Mary M. Jetha

Parents as Agents of Change (PAC) in pediatric weight management: The protocol for the PAC randomized clinical trial

BackgroundThere is an urgent need to develop and evaluate weight management interventions to address childhood obesity. Recent research suggests that interventions designed for parents exclusively, which have been named parents as agents of change (PAC) approaches, have yielded positive outcomes for managing pediatric obesity. To date, no research has combined a PAC intervention approach with cognitive behavioural therapy (CBT) to examine whether these combined elements enhance intervention effectiveness. This paper describes the protocol our team is using to examine two PAC-based interventions for pediatric weight management. We hypothesize that children with obesity whose parents complete a CBT-based PAC intervention will achieve greater reductions in adiposity and improvements in cardiometabolic risk factors, lifestyle behaviours, and psychosocial outcomes than children whose parents complete a psycho-education-based PAC intervention (PEP).Methods/DesignThis study is a pragmatic, two-armed, parallel, single-blinded, superiority, randomized clinical trial. The primary objective is to examine the differential effects of a CBT-based PAC vs PEP-based PAC intervention on children’s BMI z-score (primary outcome). Secondary objectives are to assess intervention-mediated changes in cardiometabolic, lifestyle, and psychosocial variables in children and parents. Both interventions are similar in frequency of contact, session duration, group facilitation, lifestyle behaviour goals, and educational content. However, the interventions differ insofar as the CBT-based intervention incorporates theory-based concepts to help parents link their thoughts, feelings, and behaviours; these cognitive activities are enabled by group leaders who possess formal training in CBT. Mothers and fathers of children (8–12 years of age; BMI ≥85th percentile) are eligible to participate if they are proficient in English (written and spoken) and agree for at least one parent to attend group-based sessions on a weekly basis. Anthropometry, cardiometabolic risk factors, lifestyle behaviours, and psychosocial health of children and parents are assessed at pre-intervention, post-intervention, 6-, and 12-months follow-up.DiscussionThis study is designed to extend findings from earlier efficacy studies and provide data on the effect of a CBT-based PAC intervention for managing pediatric obesity in a real-world, outpatient clinical setting.Trial RegistrationClinicalTrials.gov identifier: NCT01267097

In search of quality evidence for lifestyle management and glycemic control in children and adolescents with type 2 diabetes: A systematic review

BackgroundOur purpose was to evaluate the impact of lifestyle behavior modification on glycemic control among children and youth with clinically defined Type 2 Diabetes (T2D).MethodsWe conducted a systematic review of studies (randomized trials, quasi-experimental studies) evaluating lifestyle (diet and/or physical activity) modification and glycemic control (HbA1c). Our data sources included bibliographic databases (EMBASE, CINAHL®, Cochrane Library, Medline®, PASCAL, PsycINFO®, and Sociological Abstracts), manual reference search, and contact with study authors. Two reviewers independently selected studies that included any intervention targeting diet and/or physical activity alone or in combination as a means to reduce HbA1c in children and youth under the age of 18 with T2D.ResultsOur search strategy generated 4,572 citations. The majority of citations were not relevant to the study objective. One study met inclusion criteria. In this retrospective study, morbidly obese youth with T2D were treated with a very low carbohydrate diet. This single study received a quality index score of < 11, indicating poor study quality and thus limiting confidence in the studys conclusions.ConclusionsThere is no high quality evidence to suggest lifestyle modification improves either short- or long-term glycemic control in children and youth with T2D. Additional research is clearly warranted to define optimal lifestyle behaviour strategies for young people with T2D.

A meal high in saturated fat evokes postprandial dyslipemia, hyperinsulinemia, and altered lipoprotein expression in obese children with and without nonalcoholic fatty liver disease.

BACKGROUND Hyperinsulinemia and altered lipid and lipoprotein metabolism induced by fast-food diets may contribute to nonalcoholic fatty liver disease (NAFLD). We hypothesized that a high saturated fat (SFA) meal would evoke prolonged postprandial lipemia and hyperinsulinemia, increased inflammation, and altered lipoprotein expression in obese children with NAFLD when compared with healthy children. METHODS We prospectively studied 31 children (NAFLD, 13.1 ± 2.6 years, n = 11; age-matched obese, 14.3 ± 1.7 years, n = 9; lean, 13.6 ± 2.6 years, n = 11) following consumption of a high SFA (18.8%) meal. Prior to and at 1, 3, and 6 hours after meal consumption, blood was collected for analysis of alanine aminotransferase (ALT); aspartate aminotransferase (AST); γ-glutamyltransferase; leptin; C-reactive protein; (fasting) insulin; glucose; triglycerides (TGs); total, high-density lipoprotein, and low-density lipoprotein cholesterol; adiponectin; nonesterified fatty acids (NEFAs); inflammatory markers (TNF-α, IL-6, IL-10); apolipoproteins-B48, B100, and CIII; and fatty acid (FA) composition of TG fractions. RESULTS Children with NAFLD had significantly higher fasting levels of ALT (87 ± 54 U/L), AST (52 ± 33.5 U/L), and apolipoprotein-CIII (20.6 ± 11.3 mg/dL) with postprandial hyperinsulinemia (iAUC insulin: 225 ± 207 [NAFLD] vs 113 ± 73 [obese] vs 47 ± 19.9 [lean] mU/L-h; P < .001); suppression of NEFA (iAUC-NEFA: 1.7 ± 0.9 [NAFLD] vs 0.6 ± 0.3 [obese] vs 1 ± 0.7 [lean] mEq/L-h); and prolonged elevations in apolipoprotein-B48 3-6 hours after meal consumption when compared with obese and lean controls (P < .05). CONCLUSION A meal high in saturated fat evokes postprandial dyslipemia, hyperinsulinemia, and altered lipoprotein expression in obese children with and without NAFLD.

A novel, non-invasive 13C-glucose breath test to estimate insulin resistance in obese prepubertal children.

Insulin resistance (IR) is an important risk factor for the development of type 2 diabetes mellitus in obese boys and girls. Because needle-associated fear and anxiety are common in children, non-invasive methods to determine IR are desirable. Our objective in this cross-sectional study of obese prepubertal children (n = 39) was to compare estimates of IR using a novel, non-invasive technique (13C-glucose breath test) with common indices of IR derived from an oral glucose tolerance test (OGTT). For the 13C-glucose breath test, samples were collected before and 90 minutes after ingestion of 25 mg 13C-labelled glucose. For the OGTT, glucose and insulin samples were collected at 0, 15, 30, 45, 60, 90 and 120 minutes. The homeostatic model assessment of insulin resistance (HOMA-IR), quantitative insulin sensitivity check index (QUICKI), insulin area-under-the-curve (AUC), and sum-of-insulin were calculated as indices of IR. Pearson correlations revealed significant, but moderate, associations between the 13C-glucose breath test and fasting insulin (r = -0.50; p < 0.01), 2-hour insulin (r = plots showed acceptable levels of agreement between indices of IR. In obese prepubertal children, the 13C-glucose breath test can provide a proxy estimate of IR when gold-standard techniques are either unavailable or impractical.

Postprandial lipemia as an early predictor of cardiovascular complications in childhood obesity

Abstract. The growing trend of childhood overweight and obesity is a major health concern worldwide. Although obesity is a key risk factor for cardiovascular disease, the etiologic link between obesity and the progression of vascular disease remains unknown. Traditionally, lowering fasting blood cholesterol concentration has been the main interventional target for decreasing the risk of heart disease. However, there is increasing evidence that elevated concentrations of intestinally-derived chylomicron particles are associated with cardiovascular disease risk and that this is particularly evident in insulin-resistance and obesity in adulthood. In this review we comment on recent evidence suggesting that overweight children have fasting chylomicron concentrations equivalent to that found in adults diagnosed with cardiovascular disease. Further, we consider the hypothesis that fasting and postprandial chylomicron metabolism has a central role in the genesis of cardiovascular disease during childhood obesity.

Apolipoprotein B48: a novel marker of metabolic risk in overweight children?

Clinical studies in adults indicate there is a positive and significant association between insulin resistance, dyslipidaemia, fasting intestinally derived lipoproteins [via apoB48 (apolipoprotein B48)] and visceral fat. All of these factors contribute to increased risk of CVD (cardiovascular disease). Since little is known about postprandial dyslipidaemia in overweight children, we sought to compare fasting levels of apoB48 with the HOMA-IR (homoeostasis model assessment of insulin resistance) score, classic lipid profile and VAT (visceral adipose tissue). Pre-pubertal, overweight boys and girls were recruited from the wider-Edmonton area (Alberta). Body composition was determined using both dual-energy X-ray absorptiometry and MRI (magnetic resonance imaging). Fasting apoB48 was quantified in plasma using an adapted SDS/PAGE immunoblotting technique, and insulin, glucose, TC (total cholesterol), TAG (triacylglycerol), LDL (low-density lipoprotein) and HDL (high-density lipoprotein) were determined by calorimetric assay. In this overweight sample, we observed elevated fasting apoB48 concentrations, greater than the normal adult range. In addition, apoB48 was significantly related to HOMA-IR and TAG levels. Although apoB48 was positively correlated with TC and LDL and negatively associated with HDL, these relationships did not achieve significance. Our ongoing MRI analysis reveals a positive relationship between apoB48 and VAT volume. To our knowledge, this is the first study to report apoB48 concentrations in overweight pre-pubertal children. Thus this article will provide a brief rationale for our study and its methodology.

Lifestyle Behaviors of Parents of Children in Pediatric Weight Management Are They Meeting Recommendations

Objective: Our objective was to examine the lifestyle behaviors of parents of children in pediatric weight management. Methods: Parents were recruited upon presentation of their children (body mass index [BMI] ≥85th percentile) to a pediatric weight management clinic. Parents’ demographic, anthropometric, and lifestyle habit data were collected by self-report. Parents were grouped into weight status categories based on their BMIs; lifestyle data were compared across BMI categories and to national recommendations. Results: Parents (n = 266; 84% women; BMI, mean ± SD, 31.8 ± 7.2 kg/m2) were predominantly overweight/obese (82%), and most did not meet dietary recommendations (71%). Healthy-weight parents reported more daily steps versus parents who were overweight/obese (all P < .05). Most parents (~60%) met guidelines for physical activity, sedentary activity, and sleep. Conclusion: The high prevalence of overweight and obesity combined with suboptimal dietary behaviors highlight the need to address both children’s and parents’ lifestyle habits in pediatric weight management.

It's like rocket science...only more complex: Challenges and experiences related to managing pediatric obesity in Canada

Pediatric obesity is an urgent and complex public health issue. Approximately one-third of Canadian children are overweight or obese, a proportion that highlights the need for effective and accessible services to improve short- and long-term health risks. In our experience, we have encountered a number of challenges common in pediatric obesity management across our clinical and research centers. For the purpose of this review, these challenges and our real-world experiences are grouped as issues that span (i) caring for children, adolescents, and families, (ii) collaborating with colleagues and (iii) working within the health care system. Collectively, we highlight a number of lessons learned from our years of experience and detail ongoing initiatives designed to optimize health services for managing obesity for children and adolescents in Canada.

Elevated remnant lipoproteins may increase subclinical CVD risk in pre‐pubertal children with obesity: a case‐control study

Childhood obesity plays a fundamental role in the development of cardiovascular disease (CVD) and type 2 diabetes in adulthood. Clinical guidelines for the early management of CVD in children are poorly defined. Traditional cholesterol biomarkers such as low‐density lipoprotein cholesterol usually fall within the normal range in pre‐pubertal children with obesity. Remnant lipoproteins are overproduced by the intestine during obesity and type‐2 diabetes in adults and are an independent risk factor for CVD.

Xanthomata and diabetes in an adolescent with familial dysbetalipoproteinemia 9 yr after valproate-induced pancreatitis

A 14‐yr‐old girl presented with eruptive xanthomata and hypertriglyceridemia. This rare presentation led to diagnoses of diabetes and familial dysbetalipoproteinemia. Type 1 diabetes is a common childhood illness often presenting in adolescence. However, this patients past medical history revealed valproate‐induced severe acute pancreatitis with necrosis at the age of 5 yr. Diabetes, in this case, developed 9 yr later as a result of inadequate pancreatic tissue to support increasing insulin requirements during growth and adolescence. Diabetes was discovered only after the appearance of cutaneous eruptive xanthomata, which appeared due to the previously undiagnosed genetic dyslipidemia. Although the relationship between xanthomata, hypertriglyceridemia, and diabetes may be well known in adults, in children, xanthomata are very rarely the presenting feature of diabetes of any cause. The patient was treated with insulin which induced rapid resolution of hypertriglyceridemia and gradual disappearance of xanthomata. This case acknowledges the rarity of diabetes presenting with xanthomata in adolescence, highlights the importance of searching for an underlying dyslipidemia in such a case, and presents diabetes as a long‐term complication of acute pancreatitis in children.