Sarah E. Barlow

Prevelance of abnormal serum aminotransferase values in overweight and obese adolescents

OBJECTIVES (1) To determine the prevalence of abnormal liver enzymes in overweight and obese adolescents and (2) to determine the relationship of alcohol ingestion and serum antioxidants to the presence of abnormal liver enzymes in overweight and obese adolescents. METHODS Serum alanine aminotransferase (ALT) and gamma-glutamyl transpeptidase levels were measured in 2450 children between the ages of 12 and 18 years, enrolled in the National Health and Examination Survey, cycle III (NHANES III). Obesity was defined as a body mass index >95th percentile for age and sex. Overweight was defined as a body mass index >85th percentile for age and sex. Nutritional intake was assessed by 24-hour dietary recall and food frequency questionnaires. Serum antioxidants were measured by high-pressure liquid chromatography. RESULTS Sixty percent of adolescents with elevated ALT levels were either overweight or obese. Overall, 6% of overweight adolescents had elevated ALT levels (odds ratio: 3.4 [95% CI: 3.5-12.8]). Ten percent of obese adolescents had elevated ALT levels (odds ratio: 6.7 [95% CI: 3.5-12.8]). In addition, approximately 1% of obese adolescents demonstrated ALT levels over twice normal. Approximately 50% of of obsese adolescents who reported modest alcohol ingestion (4 times per month or more) had elevated ALT levels (odds ratio: 10.8, 95% CI: 1.5-77). Other factors associated with elevated ALT levels in overweight and obese adolescents include increased age, elevated glycolated hemoglobin, elevated triglycerides, and decreased levels of serum antioxidants-vitamin E, beta-carotene, and vitamin C. CONCLUSION Overweight and obesity are the most common findings in adolescents with elevated ALT levels. Even modest alcohol consumption may significantly increase the likelihood of obese adolescents developing obesity-related liver disease.

Severe Obesity in Children and Adolescents: Identification, Associated Health Risks, and Treatment Approaches A Scientific Statement From the American Heart Association

Severe obesity afflicts between 4% and 6% of all youth in the United States, and the prevalence is increasing. Despite the serious immediate and long-term cardiovascular, metabolic, and other health consequences of severe pediatric obesity, current treatments are limited in effectiveness and lack widespread availability. Lifestyle modification/behavior-based treatment interventions in youth with severe obesity have demonstrated modest improvement in body mass index status, but participants have generally remained severely obese and often regained weight after the conclusion of the treatment programs. The role of medical management is minimal, because only 1 medication is currently approved for the treatment of obesity in adolescents. Bariatric surgery has generally been effective in reducing body mass index and improving cardiovascular and metabolic risk factors; however, reports of long-term outcomes are few, many youth with severe obesity do not qualify for surgery, and access is limited by lack of insurance coverage. To begin to address these challenges, the purposes of this scientific statement are to (1) provide justification for and recommend a standardized definition of severe obesity in children and adolescents; (2) raise awareness of this serious and growing problem by summarizing the current literature in this area in terms of the epidemiology and trends, associated health risks (immediate and long-term), and challenges and shortcomings of currently available treatment options; and (3) highlight areas in need of future research. Innovative behavior-based treatment, minimally invasive procedures, and medications currently under development all need to be evaluated for their efficacy and safety in this group of patients with high medical and psychosocial risks.

Screening and Counseling Associated With Obesity Diagnosis in a National Survey of Ambulatory Pediatric Visits

Objective. To examine clinician-reported diagnosis of obesity and frequency of blood pressure assessment and diet and exercise counseling during ambulatory visits made by children and adolescents. Methods. The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey 1997 to 2000 were combined for visits to clinicians of 2- to 18-year-olds. Well-child visits (WCVs) were examined for frequencies of obesity diagnosis, blood pressure screening, and diet and exercise counseling in relation to patient and clinician characteristics. Multivariate models examined the relationship of patient and visit characteristics with diet and exercise counseling. Results. Of the 32 930 ambulatory visits made by 2- to 18-year-olds in 1997–2000, obesity was diagnosed at 0.78% of all visits and 0.93% of WCVs. Blood pressure assessment was reported in 61.1% of WCVs with obesity diagnosis compared with 43.9% of WCVs without obesity diagnosis. WCVs with obesity diagnosis had higher diet counseling rates (88.4% vs 35.7%) and higher exercise counseling rates (69.2% vs 18.6%). Diet counseling was reported for 88.4% and exercise counseling was reported for 69.2% of visits with an obesity diagnosis compared with 35.7% and 18.6% during WCVs without a diagnosis of obesity. In multivariate analyses, factors associated with diet counseling at WCVs were diagnosis of obesity (odds ratio [OR]: 12.9; 95% confidence interval [CI]: 3.0–55.3), being seen by pediatricians (OR: 2.5; 95% CI: 1.6–3.9), 2- to 5-year-olds compared with 12- to 18-year-olds (OR: 0.7; 95% CI: 0.5–1.0), and self-pay compared with private insurance visits (OR: 0.6; 95% CI: 0.4–0.9). Associations with exercise counseling were similar to those for diet counseling, but exercise counseling occurred less frequently in visits by black youths compared with white youths (OR: 0.5; 95% CI: 0.3–0.8). Conclusions. Clinicians may overlook obesity during WCVs. Programs to increase obesity diagnosis could improve diet and exercise counseling rates, but even with diagnosis of obesity, significant opportunities for screening and intervention are missed.

Overweight Children and Adolescents: A Clinical Report of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Childhood overweight and obesity are major health problems with immediate and long-term consequences of staggering magnitude. Despite this, there are few preventive and therapeutic strategies of proven effectiveness available to public health and clinical practitioners. Accruing such evidence is currently and appropriately a health policy priority, but there is an urgent need to intervene even before comprehensive solutions are fully established. The aim of this Clinical Report on Overweight Children and Adolescents is to present information on current understanding of pathogenesis and treatment of overweight and obesity. We report on the epidemiology, molecular biology and medical conditions associated with overweight; on dietary, exercise, behavioral, pharmacological and surgical treatments; and on the primary prevention of overweight in children and adolescents.

Recognition of Childhood Overweight during Health Supervision Visits: Does BMI Help Pediatricians?

Objective: To assess, in diverse pediatric practices, the frequency of overweight/obesity (OW/OB) identification during health supervision visits and its association with BMI curve use.

Parent reasons for nonreturn to a pediatric weight management program.

To identify parent reasons for lack of return to a weight management program, a questionnaire was sent to 85 families who attended two or fewer visits; 43 families completed the questionnaire. A total of 37% reported that the program was not what they were looking for. Specifically, they were dissatisfied with the staff or treatment focus. Other reasons for nonreturn were distance to program (23%), scheduling conflicts (21%), and lack of insurance for weight management (21%). High body mass index z score was associated with return, but age, gender, race, and medical condition were not. Matching program structure, location, and time to parent preference might improve retention.

Report of the national heart, lung, and blood institute's working group on obesity and other cardiovascular risk factors in congenital heart disease

Obesity among North American youth has risen to epidemic levels and is expected to result in costly and burdensome health problems, most notably type 2 diabetes mellitus and premature coronary artery disease. In the 2001–2002 National Health and Nutrition Examination Survey survey, 31% of children aged 6 to 19 years were overweight, defined as body mass index (BMI) at the 85th to 95th percentile, or obese (BMI ≥95th percentile).1 Recent research indicates that a significant portion of children with congenital heart disease (CHD) are also obese or overweight.2 Although much has been written on obesity prevention and management of children with normal hearts,3 little is known about how children with CHD will be affected. The National Heart, Lung, and Blood Institute convened a Working Group (WG) on obesity and other cardiovascular risk factors in congenital heart disease in May 2009 to address knowledge gaps, challenges, and opportunities related to research, policies, and the clinical care of children born with CHD who also have or are at risk for obesity and other cardiovascular risk factors.4 The WG was composed of individuals with expertise in pediatric obesity and pediatric cardiology with the goals of summarizing the existing evidence on obesity and cardiovascular risk prevention and treatment in the CHD population, raising awareness of missing data, and presenting data from “healthy” children with potential applicability to children with CHD. In this report, we discuss the prevalence of obesity, potential etiological factors, possible sequelae, and obesity and cardiovascular risk management and treatment in patients with CHD. The recommendations of the WG are presented. There are no longitudinal data on weight trends in children with CHD, and only recently have concerns been raised about obesity. In 2005, Stefan et al5 demonstrated that children with CHD whose activities are restricted are …

Naspghan Clinical Practice Guideline for the Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease in Children: Recommendations from the Expert Committee on Nafld (econ) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (naspghan)

ABSTRACT Nonalcoholic fatty liver disease (NAFLD) is a highly prevalent chronic liver disease that occurs in the setting of insulin resistance and increased adiposity. It has rapidly evolved into the most common liver disease seen in the pediatric population and is a management challenge for general pediatric practitioners, subspecialists, and for health systems. In this guideline, the expert committee on NAFLD reviewed and summarized the available literature, formulating recommendations to guide screening and clinical care of children with NAFLD.Nonalcoholic fatty liver disease (NAFLD) is a highly prevalent chronic liver disease that occurs in the setting of insulin resistance and increased adiposity. It has rapidly evolved into the most common liver disease seen in the pediatric population and is a management challenge for general pediatric practitioners, subspecialists and for health systems. In this guideline, the expert committee on NAFLD (ECON) reviewed and summarized the available literature, formulating recommendations to guide screening and clinical care of children with NAFLD.

An evolving scientific basis for the prevention and treatment of pediatric obesity

The 2013 Pennington Biomedical Research Center’s Scientific Symposium focused on the treatment and management of pediatric obesity and was designed to (i) review recent scientific advances in the prevention, clinical treatment and management of pediatric obesity, (ii) integrate the latest published and unpublished findings and (iii) explore how these advances can be integrated into clinical and public health approaches. The symposium provided an overview of important new advances in the field, which led to several recommendations for incorporating the scientific evidence into practice. The science presented covered a range of topics related to pediatric obesity, including the role of genetic differences, epigenetic events influenced by in utero development, pre-pregnancy maternal obesity status, maternal nutrition and maternal weight gain on developmental programming of adiposity in offspring. Finally, the relative merits of a range of various behavioral approaches targeted at pediatric obesity were covered, together with the specific roles of pharmacotherapy and bariatric surgery in pediatric populations. In summary, pediatric obesity is a very challenging problem that is unprecedented in evolutionary terms; one which has the capacity to negate many of the health benefits that have contributed to the increased longevity observed in the developed world.

Prevalence of prediabetes and type 2 diabetes in children with nonalcoholic fatty liver disease

Importance Nonalcoholic fatty liver disease (NAFLD) is a major chronic liver disease in children in the United States and is associated with insulin resistance. In adults, NAFLD is also associated with type 2 diabetes. To our knowledge, the prevalence of type 2 diabetes in children with NAFLD is unknown. Objective To determine the prevalence of type 2 diabetes and prediabetes in children with NAFLD and assess type 2 diabetes and prediabetes as risk factors for nonalcoholic steatohepatitis (NASH). Design, Setting, and Participants This was a multicenter, cross-sectional study at 12 pediatric clinical centers across the United States participating in the National Institute of Diabetes and Digestive and Kidney Diseases NASH Clinical Research Network. Children younger than 18 years with biopsy-confirmed NAFLD enrolled in the NASH Clinical Research Network. Main Outcomes and Measures The presence of type 2 diabetes and prediabetes as determined by American Diabetes Association screening criteria using clinical history and fasting laboratory values. Results There were 675 children with NAFLD included in the study with a mean age of 12.6 years and mean body mass index (calculated as weight in kilograms divided by height in meters squared) of 32.5. Most of the children were boys (480 of 675) and Hispanic (445 of 675).The estimated prevalence of prediabetes was 23.4% (95% CI, 20.2%-26.6%), and the estimated prevalence of type 2 diabetes was 6.5% (95% CI, 4.6%-8.4%). Girls with NAFLD had 1.6 (95% CI, 1.04-2.40) times greater odds of having prediabetes and 5.0 (95% CI, 2.49-9.98) times greater odds of having type 2 diabetes than boys with NAFLD. The prevalence of NASH was higher in those with type 2 diabetes (43.2%) compared with prediabetes (34.2%) or normal glucose (22%) (P < .001). The odds of having NASH were significantly higher in those with prediabetes (OR, 1.9; 95% CI, 1.21-2.9) or type 2 diabetes (OR, 3.1; 95% CI, 1.5-6.2) compared with those with normal glucose. Conclusions and Relevance In this study, nearly 30% of children with NAFLD also had type 2 diabetes or prediabetes. These children had greater odds of having NASH and thus were at greater long-term risk for adverse hepatic outcomes.