Systematic review of influence of ethnicity on efficacy and safety of pharmacotherapy for childhood and adolescent obesity.

Pediatric severe obesity: time to establish serious treatments for a serious disease.

Refractory sporotrichosis lesion: An effective and pioneering approach in a patient living with human immunodeficiency virus/acquired immunodeficiency syndrome

To describe characteristics and surgical and clinical outcomes of obese children with obstructive sleep apnea (OSA). At our institution from 2000 to 2010, 143 obese children with an overnight polysomnography (OPSG) diagnosis of OSA, excluding children with comorbidities, were identified. Relationships between demographics, clinical findings, and the severity of OSA were assessed. Presurgery and postsurgery OPSG indices were compared. We defined cure as an apneahypopnea index (AHI) < 1.5/h on the postsurgery OPSG, and we compared the cure rates of different surgeries. A total of 143 children, median age 12.4 y (interquartile range [IQR] 9.6-14.9) and BMI z-scores 2.8 (IQR 2.6-2.9), were included. Seventy-eight (55%) (Median age 12 y [IQR 9-15]) underwent surgery: 1 had tonsillectomy; 1 tonsillectomy + uvulopharyngopalatoplasty (UPPP); 23 adenotonsillectomy (AT); 27 AT + UPPP; 11 adenoidectomy + UPPP; 8 UPPP; and 7 AT + turbinate trim ± tongue base suspension. Overall, surgery cured 19 children (26%), but AHI improved in the majority of children (p = 0.001). Similarly, the arousal index, PETCO2, and SpO2 nadir improved significantly (p < 0.002, p = 0.019, p < 0.001, respectively). AHI improved significantly in children with mild-to-moderate OSA in comparison to severe OSA (p < 0.001). Children with enlarged tonsils and no history of prior surgery benefitted more often from surgery (p < 0.004 and p = 0.002, respectively). AT was the only surgery reducing the AHI significantly (p = 0.008). Children did not lose weight despite intervention. Adherence with PAP was poor. Surgery improved OPSG indices in the majority of obese children with OSA.

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.

Physical exercise and lifestyle modification are recognized as adjunct therapy for obstructive sleep apnea (OSA) in overweight adults. The objectives of this study were to investigate the effects of long-term physical exercise combined with a balanced diet on sleep architecture, sleep duration, and OSA in adolescents with severe obesity. This interventional study was conducted in a nursing institution. Participants were aged 14.6 ± 1.2 years with obesity (body mass index (BMI) = 40.2 ± 6.5 kg/m2). At admission and at 9 months, participants underwent ambulatory polysomnography and incremental maximal exercise testing to determine cardiorespiratory fitness. Twenty-four subjects completed the study. Analyses were performed on the whole population and on a subgroup of subjects with OSA (OSA-subgroup). OSA, defined as obstructive apnea-hypopnea index (OAHI) ≥ 2 events/h, was diagnosed in 58.3% of the population. OAHI was only associated with fat mass in males (r = .75, P < .05). At 9 months postintervention, weight loss (-11.1 kg, P < .0001) and improved cardiorespiratory fitness (VO2peak: +4.9 mL/min/kg, P < .001) were found in the whole population. Sleep duration was increased (+34 minutes, P < .05) and sleep architecture was changed with an increase of rapid eye movement sleep (+2.5%, P < .05) and a decrease of stage N3 sleep (-3.1%, P < .001). Similar results were found in the OSA subgroup. However, OAHI remained unchanged (P = .18). A combination of supervised aerobic exercise and a balanced diet led to weight loss, improved aerobic capacity, and modified sleep architecture without changes in OSA. A commentary on this article appears in this issue on page 907. Registry: ClinicalTrials.gov, Title: Exercise and Venous Compression on Upper Airway Resistance in Obese Teenagers With OSA (OBESOMAC), URL: https://clinicaltrials.gov/ct2/show/NCT02588469, Identifier: NCT02588469.

The aim of this study was to explore the association between long-term exposure to particulate matter with an aerodynamic diameter <2.5 μm (PM2.5) and its components and severe obesity in children and adolescents. Data for children and adolescents aged 9-18 in this cross-sectional study were obtained from the 2019 Chinese National Survey on Students' Constitution and Health (CNSSCH). Data for PM2.5 and its components were obtained from the Tracking Air Pollution in China (TAP) dataset and matched with information on these children. Logistic regression models were used to assess the risk of severe obesity associated with long-term exposure to PM2.5 and its components. A total of 160,205 children were included in the analysis. Long-term exposure to PM2.5 may increase the odds of severe childhood obesity, with this effect being more pronounced in girls. Among boys, the component with the most significant impact on severe obesity was organic matter (OM). The impact of PM2.5 and its components on severe obesity was greater in children from low economic and low parental education level households. Children with unhealthy lifestyle habits have higher odds of severe obesity due to long-term exposure to PM2.5 and its components. The findings of this research support the development of strategies aimed at addressing severe obesity in children, suggesting that adopting healthy lifestyle practices could mitigate the odds of severe obesity due to PM2.5 and its components. There is a need for an increased focus on children in economically underdeveloped areas and those with unhealthy lifestyle habits, particularly those in rural areas and those who do not engage in adequate physical activity or get enough sleep.

I. The Problem: Childhood Obesity—A Burgeoning Epidemic e490II. Childhood Obesity Research Summit.........e490III. Pathophysiology and Morbidity ofChildhood Obesity e490A. Pathophysiology of Obesity e490B. Medical Consequences of Childhood Obesity. . .e490C. Psychosocial and Societal Consequences ofChildhood Obesity e490IV. Current Healthcare Practices in ChildhoodObesity Prevention and Treatment e492A. Lifestyle Assessment: Diet and Physical Activity . . . .e492B. Clinical Assessment e493C. Psychosocial/Behavioral Assessment .......e493D. Implementing Effective Prevention andTreatment Options: Diet e494E. Implementing Effective Prevention and TreatmentOptions: Exercise and Sedentary Behaviors . . . .e495F. Implementing Effective Prevention TreatmentOptions: Family and Behavioral Approaches . . .e496G. Behavioral Management e497H. Medical and Pharmacological Management. . . .e497I. Surgical Management e498V. Barriers to Optimum Care e498A. Healthcare System Factors e4981. Preparedness of Providers e4982. Models of Coverage and Care e4993. Uninsurance and Underinsurance AmongChildren and Families e5004. Healthcare Providers and Settings asRole Models e500B. The Challenge of Behavior Change ........e5011. Motivational Interviewing for Pediatric Obesity. .e5012. Psychosocial Factors InfluencingBehavior Change e5023. Environmental Factors InfluencingBehavioral Change e503VI. Practice-Based Resources for Preventionand Management e503A. Models From Other Disciplines e5031. Adult Chronic Care Model e5032. Treatment of Heart Failure e5043. Treatment of Type 2 Diabetes Mellitus .....e5044. Treatment of Childhood Asthma.........e505B. Public Health Measures forChildhood Obesity e5061. Tobacco Control: Implications forChildhood Obesity e506C. Specific Research Issues e5061. Specifying Priorities in the Context of aComplex, Multifactorial Problem ........e5062. Taking a Developmental Approach .......e5073. Engaging Stakeholders e5074. Targeting the Appropriate Outcome .......e508VII. Research Challenges e509A. Research in the Busy Practice e509B. Bring Research Into Practices: Web-BasedAssessment for the PediatricObesity Clinic e509C. Research Agenda: NHLBI and thePediatric Heart Network e510D. Research Agenda: The Children’sOncology Group e510E. Research Agenda: CDC e511F. Research Agenda: Foundations e511VIII. Research and Policy: KnowledgeTranslation e512A. From Practice to Policy to Practice ........e512IX. Concluding Remarks e512Appendix A: Planning Committee e513Appendix B: Presenters e513

Background: The World Health Organization (WHO) European Childhood Obesity Surveillance Initiative (COSI) was established more than 10 years ago to estimate prevalence and monitor changes in overweight and obesity in children aged 6–9 years. Since then, there have been five rounds of data collection in more than 40 countries involving more than half a million children. To date, no comparative studies with data on severe childhood obesity from European countries have been published. Objectives: The aim of this work was to present the prevalence of severe obesity in school-aged children from 21 countries participating in COSI. Method: The data are from cross-sectional studies in 21 European WHO member states that took part in the first three COSI rounds of data collection (2007/2008, 2009/2010, 2012/2013). School-aged children were measured using standardized instruments and methodology. Children were classified as severely obese using the definitions provided by WHO and the International Obesity Task Force (IOTF). Analyses overtime, by child’s age and mother’s educational level, were performed in a select group of countries. Results:A total of 636,933 children were included in the analysis (323,648 boys and 313,285 girls). The prevalence of severe obesity varied greatly among countries, with higher values in Southern Europe. According to the WHO definition, severe obesity ranged from 1.0% in Swedish and Moldovan children (95% CI 0.7–1.3 and 0.7–1.5, respectively) to 5.5% (95% CI 4.9–6.1) in Maltese children. The prevalence was generally higher among boys compared to girls. The IOTF cut-offs lead to lower estimates, but confirm the differences among countries, and were more similar for both boys and girls. In many countries 1 in 4 obese children were severely obese. Applying the estimates of prevalence based on the WHO definition to the whole population of children aged 6–9 years in each country, around 398,000 children would be expected to be severely obese in the 21 European countries. The trend between 2007 and 2013 and the analysis by child’s age did not show a clear pattern. Severe obesity was more common among children whose mother’s educational level was lower. Conclusions: Severe obesity is a serious public health issue which affects a large number of children in Europe. Because of the impact on educational, health, social care, and economic systems, obesity needs to be addressed via a range of approaches from early prevention of overweight and obesity to treatment of those who need it.

Objectives: To examine the current status of clinical research in oriental medicine, and to assess 'risk of bias'(ROB) of randomized clinical trials(RCTs) in oriental medicine in Korea. Methods: Special committee for EBM, KOMS(Korean Oriental Medicine Society) reviewed 17 journals related to oriental medicine in Korea (from the first issue to May 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2010), and PubMed (1966 to May 2010). Then we selected eligible RCTs in terms of oriental medicine, and assessed 'risk of bias'. Results: We reviewed 12,653 articles from the 17 journals, and 41 articles from CENTRAL and PubMed. After non-clinical articles were excluded, 1,004 articles were left. Among them, the number of eligible studies in terms of oriental medicine was 306. In these eligible studies, 130 were RCTs. Of RCTs, 69 were on acupuncture, 25 on herbal medicine. The proportion of 'unclear' is high in the criteria of 'Allocation concealment', 'Blinding of participants and personnel', 'Blinding of outcome assessment' and 'Other bias'. On the other hand, 'low' has high in the criteria of 'Incomplete outcome data' and 'Selective reporting'. Conclusions: Risk of bias on oriental medicine is unclear in terms of 'allocation concealment' and 'blinding'. For high-quality research in oriental medicine, further research should be needed on randomization and blinding in the RCTs.

International data suggest the prevalence of severe obesity in young children may be increasing, yet no Canadian data are available. The objectives of this study were to examine definitions of severe obesity and to evaluate associated risk factors among young children in Ontario. A cross-sectional study was conducted in children 17 to 24months of age using two Ontario data sources: TARGet Kids! (n = 3713) and BORN Ontario (n = 768). Body mass index z score (zBMI) definitions were adapted from the World Health Organization (WHO) (z score > 3) and the US Centers for Disease Control (CDC) (> 120% of the 95th percentile) and applied to define severe obesity in young children. Multinomial logistic regression was used to evaluate associations between demographic and pregnancy risk factors and zBMI categories. A total of1.1% (95% CI, 0.8-1.4) of children met the adapted WHO definition of severe obesity compared to 0.3% (95% CI, 0.2-0.6) using the CDC definition. Median neighbourhood household income (OR = 0.80, 95% CI, 0.69-0.93) and maternal pre-pregnancy BMI (OR = 1.08, 95% CI, 1.01-1.15) were associated with severe obesity in unadjusted analyses. After adjustment for potential confounders, the OR for the association between maternal pre-pregnancy BMI and severe obesity was 1.04 (95% CI, 0.94-1.15). More than 1% of Ontario children met the adaptedWHO definition of severe obesity in very early childhood. Modifiable risk factors were identified. Future studies are needed to understand the terminology, prevalence, and risk factors for severe obesity in young children across Canada.

Childhood obesity has been increasing steadily in recent decades, and severe childhood obesity has emerged as a major public health problem both nationally and internationally. A current concern is that lockdown due to the coronavirus disease 2019 (COVID-19) pandemic could exacerbate the spread of childhood obesity and increase the gap in obesity risk. Recent research results indicate the aggravation of obesity after school closures. The consequences of severe childhood obesity are more devastating than those of mild to moderate obesity. Children with severe obesity are at greater risk than others for hypertension, type 2 diabetes, metabolic syndrome, non-alcoholic fatty liver disease, atherosclerosis, and adult obesity. Accurately assessing and diagnosing a child with severe obesity is the key to implementing successful therapy. A detailed and accurate patient history and physical examination are important to discriminate monogenic obesity and metabolic syndrome diagnoses from severe obesity without an underlying cause. Psychosocial factors, including eating behaviors, should be assessed to facilitate better weight management outcomes. Treatment options for severe pediatric obesity include lifestyle modification therapy, pharmacotherapy, and metabolic and bariatric surgery. However, lifestyle modification should be the priority. Although progress has been made, safe and effective treatment for severe pediatric obesity is still challenging. More efforts and innovations are needed to find a solution for the huge medical and emotional burden that these children and their families carry. Public health organizations also need to make efforts to encourage and normalize healthy eating habits and exercise to prevent severe obesity in childhood.

Childhood obesity is a serious and urgent public health problem. In the last 10 years, there has been a concerted effort in the USA and globally to develop and implement...

Why the Cochrane risk of bias tool should include funding source as a standard item.

IntroductionAlthough studies have shown that childhood obesity overall is on the decline among New York City (NYC) public school children, the prevalence of severe childhood obesity has not been studied.MethodsWe used height and weight measurements of 947,765 NYC public school students aged 5 to 14 years in kindergarten through 8th grade (K–8), from school years 2006–07 through 2010–11. We used age- and sex-specific body mass index (BMI) percentiles according to Centers for Disease Control and Prevention growth charts to define childhood obesity (BMI ≥ 95th percentile) and severe childhood obesity (BMI ≥120% of 95th percentile) and to identify biologically implausible values (BIV). Multivariable logistic models tested for trends in obesity and severe obesity prevalence. To evaluate misclassification, we recalculated prevalence estimates for the most recent school year (2010–11) including the student records identified as BIV who were also declared severely obese (BMI ≥ 120% of 95th percentile). We refer to this subgroup of BIVs as “high BIV.”ResultsSevere obesity among NYC public school students in grades K–8 decreased 9.5% from the 2006–07 school year (6.3%) to the 2010–11 school year (5.7%), and obesity decreased 5.5% (from 21.9% to 20.7%). The prevalence of severe obesity and obesity was highest among minority, poor, and male children. Severe obesity declined in prevalence among every subgroup, with the greatest effect among white students and wealthy students. Severe obesity prevalence increased with age, and obesity prevalence peaked among those aged 7 to 10 years. For the 2010–11 school year, including high BIVs increased severe obesity prevalence from 5.7% to 6.6% and increased obesity prevalence from 20.7% to 21.5%.ConclusionAmong all subgroups of NYC public school children in grades K–8, the reduction in severe obesity was greater than the reduction in overall obesity. Efforts to decrease obesity in NYC have affected the severely obese; however, monitoring of this specific subgroup should continue because of differences in trends and greater health risks.

Background Childhood obesity is increasing in Turkey like all countries on the world. Sociocultural and environmental factors play very important roles in increasing childhood obesity. It is aimed to find out the prevalence of severe obesity and related factors in Turkey. Methods Turkey conducted Childhood Obesity Surveillance of WHO European Region in 2016. This cross-sectional epidemiologic study was representative for Turkey, the anthropometric measurements of 11523 children in 580 primary schools were taken by health care professionals, analyzed by using WHO criteria. Logistic regression model taking into account complex sample design was used to analyze to find out the factors affecting severe obesity. Results The prevalence of severe obesity was found as 2.8% in the children aged 6 to 9 years old. Severe obesity was found significantly 1.86 times higher in male children than female children (p = 0,002); 1.65 times higher in children whose mothers' overweighed (p = 0.01) and 3.50 much higher in children whose mothers' obese than normal weighted mothers (p &amp;lt; 0.001); 2.21 times higher in children whose fathers' overweighed (p &amp;lt; 0.001) and 2.72 times higher in children whose fathers' obese than normal weighted fathers (p &amp;lt; 0.001); 1.40 times higher in children whose mothers graduated from high school (p &amp;lt; 0.001) and 2.04 times higher whose mothers graduated from university than mothers graduated from primary school (p = 0.04); 0.58 times lower in children having families with three or more children under 18 living in the household (p = 0.03) and 1.83 times higher in children who had relatives with diabetes and high cholesterol history (p = 0.03). Conclusions This is the first result on severe childhood obesity in Turkey; the percentage is one of the highest rates in Europe. The significant factors affecting severe obesity were found as overweighed and obese parents, higher educated mothers, small family size and having family members with the diseases related to obesity. Key messages Family structure and family lifestyle are found as the main social factors related to severe obesity in Turkey. Especially, mothers need more information on the health problem related to severe childhood obesity, also healthy eating behaviors.