Tag Archives: obesity

Heavy Heart due to Obesity

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A recent study (J Pediatr 2014; 165: 1184-9) documents a “cardiometabolic phenotype” which indicates that obesity and metabolic disease exert effects at a young age.

Design: A cohort of 281 white children from Italy were carefully studied with antropometrics, lipids profiles, blood pressure, glucose, and echocardiography. Of these children, 105 were obese (mean age 11 years) and 105 were morbidly obese (mean age 12 years); 31 had normal weight and 40 were overweight.

Key findings:

  • Heart disease: 53 had eccentric left ventricular hypertrophy (LVH), 36 had concentric LV remodeling, 44 had concentric LVH, 148 had normal echocardiograms.
  • Children with concentric LVH exhibited the most severe metabolic disturbances (graphically demonstrated in Figure 1)

Bottomline: The authors conclude that “we have identified a “cardiometabolic phenotype” occurring early in life, characterized by concentric LVH, visceral obesity, high BP, high Tg/HDL-C, and high-normal FPG [fasting plasma glucose].  This result may be clinically relevant because, in adulthood, a concentric LV geometric pattern is associated with a greater risk of CV events.”

Yosemite

Yosemite

Could Obesity Be Cured/Created at Birth with Manipulation of Microbiome?

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A concise review (NJEM 2014; 371: 2526-28) quickly describes the latest science on microbiota, antibiotics, and obesity chiefly by summarizing the work of Cox LM et al (Cell 2014; 158: 705-21).

Key points:

  • In mice, studies have shown that low-dose penicillin in early life induces marked effects on body composition (eg. excessive weight gain) lasting into adulthood
  • Prenatally administered penicillin to the mother and high-fat diet also induced fat mass of male mice.
  • Gut microbiota transferred from penicillin-moderated flora mice (at 18 weeks) into the cecums of 3-week-old germ-free mice also resulted in excessive fat mass compared to controls who received gut microbiota transfer from control mice (who did not receive penicillin).
  • “These results suggest that immunologic and metabolic changes are not caused by direct effects of antibiotics but rather by derived changes in the gut microbiota.”
  • “It may even be speculated that in families in which obesity is a problem, specific antibiotic treatment at birth could reverse the adverse effect of obesogenic microbiota transferred from mother to infant during delivery.”

Take-home message: Understanding the microbes in our bodies may lead to much more than curing intestinal infections and intestinal maladies.

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2015 Wish List

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A recent policy article (JAMA Pediatr 2014; 168: 1155-63 –thanks to Ben Gold for this reference) outlines “10 urgent priorities for the health and health care of US children.”  These priorities and some of the action steps are as follows:

  1. Poverty: “16.1 million children (22%) live in poverty. ” Action steps include enacting measures to improve employment in families and extending child tax credits.
  2. Food Insufficiency: “>16 million children live in food-insecure homes.” Actions could include investing rather than cutting children’s nutrition programs.
  3. Lack of health insurance: affects “7 million children (9%)” though two-thirds are eligible for coverage by Medicaid and CHIP. Actions could include fully funding CHOP and Medicaid and abolishing ACA family glitch along with improving outreach to enroll eligible children.
  4. Child abuse/neglect (maltreatment): “In 2011, 681,000 children experienced maltreatment and 1570 died” as a consequence.  Everyday, a child is abused or neglected every 47 seconds.  Action steps included focusing on domestic violence and treatment and funding more screening and preventative treatment research.
  5. Obesity: “32% of children are overweight and 17% are obese.”  Actions could include passing FIT kids Act (HR 2178) and maximizing funding for USDA’s Farmers market promotion program and the Fresh fruit and vegetable program.
  6. Firearms deaths/injuries: 5 children die daily by firearms.  Actions could include better background checks, along with regulations to require safer storage and safety classes.  Other options include higher taxation on weaponry and ammunition to “better represent societal costs.”
  7. Racial disparities: Action steps include monitoring and disclosing disparities and working to ensure all children have a medical home.
  8. Mental Health: up to 20% of children experience a mental health disorder annually.  Actions could include increasing the number of qualified mental-health providers (by enhancing reimbursement).
  9. Immigration: “children living in immigrant families are the fastest growing group of US children.” Action could include obtain health insurance for all children.
  10. Research: Increase funding for children.  Overall NIH pediatric funding is 12% of total budget whereas children represent 24% of US population.

The problems faced by this nation’s children will reverberate for a long time.  For example, with childhood poverty, it is “associated with substantially higher mortality rates in adults, regardless of adult socioeconomic status (i.e., even affluent adults who were poor as children have elevated death rates), and this increased mortality risk extends across 2 generations.”

Bottomline: Children receive a disproportionately low share of federal expenditures and this extends to healthcare.  In addition, federal spending on children in 2014 has decreased by more than $20 billion (14%) since 2010.

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Maternal Obesity and Neurodevelopmental Outcomes

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If there were not enough reasons to be concerned about the prevalence of obesity already, here’s another: there is growing evidence that maternal obesity (i.e. obesity in the mother at the beginning or prior to pregnancy) is associated with an increased risk for a number of neurodevelopment outcomes (J Pediatr 2014; 165: 891-6).  According to this medical progress report, there are a number of limitations in interpreting the studies associating obesity with these outcomes.

  1. Unclear what is the best measure of obesity and the best timing of measuring obesity
  2. “It is unclear whether obesity per se is the entity that causes adverse outcomes, or whether  obesity is only a marker for other factors” (eg. diet and activity)

With these limitations in mind, the authors review a number of studies.  Key points:

  • Cerebral palsy: “a dose-response relationship was seen, with any diagnosis of maternal obesity carrying a relative risk (RR) of 1.30 (95% CI 1.09-1.55) for CP.  With any diagnosis of morbid obesity, the RR was 2.70 (CI 1.89-3.86)
  • Autism: the risk of developing ASD (OR 1.67; CI 1.10-2.56) and NDD [neurodevelopmental delay] (OR 2.08; CI 1.20-3.61)
  • Cognitive deficits: maternal BMI “was inversely associated wit age 5 years IQ”
  • Behavioral/psychiatric disorders: “children of women who were both overweight and gained excess weight during pregnancy had a 2-fold (OR 2.10; CI 1.19-3.72) increased risk of ADHD symptoms compared with offspring of normal-weight women.” Also, some studies have shown an increased risk for schizophrenia in children of mothers with BMI >30.

Bottomline: obesity is not good for individuals and is associated with increased neuodevelopmental risk in offspring as well.

 

Clinical Science Year in Review in Pediatric GI – NASPGHAN 2014

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For many participants at NASPGHAN, the “year in review” presentations are a highlight.  This year was no exception.

This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

William Balistreri –Clinical Science Year in Review 

Lay press remains excellent source of information.

Benefit of microbiome. (from NPR) Now there is elephant poop coffee -$645/lb ($70/cup).  Link: No. 1 Most Expensive Coffee Comes From Elephant’s No. 2 : The ... Collecting elephant poop is probably a less ideal job than what most of us have.  As for coffee, “make mine de-crap.”

Elephant Microbiome Collector

Topic of the year: Hepatitis C

  • 25 years since identification of Hepatitis C in 1989
  • Now approaching cure (Related blog post: Wiping out Hepatitis C | gutsandgrowth). All-oral highly effective regimen –newest regimen as easy as one pill per day for 8-12 weeks. Direct-acting antivirals (DAAs). Moving past 1st generation of DAAs: telaprevir/boceprevir with interferon/ribavirin.(refs = Pawlotsky, Gastroenterology 146:1176, 2014 and Schmidt, Clinical Gastroent Hepatol 12:728, 2014)
  • New drugs for HCV –just in time –increasing risk of HCV complications. Ann Intern Med 2014; 160: 293.
  • Goal –SVR –sustained virological response
  • Reviewed large number of articles: Sofosbuvir, Simeprevir, Sofosbuvir/Ledipasvir (Harvoni).  3-D regimen: ABT-450, ABT-267, ABT-333 –will be approved in coming weeks (Related blog post:Have You Heard of Harvoni? | gutsandgrowth)
    • Gane, NEJM 368:34, 2013
    • Zeuzem, NEJM 370:1993,2014
    • Kowdley, N Engl J Med 370:1879, 2014
    • Lawitz, Lancet 383:515, 2014
    • Feld, New England Journal of Medicine, 370:1594, 2014
  • Mild side effects with newer drug therapies
  • Awaiting pediatric studies.
  • Costly $1000/pill –“if dog swallows it,” may have to look for it in the stool
  • Stay updated with recommendations: www.hcvguidelines.org  (AASLD/IDSA)

Hepatitis B –success of vaccination.

  • Preventing perinatal transmission with HBIG/vaccine. JAMA 2013; 310: 974. Those born after 1984, with much lower HCC. Ann Intern Med 2014; 160: 828; Hepatology 2014; 60: 448
  • Give antivirals (eg. telbivudine) for HBeAg-positive mothers prior to delivery. (Related blog post: Hepatology Update -Summer 2014 | gutsandgrowth) Greenup, Journ of Hepatology 61:502, 2014 AND Zhang, Hepatology 60:468, 2014
  • Antiviral therapy lowers the risk of HCC. Hepatology 2014; 147: 143 (Wu et al).
  • Make sure children with IBD are being screened for hepatitis B. ~13% may not be immune. Moses, Am J Gastro 107:133, 2012

Trend of the Year: Social Media

  • Genome sequencing –tremendous advance. Families may push for this option on their own.
  • Magnets –banned. Social media allowed this problem to be quickly identified. (Related blog post: Buckyball Recall –It’s Official | gutsandgrowth)
  • Social media allows family to share information and get answers. Internet blogging allows families to reach out to scientists.
    • Schumacher, Pediatrics 133:e1345, 2014
    • Enns, Genetics in Medicine, March 2014
  • BiliCam –can take picture with mobile phones.

Biliary Atresia

Threat of the Year: Obesity along with NAFLD

  •  NAFLD can have significant liver histologic abnormalities even with normal ALT levels. J Pediatr 2014; 164: 707.
  • Clinical burden of NAFLD is not restricted to liver-related morbidity or mortality Armstrong, HEPATOLOGY 59:1174, 2014. Also, concern for obstructive sleep apnea and cardiovascular disease.  Sundaram, J Pediatr 164:699, 2014. Pacifico, HEPATOLOGY 59:461, 2014
  • Elastography is promising tool. Xanthakos, J Peds 164:186, 2014
  • Current treatment –lifestyle changes. Snacking contributes to fatty liver. Sleep curtailment is associated with obesity. Spaeth. SLEEP 36:981, 2013, Taveras, Pediatrics 133:1013, 2014, Mitchell, Pediat 131:e1428, 2013
  • Increased antibiotics in early life associated with obesity due to alteration of microbiome. Bailey, JAMA Pediatrics, Sept 29, 2014
  • Suggestion for future: “Diet Water.”

Diet Water.jpg

For those who want to learn more from Dr. Balistreri directly, I would recommend the Aspen Conference:

Aspen Meeting

Related link: Dr. Balistreri’s Review of the Growth and Development of the Pediatric Gastroenterology Specialty.

 

Lack of Value of Breakfast for Weight Loss

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In contrast to previous reports (see previous blog: Skipping breakfast -boomerang effect for obesity …), a recent Study Indicates Lack of Weight Loss by Adding Breakfast (from USA Today).  Here’s an excerpt

Grandmothers, marketers and researchers alike have long touted breakfast as a must-have meal, praising its ability to rev up metabolism, stave off hunger, help calorie watchers keep their weight in check and improve concentration and cognitive function.

But for all the glowing endorsements, there have also been warnings against over-hyping the power of breakfast.

That concern was raised again this summer when a study comparing groups of overweight and obese adults dieters found that eating or skipping breakfast made no difference in how much weight was lost over a 16-week period.

“Our simple question was (when it comes to weight loss), does it help to eat breakfast? And the answer seems to be probably not,” says David Allison, director of the University of Alabama at Birmingham Nutrition Obesity Research Center and senior investigator of the study reported in the American Journal of Clinical Nutrition.

Early Antibiotics and Obesity

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A recent JAMA Pediatrics study showed that early and frequent antibiotics were associated with an increase risk of obesity.  Here’s a link to the LA Times summary of this article:  Antibiotics and Obestiy (LA Times)

Here’s an excerpt:

Broad-spectrum antibiotics — including amoxicillin, tetracycline, streptomycin, moxifloxacin and ciprofloxacin — are intended for treatment of major systemic infections, in cases where the bacteria causing the illness has not been identified, or where a patient is under attack by a strain of bacteria resistant to standard antibiotics. While they can be highly effective, their antibiotic action is indiscriminate, and beneficial bacteria in the body are often killed off as collateral damage.

The latest study tapped the medical records of 64,580 babies and children in and around Philadelphia. It was published Monday [Sept 29, 2014] in the journal JAMA Pediatrics.

The heightened risk of obesity linked to antibiotic use was not huge: Babies who got wide-spectrum antibiotics in their first two years were about 11% more likely to be obese between 2 and 5 than were those who got no such drugs. Babies who had four or more courses of any antibiotics in the first two years were also 11% more likely to be obese in early childhood than those who’d had fewer exposures to antibiotics.

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Walking with a “Z” or an “X”

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In a number of media outlets, there has been a push for a highly successful (and under appreciated) treatment: walking.

Advantages:

  • No/Low cost
  • Easy
  • Often fun
  • Excellent side effect profile

Here’s a link (Every Body Walk!) and here’s an excerpt:

Researchers have discovered a “wonder drug” for many of today’s most common medical problems, says Dr. Bob Sallis, a family practitioner at a Kaiser Permanente clinic in Fontana, California. It’s been proven to help treat or prevent diabetes, depression, breast and colon cancer, high blood pressure, cardiovascular disease, obesity, anxiety and osteoporosis, Sallis told leaders at the 2013 Walking Summit in Washington, D.C.

“The drug is called walking,” Sallis announced. “Its generic name is physical activity.”

Recommended dosage is 30 minutes a day, five days a week, but children should double that to 60 minutes a day, seven days a week. Side effects may include weight loss, improved mood, improved sleep and bowel habits, stronger muscles and bones as well as looking and feeling better.

Comment: If only “walking” was marketed better.  Physicians know that successful treatments need to have an “x” or a “z” or both to really do well (“X and Z in favor”).

 

 

 

Skinnier TVs and Heavier Kids

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A recent study showed an association between having a TV in the bedroom with increased weight gain (JAMA Pediatrics 2014; 168: 427-34).  Here’s a link: Bedroom TV and obesity study. My emphasis in bold:

Design: “We conducted a random-digit prospective telephone survey that captured children and adolescents from across the United States. Participants included 6522 boys and girls aged 10 to 14 years at baseline who were surveyed via telephone about media risk factors for obesity. Weighted regressions assessed adiposity at 2- and 4-year follow-up, controlling for television and movie viewing, video-game playing, parenting, age, sex, race or ethnicity, household income, and parental educational level.”

Results: “Distributions for age, sex, race or ethnicity, and socioeconomic status were similar to census estimates for the US population. Sample weighting methods accounted for higher dropout rates among ethnic minorities and those with lower socioeconomic status. Bedroom televisions were reported by 59.1% of participants at baseline, with boys, ethnic minorities, and those of lower socioeconomic status having significantly higher rates. In multivariate analyses, having a bedroom television was associated with an excess BMI of 0.57 (95% CI, 0.31-0.82) and 0.75 (0.38-1.12) at years 2 and 4, respectively, and a BMI gain of 0.24 (0.02-0.45) from years 2 to 4.”

Conclusion: “Having a bedroom television is associated with weight gain beyond the effect of television viewing time. This association could be the result of uncaptured effects of television viewing or of disrupted sleep patterns. With the high prevalence of bedroom televisions, the effect attributable to this risk factor among US children and adolescents is excess weight of 8.7 million kg/y.”

Comment: While this study targets TV, “screen time” has now expanded to cell phones, tablets, and computers.  All of these may be detrimental to physical well-being.

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Is Water The Best Beverage for Dieters? Maybe Not

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According to a recent study in Obesity (2014; 22: 1415-21), during the first 12 weeks of a weight loss program water is not as helpful as non-nutritive sweetened drinks (eg. diet soda) when trying to lose weight (Thanks to Jeff Schwimmer for this reference).

The study describes the findings from the 12-week weight loss phase of a 1-year randomized, clinical trial to test the hypothesis that the amount of weight lost (12 weeks) and maintained (9 months) in a behavioral weight management program will be equivalent in participants consuming beverages containing non-nutritive sweetened beverages (NNS) compared to water.

  • Demographics: n=303, mean age ~48 years, 82% female, mean BMI 33
  • Design: “Participants randomized to the NNS beverage group were asked to consume at least 24 fluid ounces of NNS beverage per day and their water consumption was not restricted. An NNS beverage qualified if it had <5 kcal per 8 ounce-serving, was pre-mixed, and contained non-nutritive sweeteners.” Similarly, in the water group, individuals were instructed to consume at least 24 fluid ounces of water per day, and not drink any NNS beverages.
  • Results: “The two treatments were not equivalent with the NNS beverage treatment group losing significantly more weight compared to the water group (5.95 kg versus 4.09 kg; P < 0.0001) after 12 weeks. Participants in the NNS beverage group reported significantly greater reductions in subjective feelings of hunger than those in the water group during 12 weeks.”
  • Conclusion: “These results show that water is not superior to NNS beverages for weight loss during a comprehensive behavioral weight loss program.”

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