U. Hoffmeister

Medical care of overweight children under real-life conditions: the German BZgA observation study.

Objective:Current care for overweight children is controversial, and only few data are available concerning the process of care, as well as the outcome under real-life conditions.Methods:A nationwide survey of treatment programs for overweight children and adolescents in Germany identified 480 treatment centers. From 135 institutions that had agreed to participate in this study of process of care and outcome, 48 randomly chosen institutions were included in the study. All 1916 overweight children (mean age 12.6 years, 57% female, mean body mass index 30.0 kg/m2), who presented at these institutions for lifestyle interventions, were included in this study. Diagnostic procedures according to guidelines and effect of lifestyle interventions on weight status at end of treatment were analyzed.Results:Children treated <3 months were older and more obese, whereas children with >3 months treatment duration demonstrated more cardiovascular risk factors at baseline. On the basis of an intention-to-treat analysis, 75% of the children reduced their overweight. The reduction of overweight varied widely between the treatment institutions (intracluster correlation coefficient 0.15 in the multiple regression model reflecting the intracenter correlation). Screening for hypertension, disturbed glucose metabolism and dyslipidemia was performed in 52% of the children at baseline and in 10% at the end of intervention.Conclusion:Overweight reduction is achievable with lifestyle intervention in clinical practice. However, because the clientele, treatment approach and outcome varied widely between different institutions, and screening for comorbidities was seldomly performed as recommended, quality criteria for institutions have to be implemented to improve medical care of overweight children under real-life conditions.

[Treatment of obesity in pediatric patients in Germany: anthropometry, comorbidity and socioeconomic gradients based on the BZgA Observational Study].

BACKGROUND In recent years, the prevalence of overweight and obesity in children and adolescents has markedly increased. Even though numerous treatment options are available for patients, these are heterogeneously structured and insufficiently evaluated. PATIENTS In this initial report of specific therapy under routine care circumstances, data from 1916 patients aged 8-16.9 years were analyzed. Patients were characterized based on cluster of therapy, sociodemographic, psychosocial and medical features. Furthermore, the quality of care procedures with regard to the diagnosis of comorbidities was analyzed. RESULTS At initial medical examination mean patient BMI-SDS was +2.43 and mean age was 12.6 years. 43.3% of patients were male. The mean duration of treatment was 6.1 months (55% outpatient, 45% inpatient care setting). 14% of patients were overweight, 48% obese and 37% were extremely obese. In 51% of the patients we could find already comorbidities. Parental BMI was related to patients BMI. Socioeconomic status was reduced compared to general population. CONCLUSION In this nationwide, pioneer multicentre observational study initiated by Federal Centre for Health Education (BZgA) in Germany, different therapeutic approaches were compared by examining somatic and psychosocial variables. The short- and long-term effects of different weight reduction programs on BMI-SDS, nutritional- and physical activity habits as well as quality of life and comorbidity will be examined at the end of therapy. Two follow-up assessments are planned for one and two years after the intervention ended.

Does obesity lead to a specific lipid disorder? Analysis from the German/Austrian/Swiss APV registry

Overweight and obese youth represent a challenge for the affected individual, the healthcare system as well as society as a whole. Increased long-term cardiovascular risk is one of the major consequences of early-onset obesity, affecting both life expectancy and quality of life. The aim of this report is to study the effects of age, gender and obesity category on the presence of individual components of dyslipidemia using normal-weight subjects from the population-based German KIGGS study including 17,641 randomly selected children and adolescents, aged 0-18 years (11,110 normal-weight subjects with lipid measurements) and the German-Austrian-Swiss APV registry, including 57,239 overweight or obese children, adolescents and young adults from 162 specialized obesity care centers (lipid measurements available in 29,711 subjects). Subjects were classified according to BMI category based on the age- and gender-adjusted BMI-z-scores as recommended by the AGA (German Pediatric Obesity working group). Cut-offs for dyslipidemia were based on the recommendations by the American Heart Association: total cholesterol: > 5.2 mmol/l, HDL-cholesterol < 0.9 mmol/l, LDL-cholesterol > 3.4 mmol/l, triglycerides > 1.7 mmol/l. Using SAS 9.2-software, hierarchic modeling with both linear and logistic regression analysis was applied. Within the group of normal-weight children, fasting triglycerides were elevated in 3.3%, LDL-cholesterol in 7.2% and HDL-cholesterol was reduced in 3.1%. With increasing BMI-category, the prevalence of hypertriglyceridemia and reduced HDL-cholesterol increased rapidly. A weaker relationship was present for LDL-cholesterol and total cholesterol. Among obese youth, 30.5% displayed any dyslipidemia, underlining the importance of adequate screening and intervention.

Gamma-glutamyl transferase is strongly associated with degree of overweight and sex.

Gamma-glutamyl transferase (GGT) is a marker for cardiovascular risk and an independent predictor of long-term outcome in adults. Epidemiological data from pediatric cohorts are rare. We studied the association of GGT to body mass index as a standard deviation score, sex, and age in 68,415 children (age 11.7 ± 4.4 years; 48% boys; body mass index 27.2 ± 7.4 kg/m2; GGT measured in n = 23,955). GGT >50 U/L is strongly associated with extreme obesity (odds ratio 27.13, 95% confidence interval 15.07–48.85) and male sex (odds ratio 2.60, 95% confidence interval 2.03–3.31). GGT seems to be of clinical relevance and may be marketable as a surrogate in risk profiling for children with obesity.

Screening for Co-Morbidity in 65,397 Obese Pediatric Patients from Germany, Austria and Switzerland: Adherence to Guidelines Improved from the Year 2000 to 2010

Objective: The aim of the study was to analyze the adherence to current guidelines for co-morbidity screening in overweight and obese pediatric patients participating in the Adipositas-Patienten-Verlaufsdokumentation (APV) initiative in three German-speaking countries. Methods: APV database: 181 centers from Germany, Austria and Switzerland, specialized in obesity care, contributed standardized, anonymous data of medical examinations from 65,397 patients performed between 2000 and 2010. Completeness of screening for hypertension, dyslipidemia, and impaired glucose metabolism was analyzed using adjusted means. Results: Mean age of the cohort was 12.5 ± 2.9 years and 46.5% were male. 17.3% were overweight (>90th-97th percentile), 45.1% obese (>97th-99.5th percentile), and 37.7% extremely obese (>99.5th percentile). In 2000, blood pressure was documented for 55.1% of patients, increasing to 88.7% in 2010. The rate of lipid diagnostics also improved from 45.0 to 67.7%, and screening for diabetes rose from 32.7 to 62.3% in the same time period. Blood pressure measurements were performed more often during inpatient care (88.5%) compared to outpatient programs (77.5%). Screening was more complete with increasing age and increasing degree of obesity. In boys screening rate was higher than in girls. Conclusion: During the 11-year period, screening for co-morbidity improved significantly in overweight or obese children and adolescents. However, adherence to guidelines is still insufficient in some institutions. Quality control based on benchmarking may improve obesity care and outcome.

The Hyperactivity/Inattention Subscale of the Strengths and Difficulties Questionnaire Predicts Short- and Long-Term Weight Loss in Overweight Children and Adolescents Treated as Outpatients

Objective: The success of treatment for pediatric obesity is variable and often unsatisfactory. This study elucidates the influence of inattention and hyperactivity/impulsivity on short- and long-term weight loss and maintenance after outpatient treatment. Methods: We included 8- to 16-year-old overweight and obese participants treated in 17 multidisciplinary outpatient treatment centers in a nationwide observational study. All treatment centers that reported long-term (1-year) follow-up weight data of at least 60% of the participants were included. At the beginning and end of treatment and at 1 year follow-up weight and height were measured at the center. Inattention and hyperactivity/impulsivity were assessed with the hyperactivity/inattention subscale (HI) of the parent-rated Strengths and Difficulty Questionnaire (SDQ). General linear models were used with the standard deviation scores of the BMI (BMI-SDS) as dependent variable and HI scores as main independent variable adjusting for age, sex, baseline BMI-SDS, and center. Results: 394 participants were included (57% female, age: 11.7± 2.0 years, baseline BMI-SDS 2.32 ±.46 kg/m2). HI scores were significantly associated with short- and long-term BMI-SDS (p < 0.0005), with higher baseline HI scores predicting less weight loss. Conclusions: Our results indicate that inattention and hyperactivity/impulsivity are linearly associated with reduced short- and long-term weight loss. Implications for treatment are discussed.

Sensitivity analysis of weight reduction results of an observational cohort study in overweight and obese children and adolescents in Germany: the EvAKuJ Study

In the German EvAKuJ observational cohort study, changes in the body mass index standard deviation score (BMI–SDS) of overweight and obese children and adolescents as primary outcome of multimodal (short, inpatient or long, outpatient) weight-loss interventions are difficult to interpret. Published intention-to-treat (ITT) and per protocol data obtained at the end of the intervention (T1), one year (T2), and two years (T3) after its end were used for sensitivity analysis of treatment success rates. The odds ratio and the number needed to treat (NNT) for BMI–SDS reduction of at least −0.2 (successful treatment) and at least −0.5 (good treatment success) were related to spontaneous BMI-SDS reduction rates in a hypothetical control group (control event rate, CER). At T1, treatment seems to be effective up to a CER of 10% in inpatients and of 5% in outpatients. ITT analysis, compromised by a loss to follow-up of 81 to 90% (inpatients) and 57 to 66% (outpatients), indicated that treatment may become less effective at a CER above 1% in inpatients (e.g., successful treatment at T2: NNT=106, at T3: NNT=51), and above 5% in outpatients (successful treatment at T2: NNT=7, at T3: NNT=8; good treatment success at T2 and T3: NNT=25). Positive short-term effects of inpatient treatment of overweight and obese children and adolescents may not be maintained in the long term. Long-term effectiveness of outpatient treatment may depend on age and the degree of overweight.