William J. Klish

Bone mineral changes in young women with hypothalamic amenorrhea treated with oral contraceptives, medroxyprogesterone, or placebo over 12 months

OBJECTIVES The objectives of this study were to assess (1) whether treatment with oral contraceptives, in comparison with medroxyprogesterone and placebo, improved bone mineral in women with hypothalamic amenorrhea and (2) whether treatment with medroxyprogesterone, in comparison with placebo, improved bone mineral in women with hypothalamic oligomenorrhea. STUDY DESIGN The study was a randomized, controlled clinical trial. Twenty-four white women, aged 14 to 28 years, with hypothalamic amenorrhea or oligomenorrhea were prospectively enrolled for a 12-month intervention period. Amenorrheic subjects were randomized to receive oral contraceptives, medroxyprogesterone, or placebo. Oligomenorrheic subjects were randomized to receive medroxyprogesterone or placebo. Bone mineral was measured by dual-energy x-ray absorptiometry at baseline and at 6 and 12 months. RESULTS In amenorrheic subjects spine and total body bone mineral measurements at 12 months were greater in the oral contraceptive group than in the medroxyprogesterone and placebo groups when baseline bone mineral measurements, body weight, and age were controlled for (p < or = 0.05). There were no differences in hip bone mineral calcium and bone mineral density measurements at 12 months among the three groups. In oligomenorrheic subjects there was no detectable improvement in bone mineral associated with medroxyprogesterone use. CONCLUSIONS This study supports the hypothesis that oral contraceptive use in women with hypothalamic amenorrhea will improve lumbar spine and total body bone mineral.

Relation of body fat indexes to vitamin D status and deficiency among obese adolescents

BACKGROUND Data on the relation between vitamin D status and body fat indexes in adolescence are lacking. OBJECTIVE The objective was to identify factors associated with vitamin D status and deficiency in obese adolescents to further evaluate the relation of body fat indexes to vitamin D status and deficiency. DESIGN Data from 58 obese adolescents were obtained. Visceral adipose tissue (VAT) was measured by computed tomography. Dual-energy X-ray absorptiometry was used to measure total bone mineral content, bone mineral density, body fat mass (FM), and lean mass. Relative measures of body fat were calculated. Blood tests included measurements of 25-hydroxyvitamin D [25(OH)D], parathyroid hormone (PTH), osteocalcin, type I collagen C-telopeptide, hormones, and metabolic factors. Vitamin D deficiency was defined as 25(OH)D < 20 ng/mL. PTH elevation was defined as PTH > 65 ng/mL. RESULTS The mean (+/-SD) age of the adolescents was 14.9 +/- 1.4 y; 38 (66%) were female, and 8 (14%) were black. The mean (+/-SD) body mass index (in kg/m(2)) was 36 +/- 5, FM was 40.0 +/- 5.5%, and VAT was 12.4 +/- 4.3%. Seventeen of the adolescents were vitamin D deficient, but none had elevated PTH concentrations. Bone mineral content and bone mineral density were within 2 SDs of national standards. In a multivariate analysis, 25(OH)D decreased by 0.46 +/- 0.22 ng/mL per 1% increment in FM (beta +/- SE, P = 0.05), whereas PTH decreased by 0.78 +/- 0.29 pg/mL per 1% increment in VAT (P = 0.01). CONCLUSIONS To the best of our knowledge, our results show for the first time that obese adolescents with 25(OH)D deficiency, but without elevated PTH concentrations, have a bone mass within the range of national standards (+/-2 SD). The findings provide initial evidence that the distribution of fat may be associated with vitamin D status, but this relation may be dependent on metabolic factors. This study was registered at www.clinicaltrials.gov as NCT00209482, NCT00120146.

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.

Obesity in children and adolescents worldwide: current views and future directions--Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.

Obesity is considered a global epidemic because its prevalence and severity in both adults and children is increasing worldwide at alarming rates (1-7). This increase has been related to an increasingly sedentary lifestyle with less physical activity as well as changing dietary habits, and it occurs not only in affluent countries, but also in developing countries and in countries in economic transition (6,8-11). One consequence is that overweight and obesity are becoming the most prevalent childhood nutritional disorders in many parts of the world. As a result, more children experience severe psychosocial burdens and health risks, and because most obese children grow into obese adults, this trend is expected to lead to huge economic costs to health and social security systems. This review explores the causes, risks, and current approaches to prevention and treatment of childhood obesity, and potential research directions are discussed.

Critical analysis of bariatric procedures in Prader-Willi syndrome

Prader-Willi syndrome (PWS) is a complex genetic disorder localized to chromosome 15 and is considered the most common genetic cause of the development of life-threatening obesity. Although some morbidities associated with PWS, including respiratory disturbance/hypoventilation, diabetes, and stroke, are commonly seen in obesity, others such as osteoporosis, growth hormone deficiency, and hypogonadism, and also altered pain threshold and inability to vomit, pose unique issues. Various bariatric procedures have been used to cause gastric stasis, decrease gastric volume, and induce malabsorption, with poor results in PWS patients in comparison with normal obese individuals.

Resting energy expenditure and nitrogen balance in critically ill pediatric patients on mechanical ventilation.

Nutritional support is important in critically ill patients, with variable energy and nitrogen requirements (e.g., sepsis, trauma, postsurgical state) in this population. This study investigates how age, severity of illness, and mechanical ventilation are related to resting energy expenditure (REE) and nitrogen balance. Nineteen critically ill children (mean age, 8 +/- 6 [SD] y and range 0.4-17.0 y) receiving total parenteral nutrition (TPN) were enrolled. We used indirect calorimetry to measure REE. Expected energy requirements (EER) were obtained from Talbot tables. Pediatric Risk of Mortality (PRISM) and Therapeutic Intervention Scoring System (TISS) score were calculated. Total urinary nitrogen was measured using the Kjeldahl method. PRISM and TISS scores were 9 +/- 5 and 31 +/- 6 points, respectively. REE was 62 +/- 25 kcal.kg-1.d-1, EER was 42 +/- 11 kcal.kg-1. d-1, and caloric intake was 49 +/- 22 kcal.kg-1.d-1. Nitrogen intake was 279 +/- 125 mg.kg-1.d-1, total urinary nitrogen was 324 +/- 133 mg.kg-1.d-1, and nitrogen balance was -120 +/- 153 mg.kg-1.d-1. The protein requirement in this population was approximately 2.8 g.kg-1.d-1. These critically ill children were hypermetabolic, with REE 48% higher (20 kcal.kg-1.d-1) than expected. Nitrogen balance significantly correlated with caloric and protein intake, urinary nitrogen, and age, but not with severity of illness scores or ventilatory parameters.

Body composition of sedentary and physically active spinal cord injured individuals estimated from total body electrical conductivity

Reliability and evidence of construct validity of Total Body Electrical Conductivity (TOBEC) for estimating body composition in spinal cord injured subjects was evaluated using 17 males with C6-L2 spinal cord transections. Subjects reporting regular exercise were categorized as active (n = 12); nonexercisers were considered sedentary (n = 5). Measures included body weight, length, circumferences, skinfolds, and three TOBEC readings. Reliability for percent fat of both single and multiple TOBEC trials (t = 3) ranged from .994 to .999. Average percent fat values were significantly (p < .009) higher in sedentary subjects. Sum of seven skinfolds was significantly correlated (r[15] = 0.73, p < .01) with percent fat measured by TOBEC. Results suggest TOBEC is reliable (rtt > 0.99) in estimating body composition in spinal cord injured individuals. High reliability estimates for single and multiple trials indicate use of a single trial will provide reliable body fat estimates. Construct validity evidence infers that TOBEC measured body composition discriminates between active and sedentary paraplegics.

Total Body Electrical Conductivity Used to Determine Body Composition in Infants

ABSTRACT. Total body electrical conductivity (TOBEC) has been introduced as a rapid, safe, and noninvasive method suitable for the estimation of fat-free mass. The instrument (EMME or TOBEC) operates on the principle that organisms placed in an electromagnetic field perturb the field to a degree that depends on the amount and volume of distribution of electrolytes present. A study was designed to measure body composition in infants by the TOBEC method and to compare the results with those obtained using the isotope dilution technique. Sixteen infants (age range, 2 days to 9.7 months; weight range, 2 to 8.7 kg) were enrolled. Total body water (TBW) was determined by the isotope dilution technique using H218O. There was a good correlation between the natural logarithm of the TOBEC number and TBW, with a linear correlation coefficient of 0.949. The fat-free body mass of the infants was calculated by TBW (fat-free body mass=/0.082) and by the TOBEC method using the standard previously derived from mature rabbits. TBW measurements by H218O dilution appeared to overestimate fat-free mass which was greater than TBW in five of the 16 infants. Measured by the TOBEC method, fat-free mass ranged from 51 to 91% of total body weight. The TOBEC method is highly suitable for use with human infants and appears to determine body composition as accurately as other available methods.

Body Composition in Adolescent Athletes

This article has set out to provide basic knowledge about body composition in athletic and nonathletic adolescents and young adults and to provide the practicing physician with methods of making body composition assessment. We suggest the physician approach the adolescent athlete who requests information about body composition in the following way: 1. Calculate the ideal body weight. 2. Estimate the percentage of body fat, realizing the errors associated with each method. If a body composition laboratory is available, use that equipment. In the absence of this equipment, we recommend the equations of Slaughter et al, given earlier. 3. The athlete should be given a range of percentage of body fat values measured in other athletes of the same gender and sport. Health and performance should be monitored as the athlete attempts to achieve or maintain body composition in this range. 4. If the athlete has an interest in altering body composition, then recommend the athlete seek the advice of a professional who has expertise in nutrition and physiology.

Childhood obesity: Pathophysiology and treatment

Childhood obesity is among the most difficult problems which pediatricians treat. It is frequently ignored by the pediatrician or viewed as a form of social deviancy, and blame for treatment failure placed on the patients or their families. The definition of obesity is difficult. Using total body electrical conductivity (TOBEC) technology, total body fat ranges between 12% and 30% of total body weight in normal children and adolescents. This is influenced not only by age, but also by physical fitness. Anthropometry is the easiest way to define obesity. Children whose weight exceeds 120% of that expected for their height are considered overweight. Skinfold thickness and body mass index are indices of obesity that are more difficult to apply to the child.