Type 2 diabetes in children

Maternal pre-pregnancy body mass index is associated with newborn offspring hypothalamic mean diffusivity: a prospective dual-cohort study

BACKGROUND

An extensive body of animal literature supports the premise that maternal obesity during pregnancy can alter the development of the fetal hypothalamus (HTH, a critical regulator of energy balance) with implications for offspring obesity risk (i.e., long-term energy imbalance). Yet, the relationship in humans between maternal overweight/obesity during pregnancy and fetal hypothalamic development remains largely unknown. Here, using an international (Finland and California, USA) multi-site diffusion tensor imaging (DTI) dataset, we test the hypothesis that maternal pre-pregnancy BMI is associated with newborn offspring HTH mean diffusivity (HTH MD, a replicable neural correlate of BMI in adults).

METHODS

HTH MD was independently quantified in two separate BMI-matched cohorts (up to class II obesity; BMIRange = 17-35) using a high-resolution atlas-based definition of HTH. A total of n = 231 mother-child dyads were available for this analysis (nSite,1 = 152, age at MRI = 26.7 ± 8.1 days, gestational age at birth = 39.9 ± 1.2 weeks, nM/F = 82/70, BMI = 24.2 ± 3.8; nSite,2 = 79, age at MRI = 25.6 ± 12.5 days, gestational age at birth = 39.3 ± 1.5 weeks, nM/F = 45/34, BMI = 25.1 ± 4.0). The association between maternal pre-pregnancy BMI and newborn offspring HTH MD was examined separately in each cohort using linear regression adjusting for gestational age at birth, postnatal age at scan, sex, whole white matter mean diffusivity, and DTI quality control criteria. In post hoc analyses, additional potentially confounding factors including socioeconomic status, ethnicity, and obstetric risk were adjusted where appropriate.

RESULTS

The distribution of maternal pre-pregnancy BMI was comparable across sites but differed by ethnicity and socioeconomic status. A positive linear association between maternal pre-pregnancy BMI and newborn offspring HTH MD was observed at both sites ([Formula: see text]Site,1 = 0.17, pSite,1 = 0.01; [Formula: see text]Site,2 = 0.22, pSite,2 = 0.03) and remained significant after adjusting for cohort-relevant covariates.

CONCLUSIONS

These findings translate the preclinically established association between maternal obesity during pregnancy and offspring hypothalamic microstructure to the human context. In addition to further replication/generalization, future efforts to identify biological mediators of the association between maternal obesity and fetal HTH development are warranted to develop targeted strategies for the primary prevention of childhood obesity.

Maternal free fatty acid concentration during pregnancy is associated with newborn hypothalamic microstructure in humans

OBJECTIVE

This study tested the hypothesis, in a prospective cohort study design, that maternal saturated free fatty acid (sFFA) concentration during pregnancy is prospectively associated with offspring (newborn) hypothalamic (HTH) microstructure and to explore the functional relevance of this association with respect to early-childhood body fat percentage (BF%).

METHODS

In N = 94 healthy newborns (born mean 39.3 [SD 1.5] weeks gestation), diffusion-weighted magnetic resonance imaging was performed shortly after birth (25.3 [12.5] postnatal days), and a subgroup (n = 37) underwent a dual-energy x-ray absorptiometry scan in early childhood (4.7 [SD 0.7] years). Maternal sFFA concentration during pregnancy was quantified in fasting blood samples via liquid chromatography-mass spectrometry. Infant HTH microstructural integrity was characterized using mean diffusivity (MD). Multiple linear regression was used to test the association between maternal sFFA and HTH MD, accounting for newborn sex, age at scan, mean white matter MD, and image quality. Multiple linear regression models also tested the association between HTH MD and early-childhood BF%, accounting for breastfeeding status.

RESULTS

Maternal sFFA during pregnancy accounted for 8.3% of the variation in newborn HTH MD (β-std = 0.25; p = 0.006). Furthermore, newborn HTH MD prospectively accounted for 15% of the variation in early-childhood BF% (β-std = 0.32; p = 0.019).

CONCLUSIONS

These findings suggest that maternal overnutrition during pregnancy may influence the development of the fetal hypothalamus, which, in turn, may have clinical relevance for childhood obesity risk.

Fetal programming of human energy homeostasis brain networks: Issues and considerations

In this paper, we present a transdisciplinary framework and testable hypotheses regarding the process of fetal programming of energy homeostasis brain circuitry. Our model proposes that key aspects of energy homeostasis brain circuitry already are functional by the time of birth (with substantial interindividual variation); that this phenotypic variation at birth is an important determinant of subsequent susceptibility for energy imbalance and childhood obesity risk; and that this brain circuitry exhibits developmental plasticity, in that it is influenced by conditions during intrauterine life, particularly maternal-placental-fetal endocrine, immune/inflammatory, and metabolic processes and their upstream determinants. We review evidence that supports the scientific premise for each element of this formulation, identify future research directions, particularly recent advances that may facilitate a better quantification of the ontogeny of energy homeostasis brain networks, highlight animal and in vitro-based approaches that may better address the determinants of interindividual variation in energy homeostasis brain networks, and discuss the implications of this formulation for the development of strategies targeted towards the primary prevention of childhood obesity.

Estimation of metabolic syndrome in acanthosis nigricans - A hospital based cross-sectional study

Background and Objectives

Acanthosis nigricans is characterized by hyperpigmentation and velvet-like thickening of the skin. It symmetrically involves the neck, axilla, groins, antecubital and popliteal fossae, umbilical, and perianal areas. Acanthosis nigricans is a marker for insulin resistance and is increasingly found to be associated with metabolic syndrome. We conducted this study to estimate the frequency of metabolic syndrome in acanthosis nigricans.

Methods

In this hospital-based, cross-sectional study, we evaluated 60 patients with acanthosis nigricans with neck involvement. They were examined for other areas of involvement by acanthosis nigricans. Axillary and neck severity was graded based on the scale described by Burke et al. Insulin resistance was interpreted using homeostatic model assessment (HOMA-IR). Metabolic syndrome was diagnosed according to the SAM-NCEP criteria. Collected data were analyzed using IBM SPSS Statistics, Version 22 (Armonk, NY: IBM Corp).

Results

Axilla was the most common site involved in 51 patients (85%) followed by knuckles (55%). Metabolic syndrome was found in 78.3% of our patients, and 56.66% had insulin resistance. A statistically significant association of severity grading of axillary acanthosis nigricans with both metabolic syndrome (P = 0.001) and insulin resistance (P = 0.03) was noted. However, no meaningful association was found between the severity grading of neck acanthosis nigricans with both metabolic syndrome (P = 0.4) and insulin resistance (P = 0.08). The association of neck texture grading of acanthosis nigricans with insulin resistance was statistically significant (P = 0.005).

Conclusions

Metabolic syndrome was seen in 78.3% of acanthosis nigricans. Axillary severity grading was associated with metabolic syndrome.

Obesogenic Behaviors of Rural Children on School and Nonschool Days

Background: Children living in rural areas are at increased risk of overweight and obesity compared with their urban-dwelling counterparts. The purpose of this study was to provide preliminary evidence of rural children's obesogenic behaviors (e.g., activity, sedentary behaviors, sleep, and diet) during school days, nonschool weekdays, and weekend days. Methods: A repeated measures 14-day observational study was conducted early March 2020. Children (n = 54, 92% 6-11 years old; 66% female; 98% non-Hispanic white; 22% overweight or obese) wore accelerometers on the nondominant wrist for 24 hours/day for 14 consecutive days to capture moderate-to-vigorous physical activity (MVPA), sedentary time, and sleep. Parents completed diaries to report daily activities, diet, and screen time of their child each day. Mixed effect models compared behaviors between school days, nonschool weekdays, and weekend days. Results: Children accumulated +16 additional minutes/day of MVPA (95% confidence interval, CI: +10 to +23 minutes/day), reduced sedentary time (-68 minutes/day, 95% CI: -84 to -51 minutes/day), and reduced screen time (-99 minutes/day; 95% CI: -117 to -81 minutes/day) on school days vs. nonschool weekdays. Similar patterns were observed on school weekdays days vs. weekend days, and on nonschool days when children attended a structured program vs. days they did not attend. Minimal differences were observed in reported consumption of food groups across different days. Conclusions: Preliminary evidence suggests rural children display multiple unfavorable obesogenic behaviors on days when they do not attend school or other structured programs. Future interventions targeting obesogenic behaviors of rural children may want to target times when rural children are not engaged in school and "school-like" environments.

Family history of non-communicable diseases and associations with weight and movement behaviours in Australian school-aged children: a prospective study

OBJECTIVE

To assess differences in weight status and movement behaviour guideline compliance among children aged 5-12 years with and without a family history of non-communicable diseases (NCDs).

DESIGN

Prospective.

SETTING AND PARTICIPANTS

Women born between 1973 and 1978 were recruited to the Australian Longitudinal Study on Women's Health (ALSWH) via the database of the Health Insurance Commission (now Medicare; Australia's universal health insurance scheme). In 2016-2017, women in that cohort were invited to participate in the Mothers and their Children's Health Study and reported on their three youngest children (aged <13 years). Data from children aged 5-12 years (n=4416) were analysed.

MEASURES

Mothers reported their children's height and weight, used to calculate body mass index (kg/m²), physical activity, screen time and sleep. In the 2015 ALSWH Survey, women reported diagnoses and family history of type 2 diabetes, heart disease and hypertension. Logistic regression models determined differences between outcomes for children with and without a family history of NCDs.

RESULTS

Boys with a family history of type 2 diabetes had 30% (95% CI: 0.51%-0.97%) and 43% lower odds (95% CI: 0.37%-0.88%) of meeting the sleep and combined guidelines, respectively, and 40% higher odds (95% CI: 1.01%- 1.95%) of being overweight/obese. Girls with a family history of hypertension had 27% lower odds (95% CI: 0.57%-0.93%) of meeting the screen time guidelines. No associations were observed for family history of heart disease.

CONCLUSIONS

Children who have a family history of type 2 diabetes and hypertension may be at risk of poorer health behaviours from a young age. Mothers with a diagnosis or a family history of these NCDs may need additional support to help their children develop healthy movement behaviours and maintain healthy weight.

Atypical diabetes: a diagnostic challenge

In medical school, we learned how to classify diabetes according to different clinical characteristics. However, at the dawn of the precision medicine era, it is clear that today's clinical reality does not always align well with textbook teachings. The terms juvenile versus elderly-onset diabetes, as well as insulin-dependent versus non-insulin-dependent diabetes, have become obsolete. Contrary to what is often taught severe ketoacidosis may occur in type 2 diabetes. Patients may also suffer from two or more forms of diabetes simultaneously or consecutively. Five authentic cases of diabetes with uncommon characteristics that pose diagnostic challenges are presented here.

Intergenerational transmission of the effects of maternal exposure to childhood maltreatment on offspring obesity risk: A fetal programming perspective

Childhood obesity constitutes a major global public health challenge. A substantial body of evidence suggests that conditions and states experienced by the embryo/fetus in utero can result in structural and functional changes in cells, tissues, organ systems and homeostatic set points related to obesity. Furthermore, growing evidence suggests that maternal conditions and states experienced prior to conception, such as stress, obesity and metabolic dysfunction, may spill over into pregnancy and influence those key aspects of gestational biology that program offspring obesity risk. In this narrative review, we advance a novel hypothesis and life-span framework to propose that maternal exposure to childhood maltreatment may constitute an important and as-yet-underappreciated risk factor implicated in developmental programming of offspring obesity risk via the long-term psychological, biological and behavioral sequelae of childhood maltreatment exposure. In this context, our framework considers the key role of maternal-placental-fetal endocrine, immune and metabolic pathways and also other processes including epigenetics, oocyte mitochondrial biology, and the maternal and infant microbiomes. Finally, our paper discusses future research directions required to elucidate the nature and mechanisms of the intergenerational transmission of the effects of maternal childhood maltreatment on offspring obesity risk.

South Asian Children Have Increased Body Fat in Comparison to White Children at the Same Body Mass Index

The ability of body mass index (BMI) to predict excess fat in South Asian children is unknown. This cross-sectional study examines the influence of ethnicity on body fatness in children. Weight status and body fat were determined using BMI, waist circumference (WC), two skinfold sites (SF; triceps and subscapula) and leg-to-leg bioelectrical impedance analysis (BIA; Tanita BF350, Tanita, Tokyo, Japan) in 194 children aged 8.47 ± 0.50 years from Coventry, United Kingdom. Biological maturity was also determined. Analysis of covariance (ANCOVA) identified significant differences between ethnic (p < 0.001) and gender groups’ BMI (p = 0.026), with a significant covariate for skinfold (p < 0.001) and bioelectrical impedance (p < 0.001). For a given body fat value, South Asian children and females had a lower BMI value (−1.12 kg/m², p < 0.001 and −0.50 kg/m², p = 0.026, respectively, when adjusted for SF; −1.56 kg/m², p < 0.001 and −0.31 kg/m², p = 0.16, respectively, when adjusted for BIA) compared with white children and boys. The prediction model including ethnicity, gender and BIA explained 80.4% of the variance in BMI. Maturation was not found to be a significant covariate (p > 0.05). To conclude, the findings suggest that BMI cut-points may need to be lowered in South Asian children, and thus age-by-sex-by-ethnicity specific BMI cut-points are needed in children. Further research examining body composition with health parameters in this population is needed.

Entrenched obesity in childhood: findings from a national cohort study

PURPOSE

Given the high levels of obesity among U.S. children, we examine whether obesity in childhood is a passing phenomenon or remains entrenched into adolescence.

METHODS

Data are from the prospective nationally representative Early Childhood Longitudinal Study, Kindergarten Class of 1998-1999 (analytic sample = 6600). Anthropometrics were measured six times during 1998-2007. Overweight and obesity were defined using CDC cut-points. Entrenched obesity was defined as obesity between ages 5-9 coupled with persistent obesity at ages 11 and 14.

RESULTS

Almost 30% of children experienced obesity at some point between ages 5.6 and 14.1 years; 63% of children who ever had obesity between ages 5.6 and 9.1 and 72% of those who had obesity at kindergarten entry experienced entrenched obesity. Children with severe obesity in kindergarten or who had obesity at more than 1 year during early elementary were very likely to experience obesity through age 14, regardless of their sex, race, or socioeconomic backgrounds.

CONCLUSIONS

Prevention should focus on early childhood, as obesity at school entry is not often a passing phenomenon. Even one timepoint of obesity measured during the early elementary school years may be an indicator of risk for long-term obesity.

Newborn insula gray matter volume is prospectively associated with early life adiposity gain

Background

The importance of energy homeostasis brain circuitry in the context of obesity is well established, however, the developmental ontogeny of this circuitry in humans is currently unknown. Here, we investigate the prospective association between newborn gray matter (GM) volume in the insula, a key brain region underlying energy homeostasis, and change in percent body fat accrual over the first six months of postnatal life, an outcome that represents among the most reliable infant predictors of childhood obesity risk.

Methods

52 infants (29 male, 23 female, gestational age at birth=39[1.5] weeks) were assessed using structural MRI shortly after birth (postnatal age at MRI scan=25.9[12.2] days), and serial Dual X-Ray Absorptiometry shortly after birth (postnatal age at DXA scan 1=24.6[11.4] days) and at six months of age (postnatal age at DXA scan 2=26.7[3.3] weeks).

Results

Insula GM volume was inversely associated with change in percent body fat from birth to six-months postnatal age and accounted for 19% of its variance (β=-3.6%/S.D., p=0.001). This association was driven by the central-posterior portion of the insula, a region of particular importance for gustation and interoception. The direction of this effect is in concordance with observations in adults, and the results remained statistically significant after adjusting for relevant covariates and potential confounding variables.

Conclusions

Together, these findings suggest an underlying neural basis of childhood obesity that precedes the influence of the postnatal environment. The identification of plausible brain-related biomarkers of childhood obesity risk that predate the influence of the postnatal obesogenic environment may contribute to an improved understanding of propensity for obesity, early identification of at-risk individuals, and intervention targets for primary prevention.

Managing care of type 2 diabetes. Learnings from T2ARDIS*

The T2ARDIS* survey reported total resource use in the NHS and Social Services for people with type 2 diabetes.

Patients and methods Cross-sectional postal survey data were acquired from a random sample of people diagnosed with type 2 diabetes from population-wide diabetes registers. Aggregated resource use, implications for healthcare management, and costs in the NHS and Social Services were considered. The data were compared to resource data in the general population to determine the impact of developing diabetic complications, particularly vascular disease. Implications for services were also considered.

Results At a population level, on average one in four patients reported microvascular complications, one in 10 macrovascular complications and one in 14 reported both. Compared to the general population, people with type 2 diabetes were admitted to hospital more often and stayed longer as in-patients. This trend was similar for out-patient care. Across the whole cohort, more than 40% of the NHS cost was due to in-patient care. Diabetic complications increased costs in the NHS and Social Services, costs of insulin products and other drugs. The average annual spend on oral antidiabetic drugs accounted for only 2% of NHS costs for diabetes.

Conclusion Most of the costs of care for the person with type 2 diabetes are borne by the NHS and the hospital sector. T2ARDIS* has probably under-estimated costs of the co-morbidity of type 2 diabetes. Complications significantly increase costs across all sectors. Evidence indicates that preventing the vascular complications of diabetes could avoid or delay hospitalisations and disability. Targeting resources should optimise the use of available services.

Diet and physical activity for children's health: a qualitative study of Nepalese mothers' perceptions

OBJECTIVES

Non-communicable diseases account for 50% of all deaths in Nepal and 25% result from cardiovascular diseases. Previous studies in Nepal indicate a high burden of behavioural cardiovascular risk factors, suggesting a low level of knowledge, attitude and practice/behaviour regarding cardiovascular health. The behavioural foundation for a healthy lifestyle begins in early childhood, when mothers play a key role in their children's lives. This qualitative study, conducted in a Nepalese peri-urban community, aimed to explore mothers' perception of their children's diet and physical activity.

DESIGN

We notated, tape-recorded and transcribed all data collected from six focus group discussions, and used qualitative content analysis for evaluation and interpretation.

SETTING

The study was conducted in the Jhaukhel-Duwakot Health Demographic Surveillance Site in the Bhaktapur district of Nepal.

PARTICIPANTS

Local health workers helped recruit 61 women with children aged 5-10 years. We distributed participants among six different groups according to educational status.

RESULTS

Although participants understood the importance of healthy food, they misunderstood its composition, perceiving it as unappetising and appropriate only for sick people. Furthermore, participants did not prioritise their children's physical activities. Moreover, mothers believed they had limited control over their children's dietary habits and physical activity. Finally, they opined that health educational programmes would help mothers and recommended various intervention strategies to increase knowledge regarding a healthy lifestyle.

CONCLUSIONS

Our data reveal that mothers of young children in a peri-urban community of Nepal lack adequate and accurate understanding about the impact of a healthy diet and physical activity. Therefore, to prevent future cardiovascular disease and other non-communicable diseases among children, Nepal needs health education programmes to improve mothers' cardiovascular health knowledge, attitude and behaviour.

Central obesity, type 2 diabetes and insulin: exploring a pathway full of thorns

The prevalence of type 2 diabetes (T2D) is rapidly increasing. This is strongly related to the contemporary lifestyle changes that have resulted in increased rates of overweight individuals and obesity. Central (intra-abdominal) obesity is observed in the majority of patients with T2D. It is associated with insulin resistance, mainly at the level of skeletal muscle, adipose tissue and liver. The discovery of macrophage infiltration in the abdominal adipose tissue and the unbalanced production of adipocyte cytokines (adipokines) was an essential step towards novel research perspectives for a better understanding of the molecular mechanisms governing the development of insulin resistance. Furthermore, in an obese state, the increased cellular uptake of non-esterified fatty acids is exacerbated without any subsequent β-oxidation. This in turn contributes to the accumulation of intermediate lipid metabolites that cause defects in the insulin signaling pathway. This paper examines the possible cellular mechanisms that connect central obesity with defects in the insulin pathway. It discusses the discrepancies observed from studies organized in cell cultures, animal models and humans. Finally, it emphasizes the need for therapeutic strategies in order to achieve weight reduction in overweight and obese patients with T2D.

Need for specific sugar-sweetened beverage lessons for fourth- and fifth-graders

OBJECTIVE

Consumption of sugar-sweetened beverages (SSB) is linked to obesity. The authors hypothesized that school-based nutrition education would decrease SSB consumption.

DESIGN

Self-selected interventional cohort with random selection for pre and post measurements.

SETTING

Arizona Supplemental Nutrition Assistance Program-Education Program-eligible schools.

PARTICIPANTS

Randomly selected (9%) fourth- and fifth-grade classroom students.

INTERVENTION

The University of Arizona Nutrition Network provided general nutrition education training and materials to teachers, to be delivered to their students. The University of Arizona Nutrition Network administered behavioral questionnaires to students in both fall and spring.

MAIN OUTCOME MEASURE(S)

Change in SSB consumption.

ANALYSES

Descriptive statistics were computed for student demographics and beverage consumption on the day before testing. Paired t tests evaluated change in classroom averages. Linear regression assessed potential correlates of SSB consumption.

RESULTS

Fall mean SSB consumption was 1.1 (± 0.2) times; mean milk and water intake were 1.6 (± 0.2) and 5.2 (± 0.7) times, respectively. Beverage consumption increased (3.2%) in springtime, with increased SSBs (14.4%) accounting for the majority (P = .006). Change in SSB consumption was negatively associated with baseline SSB and water consumption but positively associated with baseline milk fat (P ≤ .05).

CONCLUSIONS AND IMPLICATIONS

The results suggest the need for beverage-specific education to encourage children to consume more healthful beverages in warmer weather.

The Frequency of Type 2 Diabetes Mellitus among Diabetic Children in El Minia Governorate, Egypt

OBJECTIVES

Type 2 diabetes mellitus (T2DM) in children and adolescents is becoming an increasingly important public health concern throughout the world. This study aimed to estimate the frequency of T2DM among diabetic young people in El-Minia Governorate, Egypt, and to detect its risk factors.

METHODS

A total of 210 diabetic patients under 18 years old in Minia Governorate were included in the study and underwent a thorough history-taking, a physical examination and laboratory investigations.

RESULTS

T2DM was present in 28 patients (13.3%); it was significantly present in 18 females (64.3%) and 20 (71.4%) of them had a positive family history of DM. T2DM patients had significantly higher BMI and waist circumference centiles for age and sex than those with T1DM. Also, haemoglobin A1c %, serum C-peptide and cholesterol levels were significantly higher in T2DM than T1DM patients. Finally, there were weak significant positive correlations between C-peptide level and both BMI and waist circumference.

CONCLUSION

T2DM is no longer a disease of adults but can also occur in children and adolescents. The results suggested that obesity, female gender and a positive family history of DM are risk factors for T2DM. Also, patients with T2DM had poorer glycaemic control and hypercholesterolemia than those with other types of diabetes.

Does weight affect children's test scores and teacher assessments differently?

The prevalence of childhood overweight and obesity increased dramatically in the United States during the past three decades. This increase has adverse public health implications, but its implication for children's academic outcomes is less clear. This paper uses data from five waves of the Early Childhood Longitudinal Study-Kindergarten to examine how children's weight is related to their scores on standardized tests and to their teachers' assessments of their academic ability. The results indicate that children's weight is more negatively related to teacher assessments of their academic performance than to test scores.

Epidemiology of Diabetes

The incidence of diabetes mellitus, particularly type 2 diabetes, is increasing dramatically in the United States and in other Westernized, industrialized societies because of increasing obesity, sedentary lifestyle, and population aging. There are currently 20 million persons with diabetes in the United States, of whom more than 5 million remain undiagnosed. The diabetic population consumes a disproportionate share of health care resources because of both microvascular and macrovascular complications. Diabetes is a major cause of new-onset blindness, end-stage renal disease, and nontraumatic amputation in the United States. Cardiovascular disease accounts for up to 80% of premature excess mortality in diabetic patients. Strategies to lessen the disease burden in these patients include hygienic measures (diet and exercise) as well as rigorous treatment of hypertension, dyslipidemia, and hyperglycemia.

Effect of weight on outcomes of children undergoing hematopoietic cell transplantation

Chemotherapy dosing in hematopoietic cell therapy (HCT) conditioning regimens is based on patient weight. We hypothesized that potential underdosing or overdosing of patients with significant deviation of weight from normal might alter HCT outcomes, such as early mortality, overall or organ-specific toxicity, and/or relapse. We therefore conducted a retrospective analysis of 400 children between the ages of 2 and 18 years who underwent HCT for malignant or nonmalignant disease at Boston Children's Hospital over a 10-year period. Using the Centers for Disease Control and Prevention standard weight classification schema, we found no evidence to suggest a difference in survival or in time to engraftment or in relapse in patients with malignant disease. In the subgroups of patients either receiving autologous HCT or with underlying malignancy, combined overweight and obese patients had a higher rate of any organ, but not organ-specific, Grade 3-5 toxicity compared with the normal weight group. The study was not powered to detect a difference between underweight and normal weight patients. These data suggest that multiple outcome measures over the first year after HCT are unaffected by weight.

Elevated serum gamma-glutamyltransferase is a strong marker of insulin resistance in obese children

Elevated levels of serum gamma-glutamyltransferase (GGT) levels have been found to predict the development of type 2 diabetes in adults. The role of GGT in insulin resistance (IR) among children is largely unknown. We investigated whether GGT among hepatic enzymes is independently associated with IR in obese Korean children. A total of 1308 overweight (above the 85th BMI percentile of Korean reference) boys (n = 822) and girls (n = 486), aged 9-15 years, were studied. Measures acquired included weight, height, percent body fat (BF%), waist circumference, blood pressure, blood glucose and insulin, C-reactive protein, total cholesterol, triglycerides, HDL-Cholesterol, GGT, aspartate aminotransferase (AST), and alanine aminotransferase (ALT). IR was calculated using the homeostasis model assessment (HOMA-IR). Serum GGT and ALT, but not AST, were positively correlated with HOMA-IR in boys (r = 0.222 for GGT; P < 0.05, r = 0.188 for ALT; P < 0.05) and girls (r = 0.292 for GGT; P < 0.05, r = 0.258 for ALT; P < 0.05). In multiple regression analysis for HOMA-IR as dependent variable, GGT (β = 0.068; P = 0.053 in boys, β = 0.145; P = 0.002 in girls) and ALT (β = 0.074; P = 0.034 in boys, β = 0.130; P = 0.005 in girls) emerged as determinants of HOMA-IR after adjusting age, BMI, tanner stage, and triglycerides. Serum GGT level is a strong marker of IR in obese Korean children.

Prevalence of Underweight, Overweight and Obesity Among Primary School Children in Qatar

A cross-sectional stratified cluster sample of 4291 children (2187 boys and 2104 girls) aged 6 to18 years attending primary public schools in Qatar was used to determine the prevalence of underweight, overweight and obesity among primary school children in Qatar using BMI as an indicator. Structured questionnaires were used to obtain socio-demographic data. Anthropometric measures were taken by trained nurse. The study revealed a high prevalence of underweight and obesity among Qatari children, with both conditions implicating adverse short and long-term health effects. The prevalence of underweight (BMI <  5% of CDC standard for ageand sex) was 14.6%, overweight (BMI 85% to 95%) was 11.6% and obesity (BMI > 95%) was 14.7% (95% confidence level). The prevalence of overweight and obesity was higher in girls (28.7%) than boys (24%) but was similar in Qatari (26.4%) and non-Qatari children (26.2%). The prevalence of both underweight (15.6%) and obesity (15.8%) were considerably higher in Qatari children.

The diabetic heart: too sweet for its own good?

Diabetes mellitus is a major risk factor for ischemic heart disease (IHD). Patients with diabetes and IHD experience worse clinical outcomes, suggesting that the diabetic heart may be more susceptible to ischemia-reperfusion injury (IRI). In contrast, the animal data suggests that the diabetic heart may be either more, equally, or even less susceptible to IRI. The conflicting animal data may be due to the choice of diabetic and/or IRI animal model. Ischemic conditioning, a phenomenon in which the heart is protected against IRI by one or more brief nonlethal periods of ischemia and reperfusion, may provide a novel cardioprotective strategy for the diabetic heart. Whether the diabetic heart is amenable to ischemic conditioning remains to be determined using relevant animal models of IRI and/or diabetes. In this paper, we review the limitations of the current experimental models used to investigate IRI and cardioprotection in the diabetic heart.

Partial inactivation of Ankrd26 causes diabetes with enhanced insulin responsiveness of adipose tissue in mice

AIMS/HYPOTHESIS

ANKRD26 is a newly described gene located at 10p12 in humans, a locus that has been identified with some forms of hereditary obesity. Previous studies have shown that partial inactivation of Ankrd26 in mice causes hyperphagia, obesity and gigantism. Hypothesising that Ankrd26 mutant (MT) mice could develop diabetes, we sought to establish whether the observed phenotype could be (1) solely related to the development of obesity or (2) caused by a direct action of ankyrin repeat domain 26 (ANKRD26) in peripheral tissues.

METHODS

To test the hypothesis, we did a full metabolic characterisation of Ankrd26 MT mice that had free access to chow or were placed under two different energy-restricted dietary regimens.

RESULTS

Highly obese Ankrd26 MT mice developed an unusual form of diabetes in which white adipose tissue is insulin-sensitive, while other tissues are insulin-resistant. When obese MT mice were placed on a food-restricted diet, their weight and glucose homeostasis returned to normal. In addition, when young MT mice were placed on a pair-feeding diet with normal mice, they maintained normal body weight, but showed better glucose tolerance than normal mice, an increased responsiveness of white adipose tissue to insulin and enhanced phosphorylation of the insulin receptor.

CONCLUSIONS/INTERPRETATION

These findings show that the ANKRD26 protein has at least two functions in mice. One is to control the response of white adipose tissue to insulin; the other is to control appetite, which when Ankrd26 is mutated, leads to hyperphagia and diabetes in an obesity-dependent manner.

Implicit food associations as obstacles to healthy nutrition: the need for further research

Healthy nutrition is the driving force behind measures to address the obesity and diabetes epidemic. Therefore, the relevance of healthy nutrition to public health is steadily increasing. Although many consumers have positive attitudes towards healthy nutrition, their eating habits do not always match these attitudes. This paper suggests that individuals can overcome the discrepancy between attitude/intention and behaviour if they consider implicit associations with healthy or unhealthy nutrition. Our paper aims to develop a research strategy to analyse the impact of the interplay between explicit and implicit food associations on food consumption. The suggested process comprises the following steps: consumer segmentation, isolated analysis of different implicit drivers, holistic examination of interaction effects of different drivers and development of implications for policy makers and managers.

Contributions of built environment to childhood obesity

As childhood obesity has reached epidemic proportions, it is critical to devise interventions that target the root causes of obesity and its risk factors. The two main components of childhood obesity are physical inactivity and improper nutrition, and it is becoming increasingly evident that the built environment can determine the level of exposure to these risk factors. Through a multidisciplinary literature review, we investigated the association between various built environment attributes and childhood obesity. We found that neighborhood features such as walkability/bikeability, mixed land use, accessible destinations, and transit increase resident physical activity; also that access to high-caloric foods and convenience stores increases risk of overweight and obesity, whereas the presence of neighborhood supermarkets and farmers' markets is associated with lower childhood body mass index and overweight status. It is evident that a child's built environment impacts his access to nutritious foods and physical activity. In order for children, as well as adults, to prevent onset of overweight or obesity, they need safe places to be active and local markets that offer affordable, healthy food options. Interventions that are designed to provide safe, walkable neighborhoods with access to necessary destinations will be effective in combating the epidemic of obesity.

Association between obesity and atopic dermatitis in childhood: a case-control study

BACKGROUND

Obesity in children is associated with increased asthma and atopy.

OBJECTIVE

We sought to determine whether obesity in childhood or adolescence increases the risk of atopic dermatitis.

METHODS

This retrospective, practice-based, case-control study randomly sampled 414 children and adolescents (age, 1-21 years) with atopic dermatitis between January 2000 and December 2007 and 828 randomly sampled healthy control subjects. Information was obtained from an electronic medical record. Observations were made before the a priori hypothesis.

RESULTS

Obesity in children is associated with increased atopic dermatitis (conditional logistic regression: odds ratio, 2.00; 95% CI, 1.22-3.26; P = .006). These atopic dermatitis-predisposing effects are found when obesity started by less than 2 years of age (adjusted odds ratio [aOR], 15.10; 95% CI, 1.51-151.21; P = .02) and 2 to 5 years (aOR, 2.58; 95% CI, 1.24-5.41; P = .01) but not greater than 5 years (aOR, 1.32; 95% CI, 0.66-2.64; P = .43) and when obesity was prolonged for 2.5 to 5 years (aOR, 2.64; 95% CI, 1.13-6.18; P = .03) and greater than 5 years (aOR, 3.40; 95% CI, 1.34-8.63; P = 0.01). Obesity is associated with more severe atopic dermatitis (ordinal logistic regression: aOR, 2.37; 95% CI, 1.24-5.37; P = .01). Obese children who eventually have atopic dermatitis require more frequent pediatrician visits for the management of atopic dermatitis (ordinal logistic regression: aOR, 2.22; 95% CI, 1.12-4.50; P = .03).

CONCLUSION

Prolonged obesity in early childhood is a risk factor for atopic dermatitis. Weight loss might be an important approach for the prevention and treatment of atopic dermatitis in children.

A translational research intervention to reduce screen behaviours and promote physical activity among children: Switch-2-Activity

Translational or implementation research that assesses the effectiveness of strategies to promote health behaviours among children that have been previously tested under 'ideal' conditions is rarely reported. Switch-2-Activity aimed to examine the effectiveness of an abbreviated programme delivered by teachers targeting children's television viewing, computer use, physical activity and potential mediators of behaviour change. Fifteen schools from disadvantaged areas in Melbourne, Australia agreed to participate in the study (43% school-level response rate). Out of the 1566 Grades 5 and 6 (9-12 year old) children invited to take part in the study, 1048 (67% response rate) provided informed consent. Schools were randomized to either an intervention or wait-list control condition. Teachers delivered six lessons, which included strategies such as self-monitoring, behavioural contracting and budgeting of screen time. Children completed a self-report survey at baseline and post-intervention examining screen-based behaviours, physical activity, self-efficacy and behavioural capability. Teachers reported implementation of and attitudes to the programme. Seventy-one per cent of teachers delivered at least four of the six lessons. Most teachers reported that the materials were easy to follow and deliver; however, many teachers reported modifying the materials in some way. Among boys, there were favourable small intervention effects on weekend screen time [(coefficient = -0.62, 95% 95% confidence interval: -1.15, -0.10, p = 0.020)]. The intervention also had significant positive effects on children's self-efficacy for reducing television viewing and on behavioural capability (television viewing styles). Future studies that assess the translation of efficacious programmes and that test whether such programmes are equally effective in different settings (e.g. in the family setting) are urgently required.

A 10-month physical activity intervention improves body composition in young black boys

Objective. To determine if a 10-month after-school physical activity (PA) intervention could prevent deleterious changes in body composition and cardiovascular (CV) fitness in young black boys. Methods. Following baseline measures, 106 boys (8-12 yrs) were randomized to either a control group or an intervention group, further divided into attenders (ATT) and nonattenders (NATT), participating in ≥60% or <60% of the intervention, respectively. The daily intervention consisted of skills development (25 min), vigorous PA (VPA, 35 min), and strengthening/stretching (20 min) components. Body composition was measured by dual-energy X-ray absorptiometry. Results. Following the intervention, the ATT exhibited an increase in moderate-to-vigorous PA and a significant reduction in BMI, fat mass, and %BF compared to the control group. A significant association among the intervention energy expenditure and changes in body composition and CV fitness was observed only in the ATT group. Conclusion. An after-school PA program of sufficient length and intensity can promote healthy changes in body composition and fitness levels in black boys who attend at least 3 days/week.

Decreased plasma apelin levels in pubertal obese children

BACKGROUND

Apelin is a recently defined peptide relevant to the mechanism of obesity-related disorders. There has been no report so far about the levels of plasma apelin in obese children.

METHODS

In this study plasma apelin, adiponectin, and high sensitivity C reactive protein levels were investigated in obese (n=32) and nonobese (n=40) children. The effects of pubertal status on the apelin and adiponectin levels were evaluated as well.

RESULTS

When compared to nonobese controls, the obese children had significantly lower plasma apelin (p = 0.004), adiponectin and HDL cholesterol levels (p = 0.001 for both), and higher hs-CRP, triglycerides, insulin and Homeostasis Model Assessment (HOMA-IR) indexes (p < 0.001 for all). The difference between the apelin levels was present only in the pubertal period (p = 0.002).

CONCLUSIONS

The results of the present study indicate that plasma apelin levels are lower in child obesity and pubertal state is an important determinant of plasma apelin levels.

The economics of obesity

The rise in obesity rates, both nationally and internationally, is a result of changes in the environment that have simultaneously lowered the cost of food production, lowered the time and monetary cost of food consumption, increased the real cost of being physically active at work and at home, and decreased the health consequences that result from obesity by bringing a host of new drugs and devices to the market to better manage the adverse health effects that obesity promotes. This changing environment is in response to consumers' demand for labor-saving technology and convenient, affordable food. To be successful, efforts to combat obesity therefore need to recognize and address these realities.

The prevalence of impaired fasting glucose and type 2 diabetes in a population-based sample of overweight/obese children in the Middle East

BACKGROUND

Type 2 diabetes mellitus (T2DM) and impaired fasting glucose (IFG) are increasing in young population who are facing an escalating trend of overweight. The aim of this study was to determine the prevalence of IFG and T2DM for the first time in a population-based sample of Iranian obese children.

METHODS

This cross-sectional, population-based study was conducted in Isfahan, the second large city of Iran. Overall, 672 overweight and obese school students, selected from 7554 students, aged 6-19 yr, were screened for IFG and T2DM. Fasting plasma glucose (FPG) and lipid profile were measured in all participants. Oral glucose tolerance test and insulin level were measured in those children with IFG. Insulin resistance was defined as homeostasis model assessment for insulin resistance (HOMA-IR) > 3.10.

RESULTS

Among the7554 students (48.7% boys and 51.3% girls) studied, 9.34% (n = 706) were overweight and 5.3% (n = 403) were obese. A number of 672 overweight and obese students including 302 (44.9%) boys and 370 (55.1%) girls, with a mean age of 12.8 +/- 3.10 yr underwent biochemical work up. Overall, the prevalence of IFG was 4.61% (n = 31), the corresponding figure was 2% (n = 4) in the 6-10 yr age group, and 5% (n = 27) in those aged 10.1-19 yr. The prevalence of T2DM was 0.1% (n = 1; age, 18.00 yr). Impaired glucose tolerance and insulin resistance were detected in three and six participants with IFG, who consisted 0.4 and 0.8% of total obese and overweight students, respectively.

CONCLUSIONS

Although the prevalence of T2DM is low in Iranian obese children, IFG is not uncommon. Preventive measures and screening of FPG should be considered for these children.

Distribution of fasting plasma glucose and prevalence of impaired fasting glucose, impaired glucose tolerance and type 2 diabetes in the Mexican paediatric population

Published data on the distribution of fasting plasma glucose (FPG) in children are scarce. We therefore set out to examine the distribution of FPG and determine the prevalence of impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and type 2 diabetes (T2-DM) in Mexican children aged 6-18 years in a community-based cross-sectional study. A total of 1534 apparently healthy children were randomly enrolled and underwent an oral glucose tolerance test. IFG was defined by an FPG value between >or=100 and <126 mg/dL, IGT by glucose concentration 2-h post-load between >or=140 and <200 mg/dL, and T2-DM by glucose concentration 2-h post-load >or=200 mg/dL. The FPG level at the 75(th) percentile of distribution was 98.0, 100.0 and 99.0 mg/dL for children aged 6-9, 10-14 and 15-18 years, respectively; the 95(th) percentile of FPG was greater than 100 mg/dL for all the age strata. In the population overall, the prevalences of IFG, IGT, and T2-DM were 18.3%, 5.2% and 0.6%, respectively. Among obese children and adolescents, the prevalences of IFG, IGT, IFG + IGT and T2-DM were 19.1%, 5.7%, 2.5% and 1.3%. Our study shows a high prevalence of prediabetes and is the first that reports the distribution of FPG in Mexican children and adolescents.

Foot problems and effectiveness of foot care education in children and adolescents with diabetes mellitus

OBJECTIVES

To assess foot care in paediatric and adolescent patients with diabetes mellitus and to evaluate the effectiveness of foot care education given to participants.

RESEARCH DESIGN AND METHODS

An 8-month prospective study of foot care in children and adolescents with type 1 and type 2 diabetes mellitus who attended diabetes clinics at the Royal Children's Hospital, Melbourne, where foot examination was performed at baseline and at follow-up. Patients and parents were given oral and written advice regarding foot care.

RESULTS

Five hundred and fifty-seven patients were examined at baseline, and 312 patients were reviewed at follow-up 3-6 months later. The majority of foot problems found at first assessment were potentially modifiable disorders of skin and nails (68.8%). The remainder (31.2%) were structural musculoskeletal disorders requiring referral to a podiatrist/orthotist. A total of 532 foot problems were recorded at baseline in a cohort of 557 patients and 161 foot problems at follow-up of 312 patients. Significant reduction of modifiable foot problems was seen at follow-up, particularly in those with longer duration of diabetes and in those whose body mass index was higher.

CONCLUSIONS

This study highlights the importance of foot examination and foot care advice for children and adolescents with diabetes. Larger prospective studies are required to establish prevalence and to optimize preventive interventions.

Partnering with governments and other institutions: driving change in diabetes care

The human and material cost of type 2 diabetes is a cause of increasing concern for health professionals, representative organisations and governments worldwide. The scale of morbidity and mortality has led the United Nations to issue a resolution on diabetes, calling for national policies for prevention, treatment and care. There is clearly an urgent need for a concerted response from all interested parties at the community, national and international level to work towards the goals of the resolution and create effective, sustainable treatment models, care systems and prevention strategies. Action requires both a 'bottom-up' approach of public awareness campaigns and pressure from healthcare professionals, coupled with a 'top-down' drive for change, via partnerships with governments, third sector (non-governmental) organisations and other institutions. In this review, we examine how existing collaborative initiatives serve as examples for those seeking to implement change in health policy and practice in the quest to alleviate the health and economic burden of diabetes. Efforts are underway to provide continuous and comprehensive care models for those who already have type 2 diabetes; in some cases, national plans extend to prevention strategies in attempts to improve overall public health. In the spirit of partnership, collaborations with governments that incorporate sustainability, long-term goals and a holistic approach continue to be a driving force for change. It is now critical to maintain this momentum and use the growing body of compelling evidence to educate, inform and deliver a long-term, lasting impact on patient and public health worldwide.

Self-management behaviors, racial disparities, and glycemic control among adolescents with type 2 diabetes

OBJECTIVE

Type 2 diabetes is a growing problem among adolescents, but little is known about self-management behaviors in this population. Our aim was to examine self-management behaviors and glycemic control among adolescents with type 2 diabetes.

METHODS

From 2003 to 2005, a telephone survey of adolescents with type 2 diabetes was performed. Chart review obtained most recent glycated hemoglobin and clinical characteristics. Analyses compared patient characteristics and self-management behaviors to recent glycated hemoglobin levels.

RESULTS

Of 139 patients contacted, 103 (74%) completed the study. The mean age was 15.4 years: 69% were girls, 47% were white, and 46% were black. Mean glycated hemoglobin was 7.7%, and the average duration of diabetes was 2.0 years. More than 80% of patients reported > or = 75% medication compliance, and 59% monitored blood glucose > 2 times daily. However, patients reported frequent episodes of overeating, drinking sugary drinks, and eating fast food. More than 70% of patients reported exercising > or = 2 times a week, but 68% reported watching > or = 2 hours of television daily. Nonwhite patients had higher glycated hemoglobin and hospitalizations per year compared with white patients. In multivariable analyses, nonwhite race remained significantly associated with higher glycated hemoglobin even after adjusting for age, gender, BMI, insurance status, and other factors. Nonwhite patients were more likely to watch > or = 2 hours of television per day (78% vs 56%), to report exercising < or = 1 time per week (35% vs 21%), and to drink > or = 1 sugary drink daily (27% vs 13%).

CONCLUSION

Although patients reported good medication and monitoring adherence, they also reported poor diet and exercise habits and multiple barriers. Nonwhite race was significantly associated with poorer glycemic control even after adjusting for covariates. This may, in part, be related to disparities in lifestyle behaviors. Additional studies are indicated to further assess self-management behaviors and potential racial disparities in adolescents with type 2 diabetes.

Preventing childhood obesity: can we do it?

PURPOSE OF REVIEW

This review critically examines recent publications on prevention of childhood obesity and places these publications within a biologic, epidemiologic, public health, and policy context. It should help practitioners advocate effective preventive strategies and develop effective plans of action for research and policy.

RECENT FINDINGS

Risk factors for childhood obesity include low socioeconomic status, maternal obesity, rapid infancy weight gain, and decreased physical activity. Changes in food availability and activity levels during the past 30 years are well documented. Obesity prevention programs have had limited success but they demonstrate that changes in school and community environments can decrease childhood weight gain. Legislative approaches to the obesity epidemic have not led to changes in governmental agricultural policy or in the food and marketing industry.

SUMMARY

Obesity in childhood is a major public health problem and contributes to significant morbidity in adulthood. It is the natural biologic outcome of an unprecedented increase of food availability and intake, coupled with decreased energy output. Present obesity prevention measures have been small scale and timid. Public policy measures to address the obesity epidemic have not yet been sufficiently strong to be effective. Suggestions are made to intensify public education and change national behaviors.