml to 18.0 +/- 5.4 ng/ml; p < 0.001); b) non-responders to priming (n = 8), whose GH responses to pharmacological and acute GHRH tests were also < 10 ng/ml, with 12-hour sleep secretion < 3 ng/ml/min, but in whom priming with GH did not increase the plasma GH response (5.5 +/- 2.8 ng/ml to 6.2 +/- 2.9 ng/ml; p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Results of early treatment of cryptorchidism with human chorionic gonadotropin.

One hundred and fifty-three children with common cryptorchidism, 109 unilateral and 44 bilateral, excluding those with associated malformations or abnormalities, were treated at age 6 to 59 months with human chorionic gonadotropin given as nine intramuscular injections on alternate days. Treatment before age 3 years resulted in complete failure in 81%. At 3 to 4 years of age treatment resulted in failure in 55%, but 19% of the patients showed complete testicular descent and 26% showed partial descent. The percent of failures was increased when the dose of human chorionic gonadotropin was lower than 1,000 IU/m2 injection and when the cryptorchid testis was very high. No correlation was found between endocrine data and the clinical results. The plasma testosterone concentration after the third injection of human chorionic gonadotropin was not significantly different in successfully and unsuccessfully treated patients. However, testosterone levels were significantly lower in patients treated at 36 to 59 months of age than in those treated at an earlier age, in contrast to the significantly better clinical results obtained in the older group. Thus human chorionic gonadotropin is not a valuable means of obtaining descent of undescended testes before age 3 years and is of limited usefulness at age 3 to 4 years.