Kung-Ting Kao

Viewpoint article: Childhood obesity – looking back over 50 years to begin to look forward

The last 50 years have seen the emergence of childhood obesity as a major public health concern and a condition now regularly encountered in routine general paediatric practice. Causes are extremely complex, bringing together multifactorial environmental factors and individual genetics, and we still do not have a clear understanding of why some children appear predisposed to exaggerated and sometimes extreme weight gain. Overweight and obese children of today face an uncertain future. They are likely to experience higher rates of type 2 diabetes and heart disease, as well as many other health problems. However, while the prevalence of childhood obesity has progressively increased over the last few decades, so has research into its underlying causes. This has led to large‐scale trials aimed at improving prevention or treatment. As data have emerged from such studies, we have begun to accept that the heterogeneity of obesity means that broad ‘common sense’ strategies to address diet and activity will not lead to success on their own. Now is the time to begin to build on this information, dispelling myths and beliefs, in order to focus research efforts and take first steps towards more sophisticated strategies that go beyond the surface behaviours that simply potentiate obesity. Through carefully designed studies, aimed at tackling fundamental questions missed in the hasty development of ‘common sense’ approaches, will come answers that can lead to the development of more effective community‐ and health‐care‐orientated prevention and treatment programmes.

The effect of antidepressants and antipsychotics on weight gain in children and adolescents

Psychiatric illness in the paediatric population is increasing and the weight effect of medications for these problems is often unclear. A comprehensive literature search was undertaken to identify studies reporting weight in relation to antipsychotic and antidepressant use in children and adolescents. From 636 articles, 42 were selected for review. Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) do not cause weight gain and may lead to improvements in weight status over the short, but not, long term. Antipsychotics were generally associated with weight gain. In drug comparison studies, risperidone had a larger weight gain effect than lithium, divalproex sodium and pimozide. Studies assessing the weight‐protective effects of augmentation therapy with metformin or topiramate show less weight gain with addition of these agents. In conclusion, prescribing of SSRIs and SNRIs may be associated with improvements in weight status in children and adolescents but trials assessing their use in obesity, outside of established psychiatric illness, are limited and still experimental. Youth prescribed antipsychotic medication should be monitored for exaggerated weight gain and in those where obesity is a pre‐existing concern agents other than olanzapine, clozapine and risperidone may be advantageous.

Low vitamin D is associated with hypertension in paediatric obesity.

The aim of this paper was to investigate the relationship between circulating 25‐hydroxyvitamin D (25(OH)D) and cardio‐metabolic risk factors in a large cohort of obese youth attending tertiary paediatric obesity services.

Childhood insulinoma masquerading as seizure disorder

A 9 year old girl presented with seizures, weight gain and early morning behavioural changes. She had been commenced on anticonvulsants and was subsequently diagnosed with hyperinsulinaemic hypoglycaemia. This case demonstrates the importance of blood glucose monitoring in children presenting with new‐onset seizures and/or with early morning or fasting behavioural changes, the challenges in localizing the lesion, as well as the difficulties in achieving normoglycaemia prior to, and immediately following, surgery.

Adult Quality of Life and Psychosocial Outcomes of Childhood Onset Hypopituitarism

Backgroud/Aims: Poor quality of life (QoL) has been reported in adults with growth hormone deficiency. Few studies have examined QoL in adults with childhood onset multiple pituitary hormone deficiencies (COMPHD). We evaluated QoL in adults with COMPHD. Methods: COMPHD participants aged ≥18 years were identified from hospital medical records and the clinics of one author (M.Z.). Age- and sex-matched controls were recruited for every participant. The World Health Organization QoL Questionnaire, the Kessler Psychological Distress Scale, the Female Sexual Function Index (FSFI) and the Male Sexual Quotient (MSQ) were used to measure QoL, psychological distress and psychosexual function. Results: Ninety-two (68.1%) patients (males 55%; mean age 29.7 years, range 18-61) participated. COMPHD was caused by a brain tumour in 63 (68.5%), congenital hypopituitarism in 19 (20.1%), other cancers in 7 (7.6%) and trauma in 3 (3.3%) patients. COMPHD participants were shorter and more overweight, reported more childhood behavioural problems and had less education, more unemployment, lower marital rates and incomes and fewer children compared to healthy controls (p < 0.05 for each). Although they scored lower in all QoL domains (p ≤ 0.001) and psychosexual function (FSFI and MSQ, p < 0.001), there was no difference in reported psychological distress (p = 0.119). QoL was influenced by background diagnosis and treatment in a subgroup analysis. Conclusion: Adults with COMPHD have a significantly lower QoL compared to physically healthy peers. Difficulties in psychosocial and psychosexual function in these patients need to be addressed.

A Baby Boy with Hypothyroidism and Hemangioendothelioma

A full-term baby boy underwent an ultrasound scan of the abdomen at 6 weeks of age for the follow-up of an antenatal diagnosis of left-sided hydronephrosis. Although there was no hydronephrosis, the abdominal ultrasound revealed an enlarged liver with multiple hypoechoic lesions measuring up to 25 mm in diameter. He was admitted to the hospital for further evaluation of the hepatic lesions. Examination revealed multiple small external hemangiomas on the scalp and both wrists and axilla. The infants abdomen was distended with hepatomegaly 6–7 cm below the costal margin. There was no evidence of cardiac failure, an observation that was confirmed by a cardiology consult. His electrolytes, creatinine, urine catecholamine metabolites, α-fetoprotein, and liver enzymes were all within reference intervals, except for an increased γ-glutamyl transferase of 257 IU/L (reference interval, 7–64 IU/L). Thyroid function tests (TFT)7 revealed an increased thyroid-stimulating hormone (TSH) concentration of 37.7 mU/L (age-specific reference interval, 0.30–5.00 mU/L), free thyroxine (fT4) within the reference interval at 17.9 pmol/L (age-specific reference interval, 12.0–30.0 pmol/L), and low free triiodotyronine (fT3) of 3.3 pmol/L (age-specific reference interval, 3.8–6.0 pmol/L) (Beckman DxI, Beckman Coulter). Thyroid peroxidase and thyroglobulin antibodies were negative. The newborn TSH screening test results were within reference intervals. MRI scan of the abdomen showed multiple liver lesions consistent with hemangioendothelioma. ### QUESTIONS TO CONSIDER 1. What are the possible causes for discrepant TSH and fT4 results? 2. What additional biochemical testing would be helpful to elucidate the cause of the discrepancy in the TSH and fT4? 3. What is the most probable diagnosis? ### DISCREPANCY IN THYROID FUNCTION TESTS AND FURTHER INVESTIGATIONS Analytical interference in TSH or fT4 immunoassay, congenital hypothyroidism secondary to dyshormonogenesis, and consumptive hypothyroidism due to hemangioendothelioma are the possible causes for discrepant TSH and fT4 results in this patient. We excluded possible TFT assay interferences by reanalyzing the TFT after using heterophile antibody blocking tubes (Scantibodies Laboratories) and …

Serum IGFBP-2 levels are associated with reduced insulin sensitivity in obese children: Serum IGFBP-2 in children with obesity

Insulin‐like growth factor binding protein 2 (IGFBP‐2) may represent a critical link between body composition and insulin sensitivity. We investigated the relationship between circulating IGFBP‐2 levels, body composition, insulin sensitivity, energy intake and physical activity in children with obesity. Children were recruited via the Weight Management Service at the Royal Childrens Hospital, Melbourne, as part of the Childhood Overweight BioRepository of Australia (COBRA). Comprehensive anthropometric, biochemical and environmental data were collected and compared to serum IGFBP‐2 levels (measured by enzyme‐linked immunosorbent assay). Multiple regression modelling was used to assess the influence of circulating IGFBP‐2 levels on anthropometric and biochemical measures. One hundred and ninety‐four children were included in this study (46% male). Circulating IGFBP‐2 negatively correlated with age, anthropometric measures, blood pressure and insulin concentration. Positive associations were observed between insulin sensitivity index‐homeostasis model assessment (ISI‐HOMA) and serum IGFBP‐2. In multiple regression modelling, IGFBP‐2 significantly contributes to variance in systolic blood pressure (−19%, P < 0.05), circulating triglycerides (−16%, P < 0.05) and ISI‐HOMA (18%, P < 0.05). No associations were observed between dietary energy intake or physical activity and IGFBP‐2 levels. Circulating IGFBP‐2 levels in children with obesity correlate inversely with body mass and markers of metabolic dysfunction, and positively with insulin sensitivity. These findings suggest that reduced levels of IGFBP‐2 may play an important role in the pathogenesis of obesity complications in early life.

Maternal inheritance of BDNF deletion, with phenotype of obesity and developmental delay in mother and child

Childhood obesity is a significant world health problem. Understanding the genetic and environmental factors contributing to the development of obesity in childhood is important for the rational design of strategies for obesity prevention and treatment. Brain‐derived neurotrophic factor (BDNF) plays an important role in the growth and development of the central nervous system, there is also an evidence that BDNF plays a role in regulation of appetite. Disruption of the expression of this gene in a child has been previously reported to result in a phenotype of severe obesity, hyperphagia, impaired cognitive function, and hyperactivity. We report a mother and child, both with micro‐deletions encompassing the BDNF gene locus, who both have obesity and developmental delay, although without hyperactivity. This report highlights the maternal inheritance of a rare genetic cause of childhood obesity.

An adolescent girl referred with Cushing syndrome – does she or does she not have the syndrome?

Abstract Cushing syndrome and lipodystrophy syndromes share similar clinical features. This report describes an adolescent girl with newly diagnosed familial partial lipodystrophy type 2 (FPLD2) who was initially referred for Cushing syndrome. The type of abnormal fat deposition syndrome can be elucidated by careful clinical examination. FPLD2 can lead to type 2 diabetes mellitus and early cardiovascular events. Partial lipodystrophy presenting for the first time in adolescence can be mistaken for corticosteroid excess. Early diagnosis and preventative management of cardiovascular risk factors are crucial.