Decreasing Sedentary Behaviors in Youth to Prevent and Manage Childhood Obesity: Is It Realistic?

PURPOSE OF REVIEW

Decreasing sedentary behaviors has been proposed as one approach to reduce the rate of obesity in youth. This review summarizes the contemporary literature examining the efficacy of these interventions in the school and community along with an additional focus on the role of socioeconomic status in these interventions.

RECENT FINDINGS

Studies that focus on decreasing sedentary behavior have utilized a wide variety of strategies in a number of settings. The effects of these interventions are often hindered by non-standard outcome measures, study infidelity, and subjective measures of sedentary time. However, interventions that incorporate engaged stakeholders and include younger subjects appear to be the most likely to succeed. Promising interventions to decrease sedentary behaviors have been shown in recent clinical trials; however, replicating and sustaining these results is challenging. From the available literature, school-based interventions have the potential of reaching the largest group of children. In contrast, interventions in younger children, particularly those with invested parents, seem to be the most effective.

1005 Characterizing Sleep and Glycemia in Emerging Adults with Type 1 Diabetes

Introduction

Type 1 Diabetes (T1D) affects 1.25 million Americans, and only 14% of emerging adults (ages 18-30 years) achieve targets for glycemic control (A1C < 7.0%). Sleep deficiency, less than 6.5 hours total sleep time (TST), is associated with poorer glycemic control.

Methods

Emerging adults with T1D wore a wrist actigraph and their own or provided continuous glucose monitor (CGM) concurrently 24 hours/day for 6-8 days. Participants completed a 10-minute psychomotor vigilance test (PVT) on a device, 3-minute Trail Making Test on paper, and questionnaires including twice daily Pittsburgh sleep diaries in Research Electronic Data Capture (REDCap). TST, sleep onset latency (SOL), sleep efficiency (SE), wake after sleep onset (WASO), and sleep fragmentation index (SFI) were determined via actigraphy, glycemic control via A1C, and glucose variability via CGM. The purpose of this descriptive study was to explore associations between TST, sleep variability (SD of TST), neurocognitive function (psychomotor vigilance and executive function) and diabetes outcomes (glycemia and distress).

Results

The sample included 36 emerging adults (mean age 22.8±3.1; 30.6% male; 91.7% White, 86.1% non-Hispanic; A1C mean 7.1±1.0%, BMI 27.3±4.8 kg/m2). Mean TST was 7.1±1.2 hours, SOL was 19.7±13.5 minutes, SE was 85.5±4.6%, WASO was 34.7±18.2 minutes, and SFI was 17.7±6.2. Shorter TST was associated with more severe sleepiness (r=-0.48,p=0.004) and more diabetes distress (r=-0.37, p=0.03). More sleep variability was associated with more severe sleepiness (r=0.36, p=0.03), longer response times (RT) ≥ 500ms (rho=0.39, p=0.02) measured via PVT, more nocturnal glucose variability (r=0.38, p=0.04), greater mean daily differences in glucose levels (r=0.42, p=0.02). Shorter mean RT was associated with more time in glucose range (rho=-0.37, p=0.04).

Conclusion

Improving TST and sleep variability are potential therapeutic targets to improve glucoregulation in this high-risk population. Researchers should consider within-person multi-level modeling to inform our understanding of the true nature of the sleep-glucose association in emerging adults with T1D.

Support

T32 NR0008346, Sigma Theta Tau International, Dexcom provided continuous glucose monitors (G4) free of charge for participants who did not have their own device.

0927 Variations in Sleep and Glucose in Adolescents with Type 1 Diabetes

Introduction

The association between short sleep duration and poorer glycemic control in adolescents ages 10-16 with type 1 diabetes (T1D) is well established. Researchers have used cross-sectional, between-subjects’ methods, with limited focus on the potential intraindividual variation among these variables. The purpose of this analysis was to examine the within person associations between glucose variability indices (J index, low/high blood glucose index, time in range) and sleep characteristics (bedtime, waketime, total sleep time, sleep efficiency, wake after sleep onset [WASO], awakenings, and sleep fragmentation index) in adolescents with T1D.

Methods

Adolescents monitored their sleep and glucose patterns concurrently for 3-7 days with a wrist actigraph on their non-dominant wrist and either their own continuous glucose monitor (CGM) or a provided blinded CGM. General linear mixed models (GLMM) were used to determine within-person and day level associations.

Results

The sample included 38 adolescents (M age 13.4±1.8; 37.8% male; M A1C 8.2±1.2%). Average glucose levels were controlled in all GLMMs. Adolescents had earlier waketimes on days when more time was spent in hypoglycemia <70mg/dL (β=-0.15, p<0.001). At the person level, adolescents had greater WASO with more % time spent in severe hypoglycemia <54mg/dL with more severe low blood glucose indices (β=0.35, p<0.01 and β=0.34, p<0.01 respectively). At the daily level, adolescents had greater WASO (β=0.20, p=0.01) and more awakenings (β=0.16, p=0.04) on the days they had more overall glucose variability (J index) and more severe high blood glucose indices (β=0.17, p=0.04), but were less likely to have more % time in hypoglycemia (β=-0.15, p=0.02).

Conclusion

Glucose variability was positively associated with poor sleep (e.g., WASO and awakenings) in adolescents with T1D both at the daily and intraindividual level. Monitoring over a longer period of time in subsequent studies would allow researchers to determine the within person associations between habitual short sleep duration and glucose variability.

Support

NINR T32NR0008346 & P20NR014126, Medtronic MiniMed provided CGMs at a discounted rate for the study.

Correlates of Achieving Statin Therapy Goals in Children and Adolescents with Dyslipidemia

OBJECTIVE

To determine the real-world effectiveness of statins and impact of baseline factors on low-density lipoprotein cholesterol (LDL-C) reduction among children and adolescents.

STUDY DESIGN

We analyzed data prospectively collected from a quality improvement initiative in the Boston Children's Hospital Preventive Cardiology Program. We included patients ≤21 years of age initiated on statins between September 2010 and March 2014. The primary outcome was first achieving goal LDL-C, defined as <130 mg/dL, or <100 mg/dL with high-level risk factors (eg, diabetes, etc). Cox proportional hazards models were used to assess the impact of baseline clinical and lifestyle factors.

RESULTS

Among the 1521 pediatric patients evaluated in 3813 clinical encounters over 3.5 years, 97 patients (6.3%) were started on statin therapy and had follow-up data (median age 14 [IQR 7] years, 54% were female, and 24% obese, 62% with at least one lifestyle risk factor). The median baseline LDL-C was 215 (IQR 78) mg/dL, and median follow-up after starting statin was 1 (IQR 1.3) year. The cumulative probability of achieving LDL-C goal within 1 year was 60% (95% CI 47-69). A lower probability of achieving LDL-C goals was associated with male sex (HR 0.5 [95% CI 0.3-0.8]) and higher baseline LDL-C (HR 0.92 [95% CI 0.87-0.98] per 10 mg/dL), but not age, body mass index percentile, lifestyle factors, or family history.

CONCLUSIONS

The majority of pediatric patients started on statins reached LDL-C treatment goals within 1 year. Male patients and those with greater baseline LDL-C were less likely to be successful and may require increased support.

Nighttime bracing with the Providence brace in adolescent girls with idiopathic scoliosis

STUDY DESIGN

A prospective study was conducted of 102 consecutive female patients with adolescent idiopathic scoliosis. Those patients with Risser 0, 1, and 2 met the criteria for inclusion and were treated only with the Providence brace.

OBJECTIVES

To report the authors' experience with a hypercorrective nighttime brace and to evaluate the results with respect to risk factors for progression. Second, the study compares results with expectations from the natural history as reported by others.

SUMMARY OF BACKGROUND DATA

Compliance with full-time brace treatment for adolescent idiopathic scoliosis has been a problem. Since the introduction of the Milwaukee brace, alternatives such as low-profile braces, reduced wearing schedules, and nighttime only bracing have been tried. However, many factors influence the success or failure besides compliance. These include in-brace correction, brace design, and the orthotist's skills. This is the first report of the results of treatment with a new nighttime brace that is made with CAD/CAM technology that can achieve higher initial in-brace corrections than other reported methods.

METHODS

Results were analyzed with respect to curve size, curve pattern, maturity, and level of the primary curve apex. Both compliant and noncompliant patients were included in the analysis. A univariate analysis was done on those factors thought to influence success with bracing using the Pearson chi2 test.

RESULTS

The average initial in-brace correction with a supine radiograph was 96% for major curves and 98% for minor curves. Seventy-five patients (74%) did not progress >5 degrees and 27 patients (26%) progressed > or =6 degrees or went on to surgery. Twenty-nine percent of Risser 0 or 1 patients progressed and 17% of patients Risser 2 progressed. The risk of progression anticipated by natural history data, which included all curve patterns, was 68% for Risser 0 and 1 and 23% for Risser 2. Risser 3 and 4 patients were excluded from the study. Seventy-six percent of patients with curve apexes between T8 and L1 had successful outcomes using the Providence brace. This is compared with a 74% success rate in the prospective Scoliosis Research Society study of patients wearing a thoraco lumbar sacral orthosis for 16 hours per day with curve apexes between T8 and L1. With the Providence brace, 63% of thoracic curves and 65% of double curves were successful. Ninety-four percent of lumbar curves and 93% of thoracolumbar curves were successful.

CONCLUSION

Excellent initial in-brace correction of adolescent idiopathic scoliosis was observed with this computer-designed and manufactured recumbent brace. Patients with high apex curves cephalad to T8 (n = 31) had a success rate of 61% compared with a success rate of 79% (n = 71) if the apex was at or below T9. Compared with previous natural history and the prospective study data, the Providence brace is effective in preventing progression of adolescent idiopathic scoliosis for curves <35 degrees. It was effective for larger curves with a low apex. The authors' experience with patients with curves >35 degrees (n = 8) is too small to validate its effectiveness for larger curves with a higher apex.

Prospective longitudinal analysis of postoperative shoulder function : a ten-year follow-up study of full-thickness rotator cuff tears

BACKGROUND

Rotator cuff repair is associated with good short or mid-term results, but to date there have been no long-term functional outcome studies demonstrating durability of results over time. In most long-term studies, the results have been compared with those of historical controls or with those of other, short-term follow-up studies. The purpose of the present prospective study was to evaluate short and long-term shoulder function after surgical repair in a single population of patients in order to follow changes over time.

METHODS

Thirty-three patients underwent surgery, performed by one surgeon, for the treatment of a chronic, symptomatic, full-thickness rotator cuff defect. Data were obtained from questionnaires and physical examinations preoperatively, at two years, and at ten years. Identical standardized pain and function questionnaires were used and clinical evaluation was performed in a consistent fashion at all time-periods. The activity level, Constant score, level of disability, shoulder function score, and patient's subjective rating of the outcome were determined at the time of the final follow-up and compared with the same parameters at the two-year follow-up examination in order to determine if early results change with time.

RESULTS

At the ten-year follow-up examination, there was no change in the raw Constant score determined at the two-year examination. When the Constant score was normalized for expected age-related changes, the percentage of patients who had a satisfactory result at ten years was even greater than the percentage at two years. Activity level decreased significantly over the time-period (p = 0.005). At the final follow-up examination, twelve patients worked at the same occupation as they had when the two-year examination was performed, two worked at a less strenuous occupation, and the remaining patients were retired. Only two patients retired because of problems related to the shoulder. The level of disability decreased over the study period, and there was a small improvement in the patients' self-assessment shoulder function score. The patients' subjective assessment of the outcome remained unchanged.

CONCLUSIONS

The results of open rotator cuff repair for chronic tears do not deteriorate with time (ten years). The level of disability decreases, presumably because of a concurrent decrease in the activity level and in the demand on the shoulder as the patient ages. It is important to consider age-related changes when assessing the final outcome.

An effort to upgrade perinatal nursing practice in Albania

In 1994 the Jacobi Medical Center in Bronx, New York, and the University Hospital in Tirana, Albania, entered into a partnership designed to upgrade certain aspects of the health care system in Albania. During a 2-week trip, an American contingent of nurses and nurse-midwives worked to increase the knowledge base of Albanian nurses about some of the most important issues in perinatal care and of the roles of nurses and nurse-midwives in the United States as patient advocates and educators.

Malgaigne's fracture: the Larrey variant--a case report

A rare Malgaigne fracture with caudal displacement of the acetabular section is presented. This variant has not received significant mention in existing literature. It is important because it changes the approach to initial stabilization. Treatment is best accomplished with ORIF and placement of a sacral bar. Significant complications would occur if this variant were mistaken and treated with traction.