Two-year outcome of laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity: results from a Swedish Nationwide Study (AMOS).

CONTEXT: The prevalence of obesity among adolescents has increased and we lack effective treatments. OBJECTIVE: To determine if gastric bypass is safe and effective for an unselected cohort of adolescents with morbid obesity in specialized health care. DESIGN, SETTING AND PATIENTS: Intervention study for 81 adolescents (13-18 years) with a body mass index (BMI) range 36-69 kg m(-2) undergoing laparoscopic gastric bypass surgery in a university hospital setting in Sweden between April 2006 and May 2009. For weight change comparisons, we identified an adult group undergoing gastric bypass surgery (n=81) and an adolescent group (n=81) receiving conventional care. MAIN OUTCOME MEASUREMENTS: Two-year outcome regarding BMI in all groups, and metabolic risk factors and quality of life in the adolescent surgery group. RESULTS: Two-year follow-up rate was 100% in both surgery groups and 73% in the adolescent comparison group. In adolescents undergoing surgery, BMI was 45.5 ± 6.1 (mean ± s.d.) at baseline and 30.2 (confidence interval 29.1-31.3) after 2 years (P<0.001) corresponding to a 32% weight loss and a 76% loss of excess BMI. The 2-year weight loss was 31% in adult surgery patients, whereas 3% weight gain was seen in conventionally treated adolescents. At baseline, hyperinsulinemia (>20 mU l(-1)) was present in 70% of the adolescent surgery patients, which was reduced to 0% at 1 year and 3% at 2 years. Other cardiovascular risk factors were also improved. Two-thirds of adolescents undergoing surgery had a history of psychopathology. Nevertheless, the treatment was generally well tolerated and, overall, quality of life increased significantly. Adverse events were seen in 33% of patients. CONCLUSIONS: Adolescents with severe obesity demonstrated similar weight loss as adults following gastric bypass surgery yet demonstrating high prevalence of psychopathology at baseline. There were associated benefits for health and quality of life. Surgical and psychological challenges during follow-up require careful attention.

Self-esteem in a clinical sample of morbidly obese children and adolescents.

AIM: To study self-esteem in clinical sample of obese children and adolescents. METHODS: Obese children and adolescents aged 8-19 years (n = 107, mean age 13.2 years, mean BMI 32.5 [range 22.3-50.6], mean BMI z-score 3.22 [range 2.19-4.79]; 50 boys and 57 girls) were referred for treatment of primary obesity. Self-esteem was measured with a validated psychological test with five subscales: physical characteristics, talents and skills, psychological well-being, relations with the family and relations with others. A linear mixed effect model used the factors gender and adolescence group, and the continuous covariates: BMI z-scores, and BMI for the parents as fixed effects and subjects as random effects. RESULTS: Age and gender, but neither the child's BMI z-score nor the BMI of the parents were significant covariates. Self-esteem decreased (p < 0.01) with age on the global scale as well as on the subscales, and was below the normal level in higher ages in both genders. Girls had significantly lower self-esteem on the global scale (p = 0.04) and on the two subscales physical characteristics (p < 0.01) and psychological well-being (p < 0.01). CONCLUSION: Self-esteem is lower in girls and decreases with age. In treatment settings special attention should be paid to adolescent girls.

Physical activity-key issues in treatment of childhood obesity.

Changes in physical activity with the aim of increasing energy expenditure are usually an important component of childhood obesity treatment. Physical activity also has several other aspects that are positive for the obese child's health, such as improving the metabolic profile and psychological well being. The aim of this paper is to give a short review of what we know about physical activity in paediatric obesity treatment. In addition, practical recommendations will be presented which a health care provider can suggest to obese children and their families with a special focus on daily activity, participation in physical education classes and sports, sedentary behaviours, active commuting to school and how to get family and friends involved in supporting the child.

Body composition and bone health in adolescents after Roux-en-Y gastric bypass for severe obesity.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGB) causes changes in body composition and bone metabolism, yet little is known about effects in adolescents. OBJECTIVES: The objective of this study was to report dual-energy X-ray absorptiometry measures and serum bone markers, hypothesizing that bone turnover increases after surgery. METHODS: Inclusion criteria included the following: age 13-18 years and body mass index (BMI) >35 kg/m2 . Seventy-two adolescents (22 boys; mean age 16.5 years; BMI 44.8 kg/m2 ) undergoing RYGB underwent dual-energy X-ray absorptiometry and serum bone marker analyses preoperatively and annually for 2 years. RESULTS: Mean BMI reduction at 2 years was 15.1 kg/m2 . Body composition changes included a reduction in fat mass (51.8% to 39.6%, p < 0.001) and relative increase in lean mass (47.0% to 58.1%, p < 0.001). In contrast to previous studies in adults, adolescent boys lost a greater percentage of their body fat than girls (-17.3% vs. -9.5%, p < 0.001). Individual bone mineral density Z-scores (BMD-Z) at baseline were within or above the normal range. The mean (SD) BMD-Z was 2.02 (1.2) at baseline, decreasing to 0.52 (1.19) at 2 years. Higher concentrations of serum CTX (p < 0.001) and osteocalcin (p < 0.001) were observed in boys throughout the study period. Levels rose in the first year, before decreasing modestly in the second. Levels of serum markers of bone synthesis and resorption were higher in boys, whose skeletal maturity occurs later than girls'. CONCLUSIONS: Differences in body fat and lean mass proportions were observed according to sex following RYGB. Bone turnover increased, and BMD decreased to levels approaching a norm for age. Long-term outcome will determine the clinical relevance.

Prevention of progression to severe obesity in a group of obese schoolchildren treated with family therapy.

STUDY OBJECTIVE: To evaluate the effect of family therapy on childhood obesity. DESIGN: Clinical trial. One year follow-up. SETTING: Referral from school after screening. PARTICIPANTS: Of 1774 children (aged 10 to 11), screened for obesity, 44 obese children were divided into two treatment groups. In an untreated control group of 50 obese children, screened in the same manner, body mass index (BMI) values were recorded twice, at 10 to 11 and at 14 years of age. INTERVENTION: Both treatment groups received comparable dietary counseling and medical checkups for a period of 14 to 18 months, while one of the groups also received family therapy. RESULTS: At the 1-year follow-up, when the children were 14 years of age, intention-to-treat analyses were made of the weight and height data for 39 of 44 children in the two treatment groups and for 48 of the 50 control children. The increase of BMI in the family therapy group was less than in the conventional treatment group at the end of treatment, and less than in the control group (P = .04 and P = .02, respectively). Moreover, mean BMI was significantly lower in the family therapy group than in the control group (P < .05), and the family therapy group also had fewer children with BMI > 30 than the control group (P = .02). The reduction of triceps, subscapular, and suprailiac skinfold thicknesses, expressed as percentages of the initial values, was significantly greater in the family therapy group than in the conventional treatment group (P = .03, P = .005 and P = .002, respectively), and their physical fitness was significantly better (P < .05). CONCLUSIONS: Family therapy seems to be effective in preventing progression to severe obesity during adolescence if the treatment starts at 10 to 11 years of age.

[Family therapy appropriate even in somatic care. Study review of medically oriented family therapy]. / Familjeterapi tillämplig även i somatiska vården. Studieöversikt över medicinskt orienterad familjeterapi.

By observing and analyzing the influence of the therapist on the family as well as interactions between family members, the encounter with a family in a medical setting can serve to improve the health of its members, by improving their ability to use their own resources. This method of focusing on the interaction between individuals in a family or other systems has been a valuable addition to medical treatment of chronic disease. Family therapy has been shown to effectively improve treatment of diabetes, asthma and obesity. A review of the literature is presented.

Laser beam measurement of abdominal sagittal diameter in obese children: a validation study.

OBJECTIVES: Sagittal diameter (SAD) has been reported to correlate to visceral fat and cardiovascular risk factors. SAD is measured with the individual lying down, halfway between the lower rib margin and the iliac crest; it represents the mid-height of the abdomen. The aim of this study was to validate SAD measured using a recently-developed laser beam device (SAD(LDB) ) against SAD measured using MRI (SAD(MRI)). METHODS: Of 48 obese children (25 boys, 23 girls) aged 9-11 years on the waiting list for obesity treatment, 34 agreed to a baseline measurement, which was followed by repeated measurements 6 and 12 months later in 31 and 22 children respectively. MRI was used to examine SAD(MRI) at 5 cm above (SAD(MRI,cra) ) and below (SAD(MRI,cau)) the mid plane of the L4-5 intervertebral disc. RESULTS: Each of the differences SAD(LBD) - SAD(MRI, cau) and SAD(LBD) - SAD(MRI,cra) was subjected to a repeated-measurements ANOVA; the visit did not have a statistically significant effect in either case (p = 0.19 and p = 0.72, respectively). The difference SAD(LBD) - SAD(MRI, cau) was 1.50 on average (p < 0.0001; CI 1.26-1.74) while the corresponding figure for SAD(LBD) -SAD(MRI, cra) was 1.26 (p < 0.0001; CI 1.04-1.49). Regression of the difference on the mean gave slopes of -0.09 (p = 0.25) and -0.04 (p = 0.57) respectively. Prediction of SAD(MRI) from SAD(LDB) can be performed in different ways: by means of linear regression or by means of an additive correction. CONCLUSIONS: Thus, this laser device can be used instead of MRI to estimate SAD by using a simple correction.

Safety and immunogenicity of a glycoprotein D genital herpes vaccine in healthy girls 10-17 years of age: results from a randomised, controlled, double-blind trial.

OBJECTIVE: The investigational AS04-adjuvanted herpes simplex virus type 2 (HSV-2) glycoprotein D (gD2) subunit prophylactic vaccine ('HSV vaccine'; GlaxoSmithKline Vaccines) has been shown to be well tolerated in adults, but limited data exist for pre-teen and adolescent girls, a likely target population. The primary objective of this study was to compare the occurrence of serious adverse events (SAEs) over 12 months between HSV vaccine recipients and saline recipients (placebo control group) in pre-teen and adolescent girls. The immunogenicity of the HSV vaccine was also assessed. METHODS: Healthy girls aged 10-17 years, stratified by age (10-15 years; 16-17 years), were randomised 2:1:1 to receive the HSV vaccine, a hepatitis A vaccine (Havrix™; HAV control) or placebo (saline) according to a 0-, 1-, 6-month schedule. Participants and study personnel not involved in the preparation or administration of vaccines were blinded to treatment. Safety and immunogenicity analyses were performed overall and by age (10-15 years; 16-17 years) and HSV serostatus. RESULTS: No statistically significant difference in the percentage of subjects with SAEs was observed between the HSV and saline group, or between the HSV and pooled control (HAV and saline) groups. The HSV vaccine was well tolerated, although a higher incidence of solicited local symptoms was observed in the HSV group than in the control group. Neither age nor HSV serostatus at the time of study entry had an impact on the safety profile of this vaccine. The HSV vaccine was immunogenic regardless of pre-vaccination HSV serostatus. Higher anti-gD geometric mean concentrations were observed in HSV-1 seropositive participants than in HSV-1 seronegative participants. CONCLUSION: The HSV vaccine had an acceptable safety profile, and was well tolerated and immunogenic when administered to girls aged 10-17 years regardless of age or HSV pre-vaccination serostatus.

Metabolic risk-factor clustering estimation in children: to draw a line across pediatric metabolic syndrome.

BACKGROUND: The diagnostic criteria of the metabolic syndrome (MS) have been applied in studies of obese adults to estimate the metabolic risk-associated with obesity, even though no general consensus exists concerning its definition and clinical value. We reviewed the current literature on the MS, focusing on those studies that used the MS diagnostic criteria to analyze children, and we observed extreme heterogeneity for the sets of variables and cutoff values chosen. OBJECTIVES: To discuss concerns regarding the use of the existing definition of the MS (as defined in adults) in children and adolescents, analyzing the scientific evidence needed to detect a clustering of cardiovascular risk-factors. Finally, we propose a new methodological approach for estimating metabolic risk-factor clustering in children and adolescents. RESULTS: Major concerns were the lack of information on the background derived from a child's family and personal history; the lack of consensus on insulin levels, lipid parameters, markers of inflammation or steato-hepatitis; the lack of an additive relevant effect of the MS definition to obesity per se. We propose the adoption of 10 evidence-based items from which to quantify metabolic risk-factor clustering, collected in a multilevel Metabolic Individual Risk-factor And CLustering Estimation (MIRACLE) approach, and thus avoiding the use of the current MS term in children. CONCLUSION: Pediatricians should consider a novel and specific approach to assessing children/adolescents and should not simply derive or adapt definitions from adults. Evaluation of insulin and lipid levels should be included only when specific references for the relation of age, gender, pubertal status and ethnic origin to health risk become available. This new approach could be useful for improving the overall quality of patient evaluation and for optimizing the use of the limited resources available facing to the obesity epidemic.

Interventions to prevent obesity in children and adolescents: a systematic literature review.

OBJECTIVE: Preventive measures to contain the epidemic of obesity have become a major focus of attention. This report reviews the scientific evidence for medical interventions aimed at preventing obesity during childhood and adolescence. DESIGN: A systematic literature review involving selection of primary research and other systematic reviews. Articles published until 2004 were added to an earlier (2002) review by the Swedish Council on Technology Assessment in Health Care. METHODS: Inclusion criteria required controlled studies with follow-up of at least 12 months and results measured as body mass index, skinfold thickness or the percentage of overweight/obesity. Children could be recruited from normal or high-risk populations. RESULTS: Combining the new data with the previous review resulted in an evaluation of 24 studies involving 25 896 children. Of these, eight reported that prevention had a statistically significant positive effect on obesity, 16 reported neutral results and none reported a negative result (sign test; P=0.0078). Adding the studies included in five other systematic reviews yielded, in total, 15 studies with positive, 24 with neutral and none with negative results. Thus, 41% of the studies, including 40% of the 33 852 children studied, showed a positive effect from prevention. These results are unlikely to be a random chance phenomenon (P=0.000061). CONCLUSION: Evidence shows that it is possible to prevent obesity in children and adolescents through limited, school-based programs that combine the promotion of healthy dietary habits and physical activity.

The happy obese child.

OBJECTIVE: Firstly, is the negative psychological effect of obesity also present in the whole population of obese and overweight children? Secondly, what tools could be recommended to measure the psychological effects of obesity? DESIGN: Review. METHODS: Quality of life or self-esteem is often used in evaluating the psychological effects of obesity. Test instruments used have been instruments for measuring quality of life such as the pediatric quality of life inventory (PedsQL) or the KINDL instrument, and measurements of self-esteem, such as 'ITIA' ('I think I am) and the Self-Perception Profile for Children. RESULTS: The obese child studied in community samples has better quality of life and self-esteem than obese children from clinical samples. CONCLUSION: Psychosocial factors seem to be more important than the functional limitations of obesity itself. This means that we might help the obese child better by social support to a minor part of the population than to focus on the child's obesity as a cause of psychological problems. A happy obese child might have greater resources to cope with the problem than previously thought.

From birth to adolescence: Vienna 2005 European Childhood Obesity Group International Workshop.

BACKGROUND: In the last 15 y there has been a tremendous increase in the number of studies on pediatric obesity looking at epidemiology, health-related risks, etiology, methodology and treatment. During the early 1990s, the European Childhood Obesity Group (ECOG) was born as a group of scientists' expert in the field of pediatric obesity. ECOG this year celebrates the approach to early maturity with an excited and omni-comprehensive program developing through eight different tracks. METHODS: Comments on different 'key' papers in each of the eight tracks. RESULTS: The eight tracks were (1) Nutrition requirements and food habits, (2) physical activity, (3) prevention and political actions/strategies, (4) diabetes, (5) metabolism, (6) psychology, (7) pathology, and (8) treatment with emphasis on drugs. CONCLUSION: Looking at the overall picture of the ECOG workshop we could conclude that despite the fact that childhood obesity is a crisis facing worldwide youth, it is necessary that action to control it must be taken now. All the six relevant levels (ie, family, schools, health professionals, government, industry and media) could be involved in prevention of child and adolescent obesity.

Reactogenicity and immunogenicity profile of a two-dose combined hepatitis A and B vaccine in 1-11-year-old children.

This study was conducted to compare the reactogenicity, immunogenicity and safety of a combined two-dose (0, 6 months) hepatitis A and B vaccine (720ELU HAV, 20 mcg HBsAg) with the established three-dose (0, 1 and 6 months) hepatitis A and B vaccine (360ELU HAV, 10 mcg HBsAg). A total of 511 children aged 1-11 years who had not previously received a hepatitis A or B vaccine were enrolled in the study. Both vaccines were well tolerated, and were shown to be safe and immunogenic. The analysis, stratified according to two age groups (1-5 year and 6-11-year-old children) demonstrated that the reactogenicity profile of the two-dose schedule was at least as good as that of the established schedule. Both vaccines and schedules provided at least 98% seroprotection against hepatitis B and 100% seroconversion against hepatitis A, 1 month after the end of the vaccination course (Month 7).

Calculation of resting energy expenditure in obese children.

UNLABELLED: For the calculation of resting energy expenditure, which is the main part of total energy expenditure in children with low physical activity, Fusch et al. have developed an equation. CONCLUSION: This equation might be useful for research but not in daily work with obese patients.

Breastfeeding patterns: comparing the effects on infant behavior and maternal satisfaction of using one or two breasts.

In the Western world advice given by breastfeeding consultants about the use of one or two breasts at each feed has resulted in apparently arbitrary changes over time. This study compared 1-month-old breastfed infants' reactions to single- and two-breast feeds in terms of restlessness, crying, sleeping, and frequency of feeds, wet diapers, and loose stools. Eighty mothers were randomly assigned at the maternity ward, 44 to the single-breast group and 36 to the two-breast group. At one-month follow-up no differences between the groups were seen regarding any infant behavior variables, or in terms of maternal satisfaction, confidence, and mood throughout the full 24-hour observation period or during a 6-hour period in the evening. Compliance with the assigned feeding method was better in the two-breast than in the one-breast group. This may partly be due to tradition, since the two-breast practice has been recommended by child health nurses in Sweden for over 50 years. It seems reasonable that a baby should be allowed to finish the first breast and, if still hungary, be offered the second breast. The baby's appetite is the deciding factor.

Waist measurement correlates to a potentially atherogenic lipoprotein profile in obese 12-14-year-old children.

Epidemiological studies have indicated a relationship between overweight and cardiovascular disease. The present investigation was undertaken to identify anthropometric variables in childhood which may reflect the risk of cardiovascular disease in terms of unfavourable changes in apolipoprotein and lipid concentrations. Twenty-nine obese 14-year-olds and 32 obese 12-year-olds were recruited from a school screening programme and anthropometric data reflecting overweight and fat distribution were subjected to analysis of covariance, with blood pressure, apolipoprotein and lipid concentrations as dependent variables. Results from the two groups were adjusted for puberty, gender and screening group, allowing pooling of data. After such an adjustment, waist circumference was significantly correlated (r = partial correlation coefficient) to high density lipoprotein (HDL) cholesterol (r = -0.08, p < 0.05) and triglycerides (r = +0.24, p < 0.01). The waist:hip ratio was significantly correlated to HDL-cholesterol (r = -0.10, p < 0.01) and triglycerides (r = +0.22, p < 0.01). BMI was significantly correlated to triglycerides (r = +0.25, p < 0.001), and diastolic blood pressure (r = +0.08, p < 0.05). The partial regression coefficients for waist circumference versus apolipoprotein B (r = +0.07) and the apolipoprotein B:A-I ratio (r = +0.06) were as strong as those for waist:hip ratio (r = +0.03 and r = +0.05, respectively). Our results demonstrate that abdominal obesity is associated with an unfavourable lipid profile in obese 12-14-year-old children. This may be related to an increased cardiovascular risk later in life. The waist measurement appears to be a convenient and informative anthropometric indicator of such metabolic alterations.

Red cell sodium-potassium adenosine triphosphatase sites and intracellular sodium increased in obese school children.

Principally to ascertain whether mineral metabolism is involved in weight regulation, the 40 most obese of 1,774 children, aged 10-11 years, screened for obesity were compared with 46 age-matched controls. The obese children had more 3H-Ouabain erythrocyte binding sites (p = 0.04), higher intracellular sodium (p = 0.04), and lower plasma sodium (p = 0.002). After exclusion of the non-Scandinavians, the p values were p = 0.02, p = 0.03, and p = 0.03, respectively. Analysis of variance also showed the differences to be more dependent on obesity than on gender or nationality. It is concluded that obese children have more 3H-Ouabain erythrocyte binding sites indicating an increase of the sodium-potassium adenosine triphosphatase activity. The increase of intracellular sodium may increase the risk of future hypertension.