Hypoglycaemia in cystic fibrosis in the absence of diabetes: A systematic review.

BACKGROUND: Hypoglycaemia in CF in the absence of diabetes or glucose lowering therapies is a phenomenon that is receiving growing attention in the literature. These episodes are sometimes symptomatic and likely have variable aetiologies. Our first aim was to conduct a systematic review of the literature to determine what is known about hypoglycaemia in CF. Our second aim was to assess evidence based guidelines for management strategies. METHODS: A comprehensive search of databases and guideline compiler entities was performed. Inclusion criteria were primary research articles and evidence based guidelines that referred to hypoglycaemia in CF in the absence of insulin treatment or other glucose lowering therapies. RESULTS: A total of 11 studies (four manuscripts and seven abstracts) and five evidence-based guidelines met the inclusion criteria. Prevalence rates of hypoglycaemia unrelated to diabetes varied between studies (7-69%). Hypoglycaemia was diagnosed during oral glucose tolerance testing or continuous glucose monitoring (CGM). Associations between hypoglycaemia and clinical parameters of BMI, lung function, liver disease and pancreatic insufficiency were measured in some studies. There was no unifying definition of hypoglycaemia in the absence of diabetes. Only two evidence based guidelines reported possible management strategies. CONCLUSION: The systematic review found limited data on this clinical problem and supports the need for high quality methodological studies that are able to describe the experience and the aetiology(ies) of hypoglycaemia in CF.

A candidate gene approach for identifying differential iron responses in young overweight women to an energy-restricted haem iron-rich diet.

Although iron deficiency is common in women especially during dieting, weight management trials rarely examine the longitudinal impact of genetics on iron. This study examined the associations between the TMPRSS6 rs855791 polymorphism and iron indices at baseline and after a 12-month trial comparing two weight loss diets (higher-protein, higher-haem iron (HPHI) vs lower-protein, lower-haem iron (LPLI)). A total of 76 young overweight women (18-25y; BMI⩾27.5 kg/m(2)) were included at baseline, with 27 (HPHI: n=15; LPLI: n=12) completing the 12-month trial. At baseline, C allele homozygotes exhibited higher serum iron (P=0.047) and lower hepcidin (P=0.023) compared with T allele carriers. After 12 months, no genotypic differences were observed for ferritin and soluble transferrin receptor, although C homozygotes on HPHI showed higher serum iron and transferrin saturation (P<0.05). Results indicate that rs855791 can influence iron metabolism to some extent, but its impact on storage and functional iron status is small relative to dietary protein/iron manipulation.

Transition to adult care in adolescent obesity: a systematic review and why it is a neglected topic.

Transition in pediatric health care involves the purposeful, planned movement of patients from pediatric to adult services. Following the significant increases in long-term survival of chronic childhood diseases in the 1980s, transition has taken on an increasing importance in the management of these chronic diseases. In Australia, there is a conspicuous lack of programs/guidelines for transitioning adolescents with obesity. The authors sought to determine if this is an international phenomenon that should be addressed. This study aimed to identify what formal transition services or guidelines exist internationally for adolescents with overweight/obesity. Two systematic reviews of the published and 'gray' literature were implemented via searches of relevant databases, search engines and websites. The primary review eligibility criteria were documents published between 1982 and 2012 including any aspect of transitioning adolescents with overweight/obesity from pediatric to adult weight management services. The secondary review included current clinical practice guidelines/statements on pediatric obesity management published between 1992 and 2012, and transition recommendations contained within. Non-English language documents were excluded. Relevant text from eligible documents was systematically identified and extracted, and a qualitative synthesis of the data was prepared. Overall, 2272 unique records were identified from the literature searches. Three eligible articles were identified by the primary review. The secondary review identified 24 eligible guidelines/statements. In total, six of the identified documents contained information on transition in adolescent obesity-the most detailed documents provided only a brief statement recommending that transition from pediatric to adult weight management services should take place. In conclusion, internationally there is an absence of published intervention programs/policies, and brevity of clinical guidance and expert opinion, on the transition of adolescents with obesity making this a priority research area. Consideration is given to the reasons why transition in adolescent obesity is a neglected topic.

Higher protein diet for weight management in young overweight women: a 12-month randomized controlled trial.

UNLABELLED: Clinical research on weight management in young women is limited. This randomized controlled trial compared the efficacy of two iso-energetically restricted (5600 kJ) diets [higher protein (HP): 32% protein, 41% carbohydrate, 25% fat or higher carbohydrate (HC): 20, 58, 21%, respectively] in 71 (HP: n = 36; HC: n = 35) young healthy women (18-25 years; body mass index ≥ 27.5 kg/m2) for weight (kg; percent weight loss), body composition, metabolic and iron changes assessed at baseline, 6 and 12 months. DATA: mean (95% CI). In HP completers at 6 months, percent weight loss was higher [HP: 9.3 (5.6-13.1); HC: 5.1 (2.3-7.9)%; p = 0.06]; although, this did not reach statistical significance. Absolute weight [HP: 8.9 (5.3-12.5); HC: 4.6 (2.2-7.0) kg; p = 0.034] and fat loss [HP: 8.0 (4.4-11.5); HC: 3.4 (1.3-5.6) kg; p = 0.022] were significantly greater. No significant between-diet differences were observed at 12 months. Biochemistry remained within normal ranges with HP showing superior preservation of ferritin at 6 months [HP: 53 (40-66); HC: 46 (30-61) µg/l; p = 0.029]. Both diets supported clinically meaningful weight loss with HP tending to be more effective in the medium-term.

Two-year outcomes of an adjunctive telephone coaching and electronic contact intervention for adolescent weight-loss maintenance: the Loozit randomized controlled trial.

This paper reports the final 24-month outcomes of a randomized controlled trial evaluating the effect of additional therapeutic contact (ATC) as an adjunct to a community-based weight-management program for overweight and obese 13-16-year-olds. ATC involved telephone coaching or short-message-service and/or email communication once per fortnight. Adolescents were randomized to receive the Loozit group program-a two-phase behavioral lifestyle intervention with (n=73), or without (n=78), ATC in Phase 2. Adolescents/parents separately attended seven weekly group sessions (Phase 1), followed by quarterly adolescent sessions (Phase 2). Assessor-blinded, 24-month changes in anthropometry and metabolic health included primary outcomes body mass index (BMI) z-score and waist:height ratio (WHtR). Secondary outcomes were self-reported psychosocial and lifestyle changes. By 24 months, 17 adolescents had formally withdrawn. Relative to the Loozit program alone, ATC largely had no impact on outcomes. Secondary pre-post assessment of the Loozit group program showed mean (95% CI) reductions in BMI z-score (-0.13 (-0.20, -0.06)) and WHtR (-0.02 (-0.03, -0.01)) in both arms, with several metabolic and psychosocial improvements. Adjunctive ATC did not provide further benefits to the Loozit group program. We recommend that further work is needed to optimize technological support for adolescents in weight-loss maintenance. Australian New Zealand Clinical Trials Registry Number ACTRNO12606000175572.

The relationship between obesity and hypoferraemia in adults: a systematic review.

A growing number of studies suggest a potential link between obesity and altered iron metabolism. The purpose of this systematic review was to examine existing literature on iron status in obese populations. A comprehensive literature search was conducted. Included studies recruited participants ≥ 18 years with a body mass index ≥ 30 kg m(-2) and provided descriptive statistics for haemoglobin or ferritin at a minimum. There were 25 studies meeting all eligibility criteria, of these 10 examined iron status in free-living obese individuals and 15 reported baseline iron biomarkers from bariatric surgery candidates. Non-obese comparison groups were used by 10 (40%) articles. In these, seven obese groups reported higher mean haemoglobin concentration; six reported significantly higher ferritin concentration; and four significantly lower transferrin saturation. Due to insufficient data, it was not possible to make conclusions regarding mean differences for soluble transferrin receptor (sTfR), hepcidin or C-reactive protein. Existing evidence suggests a tendency for higher haemoglobin and ferritin concentration and lower transferrin saturation in obesity. Alternation of iron biomarkers in obese populations may be a result of obesity-related inflammation and/or related comorbidities. Further research incorporating measurement of inflammatory cytokines, sTfR and hepcidin is required to confirm the impact of obesity on iron status.

The role of parents in pre-adolescent and adolescent overweight and obesity treatment: a systematic review of clinical recommendations.

The study aims to describe clinical recommendations (i) on the role of parents in both pre-adolescent and adolescent overweight and obesity treatment; (ii) to health professionals on how to involve parents in paediatric overweight and obesity treatment and (iii) to identify deficiencies in the associated literature. A systematic literature review was conducted in March 2010 to identify clinical practice guidelines, position or consensus statements on clinical management of paediatric overweight or obesity, developed by a national or international health professional association or government agency, and endorsed for current use. Relevant clinical recommendations in these documents were identified via a screen for the words 'parent', 'family' and synonyms. Twenty documents were included. Most documents emphasized the importance of involving parents or the family in paediatric overweight and obesity treatment with approximately a third of documents providing separate recommendations on the role of parents/family for pre-adolescents and adolescents. The documents varied markedly with regard to the presence of recommendations on parent/family involvement in the various components of lifestyle interventions or bariatric surgery. Almost half of the documents contained recommendations to health professionals regarding interactions with parents. High-quality research is needed on age-specific techniques to optimize the involvement of parents and family members in paediatric overweight and obesity treatment.

The use of motivational enhancement strategies for the maintenance of weight loss among obese individuals: a preliminary investigation.

AIM: To investigate the efficacy of motivational enhancement strategies integrated within a standard lifestyle modification program for the maintenance of weight loss and improved psychosocial functioning of obese adults. METHODS: Twenty-two obese adults completed 20 sessions of a motivationally informed cognitive behavioural treatment for weight loss and maintenance. Treatment outcome measures included anthropometrics, obesity-specific quality of life, impulsive eating tendencies, body dissatisfaction, mood disturbance and maladaptive cognitions. RESULTS: At post-treatment, there was a significant decrease in body weight (123.04 +/- 22.06 vs. 116.84 +/- 23.53, p < 0.001) with no significant change by the 12-month follow-up. Patients also reported significant improvements in obesity-related quality of life, impulsive eating tendencies, body dissatisfaction and maladaptive cognitions at post-treatment that were maintained at the 1-year follow-up. CONCLUSIONS: The implementation of motivational enhancement strategies within a cognitive behavioural program results in sustained weight loss that compares favourably to previous lifestyle modification programs.

Clinical research in adolescents: challenges and opportunities using obesity as a model.

Adolescent medicine is relatively young, compared to paediatric or adult medicine. Descriptive and observational studies have dominated the adolescent literature, including those studies published in the International Journal of Obesity. In addition, many studies have combined child and adolescent age groups, making it difficult to determine adolescent-specific outcomes. It is important that high quality intervention studies in adolescents occur. Adolescence is a time of extraordinary plasticity. Habits, attitudes and physical morbidity that develop during adolescence set up trajectories that have a profound influence on health and wellbeing for the long term. Overweight and obesity are an excellent example of the need for high quality intervention studies and yet in the last two decades there have been very few randomized, controlled trials of overweight and obesity management in adolescents. There are a number of complexities in adolescent research that create additional challenges to those that accompany any clinical research. These include recruitment and retention, issues around consent and confidentiality and the central role that parents play in supporting the research protocol. Pubertal stage is a potential confounder and needs to be accurately measured. This is certainly true for studies in overweight and obesity where excess adiposity influences pubertal and other hormones. The opportunities to undertake quality research in adolescents are likely to be enhanced by the use of novel approaches which acknowledge the unique features of adolescents and their world.

Comparison of metabolic syndrome prevalence using six different definitions in overweight pre-pubertal children enrolled in a weight management study.

OBJECTIVES: To assess the implications of variation in Metabolic Syndrome (MS) definition (biochemical and anthropometric indicators) on MS prevalence estimates in a population of overweight and mildly obese children. DESIGN: Cross-sectional study. SUBJECTS: Ninety-nine (64 girls) overweight or mildly obese, but otherwise healthy, pre-pubertal 6-9-year olds recruited for a randomized controlled trial of weight management. MEASURES: Height, weight and waist circumference were measured with BMI and waist z-scores calculated. Fasting cholesterol and fractions, glucose and insulin were measured, together with systolic and diastolic blood pressure (BP). Anthropometric and metabolic indicators were classified as normal or elevated using adult- or child-specific cut points with clustering of MS indicators also assessed using two adult and three child-specific definitions. RESULTS: A total of 0-4% of subjects were classified with MS when adult definitions were applied. This increased to between 39 and 60% using child-specific definitions, varying according to whether hyperinsulinaemia was central to the MS classification. Systolic BP, triglycerides, total cholesterol, high-density lipoprotein cholesterol and waist z-score increased across insulin quartiles (P<0.05). The use of body mass index and waist circumference in the MS definition classified the same subjects. CONCLUSIONS: The classification of MS in children depends strongly on the definition chosen, with MS prevalence estimates higher if insulin is part of the definition and child-specific cut points for metabolic indicators are used. Hyperinsulinaemia and MS are common consequences of childhood obesity but they are not commonly part of the assessment or management plan for weight management in children. There is a need for the establishment of normal insulin ranges and consistent definition of MS in childhood and adolescence.

A proposed protocol for the development of a register of trials of weight management of childhood overweight and obesity.

INTRODUCTION: Currently, there is no international co-ordinated approach to research into childhood obesity. This is despite much research activity in this area and the universality of the condition. METHOD: This proposal involves the development of an international register of randomized controlled trials of weight management in overweight and obese children. The primary purpose of the register will be to generate and perform important, focussed prospective meta-analysis of data from trials using the conventional weight management strategies. Prospective meta-analysis is an emerging methodology and has some methodological advantages over retrospective meta-analysis. PROPOSAL: The fundamental initial tasks will be to create scientific interest in the proposal, to identify and co-ordinate Management and Advisory Committees with international membership, to determine and define inclusion and exclusion criteria for trial registration, to define the questions that need to be addressed by prospective meta-analysis and finally to engage investigators to register.

Food, activity and family--environmental vs biochemical predictors of weight gain in children.

OBJECTIVE: To identify whether measures of energy intake and expenditure predict excessive weight gain over time in children and to describe how these measures relate to similar measures in parents. DESIGN: Prospective, descriptive study over 12 months with no intervention. SETTING: University teaching hospital. SUBJECTS: Children aged between 6.0 and 9.0 y. Recruitment was through advertisement. A total of 59 children (30 F), 41 mothers and 29 fathers. In all, 41 (69%) of the children were reviewed at 12 months (20 F). RESULTS: No significant correlations were identified between body mass index (BMI) z-score change in children over 12 months for any dietary variable or for any measures of energy expenditure, including hours of television viewing or percent time spent in low-, moderate- or high-intensity activity. The BMI z-score change over 12 months was significantly correlated with LDL cholesterol and Apo B/ApoA-1 ratio, independent of percent body fat (r=0.45, P=0.01; r=0.37, P=0.03). A significant positive correlation was found for mothers and girls for percent time in moderate to high activity (r=0.44, P=0.03) and between fathers and children for percent time spent in low activity (r=0.43, P=0.005). CONCLUSIONS: The study has been unable to identify environmental predictors that indicate propensity to faster weight gain over time in this cohort of children, but has extended the evidence on lifestyle-influenced biochemical predictors that do. An overall lack of vigorous activity in this age group, and correlations between parental and child activity and inactivity have been identified.

Obesity: the science behind the management.

The prevalence of obesity is increasing in Western and Westernizing countries. The changing environment plays a major role in this increase, particularly the reduction in physical activity. There is also a strong genetic contribution to the development of obesity, although single-gene defect obesity is rare. Neither the environment nor genes is simple to modify. Obesity is an energy-balance disorder, and the human body has evolved to resist any loss of body fat. This biological drive to maintain weight is coordinated through central pathways, with the involvement of many neuropeptides. Thus, dietary restriction will induce changes designed to counter weight loss, including a fall in resting metabolic rate. The management of obesity demands reasonable goals, which focus on metabolic, rather than cosmetic, improvement. As obesity is a complex condition, multiple therapeutic strategies are required. Dietary modification, an increase in physical activity, a reduction in sedentary activity and behaviour modification all form the basis of obesity therapy. Drug therapy options at present are limited and may have a stronger role in weight maintenance. Currently, surgical management of obesity has the best long-term outcomes. Long-term maintenance of weight loss is achieved by few individuals. Those individuals who are successful are able to maintain long-term restrictive eating habits and high levels of physical activity.

The use of body mass index to predict body composition in children.

BACKGROUND: Simple anthropometric indices of body composition have particular appeal for use in children, and as such body mass index (BMI) has been used to predict percentage body fat in a number of studies. AIM: To evaluate the relationship between BMI and percentage body fat (%body fat) and a proposed, more appropriate relationship between BMI and fat mass/height(2) in a cohort of young children. SUBJECTS AND METHODS: Cross-sectional study of 109 children aged between 6 and 10 years residing in either Sydney or Brisbane, Australia. Weight and height were measured using standard methods. Body composition was measured using a stable isotope method to firstly determine total body water and subsequently fat free mass. RESULTS: The correlation between BMI and fat mass/height(2) was markedly greater than that between BMI and percentage body fat. In the entire group of children the R(2) (x100%) value for the relationship between BMI and fat mass/height(2) was 73.3% compared with 46.5% for the relationship between BMI and percentage body fat. CONCLUSIONS: We have shown that the use of BMI to predict fat mass/height(2), and consequently percentage body fat, is superior to the use of BMI to predict percentage body fat based directly upon the R(2) values of the above analysis.

Comparison of total energy expenditure and energy intake in children aged 6-9 y.

BACKGROUND: The accurate measurement of food intake in children is important for assessing nutritional status. OBJECTIVE: We sought to both compare measurements of energy intake (EI) from diet records and of total energy expenditure (TEE) by the doubly labeled water (DLW) method and to investigate misreporting of EI. DESIGN: Forty-seven children (22 boys and 25 girls) aged 7.4 +/- 0.8 y ( +/- SD) were recruited from 25 schools in western Sydney. TEE was measured by DLW over 10 d and EI by use of 3-d food records. Misreporting was defined as [(EI - TEE)/TEE] x 100%. RESULTS: Girls had a higher (P = 0.02) percentage of body fat (28.2 +/- 7.0%) than did boys (22.9 +/- 8.0%); otherwise there were no differences among sex. Although mean (+/-SD) values for EI (7514 +/- 1260 kJ/d) and TEE (7396 +/- 1281 kJ/d) were not significantly different, there was no significant correlation between EI and TEE. EI and TEE were 9% and 11% lower, respectively, than current World Health Organization recommendations for EI. The relative bias (mean difference, EI - TEE) was low at 118 kJ/d, but the limits of agreement (bias +/- 2 SD of the difference) were wide at 118 +/- 3345 kJ/d. Although the mean percentage of misreporting was low (4 +/- 23%), the high SD indicates large intraindividual differences between EI and TEE. The most significant predictor of misreporting was dietary fat intake (r(2) = 0.45, P < 0.0001). Misreporting was not associated with sex or body composition. CONCLUSIONS: In this age group, reported EI is not representative of TEE at the individual level. However, at the population level, 3-d food records may be used for surveys of EI by 6-9-y-old children.