Cuff size influences blood pressure measurement in obese children and adolescents.

INTRODUCTION: Recently, we established that a group of obese children and adolescents had a higher blood pressure (BP) than a healthy control group. In the present study, we investigate whether the higher BP in the obese group was influenced by BP cuff sizes. METHODS: A total of 104 obese patients aged 10-18 years were compared with 50 controls. BP was measured with a validated oscillometric device using an appropriate cuff size depending on each person's arm circumferences (AC) according to the manufacturer's recommendation; small (AC < 23 cm), medium (23 ≤ AC < 32 cm) and large (AC ≥ 32 cm). RESULTS: Cuff sizes had a significant impact on BP measurements. Despite the influence of cuff size, multiple regression analyses revealed that systolic BP was 6.8 mmHg higher and diastolic BP 3.2 mmHg higher in the obese group than in the control group. A step function, i.e. a sudden fall in BP, was seen at the point of switching from small to medium cuff size in the control group, which suggests that systolic BP was overestimated when using small cuff size and underestimated when using medium cuff size in subjects with an AC near 23 cm. CONCLUSIONS: BP was higher in the obese group than in the control group although BP was influenced by BP cuff sizes. FUNDING: The present project received funding from The Health Sciences Research Foundation of Region Zealand, The Danish Heart Foundation, Kathrine og Vigo Skovgaards Fond, Det Medicinske Selskab i København, Edith og Henrik Henriksens Mindelegat and LEO Pharma's Travel Grant. TRIAL REGISTRATION: ClinicalTrials.gov id: NCT01310088.

Blood pressure and arterial stiffness in obese children and adolescents.

Obesity, elevated blood pressure (BP) and arterial stiffness are risk factors for cardiovascular disease. A strong relationship exists between obesity and elevated BP in both children and adults. Obesity and elevated BP in childhood track into adult life increasing the risk of cardiovascular disease in adulthood. Ambulatory BP is the most precise measure to evaluate the BP burden, whereas carotid-femoral pulse wave velocity (cfPWV) is regarded as the gold standard for evaluating arterial (i.e. aortic) stiffness. These measures might contribute to a better understanding of obesity's adverse impact on the cardiovascular system, and ultimately a better prevention and treatment of childhood obesity. The overall aim of the present PhD thesis is to investigate arterial stiffness and 24-hour BP in obese children and adolescents, and evaluate whether these measures are influenced by weight reduction. The present PhD thesis is based on four scientific papers.  In a cross-sectional design, 104 severe obese children and adolescents with an age of 10-18 years were recruited when newly referred to the Children's Obesity Clinic, Holbæk University Hospital, and compared to 50 normal weighted age and gender matched control individuals. Ambulatory BP was measured, and cfPWV was investigated in two ways in respect to the distance measure of aorta; the previously recommended length - the so called subtracted distance, and the currently recommended length - the direct distance. In a longitudinal design, the obese patients were re-investigated after one-year of lifestyle intervention at the Children's Obesity Clinic in purpose of reducing the degree of obesity. In the cross-sectional design, the obese group had higher measures of obesity, while matched for age, gender and height, when compared to the control group. In the longitudinal design, 74% of the 72 followed up obese patients experienced a significant weight reduction. CfPWV was dependent on the method used to measure the length of the aorta. The subtracted distance was not consistent in its relation to height in the obese and the control group. Opposite, the direct distance was consistent in its relation to height in the two groups. Therefore, cfPWV using the direct distance (cfPWV-direct) was regarded as the appropriate measure of arterial stiffness. CfPWV-direct was reduced in the obese group after adjustment for known confounders. In the longitudinal design, weight reduction across one year did not have an impact on cfPWV-direct in the obese patients. In fact, cfPWV-direct was higher at follow-up, which was explained by the increased age and partly by changes in BP and heart rate. The obese group had a relatively higher night- than day-time BP when compared to the control group. The obesity-related elevated night-time BP was independent of arterial stiffness and insulin resistance. Although night-time systolic BP was related to arterial stiffness and tended to be related to insulin resistance, insulin resistance and arterial stiffness were not related. In the longitudinal design, changes in anthropometric obesity measures across one year were associated with changes in 24-hour, day- and night-time BP, and consistent when evaluated in standardised values that accounted for growth. No association was found between changes in anthropometric obesity measures and changes in clinic BP. In conclusion, the results suggest that obesity in children is not "yet" associated with structural changes in aorta when evaluated with the appropriate new method of cfPWV. In this respect, weight reduction did not have an impact on arterial stiffness. The ambulatory BP, namely the night-time BP, was elevated in the obese patients, whereas changes in anthropometric obesity measures were related to changes in ambulatory BP but not to changes in clinic BP. In perspective, it is reassuring that weight changes are accompanied with a change in 24-hour BP as ambulatory BP is the most precise measure to evaluate the BP burden, and it emphasises the use of 24-hour ambulatory BP measurements in children and adolescents. It is important to recognise, that obese children who recover their normal weight before adulthood will have a similar cardiovascular risk as those who were never obese. Hence, early treatment and prevention of childhood obesity is important because it may prevent irreversible damage to the cardiovascular system.

Comprehension deficits among older patients in a quick diagnostic unit.

BACKGROUND: Higher prevalence of multiple illnesses and cognitive impairment among older patients pose a risk of comprehension difficulties, potentially leading to medication errors. Therefore, the objective of this study was to investigate comprehension of discharge instructions among older patients admitted to a Quick Diagnostic Unit (QDU). METHODS: One hundred and two patients discharged from the QDU answered a questionnaire covering understanding of their hospitalization and discharge plan. Patients' ability to recall discharge instructions and awareness of comprehension deficits, ie, ability to identify the misconceived information, were evaluated by comparing the questionnaires with the discharge letters. The population was divided into an older group (age ≥65 years) and a younger group. RESULTS: The older group (n=40) was less able to recall correct medication instructions when compared to the younger group (54% versus 78%, respectively; P=0.02). In multiple logistic regression analysis, correct recall of medication instructions was 4.2 times higher for the younger group compared to the older group (odds ratio 4.2, 95% confidence interval 1.5-11.9, P=0.007) when adjusted for sex and education. The older patients were less aware of their own comprehension deficits, and in respect to medication instructions awareness decreased 6.1% for each additional year of age (odds ratio 0.939, 95% confidence interval 0.904-0.98, P=0.001) when adjusted for sex and education. CONCLUSION: Older patients were less able to recall correct medication instructions and less aware of their comprehension deficits after discharge from a QDU. The findings of the present study emphasize the importance of thorough communication and follow-up when treating older patients.

Effect of changes in BMI and waist circumference on ambulatory blood pressure in obese children and adolescents.

BACKGROUND: Weight reduction has been accompanied with a reduction in clinic blood pressure (BP) in children and adolescents; however, the effect on ambulatory BP (ABP) is uncertain. The objective was to investigate the impact of weight changes on ABP in obese children and adolescents. METHODS: Sixty-one severely obese patients aged 10-18 years underwent lifestyle intervention at the Children's Obesity Clinic. Patients were examined with ABP monitoring at baseline and after 1 year of treatment (follow-up). To account for growth, BP and BMI were standardized into z scores, whereas waist circumference was indexed by height [waist/height ratio (WHR)]. RESULTS: Patients experienced a reduction at follow-up in the degree of obesity [ΔBMI z score: -0.21, 95% confidence interval (CI) -0.32 to -0.10, P = 0.0003; and ΔWHR: -0.02, 95% CI -0.03 to -0.004, P = 0.009]. Δ24-h, Δdaytime and Δnight-time SBP and DBP in mmHg and changes in equivalent z scores were related to ΔBMI z scores and ΔWHR. These relationships were reproduced in multiple regression analyses adjusted for relevant confounders, for example, a reduction in one BMI z score corresponds to a reduction in 24-h SBP by 6.5 mmHg (P < 0.05). No relationship was found between changes in these anthropometric obesity measures and changes in clinic BP. CONCLUSION: Changes in obesity measures were closely related to changes in ABP, but not to changes in clinic BP, in severe obese children and adolescents after 1 year of lifestyle intervention. The findings emphasize the use of 24-h ABP measurements in children and adolescents.

[Participation in dinner at a medical conference reduces vascular age and is recommended]. / Deltagelse i konferencemiddag reducerer den vaskulære alder og anbefales af helbredsmæssige grunde

A total of 60 attendees at a medical conference had their peripheral and central blood pressure measured before and after the conference dinner. While heart rate increased, all measurements of peripheral and central blood pressure showed lower values after dinner. Furthermore, attendees' central vascular age was reduced by 13 years after dinner when augmentation index was evaluated in relation to age. Although 13% experienced postprandial hypotension, the present study motivates attendance at medical conference dinners due to the health implications of lowered blood pressure.

Changes in lipidemia during chronic care treatment of childhood obesity.

BACKGROUND: Childhood obesity and related co-morbidities are increasing. This intervention study assessed the associations between weight changes and lipidemia in obese children and adolescents. METHODS: A total of 240 obese children and adolescents (median age, 11.3 years; range, 3.9-20.9) were enrolled in a best-practice multidisciplinary chronic care treatment program. The concentrations of total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides (TGs) and anthropometric data comprising height and weight were collected at baseline and after up to 39 months of continuous treatment. RESULTS: The BMI standard deviation score (SDS) decreased in 51% of patients and maintained unchanged in 32% of patients during the treatment. At baseline, 65 (27.1%) of the patients exhibited dyslipidemia defined as increased concentrations of total cholesterol (>200 mg/dL), LDL (>130 mg/dL), or TGs (>150 mg/dL), or decreased HDL concentration (<35 mg/dL). Dyslipidemia improved with weight loss; the odds ratio (OR) was 0.37 per BMI SDS (p = 0.014) after adjusting for age, sex, and baseline BMI SDS. Baseline TG concentration correlated positively and HDL concentration correlated negatively with baseline BMI SDS. Weight loss was associated with a decrease in the concentrations of total cholesterol (p = 0.0005), LDL (p < 0.0001), non-HDL (p < 0.0001), and TGs (p < 0.0001), and with an increase in HDL concentration (p < 0.0001). CONCLUSION: High lipid concentrations were associated with childhood obesity. The lipid profile improved during weight loss independently of the baseline BMI SDS and baseline lipid concentration.