Carl-Erik Flodmark

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

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

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

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

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

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

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

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

Family in pediatric obesity management: A literature review

A dramatic increase in prevalence of pediatric obesity has occurred in most countries over the past few decades. This is of particular significance given the fact that overweight children and adolescents are at increased risk for multiple medical co-morbidities, as well as psychosocial and behavioral difficulties. While considerable attention has recently been paid to identifying obesity and the importance of associated co-morbidities, there has been less focus on considerations related to effective interventions. Interventions aimed at childhood obesity include prevention and treatment. Both prevention and treatment need improvement to be useful in the clinical setting. Few investigators have demonstrated that treatment is effective. The aim of this review is to examine the effectiveness of family-based interventions in obese pediatric subjects and to explore what specific components of family-based programs are of particular significance when treating obese children. A literature search was performed and relevant studies are presented. A majority of the studies support the use of family-based treatment. Furthermore, to develop a fully interactive model, more focus is needed on the specific techniques used in evidence-based programs.

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

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

The happy obese child.

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

Physical activity-key issues in treatment of childhood obesity.

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

Laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity (AMOS): a prospective, 5-year, Swedish nationwide study

Background Severe obesity in adolescence is associated with reduced life expectancy and impaired quality of life. Long-term benefits of conservative treatments in adolescents are limited, while short-term outcomes of adolescent bariatric surgery are promising. This study aimed to report 5-year outcomes following Roux-en-Y gastric bypass (RYGB) in adolescents, compared with conservatively treated adolescents and adults undergoing RYGB. Methods A nationwide prospective non-randomised controlled study of adolescents (13–18 years) with severe obesity undergoing RYGB, a matched adolescent control group undergoing conservative treatment, and an adult comparison group undergoing RYGB. The primary outcome measure was change in weight over 5 years. Multilevel mixed-effect regression models were used to assess longitudinal changes. Healthcare usage was analysed with linear regression together with nonparametric bootstrapping. Findings Eighty-one adolescents with baseline age 16·5 years (SD 1·2), weight 132·8 kg (SD 22·1) and body mass index (BMI) 45·5 kg/m2 (SD 6·1) underwent RYGB. Five-year weight change was −36·8 kg (95% CI −40·9 to −32·8) resulting in a BMI reduction of 13·1 kg/m2, although weight loss <10% occurred in 11%. Comorbidities and cardiovascular risk factors resolved in 74–100%: type 2 diabetes (3/3), disturbed glucose homeostasis (18/21), dyslipidaemia (43/52), elevated blood pressure (11/12), inflammation (hs-CRP ≥ 2 mg/L; 45/61) and elevated liver enzymes (19/19), each comparing favourably with adolescent controls at 5 years. Functional (SF-36) and obesity-specific (OP-14) quality of life improved in the adolescent RYGB group (mean difference 4·2, p=0·006 and −9·9 p=0·009). Twenty RYGB participants (25%) underwent additional abdominal surgery for complications of surgery or rapid weight loss, 72% demonstrated some nutritional deficiency, and healthcare consumption increased. Mean BMI increased in control adolescents (3·3 kg/m2, 95% CI 1·9 to 4·8), while BMI change in adults was similar to surgical adolescents (mean difference 0·8 kg/m2, 95% CI −1·1 to 2·8). Twenty adolescent controls (25%) underwent bariatric surgery within 5 years. Interpretation Adolescents with severe obesity undergoing RYGB experienced substantial weight loss over 5 years, alongside improvements in comorbidities, risk factors and quality of life. Surgical intervention was, however, associated with additional surgical interventions and nutritional deficiencies. Non-surgical treatment was associated with weight gain and 25% underwent bariatric surgery within 5 years.

Family Weight School treatment: 1-year results in obese adolescents.

OBJECTIVE The aim was to evaluate the efficacy of a Family Weight School treatment based on family therapy in group meetings with adolescents with a high degree of obesity. METHODS Seventy-two obese adolescents aged 12-19 years old were referred to a childhood obesity center by pediatricians and school nurses and offered a Family Weight School therapy program in group meetings given by a multidisciplinary team. Intervention was compared with an untreated waiting list control group. Body mass index (BMI) and BMI z-scores were calculated before and after intervention. RESULTS Ninety percent of the intervention group completed the program (34 boys, 31 girls; baseline age = 14.8 +/- 1.8 years [mean +/- standard deviation, SD], BMI = 34 +/- 4.0, BMI z-score = 3.3 +/- 0.4). In the control group 10 boys and 13 girls (baseline age = 14.3 +/- 1.6, BMI = 34.1 +/- 4.8, BMI z-score = 3.2 +/- 0.4) participated in the 1-year follow-up. Adolescents in the intervention group with initial BMI z-score < 3.5 (n = 49 out of 65, baseline mean age = 14.8, mean BMI = 33.0, mean BMI z-score = 3.1), showed a significant decrease in BMI z-scores in both genders (-0.09 +/- 0.04, p = 0.039) compared with those in the control group with initial BMI z-score < 3.5 (n = 17 out of 23, mean baseline age = 14.1, mean baseline BMI = 31.6, mean baseline BMI z-score = 3.01). No difference was found in adolescents with BMI z-scores > 3.5. CONCLUSIONS Family Weight School treatment model might be suitable for adolescents with BMI z-score < 3.5 treated with a few sessions in a multidisciplinary program.