Managing cardiovascular risk in overweight children and adolescents

ISPAD Clinical Practice Consensus Guidelines 2024: Type 2 Diabetes in Children and Adolescents

Youth-onset type 2 diabetes (T2D) results from genetic, environmental, and metabolic causes that differ among individuals and populations. This chapter builds on the 2022 ISPAD guidelines and summarizes recent advances in the management of T2D in children and adolescents. Updates include diagnostic algorithm for youth with new onset T2D, algorithms and tables for treatment, management, and assessment of comorbidities and complications and recommendations on recently approved pharmacologic therapies for the treatment of youth-onset T2D and management strategies. Youth-onset type 2 diabetes (T2D) results from genetic, environmental, and metabolic causes that differ among individuals and populations. This chapter builds on the 2022 ISPAD guidelines and summarizes recent advances in the management of T2D in children and adolescents. Updates include diagnostic algorithm for youth with new onset T2D, algorithms and tables for treatment, management, and assessment of comorbidities and complications and recommendations on recently approved pharmacologic therapies for the treatment of youth-onset T2D and management strategies.

Treatment strategy for children and adolescents with type 2 diabetes-based on ISPAD Clinical Practice Consensus Guidelines 2022

The principles of treatment for children and adolescents with type 2 diabetes include dietary and exercise management. For dietary management, a relatively modest dietary regimen with an appropriate energy source composition is recommended. Moderate- to vigorous-intensity aerobic activity is recommended for at least 60 min/d. Family members are encouraged to modify their lifestyles. Some patients fail to improve hyperglycemia through dietary and exercise management and eventually require pharmacological treatment. If the patient is metabolically stable (HbA1c level < 8.5% [69 mmol/mol]), metformin is the first-line treatment of first choice. In a case with ketosis or HbA1c of more than 8.5% (69 mmol/mol), insulin will be required initially with once daily basal insulin (0.25-0.5 units/kg). The goal of the initial treatment is to attain an HbA1c level < 7.0% (53 mmol/mol). If the glycemic goal is not attained, the addition of a second agent should be considered. However, the use of antihyperglycemic drugs in pediatric patients is limited in most countries. Therefore, the efficacy and safety of these drugs used in adult patients, including GLP-1 receptor agonists and SGLT2 inhibitors, should be evaluated in pediatric patients worldwide.

Untargeted Metabolomics Analysis Using UHPLC-Q-TOF/MS Reveals Metabolic Changes Associated with Hypertension in Children

The mechanism of hypertension in children remains elusive. The objective of this study was to analyze plasma metabolomics characteristics to explore the potential mechanism of hypertension in children. Serum samples from 29 control children, 38 children with normal body mass index and simple hypertension (NBp), 8 children overweight with simple hypertension (OBp), 37 children with normal body mass index and H-type hypertension (NH) and 19 children overweight with H-type hypertension (OH) were analyzed by non-targeted metabolomics. A total of 1235 differential metabolites were identified between children with hypertension and normal controls, of which 193 metabolites including various lipids were significantly expressed. Compared with the control group, 3-dehydroepiandrosterone sulfate, oleic acid and linoleic acid were up-regulated, and gamma-muricholic acid was down-regulated in the NBp group; 3-dehydroepiandrosterone sulfate, 4-acetamidobutanoate and 1-hexadecanoyl-2-octadecadienoyl-sn-glyero-3-phosphocholine were up-regulated in the OBp group, whereas adenosine and 1-myristoyl-sn-glyero-3-phosphocholine were down-regulated; in the NH group, 1-palmitoyl-2-linoleoyl-sn-glycero-3-phosphocholine, phenol and 3-methoxytyramine were up-regulated, while pentadecanoic acid was down-regulated; in the OH group, NG,NG-dimethyl-L-arginine, 1-palmitoyl-sn-glycero-3-phosphocholine and monoethyl phthalate were up-regulated, while phloretin and glycine were down-regulated. The results showed that the children with hypertension had obvious disorders of lipid metabolism (especially in the overweight hypertension group), which led to the occurrence of hypertension. Additionally, the concentration of NO production-related NG, NG-dimethyl-L-arginine, was significantly increased, which may play an important role in H-type hypertension in children.

ISPAD Clinical Practice Consensus Guidelines 2022: Type 2 diabetes in children and adolescents

Since the 2018 ISPAD guidelines on this topic, follow-up of large cohorts from around the globe have continued informing the current incidence and prevalence of co-morbidities and complications in young adults with youth-onset type 2 diabetes (T2D). This chapter focuses on the risk factors, diagnosis and presentation of youth-onset T2D, the initial and subsequent management of youth-onset T2D, and management of co-morbidities and complications. We include key updates from the observational phase of the multi-center Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial, the SEARCH for Diabetes in Youth (SEARCH) study and new data from the Restoring Insulin Secretion (RISE) study, a head-to-head comparison of youth onset vs adult-onset T2D. We also include an expanded section on risk factors associated with T2D, algorithms and tables for treatment, management, and assessment of co-morbidities and complications, and sections on recently approved pharmacologic therapies for the treatment of youth-onset T2D, social determinants of health, and settings of care given COVID-19 pandemic.

Caring for US Children: Barriers to Effective Treatment in Children with the Disease of Obesity

In 2020, impediments to pediatric obesity (PO) treatment remain pervasive, even though these barriers are clearly documented in medical literature. Providers must invest considerable resources to overcome these barriers to care. Notable barriers include gaps in medical education, misperceptions of the disease, weight bias and stigma, exclusion of coverage in health plans, and thus an unsustainable financial framework. Hence, this review offers an updated social-ecological framework of accessibility to care, wherein each barrier to care or variable is interdependent on the other and each is critical to creating forward momentum. The sum of all these variables is instrumental to overall smooth function, configured as a wheel. To treat PO effectively, all variables must be adequately addressed by stakeholders throughout the health care system in order to holistically comprehend and appreciate undertakings to advance the burgeoning field of PO medicine.

Complications in Bariatric Surgery

Bariatric surgery represents the most valid option to treat the chronic disease of morbid obesity and all its related comorbid conditions with the purpose to increase life expectancy. Despite multiple recommendations of the different scientific societies, bariatric surgery remains worldwide largely underused. Considering only a 16% rate of obesity disease, with the largest number of bariatric surgeries performed in Europe of 50k procedures a year, France should need more than 200 years to surgically approach all morbid obese patients. Similarly, in the United States, obesity is a chronic condition that affects more than 1 in 3 adults, with a mean number of 250k bariatric procedures a year, hence they would need 437 years to manage this population. Definitely, the bariatric surgery is very poorly used and there are several factors to explain it. Inadequate access to medical care and insufficient information provided by the general practitioner are frequently encountered in our practice. But the main limitation for the bariatric treatment remains the patients' "fear" of a surgical complication.

Combined effect of different factors on weight status and cardiometabolic risk in Italian adolescents

Background

The observed increase in body weight and cardiometabolic risk (CR) in youth from developed countries contributes to the global burden of chronic diseases in adult age. The aim of this work is to provide a patterning of the associations between different factors and the weight status and CR of the subjects involved in the Italian ministerial ASSO project.

Methods

This study involved 919 students from high schools in Palermo. Weight, height and waist circumference were collected by trained teachers; weight status was estimated by the BMI cut-offs for adolescents and CR through the waist-to-height ratio. Questionnaires were administered through the web-based ASSO-NutFit software. Chi-square test investigated the variables significantly associated with the outcomes, which were then included in a Multiple Correspondence Analysis (MCA), to explore their dimensional relationship to weight status and CR. Poisson regressions were conducted separately for the two outcomes, reporting raw and adjusted prevalence ratios (PRs) and Bootstrap Method was used to determine confidence intervals (CIs), to assessing the degree of effect of the explanatory variables over the outcomes.

Results

Two main dimensions were evidenced, with the overweight/obese group and the group at CR characterized by the following strongly associated factors: male gender, overweight/obese parents, following a slimming regime, caesarean birth, sedentariness, being under/overweight at birth, presence of metabolic risk, going to school by car/scooter, not using supplements.

Conclusions

This study contributed to identifying those adolescents that should be prioritized in interventions aiming at reducing overweight/obesity and CR in this age group.

Electronic supplementary material

The online version of this article (10.1186/s13052-019-0619-9) contains supplementary material, which is available to authorized users.

Insufficient Sleep Is Associated with Obesity and Excessive Screen Time Amongst Ten-Year-Old Children in Sweden

PURPOSE

This study investigated sleep, television, computer habits, and obesity in school-age children.

DESIGN AND METHODS

This was a cross-sectional self-report survey of 1260 children in grade 4 (mean age, 10.1) living in southern Sweden (49.1% boys). The heights and weights of 1097 (87.1%) of the children were recorded. Descriptive statistics, bivariate analyses, and multiple logistic regression were employed.

RESULTS

The median length of self-reported sleep on weeknights was 9.5h. Approximately 40% of the children reported receiving <9h of sleep. The median bedtime was 9PM (21:00). On weekends, the median bedtime was 1 h later, and they delayed getting up by 1.5h. The median time spent watching TV and using a computer was 1 h each. The prevalence of being overweight (including obesity) was 18%. Insufficient sleep (<9h) was associated with being overweight, watching TV, or using a computer for two or more hours each day, difficulty falling asleep, and being tired at school.

CONCLUSIONS

School-age children who receive less sleep are more likely to be overweight and report excessive television and computer use. A strong and urgent need exists to highlight the importance of healthy sleep and media habits. It is challenging for pediatric nurses and school nurses to teach children and their families about healthy sleep and media habits.

New insights into the pharmacological treatment of pediatric patients with type 2 diabetes

The principal treatment for children and adolescents with type 2 diabetes is dietary and exercise management. However, the blood glucose levels of some patients receiving this treatment fail to improve; thus, pharmacological treatment is eventually required. The pathophysiology of type 2 diabetes in pediatric patients appears to be similar to that in adults; thus, the range of antidiabetic drugs used in adults is likely to be effective in pediatric patients as well. However, in the majority of countries, including Japan, only metformin, glimepiride, and insulin have been approved for use in pediatric patients. Indeed, the evidence for the usefulness of antidiabetic drugs other than metformin and insulin in children and adolescents is limited at this time. Therefore, the efficacy and safety of various antidiabetic drugs, including DPP-4 inhibitors, GLP-1 receptor agonists, and SGLT2 inhibitors, which are used in adult patients, should be evaluated in the pediatric population in a large number of centers worldwide. In addition, it is critical that researchers and clinicians establish treatment guidelines for children and adolescents with type 2 diabetes in all racial groups worldwide.

Rationale and design of GENEiUS: a prospective observational study on the genetic and environmental determinants of body mass index evolution in Canadian undergraduate students

INTRODUCTION

Obesity is a global epidemic and is a risk factor for developing other comorbidities. Young adulthood is a critical period for body weight change and establishing healthy lifestyle behaviours. The 'Freshman 15' suggests that undergraduate students gain 15 lbs (6.8 kg) during their first year of university, although evidence estimates a more modest weight gain of approximately 3-5 lbs (1.4-2.3 kg). Previous studies have only investigated weight change in the first year and do not study potential risk factors. Genetic and EnviroNmental Effects on weight in University Students (GENEiUS) is a prospective observational study which will investigate the environmental and biological determinants of weight change in undergraduate students over 4 years.

METHODS AND ANALYSIS

The GENEiUS study will recruit 2500 multiethnic undergraduates aged 17-25 years at McMaster University at the start of their first year and will follow them every 6 months for 4 years. Primary outcomes are obesity traits: body mass index, waist circumference, waist-to-hip ratio, body fat mass and body fat percentage. The contribution of well-established and novel genetic variants for obesity traits and heritability values will be derived from whole-genome single-nucleotide polymorphism genotyping arrays. Civil status, age, sex, ethnicity, length of residence in Canada, religiosity, energy intake, physical activity, exercise motivation, electronic screen time, sleep patterns, history of assault, smoking status, alcohol consumption, medication and drug use, stress, impulsivity, body image perception, self-esteem, anxiety, eating disorders and depression will be investigated for their effect on obesity traits. The findings of the GENEiUS study will be used to help design obesity prevention programme in North American universities with multiethnic populations.

ETHICS AND DISSEMINATION

Ethical approval of the study protocol has been obtained from the Hamilton Integrated Research Ethics Board. Study results will be disseminated through scientific publications, scholarly meetings, and collaborative meetings with university administration and student groups.

Effectiveness of a publicly funded clinical paediatric weight management program on obesity outcomes

OBJECTIVE

To determine the effectiveness of a publicly funded, paediatric weight management clinic in decreasing obesity.

METHODS

A retrospective chart review of patients four to 16 years of age, from 2006 to 2009, was performed at a medically supervised weight management clinic (n=121). Patients participated in monthly visits and were educated about the cognitive behavioural and nutritional aspects of weight management.

RESULTS

The sample included 51 male and 70 female patients with a mean (± SD) initial age of 11.7±3.0 years. Patients participated in 6.4±6.5 visits (range one to 31 visits) over 13.7±15.5 months and 7.4% of patients discontinued treatment after their initial visit. Of the patients who attended the clinic >1 time, 66.1% attended for at least four months, 48.2% attended for >8 months and 33.0% attended for >1 year. Over the course of their treatment, patients experienced a weight gain of 3.8±9.5 kg, but a reduction in body mass index (BMI) percentile (-1.1±3.6%). Post-treatment, the prevalence of obesity decreased from 96.7% to 87.5%. Patients with longer treatment times (>12 months) attained significantly lower final BMI percentiles than patients with shorter treatment times; however, there was no difference in the rate of reduction. Initial treatment age, sex and medical conditions were not related to BMI percentile change.

CONCLUSIONS

This paediatric weight management program effectively reduced the prevalence of obesity. Patients who had longer treatment times experienced greater reductions in obesity. Overall, the present study highlights that long-term patient attendance may be needed to better support paediatric weight management patients.

Passive commuting and dietary intake in fourth and fifth grade students

BACKGROUND

Promoting active commuting by walking or biking to and from school could increase physical activity and reduce obesity among youth. However, exposure to the retail food environment while commuting may lead to greater dietary intake among active commuters.

PURPOSE

To examine the relationship between commute patterns and dietary intake and quality in elementary students.

METHODS

Fourth and fifth grade students (N=3,316) in 44 California schools reported commute modes to and from school and dietary intake for the same 24-hour period in 2012. Differences between active and passive commuters in total energy intake (kcal), energy from purchased foods, and energy from sweets and snack-type foods were compared, stratified by after-school program (ASP) participation (analysis conducted in 2013).

RESULTS

Twenty-three percent of youth actively commuted to school; 27% actively commuted from school. Passive commuters, 87% of whom traveled by car, consumed 78 more kcal from purchased foods (p<0.01) than active commuters in the 24-hour period, though total energy intake did not differ by commute mode overall or by ASP participation. Among the 72% of students who did not attend an ASP, passive commuters consumed 56 more kcal from purchased foods (p<0.01) and 25 more kcal from sweets and snack-type foods (p=0.02) than active commuters.

CONCLUSIONS

Passive commuters consumed more sweets and snack-type foods and more purchased foods than active commuters. These results, which suggest that parents are providing unhealthy foods for their children during the school commute, reinforce the need for multilevel strategies to promote energy balance in youth.

Correlation between antrhopometric indicators and blood pressure in adolescents

The objective of the present study was to analyze the correlation between anthropometric indicators and blood pressure of adolescents from Imperatriz, state of Maranhão, Brazil. It is a quantitative cross-sectional study, developed between September and November of 2012 with 218 students. We used a questionnaire to collect data regarding identification, anthropometrics, and systolic and diastolic blood pressure. Considering blood pressure, we found that 4.6%, 2.4% and 1.3% of the sample were included in the borderline, stage 1 and stage 2 hypertension categories, respectively. Among female participants, body adiposity index and skinfold presented higher mean values than those of their male counterparts. Furthermore, we observed a positive correlation between systolic blood pressure and height (r=0.18), weight (r=0.20) and waist circumference (r=0.17), and a negative correlation between diastolic blood pressure and body adiposity index (r=-0.18). The measures of neck and waist circumference were the only anthropometric measures with positive and simultaneous correlations with systolic blood pressure for both genders.

Obesity and lifespan health--importance of the fetal environment

A marked increase in the frequency of obesity at the population level has resulted in an increasing number of obese women entering pregnancy. The increasing realization of the importance of the fetal environment in relation to chronic disease across the lifespan has focused attention on the role of maternal obesity in fetal development. Previous studies have demonstrated that obesity during adolescence and adulthood can be traced back to fetal and early childhood exposures. This review focuses on factors that contribute to early developmental events, such as epigenetic modifications, the potential for an increase in inflammatory burden, early developmental programming changes such as the variable development of white versus brown adipose tissue, and alterations in organ ontogeny. We hypothesize that these mechanisms promote an unfavorable fetal environment and can have a long-standing impact, with early manifestations of chronic disease that can result in an increased demand for future health care. In order to identify appropriate preventive measures, attention needs to be placed both on reducing maternal obesity as well as understanding the molecular, cellular, and epigenetic mechanisms that may be responsible for the prenatal onset of chronic disease.

Effect of BMI on cardiovascular and metabolic syndrome risk factors in an Appalachian pediatric population

BACKGROUND

The purpose of this study was to characterize cardiovascular risk factors in a rural pediatric population by body mass index (BMI) category and the presence of the metabolic syndrome.

METHODS

Data on 13,018 children and adolescents (aged younger than 20 years) from West Virginia and Ohio in 2005-2006 were obtained from the C8 Health Project to determine the prevalence of overweight/obesity and the metabolic syndrome, which was then compared with National Health and Nutrition Examination Survey 2005-2006 data. Cardiovascular risk factors were assessed by age-standardized and sex-standardized BMI category (<85th, 85th-95th, >95th percentiles) and the presence of metabolic syndrome, defined as the presence of three or more of the following criteria: BMI >97th percentile, triglycerides >110 mg/dL, high-density lipoprotein cholesterol <40 mg/dL, and fasting blood glucose >110 mg/dL.

RESULTS

The population was 51% male and 95% white. The prevalence of overweight/obesity was 38% and metabolic syndrome was 4.6% in the C8 population, compared with a prevalence of 30% and 3.4%, respectively, within the National Health and Nutrition Examination Survey population. In our Appalachian population, a significant adverse trend across BMI categories was observed for lipids, insulin, inflammatory markers, white blood cell count, and C-reactive protein. Significant differences in these risk factors were seen among those with metabolic syndrome compared with those without metabolic syndrome.

CONCLUSION

The increased prevalence of overweight/obesity and the metabolic syndrome along with the increase in cardiovascular risk factors in Appalachian children and adolescents, suggests a cohort that may develop earlier onset and possibly increased severity of cardiovascular disease and other complications associated with metabolic syndrome and obesity.