Obese and Overweight Teens at Higher Risk for Chronic Diseases

News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD

June 2, 2008 — Teens who were obese and overweight had a higher risk for chronic diseases such as type 2 diabetes, cardiovascular disease, and fatty liver disease, according to the results of an Australian cross-sectional study reported in the June issue of the Archives of Pediatrics & Adolescent Medicine.

"Several studies have shown that obese children and adolescents have an increased prevalence of metabolic risk factors for cardiovascular disease, type 2 diabetes, and, more recently, fatty liver disease," write Elizabeth Denney-Wilson, PhD, MPH, BN, from the University of Sydney in Sydney, Australia, and colleagues. "Although morbidity could be expected to increase in parallel with the prevalence of obesity, little is known about chronic disease risk factors in the general adolescent population. Most studies of comorbidities either have been conducted in clinic-based groups of severely obese adolescents or have not studied the full range of metabolic complications."

The goal of this study was to evaluate the association between measures of adiposity (body mass index [BMI] and waist circumference) and risk factors for heart disease, type 2 diabetes, and fatty liver disease as well as the clustering of risk factors in middle adolescence.

At secondary schools in Sydney, 496 grade 10 students were categorized as overweight or obese by the International Obesity Task Force cutoff points and the UK waist circumference cutoff points. Mean age was 15.4 ± 0.4 years; 58.4% were boys. Blood samples were tested for high-density lipoprotein (HDL) and low-density lipoprotein (HDL) cholesterol, triglycerides, insulin, glucose, alanine aminotransferase (ALT), gamma-glutamyltransferase (GGT), and high-sensitivity C-reactive protein (CRP) levels. Published guidelines were used to categorize these results as normal or abnormal. Logistic regression helped define associations between overweight and obesity and risk factors, and clustering of risk factors within individuals was also examined.

In adolescent boys, factors significantly associated with overweight and obesity were insulin levels (P <.001), ALT (P <.001), GGT (P = .005), HDL cholesterol levels (P < .001), high-sensitivity CRP levels (P <.001), and blood pressure (P <.001). Factors significantly associated with overweight and obesity in adolescent girls were insulin, HDL cholesterol (P <.001) and high-sensitivity CRP levels (P < .001).

Compared with adolescents who were not overweight, obese adolescent boys and girls were significantly more likely to have 2 or more risk factors (boys: 73.5% vs 7.6%; girls: 44.4% vs 5.4%; P < .001 for both).

"Overweight and obese adolescents, especially boys, are at substantial risk for chronic conditions," the study authors write. "Waist circumference is not a better predictor of metabolic risk factors than is . . . BMI."

Limitations of this study include lack of data on family history of cardiovascular disease and lack of reporting of the consumption of alcohol and other drugs.

"The propensity of adiposity, behaviors, and risk factors to track from adolescence through adulthood would suggest that health care systems can expect a greater burden of disease from obesity-related conditions when today's young people achieve adulthood," the study authors conclude.

Pearls for Practice

• In adolescent boys, overweight and obesity are linked with abnormal values of insulin, ALT, GGT, HDL cholesterol, high sensitivity CRP, and blood pressure. In adolescent girls, overweight and obesity are linked with abnormal values of insulin, HDL cholesterol, and high sensitivity CRP.
• Obese adolescents, especially boys, are more likely to have at least 2 risk factors for heart disease, type 2 diabetes, and fatty liver disease than nonobese adolescents.

The New South Wales Department of Health supported this study. The study authors have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. 2008;162:566-573.

Sucrose before Vaccination can Reduce pain

How to Stop the Hurt -- Sucrose Prior to Infant Vaccinations:
A Best Evidence Review Medscape CME/CE Posted 06/16/2008

Charles P. Vega, MD

Vaccination is the most common procedure performed in infancy, although parents might have significant concerns regarding the pain associated with routine vaccinations. Moreover, painful experiences very early in life can promote somatization later in life. Oral sucrose has been demonstrated to reduce pain reactions among neonates, and the current study examines this simple intervention prior to administration of routine vaccination at 2 and 4 months of age.

Participants received either a 24% disaccharide solution at a dose of 0.6 mL/kg, or matching placebo. Infants were not swaddled, cuddled, or restrained during vaccination or the ensuing data collection period.

Sucrose has previously been demonstrated to improve outcomes among neonates undergoing painful procedures. In an analysis of 21 randomized controlled trials involving 1616 infants, sucrose at a wide range of doses (0.012 mg to 0.12 mg) improved the rate of crying at 30 and 60 seconds after heel lance.^[8] However, sucrose was not effective in reducing heart rate at 1 and 3 minutes after heel lance.

Some practices employ other analgesic measures to reduce the pain of pediatric vaccinations. The application of the lidocaine-prilocaine patch prior to the first measles-mumps-rubella vaccine among children at least 12 months of age resulted in a significant reduction in Behavior Pain Scale scores vs placebo treatment.^[9] Moreover, rates of irritability after vaccination were 16% in the lidocaine-prilocaine group vs 31% in the placebo group, and the antibody responses in the 2 groups to the vaccine components were similar.

Parents may also pretreat their children with oral analgesic medications prior to appointments for vaccination, and a study of acetaminophen delivered prior to administration of the diphtheria-pertussis-tetanus toxoids-polio vaccine largely supports this practice.^[10] Compared with placebo, acetaminophen reduced the risk for fever greater than 38 degrees Celsius from 44% to 27%. Rates of behavioral changes after vaccination were 0.9% among the acetaminophen group vs 13% with placebo. However, acetaminophen was superior to placebo for primary vaccinations at 2 to 6 months of age but not for booster vaccination at 18 months of age. At the 18-month vaccination, the overall rate of systemic and local reactions was higher in both the acetaminophen and placebo groups. Another study has demonstrated that neither acetaminophen nor ibuprofen was effective in reducing the risk for local reactions such as erythema and swelling following the fifth diphtheria-tetanus toxoids-acellular pertussis vaccination.

Two key questions remain regarding the implementation of sucrose for the prevention of pain in pediatric vaccinations. First, the weight-based dosing algorithm for sucrose in the current study certainly appeared effective, but the dosage range used in different studies has generally been quite wide. Further research should address the issue of the optimal dose of sucrose. In addition, it would be very easy to conceive that using other analgesics such as acetaminophen in addition to sucrose could be synergistic in improving pain and behavior after vaccination. Moreover, the use of antipyretic medications could also reduce the risk for postvaccination fever.

Regarding the practical utility of different methods of analgesia for routine infant vaccinations, lidocaine-prilocaine can be difficult to apply and maintain in place for the 30 minutes required for effective analgesia prior to procedures.

Oral analgesics must also be delivered well before the vaccine is administered to be effective, and they expose infants and children to the remote possibility of significant adverse events.

In contrast, sucrose appears to be a readily available and applicable means to reduce infants' pain with vaccination. It is inexpensive and safe. Sucrose can also help parents to feel actively involved in protecting their infant from pain, and this should help increase acceptance of routine vaccinations. And that outcome should taste just like sugar for clinicians.

Probiotic Relieves Diarrhea in Infants and Toddlers

By Will Boggs, MD

NEW YORK (Reuters Health) Jun 25 - The probiotic Escherichia coli Nissle 1917 is effective in treating diarrhea greater than 4 days' duration in infants and toddlers, according to a report in the June issue of The Pediatric Infectious Disease Journal.

"There is more and more evidence now for the effectiveness and safety of probiotic drugs," Dr. Jobst Henker from University Carl-Gustav-Carus, Dresden, Germany told Reuters Health. "Earlier data for probiotic foods or food supplements show an excellent safety record but sometimes lack firm data on efficacy."

Dr. Henker and colleagues note that the nonpathogenic E. coli strain Nissle 1917 (EcN) has been licensed in Europe for 90 years for treating bowel diseases. They investigated the response rate and time to response using EcN suspension or placebo in 151 infants and toddlers with diarrhea lasting more than 4 days.

More children treated with EcN than with placebo showed a response to treatment on day 7 (78.7% versus 59.2%, respectively), day 14 (93.3% versus 65.8%), and day 21 (98.7% versus 71.1%), the investigators report.

Diarrhea lasted a median 3.3 days less in children treated with EcN, the report indicates, and the number of stools decreased to three or less daily 2 days sooner in the EcN group than in the placebo group.

More children in the placebo group exhibited dehydration at the end of the study, the researchers note, and more children in the EcN group (97.0%) than in the placebo group (62.3%) improved from a "moderate" state of health to a "good" or "very good" state of health in the course of treatment.

There were no serious or severe adverse events, the investigators say, and only four events were judged to be possibly related to study medication. Parents' and investigators' ratings indicated that EcN was well tolerated by the children.

"Since there is one other successful EcN study by our group in acute children's diarrhea, we believe it is best to start probiotic therapy as early as possible," Dr. Henker said.

"We would like to address the subject of inflammatory bowel disease," Dr. Henker added. "Not only do excellent data exist for the use of EcN in ulcerative colitis remission maintenance in an adult population, but we were able to show similar results in children."

Pediatr Infect Dis J 2008;27:494-499.

Secondhand Smoke Decrease Lung function in Child

Children exposed to secondhand smoke (SHS) at home during early infancy have an increased risk for serious infections requiring hospitalization, according to the results of a prospective cohort study reported in the May 27 Online First issue of Tobacco Control.

"Second-hand smoke ... exposure is a modifiable cause of ill health," write M.K. Kwok from the University of Hong Kong in Hong Kong SAR, China, and colleagues.

Previous research by Moshammer and colleagues suggests that passive smoking has a significant deleterious effect on lung function among children. Their study, which was published in the June 1, 2006, issue of the American Journal of Respiratory and Critical Care Medicine, examined more than 20,000 children between the ages of 6 and 12 years.

They found that maternal smoking during pregnancy was associated with a reduced forced expiratory volume in 1 second as well as a lower maximal expiratory flow among children. Passive smoking during childhood also reduced lung function in children though not to the same degree as in utero exposure to smoking.

Medscape News Author: Laurie Barclay, MD