[Current Guidelines to Prevent Obesity in Childhood and Adolescence]. / Aktuelle Empfehlungen zur Prävention der Adipositas im Kindes- und Jugendalter.

BACKGROUND: Current guidelines for the prevention of obesity in childhood and adolescence are presented. METHODS: A literature search was performed in Medline via PubMed, and appropriate studies were analysed. RESULTS: Programs to prevent childhood obesity were to date mainly school-based. Effects were limited to date. Analyses tailored to different age groups show that prevention programs have the best effects in younger children (< 12 years). Evidence based recommendations for preschool- and early school age imply the need for interventions addressing parents and teachers alike. During adolescence, school-based interventions were most effective when adolescents were directly addressed. To date, obesity prevention programs have mainly focused on behavior oriented prevention. Recommendations for condition oriented prevention have been suggested by the German Alliance of Non-communicable Diseases and include one hour of physical activity at school, promotion of healthy food choices by taxing unhealthy foods, mandatory quality standards for meals at kindergarten and schools as well as a ban on unhealthy food advertisement addressing children. CONCLUSION: Behavior oriented prevention programs showed hardly any or only limited effects in the long term. Certain risk groups for the development of obesity are not reached effectively by available programs. Due to the heterogeneity of available studies, universally valid conclusions cannot be drawn. The combination with condition oriented prevention, which has to counteract on an obesogenic environment, is crucial for sustainable success of future obesity prevention programs.

Introducing excess body weight in childhood and adolescence and comparison with body mass index and waist-to-height ratio.

BACKGROUND: Weight status in children and adolescents is commonly defined using age- and gender-corrected standard deviation scores for body mass index (BMI-SDS, also called z-scores). Values are not reliable for the extremely obese however. Moreover, paediatricians and parents may have difficulties understanding z-scores, and while percentiles are easier to gauge, the very obese have values above the 99th percentile, making distinction difficult. The notion of excess body weight (EBW) is increasingly applied in adult patients, mainly in the context of bariatric surgery. However, a clear definition is not available to date for the paediatric population. METHODS: A simple definition of EBW for children and adolescents is introduced, with median weight as a function of height, age and gender (characterized by an asterisk): EBW (%) = 100x(weight-median weight*)/median weight*. EBW is compared with BMI-SDS and waist-to-height ratio (WHtR). Using two data sources (APV registry and German Health Interview and Examination Survey for Children and Adolescents (KiGGS)) including more than 14,000 children, the relationships between these anthropometric and various metabolic parameters are analysed for a group of overweight/obese children who have sought obesity therapy (APV), for the general paediatric population and for the subset of overweight/obese children from the general population (KiGGS). RESULTS: The three anthropometric parameters are strongly correlated, with the linear correlation coefficients exceeding 0.8 in the general population and 0.75 in those seeking obesity therapy. Moreover, their relationship to metabolic parameters is quite similar regarding correlations and area under the curve from receiver operating characteristic analyses. CONCLUSIONS: EBW has similar predictive value for metabolic or cardiovascular comorbidities compared with BMI and WHtR. As it is reliable at the extreme end of the obesity spectrum, easily communicable and simple to use in daily practice, it would make a very useful addition to existing tools for working with obese children and adolescents. Its usefulness in assessing weight change needs to be studied however.

[Family Caregivers as a Target Group for Health Promotion and Prevention]. / Pflegende Angehörige als Zielgruppe für Gesundheitsförderung und Prävention.

Family caregivers are a target group for health promotion, due to the various burdens. Against this background an assessment (ARR) was developed, implemented, and validated in the project "Health Promotion for Elderly Family Caregiver". On the basis of the ARR, family caregivers received an individual, need-oriented, and specific offer for health promotion. In order to reach the target group optimally, a national health insurance company was used.

[Residential mobility in old age. Age-appropriate housing as a primary preventive strategy]. / Wohnmobilität im Alter. Altersgerechtes Wohnen als primärpräventive Strategie.

BACKGROUND: Unfavorable living conditions in old age have negative physical, psychological and social implications and increase the risk of institutionalization. The aim of this study is to examine older adults' readiness to relocate to age-appropriate housing versus the wish to stay where they are. METHODS: A total of 103 older men and women were questioned prospectively, face-to-face, regarding their readiness to relocate. In addition to assessing several established predictors of residential mobility, data on objective living situations were collected. The data were subjected to bi- and multivariate analysis. RESULTS: At 70.9%, the proportion of respondents who are not willing to move (stayers) far exceeds the proportion of those who are (movers, 29.1%). Older respondents are more satisfied with their living situation and less likely to move. This study provides empirical evidence for the "satisfaction paradox" with respect to living conditions and for the importance of the subjective standard of living for quality of life in old age. CONCLUSION: Modern housing counseling should more strongly reflect the variety of needs, requirements and living situations of older people today than it has done in the past. It is therefore recommended that the currently dominating paradigm of "aging in place" be critically re-evaluated.

[National health target "healthy ageing". Medical, psychosocial and nursing care for elderly people]. / Nationales Gesundheitsziel "Gesund älter werden". Handlungsfeld II: Medizinische, psychosoziale und pflegerische Versorgung älterer Menschen.

What kind of health targets should be pursued concerning the health care of elderly people? What kind of activities should be implemented to ensure good health care with regard to future challenges? The Association for the Continuous Development of the National Health Target Process, health-targets.de, deals with these issues under the new national health target "Healthy Ageing". We develop concrete objectives and proposals for practical implementation in the areas of "outpatient and inpatient care", "nursing" and "rehabilitation in old age". health-targets.de supports a common health target process and initiates interventions in the field of health care for elderly people.

[Family caregivers and health promotion. Pilot study to validate a German assessment to survey resources and risks of elderly family caregivers (ARR)]. / Pflegende Angehörige und Gesundheitsförderung. Pilotstudie zur Validität eines deutschsprachigen Assessments zur Erfassung von Ressourcen und Risiken älterer pflegender Angehöriger (ARR).

The ARR is a German assessment instrument to survey physical and psychological resources and risks of elderly family caregivers (50+). Factor structure, reliability, and validity were investigated using a sample of 202 caregivers from a national health insurance company. The factorial validity was confirmed for the physical profile (PHP) and the psychological profile (PSP). Reliability is good (PHP: Cronbach's α=0.73; PSP: Cronbach's α=0.71) for the shortness of the profiles. The correlation with self-efficacy constitutes an indicator for construct validity. The psychometric qualities allow the conclusion that the ARR is a reliable and valid instrument which is of interest for family caregivers. Nevertheless, further testing of validity is required.

The promoter variant -803 G>A in the RBP4 gene is not associated with BMI, metabolic parameters or blood pressure in Caucasian children.

OBJECTIVE: Studies in adults identified the -803 G>A promoter polymorphism (rs3758539) in the RBP4 gene (RBP4) as a functional variant conferring an increased risk for obesity and type 2 diabetes. METHODS: We genotyped this polymorphism in a cohort of 304 lean and 283 obese children to assess a potential association with early onset obesity and blood pressure and evaluated the effect of this SNP on metabolic parameters in a smaller subset. RESULTS: The allele frequency of -803 G>A was similar in obese compared to lean subjects (0.159 vs. 0.191, P=0.318). We did not detect an association of the variant with adiposity parameters nor with parameters of glucose and lipid metabolism or blood pressure in quantitative analyses. CONCLUSION: Our study revealed that the promoter polymorphism -803 G>A in RBP4 is not associated with BMI, metabolic parameters or blood pressure in Caucasian children.

[Bariatric surgery in extremely obese children and adolescents]. / Bariatrische Chirurgie bei extremer Adipositas im Kindes- und Jugendalter.

The management of childhood obesity is a clinical dilemma. Validated and evidence-based intervention programs are still missing for this age group, and pediatricians increasingly see children with morbid obesity and with obesity-related comorbidities. For those extremely obese patients who failed to respond to the classical therapeutic approaches, bariatric surgery is a therapeutic option. Although available data for bariatric surgery in childhood and adolescence is limited to date, significant postoperative reduction in BMI and an evident improvement of preoperatively existing metabolic and cardiovascular comorbidities and psychosocial well-being have been reported. The indication for bariatric surgery in adolescents follows strict criteria and should be proposed within an interdisciplinary team in specialized centers, including a clinical ethics committee. This review discusses the present guidelines for bariatric surgery in childhood and adolescence as well as available follow-up data for both adults and pediatric patients.

Leucocytes are a major source of circulating nicotinamide phosphoribosyltransferase (NAMPT)/pre-B cell colony (PBEF)/visfatin linking obesity and inflammation in humans.

AIMS/HYPOTHESIS: Nicotinamide phosphoribosyltransferase (NAMPT) is a multifunctional protein potentially involved in obesity and glucose metabolism. We systematically studied the association between circulating NAMPT, obesity, interventions and glucose metabolism and investigated potential underlying inflammatory mechanisms. METHODS: Fasting morning NAMPT serum levels were measured in cohorts of lean vs obese children, cohorts of intervention by lifestyle, exercise and bariatric surgery, and during an OGTT. In addition, mRNA expression, protein production and enzymatic activity of NAMPT were assessed from isolated leucocytes and subpopulations. RESULTS: Circulating NAMPT was significantly elevated in obese compared with lean children and declined after obesity interventions concomitantly with the decline in BMI, high-sensitivity C-reactive protein (hsCrP) and leucocyte counts. Circulating NAMPT significantly correlated with glucose metabolism and cardiovascular variables in univariate analyses, but only the association with glucose response during an OGTT was independent from BMI. We therefore assessed the NAMPT dynamic following an oral glucose load and found a significant decline of NAMPT levels to 77.0 ± 0.1% as a function of time, and insulin-to-glucose ratio during an OGTT in obese insulin-resistant adolescents. Circulating NAMPT was, however, most strongly associated with leucocyte counts (r = 0.46, p < 0.001). The leucocyte count itself determined significantly and independently from BMI insulin resistance in multiple regression analyses. We systematically evaluated NAMPT expression among several tissues and found that NAMPT was predominantly expressed in leucocytes. In subsequent analyses of leucocyte subpopulations, we identified higher NAMPT protein concentrations in lysates of granulocytes and monocytes compared with lymphocytes, whereas granulocytes secreted highest amounts of NAMPT protein into cell culture supernatant fractions. We confirmed nicotinamide mononucleotide enzymatic activity of NAMPT in all lysates and supernatant fractions. In monocytes, NAMPT release was significantly stimulated by lipopolysaccharide (LPS) exposure. CONCLUSIONS: Leucocytes are a major source of enzymatically active NAMPT, which may serve as a biomarker or even mediator linking obesity, inflammation and insulin resistance.

Vaspin is related to gender, puberty and deteriorating insulin sensitivity in children.

BACKGROUND: Visceral adipose tissue-derived serine protease inhibitor (vaspin) has been suggested as a novel adipocytokine related to obesity and insulin sensitivity in adults. DESIGN: We quantified vaspin serum concentrations in 65 lean and 67 obese children and aimed to evaluate the relationship of vaspin with physical development, obesity, and metabolic and cardiovascular phenotypes in children. We further assessed the acute vaspin response to glucose provocation in 20 obese adolescents and evaluated tissue expression patterns of vaspin in humans. RESULTS: Vaspin levels were significantly higher in girls than in boys. In girls, vaspin increased with age and pubertal stage, whereas there was no change with development in boys. Obese girls had lower vaspin serum levels than those of lean controls, but there was no significant correlation with body mass index (BMI). Independent of sex, age and BMI, lower vaspin was associated with better insulin sensitivity, with higher systolic blood pressure and impaired endothelial function. In response to glucose provocation during an oral glucose tolerance test, vaspin serum levels declined by approximately 25% in adolescents with hyperinsulinemia, whereas there was no significant decline in normoinsulinemic patients. In support of our clinical data, we not only confirmed vaspin mRNA expression in adipose tissue but also found consistent expression of vaspin in the liver and indications for expression in the pancreas and the skin. CONCLUSION: We showed that gender differences in circulating vaspin levels develop during pubertal progression in girls. Although vaspin's association with obesity remains controversial, vaspin was increased with worsening insulin resistance already in children and was acutely down-regulated following glucose provocation in insulin-resistant adolescents independent of obesity. Besides adipose tissue, vaspin expression in the liver and the pancreas may potentially contribute to circulating vaspin levels and their regulation.

Etilefrinhydrochloride tablet ingestion: successful therapy by endoscopic removal of tablet conglomerate.

We report here on a case of etilefrinhydrochloride tablet intoxication in suicidal intention in a female adolescent. Tablet ingestion resulted in the formation of a tablet conglomerate in the stomach, which could neither be effectively treated with activated charcoal nor by gastric lavage. Endoscopic dissemination and removal of the fragments finally led to the elimination of the tables and the symptoms of intoxication resolved completely. The case presented here offers an explanation as to why the use of activated charcoal and/or a gastric lavage may not be successful in some cases of ingestion/intoxication. Endoscopic removal of ingested fragments of the toxic substance, such as etilefrinhydrochloride tablets, may be useful even hours following ingestion and should be considered when treatment with activated charcoal or gastric lavage fail to eliminate toxic substances in cases of tablet ingestion.

Efficacy of laparoscopic sleeve gastrectomy (LSG) as a stand-alone technique for children with morbid obesity.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is basically unknown as a stand-alone technique for bariatric surgery in children and adolescents. It may be advantageous for this age group though, since it requires neither foreign body placement nor life-long malabsorption. We present the first report about the efficacy of LSG in a small pediatric series. METHODS: All patients (n = 4, female) had been in a multi-modal weight loss program for several years without long-term success. At referral, the mean age was 14.5 years (range 8-17), mean body mass index (BMI in kg/m(2)) was 48.4 (range 40.6-56.3). All suffered from various features of a metabolic-vascular syndrome like diabetes, dislipidemia, cholecystolithiasis, arterial hypertension. The 8-year-old girl was diagnosed Prader-Willi Syndrome at the age of 2. The decision for bariatric surgery was taken unanimously by the parents, patient, and the obesity team. LSG was performed in a five-trocar technique. With a gastroscope (size 40-F) protecting the lesser curvature, the stomach was resected from the proximal antrum to the angle of His using an ENDO-GIA stapler. The stapler line was secured by a continuous suture 3-0 vicryl. RESULTS: There were no intra- or postoperative complications. Contrast studies confirmed a J-like gastric remnant (mean volume 76 ml) and ruled out leaks in all cases. After a mean follow-up time of 12 months (range 6-19 months), all the patients had reduced weight (mean BMI to 37.2). The girl with the longest postoperative period went from 121 to 83 kg (BMI from 40.6 to 28.4). Laboratory studies ruled out malnutrition or vitamin deficiency. Monitoring of metabolic parameters showed gradual improvement or even resolution for most features. CONCLUSION: At a 1-year follow-up, LSG proved a safe and effective option for bariatric surgery in children, achieving moderate weight loss and improvement of comorbidities. Thus, it may be considered as stand-alone technique. Long-term studies however must compare these results with time-tested procedures like gastric banding and Roux-en-Y gastric bypass.

[Everlasting solidarity? Longevity and generational relations]. / Wie langlebig ist die Solidarität? Generationsbeziehungen in den späten Lebensjahren.

Demographic development of industrial societies is determined by continuous low birth rates and increasing life expectancy. The dramatic change in generational structure will be an enormous challenge not only for the public social security systems; as an original place of inter-generational relations, family is particularly faced with increasing life expectancy and the chances and risks of longevity. Need for nursing care is such a risk of longevity, realizing that only about 3% aged between 60 and 80 are in need of care, but about 25% at the age of 80 or older. The majority of nursing cases is well-cared at home, mostly by relatives. Although one might care for relatives for many reasons--not only for love and altruism--empirical data insist on indicating strong family ties based on senses of solidarity and commitment. The focal point of the following article is a case review describing highly emotional family relationships in a home care situation. On the one hand, the description clarifies family solidarity representing the basis of German long-term care insurance since 1995; on the other hand it demonstrates the enormous burden caring for an old mother or father. Increasing life expectancy might even intensify burdens, so that fewer and fewer relatives might be able or willing to accept them. In this matter, new mixtures of private and public services will attain increasing importance. Considering German long-term care insurance a pioneer, it expresses a new sense of limited public responsibility assuming the existence of sufficiently strong family ties.