The Impact of Childhood Obesity on Skeletal Health and Development

Disparities in Pediatric Bone Health

Bone mass which is attained during childhood is a key determinant of bone health throughout the life span. Primary and secondary bone health pathologies that affect normal bone accretion can have lasting effects on bone health and increase the risk for osteoporosis and osteomalacia in adulthood. Health disparities in race, socioeconomic status, and geopolitical factors impact timely screening and diagnosis, treatment, disease burden, and long-term health outcomes. Acknowledging these disparities can inform global policy change and improve care for patients in these vulnerable populations.

Fat, flames and ultrasounds: the effects of obesity on pediatric joint inflammation

The association between childhood obesity and the early appearance of joint degeneration, particularly in the infrapatellar "Hoffa's" fat pad, highlights the importance of early diagnosis and treatment. The purpose of this review is to describe the role of ultrasound imaging as a first-line imaging tool for the early detection, prevention, and follow-up of degenerative structural changes in children's joints. By combining ultrasound findings with clinical assessments and indices, healthcare providers can gain a more comprehensive understanding of obesity-related joint alterations. This integrative approach enables early therapeutic interventions, improving outcomes for affected children. Proactive management of pediatric obesity will not only improve the long-term outcomes of obesity-related joint disorders but also reduce the burden of related complications, such as osteoarthritis, in adulthood.

Obesity and Overweight Conditions in Children and Adolescents (6-18 Years) and Their Impact on Craniofacial Morphology: A Systematic Review

Background: Childhood obesity and overweight conditions impact systemic health and craniofacial development. Objectives: This review assessed the influence of elevated body mass index (BMI) on craniofacial morphology, considering age, sex, and ethnicity. Methods: A comprehensive search of Scopus, Web of Science, Embase, Cochrane, PubMed, and OpenGrey was conducted following PRISMA guidelines. Ten cross-sectional studies involving 1383 individuals aged 6 to 18 years were included. The sample comprised 812 females and 571 males, with most studies focusing on adolescents aged 12-18 years of different ethnicities depending on the study. Craniofacial structures were compared between overweight/obese and normal weight groups through cephalometric analysis. Study quality was assessed using the Newcastle-Ottawa Scale (NOS). Results: Overweight and obese individuals showed significant craniofacial changes, including increased anterior cranial base length, maxillary and mandibular dimensions, bimaxillary prognathism, and greater soft tissue thickness. These alterations may be influenced by differences in tissue composition, hormonal fluctuations, fat-to-bone ratio, and metabolic disorders. Variations in skeletal divergence, dental alignment, and airway space were also observed. The methodological quality ranged from moderate to high. Conclusions: Excess weight during growth is linked to distinct craniofacial alterations. Orthodontic diagnostics should integrate metabolic and hormonal considerations to optimize treatment outcomes. These changes should be carefully considered by orthodontists and pediatric dentists. Longitudinal studies are needed to understand the long-term effects of obesity on craniofacial development.

Assessment of the Mechanical Properties and Fragment Characteristics of a 3D-Printed Forearm Orthosis

Distal radius fractures (DRF) are one of the most prevalent injuries a person may sustain. The current treatment of DRF involves the use of casts made from Plaster of Paris or fiberglass. The application of these materials is a serious endeavor that influences their intended use, and should be conducted by specially trained personnel. In this research, with the use of the full-body 3D scanner Vitus Smart, 3D modelling software Rhinoceros 3D, and 3D printer Creality CR-10 max, an easy, yet effective workflow of orthosis fabrication was developed. Furthermore, samples that represent segments of the orthosis were subjected to static loading. Lastly, fragments that occurred due to excessive force were characterized with the use of a digital microscope. It was observed that with the implementation of the designed workflow, a faster 3D printing process was present. Samples subjected to mechanical loading had values that exceeded those of conventional Plaster of Paris; the minimum recorded value was 681 N, while the highest was 914 N. Microscopic characterization enabled a clear insight into the occurrence of fragments, as well as their potential risk. Therefore, in this research, an insight into different stages of fabrication, characterization of undesirable events, as well as the risks they may pose were presented.

Body shape from birth to adulthood is associated with skeletal development: A Mendelian randomization study

BACKGROUND

Observational studies have shown that childhood obesity is associated with adult bone health but yield inconsistent results. We aimed to explore the potential causal association between body shape and skeletal development.

METHODS

We used two-sample Mendelian randomization (MR) to estimate causal relationships between body shape from birth to adulthood and skeletal phenotypes, with exposures including placental weight, birth weight, childhood obesity, BMI, lean mass, fat mass, waist circumference, and hip circumference. Independent genetic instruments associated with the exposures at the genome-wide significance level (P < 5 × 10-8) were selected from corresponding large-scale genome-wide association studies. The inverse-variance weighted analysis was chosen as the primary method, and complementary MR analyses included the weighted median, MR-Egger, weighted mode, and simple mode.

RESULTS

The MR analysis shows strong evidence that childhood (β = -1.29 × 10-3, P = 8.61 × 10-5) and adulthood BMI (β = -1.28 × 10-3, P = 1.45 × 10-10) were associated with humerus length. Tibiofemoral angle was negatively associated with childhood BMI (β = -3.60 × 10-1, P = 3.00 × 10-5) and adolescent BMI (β = -3.62 × 10-1, P = 2.68 × 10-3). In addition, genetically predicted levels of appendicular lean mass (β = 1.16 × 10-3, P = 1.49 × 10-13), whole body fat mass (β = 1.66 × 10-3, P = 1.35 × 10-9), waist circumference (β = 1.72 × 10-3, P = 6.93 × 10-8) and hip circumference (β =1.28 × 10-3, P = 4.34 × 10-6) were all associated with tibia length. However, we found no causal association between placental weight, birth weight and bone length/width.

CONCLUSIONS

This large-scale MR analysis explores changes in growth patterns in the length/width of major bone sites, highlighting the important role of childhood body shape in bone development and providing insights into factors that may drive bone maturation.

Causal link between childhood obesity and adult osteoporosis: An investigation through Mendelian randomization

The intricate link between childhood obesity and adult osteoporosis has been a subject of numerous clinical inquiries, yet the genetic underpinnings of this association remain enigmatic. Our research aims to unravel the association between adult osteoporosis and childhood obesity using genome-wide association study data for Mendelian randomization (MR) analysis. Utilizing a pool of single-nucleotide polymorphism data associated with childhood obesity obtained from a previous genome-wide association study report involving a study population of 13,848 people in Europe, alongside data of adult osteoporosis sourced from Neale Lab (5266 cases and 331,893 controls). Various methods for MR were used in our research, including weighted mode, simple mode, weighted median, MR-Egger, and the inverse-variance weighted (IVW). We also used Cochran Q test of IVW to assess for heterogeneity, MR-Egger intercept and MR-Pleiotropy RESidual Sum and Outlier (MR-PRESSO) analysis for pleiotropy, and leave-one-out analysis for the result stability. The instrumental variables associated with 11 single-nucleotide polymorphisms were selected. MR analyses unveiled a noteworthy link between genetically forecasted childhood obesity and the onset of adult osteoporosis based on the odds ratio, 95% confidence interval, and P-value from the results of IVW, MR-Egger, weighted median: simple mode, and weighted mode analyses. No significant heterogeneity was found by the assessment using MR-Egger and IVW. Similarly, there was no indication of pleiotropy based on the MR-PRESSO and MR-Egger analyses. Leave-one-out analysis confirmed the stability of the results. Our research suggests that childhood obesity, as predicted by genetic factors, may pose a significant risk for the development of osteoporosis in adulthood.

Dietary content and combined training, but not daily physical activity, are associated with 6-month bone mineral changes in adolescents with obesity: A Secondary analysis of the PAC-MAnO trial

PURPOSE

The present study aimed to explore the influence of diet and physical activity (PA) changes on bone mineral content (BMC) and density (BMD) alterations in adolescents with obesity undergoing a weight loss program.

METHODS

Six-month longitudinal data from 71 adolescents (aged 15.1 [± 1.6] years; 57.7% girls) with a BMI z-score of 3.03 (± 0.78), previously recruited for the PAC-MAnO trial, were analyzed using Generalized Estimation Equations for over time changes and linear regressions with BMC, BMD and BMD z-score as dependent variables, adjusting for confounders (including type of exercise- aerobic vs. combined).

RESULTS

Adjusting for confounders, changes in carbohydrate (CH) and protein content showed to positively and negatively predict BMD z-score variance, respectively (β = 0.44, 95%CI: 0.01, 0.04, p < .001); β = -0.57, 95%CI: -0.06, -0.03, p < .001), yet no associations were found between PA and bone-related parameters. Combined exercise showed better results on BMC compared to aerobic exercise (β = 0.09, 95%CI: 0.05 to 0.13, p < .001).

CONCLUSIONS

Increased CH content, instead of protein, may be associated with BMD improvements in adolescents with obesity. Type of exercise may moderate the impact of PA on bone health.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02941770. What is Known • Adolescents with obesity may be at a higher risk of osteopenia/osteoporosis • Obesity and inadequate diet and physical activity (PA) may have an adverse effect on bone metabolism What is New • Improvements in adiposity and muscle mass and increased diet carbohydrate content are associated with bone mineral density (BMD) improvements • Type of exercise (i.e., combined training vs. aerobic) may moderate the impact of PA on BMD, and calcium intake may mediate this impact.

High muscular fitness level may positively affect bone strength and body composition in children with overweight and obesity

Muscular fitness plays a major role in bone health and body composition in overweight and obese children. It is key that the development of this muscle fitness is affected by absolute isometric strength and dynamic strength.

PURPOSE

To compare bone health and body composition between overweight/obese children considering muscular fitness (MF) levels, and to investigate whether weight-bearing dynamic or absolute isometric strength, both involved in the development of this muscular fitness, are more related with bone health.

METHODS

MF of 59 overweight or obese children (10.1 ± 0.9 years, 27 females) was measured by a countermovement jump (CMJ), handgrip, and maximal isometric strength of knee extension. Participants were divided into four groups depending on their MF level performing a cluster analysis: 16 children with high MF (HMF) in all tests, 18 with high performance in isometric strength (HIS), 15 with high performance in CMJ (HCMJ) and 10 low isometric and low dynamic force values (LMF). Body composition values were measured by dual energy X-ray absorptiometry, and bone strength values were assessed by peripheral quantitative computed tomography. Motor skills were evaluated using TGMD-3. Multivariate analysis of covariance test was applied to analyse bone strength differences between children in the different MF groups, using maturity offset, height and weight as covariates, and correlations were investigated.

RESULTS

HMF excelled in bone health. HIS had higher cortical bone area, periosteal circumference, bone mass, polar strength strain index and fracture load than LMF, while HCMJ only showed better results in trabecular bone area than LMF. HMF had significantly better values of fracture load and periosteal and endosteal circumferences than HCMJ, but not than HIS.

CONCLUSIONS

High MF level shows positive effects on bone health in overweight/obese children. Those with highest isometric strength had better bone health compared to those with higher dynamic strength.

TRIAL REGISTRATION

The research project was registered in a public database Clinicaltrials.gov in June 2020 with the identification number NCT04418713.

Mendelian randomization shows causal effects of birth weight and childhood body mass index on the risk of frailty

Background

The association between birth weight and childhood body mass index (BMI) and frailty has been extensively studied, but it is currently unclear whether this relationship is causal.

Methods

We utilized a two-sample Mendelian randomization (MR) methodology to investigate the causal effects of birth weight and childhood BMI on the risk of frailty. Instrumental variables (p < 5E-08) strongly associated with own birth weight (N = 298,142 infants), offspring birth weight (N = 210,267 mothers), and childhood BMI (N = 39,620) were identified from large-scale genomic data from genome-wide association studies (GWAS). The frailty status was assessed using the frailty index, which was derived from comprehensive geriatric assessments of older adults within the UK Biobank and the TwinGene database (N = 175,226).

Results

Genetically predicted one standard deviation (SD) increase in own birth weight, but not offspring birth weight (maternal-specific), was linked to a decreased frailty index (β per SD increase = -0.068, 95%CI = -0.106 to -0.030, p = 3.92E-04). Conversely, genetically predicted one SD increase in childhood BMI was associated with an elevated frailty index (β per SD increase = 0.080, 95%CI = 0.046 to 0.114, p = 3.43E-06) with good statistical power (99.8%). The findings remained consistent across sensitivity analyses and showed no horizontal pleiotropy (p > 0.05).

Conclusion

This MR study provides evidence supporting a causal relationship between lower birth weight, higher childhood BMI, and an increased risk of frailty.

Bone health following paediatric and adolescent bariatric surgery: a systematic review and meta-analysis

Background

Childhood obesity is a pressing health crisis of epidemic proportions. Bariatric surgery (BS) is an effective weight loss solution however its role in the paediatric population is contentious owing to the paucity of weight specific and generalised health outcomes. This systematic review and meta-analysis aimed to assess the impact of paediatric BS on bone health.

Methods

This prospectively registered systematic review (PROSPERO ID: CRD42023432035) was performed in accordance with PRISMA guidelines. We searched MEDLINE (1946-1928 September 2023), EMBASE (1947-1928 September 2023) via the Ovid platform, and the Cochrane Review Library to identify scientific publications reporting bone outcome measures in patients under the age of 18 years who underwent BS. Meta-analysis was undertaken on post-operative weight and bone parameters in paediatric patients following BS. Outcomes were reported as weighted or standardized mean difference with 95 percent confidence intervals. Subgroup analysis by intervention, quality scoring and risk of bias were assessed.

Findings

Twelve studies with 681 patients across 5 countries (mean age 17 ± 0.57 years) were included. The quality of included studies was rated as high and there was substantial between-study heterogeneity for most factors included in the meta-analysis (I2 from 0% to 99.1%). Patients underwent Roux-en-Y gastric bypass (RYGB, n = 216), sleeve gastrectomy (SG, n = 257), gastric band (n = 184) or intragastric balloon placement (n = 24). BS was associated with significant weight reduction, body mass index (BMI) -12.7 kg/m2 (95% CI -14.5 to -10.9, p < 0.001), with RYGB being most effective, BMI -16.58 kg/m2 (95% CI -19.6 to -13.6, p < 0.001). Patients who underwent SG or RYGB had significantly lower lumbar bone mineral density, -0.96 g/cm2 (95% CI -0.1 to -0.03, p < 0.001), Z score, -1.132 (95% CI -1.8 to -0.45, p < 0.001) and subtotal body bone mineral density, -0.7 g/cm2 (95% CI -1.2 to -0.2, p < 0.001) following surgery. This was accompanied with higher markers of bone resorption, C-terminal telopeptide of type 1 collagen 0.22 ng/ml (95% CI 0.12-0.32, p < 0.001) and osteocalcin, 10.83 ng/ml (95% CI 6.01-15.67, p < 0.001). There was a significant reduction in calcium levels following BS, -3.78 mg/dl (95% CI -6.1 to -1.5, p < 0.001) but no difference in 25-hydroxyvitamin D, phosphate, bone alkaline phosphatase, procollagen type 1 N propeptide or parathyroid hormone.

Interpretation

BS effectively reduces weight in paediatric patients, but RYGB and SG may have adverse effects on bone health in the medium term. It is crucial to monitor and support bone health through appropriate nutritional supplementation and judicious follow-up. Long-term data is needed to fully understand the clinical implications of these findings on bone outcomes.

Funding

Medical Research Council (MRC), United Kingdom.

Effects of endocrine disorders on maxillary and mandibular growth in Colombian children and adolescents: a cross-sectional study

OBJECTIVE

To establish the influence of overweight/obesity, medicated hypothyroidism, and medicated non-syndromic hypogrowth on maxillary and mandibular growth.

MATERIALS AND METHODS

The relation between 10 craniofacial anthropometric measurements and hypothyroidism (n = 216), overweight/obesity (n = 108), and non-syndromic hypogrowth (n = 250) were evaluated in patients aged 1-19 years and a control group of healthy patients (n = 587). A subgroup analysis was performed at the peak growth in all groups.

RESULTS

Patients with overweight/obesity and hypothyroidism showed increased craniofacial growth, while hypogrowth patients showed differences in zygomatic width and nasal base growth. Females with hypothyroidism and non-syndromic hypogrowth showed decreased head circumference at peak growth. Several anthropometric measurements were increased in patients with overweight/obesity, including head circumference. When all age groups were analyzed, overweight/obese and hypothyroidism patients showed increased zygomatic width while decreased hypogrowth. Overall, most craniofacial anthropometric measurements in overweight/obese patients were increased. Finally, the peak growth in males with hypothyroidism and subjects with non-syndromic hypogrowth was delayed compared to the control group (p < 0.05).

CONCLUSIONS

Children and adolescents with overweight/obesity and endocrine disorders showed alterations in craniofacial growth. Clinicians must be aware that the growth peak in these patients may be delayed when planning maxillary and mandibular orthopedic treatment.

Racial/Ethnic Differences in Bone Mineral Density for Osteoporosis

PURPOSE OF REVIEW

We primarily aim to review differences in bone mineral density (BMD) for osteoporosis among different racial/ethnic groups and to highlight the magnitude of racial/ethnic differences in obesity and diabetes. We also explore the factors contributing to the BMD differences among various subgroups. In addition, we investigate the existing disparities in research, educational initiatives, screening practices, and treatment options for osteoporosis and discuss these findings' clinical and public health implications.

RECENT FINDINGS

Racial/ethnic differences in BMD for osteoporosis exist in the USA and other countries. There are disparities regarding osteoporosis screening and treatment. Understanding the factors contributing to these differences can help develop targeted interventions and policies to reduce their impact. Clinicians should consider the racial/ethnic differences in BMD when making treatment decisions and providing preventive care. Future research could contribute to developing effective strategies for preventing osteoporosis among different racial/ethnic groups. This review offered a comprehensive examination of differences in BMD across various racial and ethnic groups, elucidating the influence of genetic, lifestyle, and cultural factors on these differences. This review also highlighted the disparities in osteoporosis screening, treatment options, research on medical effectiveness, and educational outreach tailored to each subgroup. Recognizing the importance of addressing these inequalities, we present this review to advocate for targeted interventions to reduce disparities in osteoporosis and improve bone health for all populations.

Sedentary Behavior and Lack of Physical Activity among Children in Indonesia

Sedentary behavior and lack of physical activity among children in Indonesia is an important issue that needs to be addressed. It is estimated that 57% of children in Indonesia have insufficient physical activity. Studies have shown that children who engage in sedentary behaviors are at an increased risk for various negative health outcomes, including obesity, type 2 diabetes, cardiovascular disease, and poor mental health, compared to physically active ones. This article aims to provide recommendations to increase physical activity and reduce passive behavior in children in Indonesia. This is a commentary article developed from observing the recent progress of sedentary behavior and lack of physical activity among children in Indonesia and the potential consequences. The level of inactive behavior in children in Indonesia is relatively high. Factors that contribute to sedentary behavior and lack of physical activity among children in Indonesia are the increasing use of electronic devices and screen time, the lack of safe and accessible places to be physically active, the COVID-19 pandemic, as well as cultural and social norms that prioritize academic achievement over physical activity. To address sedentary lifestyles among children, there is a need for a comprehensive approach that addresses both the individual and societal factors contributing to the problem. This might include increasing access to healthy food options, promoting physical activity, and implementing education programs to raise awareness about the importance of healthy eating and physical activity, as well as limiting screen time.

Vitamin D Deficiency in Chronic Childhood Disorders: Importance of Screening and Prevention

Vitamin D plays a vital role in regulating calcium and phosphate metabolism and maintaining bone health. A state of prolonged or profound vitamin D deficiency (VDD) can result in rickets in children and osteomalacia in children and adults. Recent studies have demonstrated the pleiotropic action of vitamin D and identified its effects on multiple biological processes in addition to bone health. VDD is more prevalent in chronic childhood conditions such as long-standing systemic illnesses affecting the renal, liver, gastrointestinal, skin, neurologic and musculoskeletal systems. VDD superimposed on the underlying disease process and treatments that can adversely affect bone turnover can all add to the disease burden in these groups of children. The current review outlines the causes and mechanisms underlying poor bone health in certain groups of children and young people with chronic diseases with an emphasis on the proactive screening and treatment of VDD.

Muscle-to-Bone and Soft Tissue-to-Bone Ratio in Children and Adolescents with Obesity

OBJECTIVES

To explore the total and regional muscle-to-bone ratio in children and adolescents with obesity and compare the muscle-to-bone ratio (MBR) and soft tissue-to-bone ratio (SBR) to their peers with normal weight or overweight.

STUDY DESIGN

A total of 219 male and female pediatrics (mean age=12.3±2.5 years) participated in this study. Body composition was assessed with a total body dual X-ray absorptiometry. The MBR was calculated by dividing lean mass by bone mineral content. The SBR was determined by dividing the soft tissue mass (i.e., lean mass+fat mass) by bone mineral content. Differences in total and regional body composition measures between body mass index (BMI) percentile groups was assessed by ANOVA.

RESULTS

The obesity group had significantly higher MBR compared to the normal weight group for total (19.24±1.56 vs. 18.26±1.64), arm (17.11±1.67 vs. 15.88±1.81), and leg (18.41±1.68 vs. 16.62±1.55). Similarly, the obesity group had significantly higher MBR in the leg (18.41±1.68) compared to the overweight group (17.24±1.45). However, the overweight group was not significantly different from the normal weight or the obesity group for total and arm MBR. The total, arm, and leg SBR was significantly different between all BMI groups. Across the entire sample, MBR and SBR were negatively associated with high-density lipoprotein. SBR was positively associated with insulin, HOMA-IR, low-density lipoprotein, very low-density lipoprotein, triglycerides, and systolic blood pressure.

CONCLUSIONS

Children with obesity had a higher MBR and SBR compared to their normal weight peers. In addition, there were significant associations between SBR, higher levels of insulin, atherogenic lipoproteins, and increased systolic blood pressure. Thus, SBR may be useful as a marker for increased cardiometabolic disease risk, though more research in this area is warranted.

Adolescent obesity incurs adult skeletal deficits in murine induced obesity model

Adolescent obesity has risen dramatically in the last few decades. While adult obesity may be osteoprotective, the effects of obesity during adolescence, which is a period of massive bone accrual, are not clear. We used a murine model of induced adolescent obesity to examine the structural, mechanical, and compositional differences between obese and healthy weight bone in 16-week-old female C57Bl6 mice. We also examined the effects of a return to normal weight after skeletal maturity (24 weeks old). We found obese adolescent bone exhibited decreased trabecular bone volume, increased cortical diameter, increased ultimate stress, and increased brittleness (decreased plastic energy to fracture), similar to an aging phenotype. The trabecular bone deficits remained after return to normal weight after skeletal maturity. However, after returning to normal diet, there was no difference in ultimate stress nor plastic energy to fracture between groups as the normal diet group increased ultimate stress and brittleness. Interestingly, compositional changes appeared in the former high-fat diet mice after skeletal maturity with a lower mineral to matrix ratio compared to normal diet mice. In addition there was a trend toward increased fluorescent advanced glycation endproducts in the former high-fat diet mice compared to normal diet mice but this did not reach significance (p < 0.05) due to the large variability. The skeletal consequences of adolescent obesity may have lasting implications for the adult skeleton even after return to normal weight. Given the rates of adolescent obesity, skeletal health should be a concern.

Circulating Extracellular Vesicles Impair Mesenchymal Stromal Cell Differentiation Favoring Adipogenic Rather than Osteogenic Differentiation in Adolescents with Obesity

Excess body weight has been considered beneficial to bone health because of its anabolic effect on bone formation; however, this results in a poor quality bone structure. In this context, we evaluated the involvement of circulating extracellular vesicles in the impairment of the bone phenotype associated with obesity. Circulating extracellular vesicles were collected from the plasma of participants with normal weight, as well as overweight and obese participants, quantified by flow cytometry analysis and used to treat mesenchymal stromal cells and osteoblasts to assess their effect on cell differentiation and activity. Children with obesity had the highest amount of circulating extracellular vesicles compared to controls. The treatment of mesenchymal stromal cells with extracellular vesicles from obese participants led to an adipogenic differentiation in comparison to vesicles from controls. Mature osteoblasts treated with extracellular vesicles from obese participants showed a reduction in differentiation markers in comparison to controls. Children with obesity who regularly performed physical exercise had a lower circulating extracellular vesicle amount in comparison to those with a sedentary lifestyle. This pilot study demonstrates how the high amount of circulating extracellular vesicles in children with obesity affects the bone phenotype and that physical activity can partially rescue this phenotype.

Relationship between body composition and bone mass in normal-weight and overweight adolescents

Adolescence is a period characterized by large accumulation of bone mass. Body composition is an important determinant of bone mass. This study aimed to assess the relationship of bone mass with lean mass (LM) and fat mass (FM) in normal-weight and overweight adolescents with consideration of sex, sexual maturation and physical activity covariates. A total of 118 adolescents (60 girls and 58 boys) aged between 10 and 14 years participated in the study. Individuals were classified as normal weight or overweight according to body mass index. Bone mineral density (BMD), bone mineral content (BMC), LM, and FM were measured by dual-energy X-ray absorptiometry. In normal-weight adolescents, LM (β = 0.725, p < 0.001) and FM (β = 0.185, p = 0.019) were associated with lumbar spine BMC, whereas in overweight adolescents only LM (β = 0.736, p < 0.001) was associated with lumbar spine BMC. Furthermore, in the normal-weight group, FM and LM were associated with total body less head BMD (LM, β = 0.792, p < 0.001; FM, β = 0.257, p = 0.007) and lumbar spine BMD (LM, β = 0.553, p < 0.001; FM, β = 0.199, p < 0.035). In the overweight group, only LM was associated with total body less head BMD (β = 0.682, p < 0.001) and lumbar spine BMD (β = 0.528, p < 0.001). LM was the main predictor of bone mass in normal-weight and overweight adolescents. FM was associated with bone mass in normal-weight adolescents only. LM may be considered an important and useful marker in adolescents, when investigating bone health in this population. Activities that promote LM gain to reduce the risk of bone fractures and diseases in adulthood are recommended.

Leptin levels were negatively associated with lumbar spine bone mineral content in children with overweight or obesity

AIM

Adipokines seem to play a role in bone morphogenesis, although this also depends on the mechanical forces applied to the skeleton. The aim was to assess the relationships of resting leptin and adiponectin with bone parameters and whether high muscular fitness levels affect these relationships in children with overweight or obesity.

METHODS

This cross-sectional study took part from 2014 to 2016 in Granada, Spain. Participants were recruited from University Hospitals, and we also used advertisements in local media and school contacts in the city. Adipokines were analysed in plasma. Muscular fitness was assessed by 1 repetition maximum in bench and leg press tests. Dual-energy X-ray absorptiometry was used to measure bone parameters.

RESULTS

We included 84 children (10.0±1.2y; 63% boys) in this analysis. Leptin was negatively associated with lumbar spine bone mineral content (β=-0.162, p=0.053). No significant interaction was found for muscular fitness. Simple slope estimates suggested that children performing more than 133.3kg in leg press test ameliorated the negative association between leptin and lumbar spine bone mineral content.

CONCLUSION

Leptin levels were negatively associated with lumbar spine bone mineral content in children with overweight or obesity. A high muscular fitness at the lower body could counteract this association.

Bone mineral density and body composition in normal weight, overweight and obese children

BACKGROUND

There is a possibility that excess body fat affects bone mass gain and may compromise skeletal health in obese children. The purpose of the study was to identify the relationship between bone mineral density (BMD) and body composition in normal weight, overweight and obese children.

METHODS

This was a cross-sectional study of 6- to 11-year-old children who attended the hospital's outpatient clinic. They were apparently healthy and had no history of prematurity, low birth weight, or chronic diseases. Body mass index (BMI) was used to identify subjects as normal weight, overweight or obese. BMD and body composition were assessed by dual energy X-ray absorptiometry. The BMD values (total and lumbar spine) were compared between normal weight, overweight and obese children. Correlation coefficients were calculated, and multivariate models were performed.

RESULTS

Forty-nine children were included: 16 with normal weight, 15 that were overweight and 18 with obesity; the mean age was 8.4 ± 1.7 years. All the participants had a normal BMD (> - 2 SD). BMD was higher in obese children and had a positive correlation with total and trunk lean mass in the three study groups (p < 0.001). In obese children, an inverse correlation of lumbar spine BMD (Z score) with total and trunk fat mass (p < 0.05) was identified. In the multivariate models (with the whole group), the total lean mass was the only significant variable that explained BMD variability.

CONCLUSIONS

BMD in obese children was higher than that in normal weight children, which is explained by their greater lean mass and not by excess body fat. In obese children, a higher fat mass was related to a lower lumbar spine BMD. Lean mass had a direct correlation with BMD in the three study groups and was the most important predictor of BMD, reflecting the importance of strengthening the muscular system through performing physical activity and practicing a healthy lifestyle.

Anorexia Nervosa and Osteoporosis

Patients with anorexia nervosa (AN) often experience low bone mineral density (BMD) and increased fracture risk, with low body weight and decreased gonadal function being the strongest predictors of the observed bone mineral deficit and fractures. Other metabolic disturbances have also been linked to bone loss in this group of patients, including growth hormone resistance, low insulin-like growth factor-1 (IGF-1) concentrations, low leptin concentrations, and hypercortisolemia. However, these correlations lack definitive evidence of causality. Weight restoration and resumption of menstrual function have the strongest impact on increasing BMD. Other potential treatment options include bisphosphonates and teriparatide, supported by data from small clinical trials, but these agents are not approved for the treatment of low BMD in adolescents or premenopausal women with AN.

Severe Infraclavicular Displacement of a Proximal Humerus Fracture with Concomitant Olecranon Fracture in a Pediatric Patient

Proximal humerus fractures with severe medial displacement of the humeral head are rare in adults and especially so in children. Concomitant vascular/neurovascular injury is even more uncommon but must be considered as the associated complications can carry significant morbidity. We present a case of a 12-year-old transported to the ED after a mountain bike accident in which she lost control and hit a cement wall, injuring her left upper extremity (LUE). Despite a normal vascular/sensory exam, imaging demonstrated a left comminuted proximal humerus fracture with the humerus displaced medially into the thoracic inlet as well as concern for left subclavian vessel injury. Given the possibility of vascular injury and the severe humeral head displacement, she was taken to surgery with orthopedic and vascular surgical teams. Although surgical exploration did not reveal vascular injury, this case underlines the importance of maintaining a high index of suspicion for neurovascular injury with such fractures as prompt intervention may reduce the likelihood of complications. This case also underscores the need for further research into the management of pediatric proximal humerus fractures in early adolescence.

The Mediating Role of Endocrine Factors in the Positive Relationship Between Fat Mass and Bone Mineral Content in Children Aged 9-11 Years: The Physical Activity and Nutrition in Children Study

INTRODUCTION

We aimed to investigate whether the relationship between fat mass and bone mineral content (BMC) is mediated by insulin, leptin, adiponectin, dehydroepiandrosterone sulphate, testosterone and estradiol in children aged 9-11 years.

MATERIALS AND METHODS

We utilised cross-sectional data from the Physical Activity and Nutrition in Children study (n = 230 to 396; 112 to 203 girls). Fat mass and BMC were assessed with dual-energy X-ray absorptiometry. Endocrine factors were assessed from fasted blood samples. We applied the novel 4-way decomposition method to analyse associations between fat mass, endocrine factors, and BMC.

RESULTS

Fat mass was positively associated with BMC in girls (ß = 0.007 to 0.015, 95% confidence interval (CI) 0.005 to 0.020) and boys (ß = 0.009 to 0.015, 95% CI 0.005 to 0.019). The relationship between fat mass and BMC was mediated by free leptin index in girls (ß = -0.025, 95% CI -0.039 to -0.010) and boys (ß = -0.014, 95% CI -0.027 to -0.001). The relationship between fat mass and BMC was partially explained by mediated interaction between fat mass and free leptin index in boys (ß = -0.009, 95% CI -0.013 to -0.004) and by interaction between fat mass and adiponectin in girls (ß = -0.003, 95% CI -0.006 to -0.000).

CONCLUSION

At greater levels of adiponectin and free leptin index, the fat mass and BMC relationship becomes less positive in girls and boys respectively. The positive association between fat mass with BMC was largely not explained by the endocrine factors we assessed.

CLINICAL TRIAL REGISTRATION

[https://clinicaltrials.gov/ct2/show/NCT01803776], identifier NCT01803776.

Bone Response to High-Intensity Interval Training versus Moderate-Intensity Continuous Training in Adolescents with Obesity

INTRODUCTION

Since adolescents with obesity are prone to bone fragility during weight loss, the aim was to compare the impact of high-intensity interval training (HIIT) versus moderate-intensity continuous training (MICT) on bone density, geometry, and strength.

METHODS

Sixty-one adolescents were randomly assigned to 2 cycling trainings (HIIT and MICT) and a control (CTR, without training) group. Anthropometry, dual-energy X-ray absorptiometry with hip structural analysis and the trabecular bone score (TBS) were assessed before and after the 16-week intervention.

RESULTS

Body mass index (BMI) and fat mass (FM) percentage decreased at T1 versus T0 in both training groups (p < 0.001 for HIIT, p = 0.01 for MICT), though to a larger extent in HIIT (p < 0.05). Total body bone mineral density (BMD) and bone mineral content (BMC) increased in both training groups (p < 0.001), but to a greater extent in HIIT for BMC (p < 0.05). Lumbar spine BMD and BMC increased in both training groups (p < 0.001 for HIIT, p < 0.01 for MICT), with a time × group interaction between HIIT and CTR (p < 0.05) only. TBS increased in both training groups (p < 0.01 for HIIT, p < 0.05 for MICT). Hip BMD and BMC increased in both HIIT (p < 0.001 and p < 0.01) and MICT (p < 0.01 and p < 0.05). At the narrow neck (NN), endocortical diameter, width (p < 0.01), cross-sectional moment of inertia, and section modulus (Z) (p < 0.05) increased only in the HIIT group, such as BMD and Z (p < 0.05) at the intertrochanteric region (IT) and average cortical thickness (p < 0.001) and width (p < 0.05) at the femoral shaft. At the NN and IT, the buckling ratio decreased only in the HIIT group (p < 0.05), predicting higher resistance to fracture.

CONCLUSIONS

In addition to inducing greater BMI and FM percentage decreases in comparison to MICT, HIIT improves multisite bone density, geometry, and strength, which heighten the justification for HIIT as part of weight loss interventions in adolescents with obesity.

A Study Investigating Whether BMI Is Associated With Acetabular Bone Size: Big Bones or a Big Myth?

Background

There is a common conception held by patients with a high body mass index (BMI) that they have “big bones”. Some people hold the assumption that their weight is attributed to larger bone stock rather than adipose tissue. It was the suspicion of the surgeons at our unit that this is often not the case. We therefore conducted a study investigating if there is any association between BMI and acetabular bone size.

Methods

We conducted a retrospective chart review of all patients undergoing total hip arthroplasty using the Trident acetabular system from Stryker at our tertiary level 1 trauma centre between September 2016 and August 2020. Patient demographic and surgical data were collected, and the association of BMI, height, and weight, with acetabular cup size was investigated using Pearson’s correlation coefficient and chi-square test for independence.

Results

A total of 418 patients were included in this study (52.4% female; age: 20-93 years; mean age: 62.51 years), with a mean BMI of 29.55 kg/m²(range: 14.95-52.32 kg/m²). A weak positive association between BMI and cup size, which was statistically significant (r = 0.107; n = 418; p = 0.02). The chi-square test for independence was used to study the association between obesity and cup size (large vs small), which demonstrated no significant difference (p = 0.08). There was a moderately strong positive association between height and cup size (r = 0.551; n = 418; p < 0.01). There was a weak positive association between weight and cup size, which was statistically significant (r = 0.355; n = 418; p < 0.01).

Conclusion

Our study suggests that there is indeed a weakly positive linear association between BMI and cup size among total hip arthroplasty patients. This effect was, however, more significant for height and weight, and there was no significant association between obese and non-obese groups with small versus large cup size implanted. We therefore conclude that clinically there is no significant relationship between obesity and acetabular bone size and that the “big bones” claim is indeed fallacious.

Obesity and Bone: A Complex Relationship

There is a large literature on the relationship between obesity and bone. What we can conclude from this review is that the increase in body weight causes an increase in BMD, both for a mechanical effect and for the greater amount of estrogens present in the adipose tissue. Nevertheless, despite an apparent strengthening of the bone witnessed by the increased BMD, the risk of fracture is higher. The greater risk of fracture in the obese subject is due to various factors, which are carefully analyzed by the Authors. These factors can be divided into metabolic factors and increased risk of falls. Fractures have an atypical distribution in the obese, with a lower incidence of typical osteoporotic fractures, such as those of hip, spine and wrist, and an increase in fractures of the ankle, upper leg, and humerus. In children, the distribution is different, but it is not the same in obese and normal-weight children. Specifically, the fractures of the lower limb are much more frequent in obese children. Sarcopenic obesity plays an important role. The authors also review the available literature regarding the effects of high-fat diet, weight loss and bariatric surgery.

Bone health in adolescence

Adolescence is a fundamental period for the formation of the skeleton, because is the stage in which bones grow more in both size and strength, laying a solid foundation for the future health of the skeleton. Any condition interfering with optimal peak bone mass accrual can increase fracture risk later in life. Up to 80% of peak bone mass is genetically determined while the remaining 20% is modulated by environmental factors that, if deleterious, may result in low bone mineral density (BMD) and an increased risk of fracture. The preferred test to assess bone health is dual-energy x-ray absorptiometry (spine or total body less head) using Z scores instead of T scores, even though in short stature or growth delay, should be used the height Z-score. The correction of risk factors is the first treatment for low BMD in children and adolescents. It's necessary having a correct lifestyle for preserving bone health: a proper nutrition, an adequate physical weight-bearing activity and avoidance of alcohol intake and tobacco smoke. Bisphosphonates could be used in children who sustained osteoporotic fractures, impairing quality of life, when spontaneous recovery is low for the persistence of osteoporosis risk factors. This clinical review discusses factors affecting bone health during childhood and adolescence and deals with diagnosis and treatment of low bone mass or osteoporosis in this age group.

Does the severity of obesity influence bone density, geometry and strength in adolescents?

BACKGROUND

Relationships between the severity of obesity and bone health remain underexplored.

OBJECTIVES

To compare whole-body and localized bone mineral content (BMC) and density (BMD), trabecular bone score (TBS) and hip geometry and strength between adolescents with obesity versus extreme obesity.

METHODS

This cross-sectional study included 154 adolescents (12-15 years, 62% females) who were classified as having obesity (OG, [95th-99th] percentile) or extreme obesity (EOG, >99th percentile). Fat mass (FM), lean mass (LM), BMC, BMD for total-body-less-head (TBLH), lumbar spine (LS), hip, TBS and geometric and strength indices at the narrow-neck (NN), femoral shaft (FS) and intertrochanteric regions (IT) were assessed by Dual-X-ray Absorptiometry (DXA).

RESULTS

There was no significant sex-interaction. For both sexes, TBLH BMC and BMD were not different between groups. TBS was lower in EOG compared with OG in both sexes in univariate analysis and after adjustment with maturation and body weight (p < 0.05). Hip BMD was significantly higher in the EOG compared to OG only after adjustment with maturation and fat mass percentage (p < 0.05 for men, p < 0.01 for women). For both sexes, TBLH, LS and hip BMC and BMD positively correlated with weight, BMI, LM and FM. TBS negatively correlated with BMI-percentile in both sexes, with a negative correlation with FM for males alone. Hip BMC and BMD, BMD, ACT and CSA at the three hip sites positively correlated with BMI-percentile in males.

CONCLUSIONS

Extreme obesity impacts bone health depending on anatomical sites, altering lumbar trabecular bone in both males and females adolescents.

A Novel High-Intensity Short Interval Dance Intervention (THANDAV) to Improve Physical Fitness in Asian Indian Adolescent Girls

Background: There exist several barriers to physical activity (PA) among adolescent girls. We therefore developed a culturally acceptable dance/fitness intervention called THANDAV (Taking High-Intensity Interval Training [HIIT] ANd Dance to Adolescents for Victory over noncommunicable diseases [NCDs]). The main aim of this study was to evaluate the THANDAV protocol among Asian Indian girls aged 10 to 17 years. Materials and Methods: THANDAV consisted of a 10-min routine with high- and low-intensity dance steps that was taught to 23 adolescent girls. Heart rate (HR), energy expenditure, body mass index (BMI), and blood pressure (BP) were recorded. Focused group discussions (FGDs) were conducted after the quantitative measurements were completed. Results: The average age of the girls was 13.9 ± 2.1 years, and the mean BMI and BP were 19.8 ± 3.3 kg/m² and 107/68 (±8/7) mm/Hg, respectively. All participants achieved 80% of their maximum HR during the first dance and managed to sustain this HR throughout the 10-min routine. There was a significant increase in the HR (bpm) [88.7 ± 8.4 to 195.6 ± 11.8, P < 0.001] and VO₂ (L/min) [0.025 ± 0.0 to 0.395 ± 0.1, P < 0.001] postintervention. The average energy cost of the activity (metabolic equivalent) was 6.3. The FGDs revealed that THANDAV was a socially acceptable, fun, and energetic form of PA. Conclusions: The THANDAV intervention meets HIIT norms and is a novel culturally appropriate form of PA that is enjoyable, takes little time, and can be done at home. It has the potential to be a sustainable intervention to improve cardiorespiratory fitness and prevent NCDs in Asian Indian adolescent girls. Clinical Trials Registry of India: CTRI/2020/02/023384.

Bone Health and Its Positive Relationships with Body Composition in Malaysian Schoolchildren: Findings from a Cross-Sectional Study

Background: Optimal bone health is vital in children to prevent osteoporosis later in life, and body composition plays a crucial role in it. However, the literature reports contradictory results when considering the relationship between body composition and bone health in children. This study aimed to examine the bone health and its relationship with body composition in Malaysian schoolchildren. Methods: In this cross sectional study, body composition data (weight, height, body fat percentage [% fat], fat mass, fat free mass, visceral fat, waist circumference [WC] and body mass index-for-age [BMI z-score]) and bone health data (Z-score and broadband ultrasound attenuation [BUA]) were collected from 415 schoolchildren aged 9–12 years, cluster sampled from randomly selected primary schools in Kuala Lumpur, Malaysia. Results: Girls generally had significantly higher height, body fat percentage, fat mass, visceral fat and Z-score as compared to boys. A steady increase of the mean BUA value was observed with increasing age in both sexes. The mean BUA value of the present study across the population was significantly higher than that of schoolchildren from Nigeria (p < 0.001), Colombia (p < 0.001) and Spain (p = 0.002). Significant positive correlations were found between all the body composition variables and bone outcome variables across the population. Further, BUA was significantly correlated with weight (β = 0.172; p = 0.001), height (β = 0.299; p < 0.001), % fat (β = 0.131; p = 0.007), fat mass (β = 0.130; p = 0.007), fat free mass (β = 0.209; p < 0.001), visceral fat (β = 0.127, p = 0.008), WC (β = 0.165; p = 0.001) and BMI z-score (β = 0.162; p = 0.001), after controlling for sex, age and ethnicity. Similarly, after confounders adjusted, Z-score was significantly predicted by weight (β = 0.160; p = 0.001), height (β = 0.310; p < 0.001), % fat (β = 0.104; p = 0.032), fat mass (β = 0.107; p = 0.026), fat free mass (β = 0.218; p < 0.001), visceral fat (β = 0.107, p = 0.026), WC (β = 0.145; p = 0.002) and BMI z-score (β = 0.150; p = 0.002). Conclusions: Our findings have revealed that body composition variables were positive correlated with bone outcome variables, suggesting that adipose tissue acts to stimulate bone growth. Further clinical and molecular studies in the future is recommended to fully illustrate the complex interactions between adiposity and bone health.

Effects of ammonia on growth performance, lipid metabolism and cecal microbial community of rabbits

This study was designed to investigate the effect of ammonia on growth performance, lipid metabolism and intestinal flora of rabbits. A total of 150 female IRA rabbits (35-days-old) were randomly divided into three groups including 0 ppm (CG), 10 ppm (LAC) and 30 ppm ammonia (HAC) groups for a period of 28 days. The average daily weight gain (ADG) of rabbits was significantly reduced in LAC (-17.11%; p < 0.001) and HAC groups (-17.46%; p < 0.001) as compared with the CG. Serum concentration of high density lipoprotein (HDL) and glucose (Glu) were increased in LAC (+80.95%; +45.99; p < 0.05) and HAC groups (+219.05%; +45.89; p < 0.001), while apolipoprotein A1 (apoA1) was decreased in LAC (-58.49%; p < 0.001) and HAC groups (-36.92%; p < 0.001). The structural integrity of cecum was damaged, and the thickness of mucosa and serosa were significantly decreased in LAC and HAC. The acetate, butyrate and propionate level of cecal chyme were reduced in HAC group (-21.67%; -19.82%; -30.81%; p < 0.05). Microbial diversity and burden of Firmicutes were significantly decreased, while that of pathogenic bacteria, such as Bacteroidetes, Clostridium and Proteobacteria were increased in ammonia treated groups. Spearman's correlation confirmed that burden of Ruminococcaceae_NK4A214_group showed significantly negative correlation with acetic acid (r = -0.67; p < 0.001) while Barnesiellaceae_unclassified showed significantly positive correlation with propionic acid (r = 0.50; p < 0.001). In conclusion, ammonia treatment was responsible for an imbalance of intestinal flora, which affected lipid metabolism and damaged intestinal barrier of rabbits, resulting in low growth performance due to lipid metabolism dysfunction.

Mechanoadaptation of the bones of mice with high fat diet induced obesity in response to cyclical loading

An upward trend in childhood obesity implies a great need to determine its effects, both immediate and long-term. Obesity is osteoprotective in adults, but we know very little about the effects of obesity on the growing skeleton, particularly its ability to adapt to load. The objective of this research is to assess bone mechanoadaptation in adolescent obese mice. Ten mice were fed a high-fat diet (HFD) from 4 to 16 weeks of age, while a control group of the same size received a normal diet (ND). At 14 weeks of age, right tibiae were cyclically loaded with a 12 N peak load for HFD mice and a 9 N peak load for ND mice three times a week for two weeks, resulting in equal peak strains of about 2500 microstrain. At 16 weeks of age, mice were sacrificed, and tibiae and gonadal fat pads were dissected. Fat pads were weighed as an obesity indicator, and tibiae were imaged with microCT to measure bone structure. The left tibiae (nonloaded) were subsequently decalcified, stained with osmium, and scanned to quantify marrow fat. Results showed that HFD mice had larger tibial cross-sectional areas compared to ND mice, as well as greater marrow adiposity. However, there was no significant difference in the amount of bone adaptation in the cortical or trabecular bone between the two groups. This indicates that the bones of HFD and ND mice adapt equally well to loading.

Factors influencing peak bone mass gain

Bone mass is a key determinant of osteoporosis and fragility fractures. Epidemiologic studies have shown that a 10% increase in peak bone mass (PBM) at the population level reduces the risk of fracture later in life by 50%. Low PBM is possibly due to the bone loss caused by various conditions or processes that occur during adolescence and young adulthood. Race, gender, and family history (genetics) are responsible for the majority of PBM, but other factors, such as physical activity, calcium and vitamin D intake, weight, smoking and alcohol consumption, socioeconomic status, age at menarche, and other secondary causes (diseases and medications), play important roles in PBM gain during childhood and adolescence. Hence, the optimization of lifestyle factors that affect PBM and bone strength is an important strategy to maximize PBM among adolescents and young people, and thus to reduce the low bone mass or osteoporosis risk in later life. This review aims to summarize the available evidence for the common but important factors that influence bone mass gain during growth and development and discuss the advances of developing high PBM.

Bone response to eccentric versus concentric cycling in adolescents with obesity

OBJECTIVES

Because adolescents with obesity are susceptible to bone fragility during weight loss (WL), we evaluated the impact of eccentric (ECC) versus classical concentric (CON) training at the same oxygen consumption (V˙O₂) on bone density, geometry and strength.

METHODS

Thirty five adolescents were included into 2 training (CON and ECC cycling) and a control (CTR, without training) groups. Anthropometry, dual-energy X-ray absorptiometry, hip structural analysis and quantitative bone ultrasound were assessed before and after the 12-week intervention.

RESULTS

The trainings promoted significant improvements in body mass index, total fat (FM) and lean mass (LM), with better improvements for FM and LM in the ECC group (p < 0.05). Leg LM percentage increased only in the ECC group (p < 0.05). Total body bone mineral content and density increased in both training groups (p < 0.001) with significant time x group interactions only between ECC and CTR (p < 0.05). Buckling ratio at the intertrochanteric region and femoral shaft increased only in CTR and CON groups (p < 0.05). Speeds of sounds at the calcaneum increased only in ECC group (p < 0.01).

CONCLUSIONS

Bone fragility, from a compromised relationship between density, geometry and strength, might be prevented with the ECC modality.

Substantial decrease in paediatric lower extremity fracture rates in German hospitals in 2017 compared with 2002: an epidemiological study

Background

There are no recent studies on the frequency of paediatric lower extremity fractures in Germany. The aims of this study were to report fracture rates of paediatric lower extremity fractures treated in German hospitals in 2002 and 2017 and to detect changes over time as well as to evaluate the gender and age distribution for each fracture location.

Methods

Data from the German National Hospital Discharge Registry, which covers over 99% of all German hospitals, were used for this study. The absolute frequencies and incidence of lower extremity fractures as well as age at the time of fracture and gender were included in the data. The population was subdivided into four age groups: 0–4, 5–9, 10–14, and 15–19 years. The boy: girl ratio (BGR) for all fracture locations was calculated by dividing the absolute frequency of boys by that of girls. The fracture incidence in 2017 was compared with 2002 by calculating the incidence rate ratio (IRR).

Results

The total number of fractures decreased by 39.9% from 2002 to 2017. The most common fracture locations in 2002 were femoral shaft, tibial shaft, distal tibia, and lateral and medial malleolus; the absolute number of all these fractures was lower in 2017 than in 2002 in all age groups. The incidence of hip and thigh fractures, knee and lower leg fractures, and foot fractures decreased by 39.0, 41.1, and 33.3%. Proximal tibial fractures increased both in absolute numbers and in incidence in the age groups 0–4, 10–14, and 15–19 years (IRR ≥ 1.1). The overall BGR was 2.3 in 2002 and 2.0 in 2017, indicating that the number of girls relative to that of boys who suffered a lower extremity fracture was higher in 2017 than in 2002. Furthermore, the BGR of all fracture locations increased with age in both years.

Conclusions

The number of paediatric lower extremity fractures treated in German hospitals in 2017 was significantly lower than that in 2002. However, the fracture frequency in girls decreased to a lesser extent than that in boys. The incidence of proximal tibial fractures increased.

The relationship between adolescent obesity and pelvis dimensions in adulthood: a retrospective longitudinal study

Background

The effect of fat tissue on a developing individual is fundamentally different from the effect on an adult. Several changes caused by obesity during sexual maturation have an irreversible and severe negative effect (lower fertility, reduced final height, type 2 diabetes mellitus) even for those who have subsequently lost weight. Our study was focused on monitoring the skeletal structure substantially influenced by sex hormones—the pelvis. The adult pelvis is strongly sexually dimorphic, which is not the case for the juvenile pelvis; skeletal differences between sexes are not so prominent and start to manifest with the onset of puberty. Evidence from animal models and case studies of treatment of gender dysphoria suggests that estrogens have a stimulatory effect on the growth plates present on the pelvis, leading to morphological change. Male obesity, especially in puberty, is connected with hypogonadism, manifesting in low levels of testosterone, and high levels of estrogens. The goal of our study was to evaluate the influence of obesity during adolescence on the morphology of the adult pelvis in the context of androgen and estrogen status.

Sample and Methods

Our sample consists of 238 individuals (144 females, 94 males) observed after an 8 year follow-up (mean age during enrollment 15.2 years, follow-up 23.3 years). Anthropometry and body composition using bioimpedance analysis (BIA) were obtained. During the follow-up, saliva samples from male participants were also collected to estimate testosterone and estradiol levels using the salivary ELISA kit (Salimetrics LLC, State College, PA, USA).

Results

The body fat (percentage of body fat estimated using BIA) was strongly positively associated with relative pelvic breadths in adulthood (males r = 0.64; females r = 0.56, both with p < 0.001). Adulthood pelvic breadth was a highly sensitive (0.81) and specific (0.74) retrospective marker of obesity during adolescence. The complex regression model (with reduction of dimensionality) including testosterone, estradiol to testosterone ratio and body fat (adolescent and adulthood) was able to describe 54.8% variability of pelvic breadth among males.

Discussion

We observed that adults with a history of obesity from adolescence tend to have a wider dimension of the bony pelvis in adulthood. Based on the parameters of the adult pelvis, the history of obesity can be determined with satisfactory sensitivity and specificity (<70%). One of the explanations for this observation can be the influence of relatively elevated estrogens levels connected with excessive adiposity leading to a wider pelvis. However, the biomechanical stress connected with elevated body mass also has to be considered, as does the influence of physical activity and gait pattern on the skeletal build.

A Perspective on Management of Limb Fractures in Obese Children: Is It Time for Dedicated Guidelines?

Limb fractures are the most common injuries in pediatric orthopedics. Early and late complications are often not preventable, even when providing the best treatment; furthermore, these injuries are largely implicated in medico-legal claims. The development of evidence-based guidelines is one of the main goals of medical research. Approved guidelines for diagnosis, treatment, and follow up are fundamental to obtain the best results in medical practice. Guidelines in pediatric traumatology have been developed, even though specific conditions, like obesity, could influence their drafting. The cast and fixation systems usually applied in pediatric fractures provide a growth plate sparing, a satisfying reduction, and good stress resistance, mostly because of a lower bodyweight compared to adults. Several studies suggest that obesity influences the bone quality, the management, and the outcomes in cases of fracture. High body weight increases the risk of trauma, modifies fracture characteristics, and increases the risk of incomplete reduction. Fractures in obese children have a higher rate of complications, regardless of conservative or surgical treatment. In obese children, surgical treatment is often used more frequently than with non-obese children. Such considerations are valid both for lower and upper limb fractures. The aim of this paper is to discuss recent scientific literature and provide a perspective on the benefits of a dedicated approach in the management of obese children. Guideline updates could improve healthcare quality in a pediatric setting, and also reduce medico-legal implications.

The Bones of Children With Obesity

Excess adiposity in childhood may affect bone development, ultimately leading to bone frailty. Previous reports showing an increased rate of extremity fractures in children with obesity support this fear. On the other hand, there is also evidence suggesting that bone mineral content is higher in obese children than in normal weight peers. Both adipocytes and osteoblasts derive from multipotent mesenchymal stem cells (MSCs) and obesity drives the differentiation of MSCs toward adipocytes at the expense of osteoblast differentiation. Furthermore, adipocytes in bone marrow microenvironment release a number of pro-inflammatory and immunomodulatory molecules that up-regulate formation and activation of osteoclasts, thus favoring bone frailty. On the other hand, body adiposity represents a mechanical load, which is beneficial for bone accrual. In this frame, bone quality, and structure result from the balance of inflammatory and mechanical stimuli. Diet, physical activity and the hormonal milieu at puberty play a pivotal role on this balance. In this review, we will address the question whether the bone of obese children and adolescents is unhealthy in comparison with normal-weight peers and discuss mechanisms underlying the differences in bone quality and structure. We anticipate that many biases and confounders affect the clinical studies conducted so far and preclude us from achieving robust conclusions. Sample-size, lack of adequate controls, heterogeneity of study designs are the major drawbacks of the existing reports. Due to the increased body size of children with obesity, dual energy absorptiometry might overestimate bone mineral density in these individuals. Magnetic resonance imaging, peripheral quantitative CT (pQCT) scanning and high-resolution pQCT are promising techniques for the accurate estimate of bone mineral content in obese children. Moreover, no longitudinal study on the risk of incident osteoporosis in early adulthood of children and adolescents with obesity is available. Finally, we will address emerging dietary issues (i.e., the likely benefits for the bone health of polyunsaturated fatty acids and polyphenols) since an healthy diet (i.e., the Mediterranean diet) with balanced intake of certain nutrients associated with physical activity remain the cornerstones for achieving an adequate bone accrual in young individuals regardless of their adiposity degree.

Faecal microbiota and functional capacity associated with weaning weight in meat rabbits

Weaning weight is an important economic trait in the meat rabbit industry. Evidence has linked the gut microbiota to health and production performance in rabbits. However, the effect of gut microbiota on meat rabbit weaning weight remains unclear. In this study, we performed 16S rRNA gene sequencing analysis of 135 faecal samples from commercial Ira rabbits. We detected 50 OTUs significantly associated with weaning weight. OTUs that showed positive associations with weaning weight were mostly members of the family Ruminococcaceae which are important in degrading dietary fibres and producing butyrate. On the contrary, OTUs annotated to genera Blautia, Lachnoclostridium and Butyricicoccus correlated with fat deposition were negatively associated with weaning weight. Predicted functional capacity analysis revealed that 91 KOs and 26 KEGG pathways exhibited potential correlations with weaning weight. We found that gut microbiota involved in the metabolism of amino acids, butanoate, energy and monosaccharides affected weaning weight. Additionally, cross-validation analysis indicated that 16.16% of the variation in weaning weight was explained by the gut microbiome. Our findings provide important information to improve weaning weight of meat rabbits by modulating their gut microbiome.

Functional Relationship between Leptin and Nitric Oxide in Metabolism

Leptin, the product of the ob gene, was originally described as a satiety factor, playing a crucial role in the control of body weight. Nevertheless, the wide distribution of leptin receptors in peripheral tissues supports that leptin exerts pleiotropic biological effects, consisting of the modulation of numerous processes including thermogenesis, reproduction, angiogenesis, hematopoiesis, osteogenesis, neuroendocrine, and immune functions as well as arterial pressure control. Nitric oxide (NO) is a free radical synthesized from L-arginine by the action of the NO synthase (NOS) enzyme. Three NOS isoforms have been identified: the neuronal NOS (nNOS) and endothelial NOS (eNOS) constitutive isoforms, and the inducible NOS (iNOS). NO mediates multiple biological effects in a variety of physiological systems such as energy balance, blood pressure, reproduction, immune response, or reproduction. Leptin and NO on their own participate in multiple common physiological processes, with a functional relationship between both factors having been identified. The present review describes the functional relationship between leptin and NO in different physiological processes.