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1.  Single versus multiple-family intervention in childhood overweight—Finnmark Activity School: a randomised trial 
Archives of Disease in Childhood  2013;99(3):225-231.
Objective
To compare a new comprehensive lifestyle programme performed in groups of families with overweight (included obese) children with a more conventional single-family programme. The study design and interim anthropometrical results after 12 months are presented.
Design
Altogether 97 overweight and obese children aged 6–12 years with body mass index (BMI) corresponding to cut-off point ≥27.5 in adults were included. Study participants were randomised to multiple-family intervention (MUFI) or single-family intervention (SIFI) in a parallel design. MUFI comprised a 3-day inpatient programme at the hospital with other families and a multidisciplinary team, follow-up visits in their hometown individually and in groups, organised physical activity twice weekly and a 4-day family camp after 6 months. SIFI comprised individual counselling by paediatric nurse, paediatric consultant and nutritionist at the hospital and follow-up by public health nurse in the community. Solution focused approach was applied in both interventions. Primary outcome measures were change in BMI kg/m2 and BMI SD score (BMI SDS).
Results
BMI increased by 0.37 units in the MUFI compared to 0.77 units in the SIFI (p=0.18). BMI SDS decreased by 0.16 units in the MUFI group compared to 0.07 units in the SIFI group (p=0.07). Secondary endpoint waist circumference decreased 0.94 cm in the multiple-family group and increased 0.95 cm in the single-family group, p=0.04.
Conclusions
Interim analysis after 12 months showed no between-group difference in terms of BMI or BMI SDS. The MUFI group had a significant decrease in waist circumference compared to the SIFI group.
The trial is registered
at http://www.clinicaltrials.gov (NCT00872807)
doi:10.1136/archdischild-2012-303571
PMCID: PMC3932955  PMID: 24336385
Obesity; Paediatric Practice; Comm Child Health; Nutrition; Therapeutics
2.  The relationship between physical activity, physical fitness and overweight in adolescents: a systematic review of studies published in or after 2000 
BMC Pediatrics  2013;13:19.
Background
Not only in adults but also in children and adolescents, obesity increases the risk for several health disorders. In turn, many factors including genetic variations and environmental influences (e.g. physical activity) increase the risk of obesity. For instance, 25 to 40 percent of people inherit a predisposition for a high body mass index (BMI). The purpose of this systematic review was to summarize current cross-sectional and longitudinal studies on physical activity, fitness and overweight in adolescents and to identify mediator and moderator effects by evaluating the interaction between these three parameters.
Methods
The electronic academic databases PubMed, SportDiscus, WEB OF KNOWLEDGE and Ovid were searched for studies on physical activity, fitness and overweight in adolescents aged 11 to 19 years (cross-sectional studies) and in adolescents up to 23 years old (longitudinal studies) published in English in or after 2000.
Results
Twelve cross-sectional and two longitudinal studies were included. Only four studies analyzed the interaction among physical activity, fitness and overweight in adolescents and reported inconsistent results. All other studies analyzed the relationship between either physical activity and overweight, or between fitness and overweight. Overweight—here including obesity—was inversely related to physical activity. Similarly, all studies reported inverse relations between physical fitness and overweight. Mediator and moderator effects were detected in the interrelationship of BMI, fitness and physical activity. Overall, a distinction of excessive body weight as cause or effect of low levels of physical activity and fitness is lacking.
Conclusions
The small number of studies on the interrelationship of BMI, fitness and physical activity emphasizes the need for longitudinal studies that would reveal 1) the causality between physical activity and overweight / fitness and overweight and 2) the causal interrelationships among overweight, physical activity and fitness. These results must be carefully interpreted given the lack of distinction between self-reported and objective physical activity and that studies analyzing the metabolic syndrome or cardiovascular disease were not considered. The importance of physical activity or fitness in predicting overweight remains unknown.
doi:10.1186/1471-2431-13-19
PMCID: PMC3571910  PMID: 23375072
Physical activity; Cardiorespiratory fitness; Motor fitness; Overweight; Obesity; Adolescent; Youth; Cross-sectional studies; Longitudinal studies
3.  Early echocardiography abnormalities in obese children and adolescent and reversibility of these abnormalities after significant weight reduction 
Background
Obesity is becoming an epidemic threat for the individual and society. The increasing prevalence of overweight children and adolescents is likely to have a great impact on the future cardiovascular health of these subjects. Obesity is a strong risk factor for cardiovascular morbidity and mortality. Cardiac abnormalities of obese children and adolescents include the echocardiographically revealed early and preclinical LV or septal hypertrophy, and left or right ventricular dysfunction. Most of these abnormalities, which are usually more pronounced in patients with morbid obesity, can be partially reversed after weight reduction.
Aim of the study
Evaluate early echocardiography changes in obese children and whether these cardiac abnormalities reverse with significant weight reduction in children and adolescents or not.
Methods
We started this study by 50 obese children and adolescents and 30 non obese controls matched for age and sex. BMI was calculated. Complete echocardiographic study was performed on each patient and control subject. Hematological and biochemical variables were determined in the obese subjects from fasting blood samples and included glucose, total cholesterol, triglycerides (TG), HDL cholesterol and LDL cholesterol. All our patients’ strict dietetic regime with exercises for 6 months. After 6 months full examination, including all measurements and echocardiography and laboratory investigations were done again.
Results
Obese children has abnormalities of left ventricle structure and function (consisting of increased left ventricular wall dimensions and mass and alteration of diastolic function) that can be detected by echocardiography. Furthermore, (parameters of lipid metabolism) were found to be independent predictors of adverse LV remodeling and of diastolic dysfunction. As well as this study provides evidence that abnormalities of left ventricular wall dimension and mass in obese children and adolescents can improve with significant weight reduction.
Conclusion
This study has demonstrated that young, obese children and adolescents have early significant changes in left ventricular wall dimensions and early diastolic filling compared with non obese and this changes are reversible with weight reduction.
doi:10.1016/j.jsha.2010.03.003
PMCID: PMC3727446  PMID: 23960587
Obesity; Overweight; Echocardiography; Diet; Exercise; Children; Adolescent
4.  Body mass index, waist circumference, and cardiometabolic risk factors in young and middle-aged Chinese women 
Objective: To assess the associations between body mass index (BMI), waist circumference (WC), and cardiometabolic risk factors in young and middle-aged Chinese women. Methods: A total of 3011 women (1938 young women, 1073 middle-aged women), who visited our health care center for a related health checkup, were eligible for study. BMI and WC were measured. The subjects were divided into normal and overweight/obesity groups based on BMI, and normal and abdominal obesity groups based on WC. Cardiometabolic variables included triglyceride (TG), high density lipoprotein cholesterol (HDL-C), fasting blood glucose (FBG), homeostasis model assessment of insulin resistance (HOMA-IR), and blood pressure (BP). Results: The prevalence of overweight/obesity was significantly higher in middle-aged women (32.4%) than in young women (12.0%). The prevalence of abdominal obesity was also higher in middle-aged women (60.3%) than in young women (36.2%). There were significant differences in the comparison of all related cardiometabolic variables between different BMI (or WC) categories in young and middle-aged women groups, respectively. After adjustment for age, partial correlation analysis indicated that both BMI and WC were correlated significantly with all related cardiometabolic variables. After adjustment for age and WC, although the correlation coefficient r′ was attenuated, BMI was still correlated significantly with all related cardiometabolic variables in young and middle-aged women. After adjustment for age and BMI, partial correlation analysis showed that WC was correlated significantly with TG, FBG, HOMA-IR, and HDL-C in young women and significantly with TG, HOMA-IR, and HDL-C in middle-aged women. Conclusions: The prevalence of overweight/obesity and abdominal obesity was high in Chinese young and middle-aged women. BMI was a better predictor of cardiovascular disease and diabetes than WC in young and middle-aged women, and moreover, measurement of both WC and BMI may be a better predictor of cardiovascular disease and diabetes mellitus than BMI or WC alone.
doi:10.1631/jzus.B1000105
PMCID: PMC2932873  PMID: 20803767
Body mass index; Waist circumference; Obesity; Cardiovascular disease; Diabetes mellitus; Women
5.  BMI Change, Fitness Change and Cardiometabolic Risk Factors Among 8th Grade Youth 
Pediatric exercise science  2013;25(1):52-68.
This paper examined whether a two-year change in fitness, body mass index (BMI) or the additive effect of change in fitness and BMI were associated with change in cardiometabolic risk factors among youth. Cardiometabolic risk factors, BMI group (normal weight, overweight or obese) were obtained from participants at the start of 6th grade and end of 8th grade. Shuttle run laps were assessed and categorized in quintiles at both time points. Regression models were used to examine whether changes in obesity, fitness or the additive effect of change in BMI and fitness were associated with change in risk factors. There was strong evidence (p < .001) that change in BMI was associated with change in cardiometabolic risk factors. There was weaker evidence of a fitness effect, with some evidence that change in fitness was associated with change in total cholesterol, HDL-C, LDL-C and clustered risk score among boys, as well as HDL-C among girls. Male HDL-C was the only model for which there was some evidence of a BMI, fitness and additive BMI*fitness effect. Changing body mass is central to the reduction of youth cardiometabolic risk. Fitness effects were negligible once change in body mass had been taken into account.
PMCID: PMC3702158  PMID: 23406707
6.  Cardiovascular Risk Factors in Portuguese Obese Children and Adolescents: Impact of Small Reductions in Body Mass Index Imposed by Lifestyle Modifications 
Objectives:
Evaluate cardiovascular risk factors in Portuguese obese children and adolescents and the long-term effects of lifestyle modifications on such risk factors.
Design:
Transversal cohort study and longitudinal study.
Setting:
University Hospital S. João and Children’s Hospital Maria Pia, Porto.
Patients/Participants:
148 obese children and adolescents [81 females (54.7%); mean age of 11.0 years] and 33 controls (sex and age matched) participated in a cross-sectional study. Sixty obese patients agreed to participate in an one year longitudinal study after medical and nutritionist appointments to improve lifestyle modification; a substantial body mass index (BMI) reduction was defined by a decrease in BMI z-score (BMI z-sc) of 0.3 or more over the studied period.
Main Outcome measures:
Lipid profile (triglycerides, cholesterol, HDLc, LDLc, lipoprotein (a), apolipoproteins A and B) and circulating levels of C-reactive protein (CRP), adiponectin, glucose, and insulin.
Results:
Compared with the lean children, obese patients demonstrated statistically significantly higher insulin resistance index [Homeostasis model assessment (HOMA)], and triglycerides, LDLc, apolipoprotein (apo) B, insulin and CRP concentrations, whereas their HDLc and apo A levels were significantly lower (cross-sectional study). In the longitudinal study (n=60), a substantial BMI reduction occurred in 17 (28.3%) obese patients which led to a significant reduction in triglycerides, cholesterol, LDLc, apo B, glucose and insulin levels and in HOMA. The ΔBMI values over the studied period correlated inversely and significantly with BMI (P<0.001) and HOMA (P=0.026) values observed at baseline. In multiple linear regression analysis, BMI at baseline remained associated to changes in BMI over the studied period (standardised Beta: -0.271, P=0.05).
Conclusion:
Our data demonstrates that small reductions in BMI-zc, imposed by lifestyle modifications in obese children and adolescents, improve the cardiovascular risk profile of such patients. Furthermore, patients with higher BMI and/or insulin resistance seem to experience a greater relative reduction in their BMI after lifestyle improvements.
doi:10.2174/1874091X01206010043
PMCID: PMC3358715  PMID: 22629286
Lipid profile; insulin resistance; inflammation; childhood obesity; lifestyle modifications.
7.  Physical Activity and Screen Time in Metabolically Healthy Obese Phenotypes in Adolescents and Adults 
Journal of Obesity  2013;2013:984613.
Introduction. The purpose of this study was to examine levels of physical activity (PA) and screen time (ST) in metabolically healthy obese (MHO) and metabolically unhealthy obese (MUO) adolescents and adults. Methods. NHANES data from obese adolescents (12–18 years, BMI z-score ≥ 95th percentile) and adults (19–85 years, BMI ≥ 30 kg/m2) were pooled from 2003–2005 cycles. Metabolic phenotypes were categorized as MHO (0 or 1 cardiometabolic risk factor; triglycerides, HDL-C, blood pressure, or glucose) or MUO (≥2 cardiometabolic risk factors). Logistic regression models estimated associations between phenotype and PA/ST adjusted for age, gender, BMI, race/ethnicity, menopausal status, and NHANES cycle. Results. Among adolescents, PA was not associated with MHO. In contrast, MHO adults 19–44 years were 85% more likely to engage in active transportation and 2.7 times more likely to be involved in light intensity usual daily activity versus sitting. For each minute per day, adults 45–85 years were 36% more likely to have the MHO phenotype with higher levels of moderate PA. ST was not associated with metabolic phenotypes in adolescents or adults. Conclusion. The current study provides evidence that PA, but not ST, differs between MHO and MUO in adults, but not in adolescents. Future studies are needed to confirm results.
doi:10.1155/2013/984613
PMCID: PMC3786460  PMID: 24102022
8.  Do Self- or Parent-Reported Dietary, Physical Activity and Sedentary Behaviors Predict Worsening Obesity in Children? 
The Journal of pediatrics  2010;157(4):566-571.
Objective
To determine whether information gathered during routine healthcare visits regarding obesity related risk factors and risk behaviors predicts increases in BMI z-score over time among overweight and obese children.
Study design
Medical records from 168 overweight and 441 obese patients seen for repeated visits between September 2003 and April 2006 were examined for reported dietary, physical activity, and sedentary behaviors, family history of obesity and diabetes mellitus, documented acanthosis nigricans, and BMI values. Random-effects regression analysis was done to determine whether demographic, familial, or behavioral data predicted changes in BMI z-score over time. Results The presence of acanthosis nigricans and a family history of obesity were associated with an increase in BMI z-score (β= 0.56, SE=0.09, p<.001 and β=0.31, SE=0.13, p=0.021). These risk factors explained 8% and 7% of the variation in BMI z-score respectively. Self- or parent-reported dietary and physical activity behaviors did not predict change in BMI z-score.
Conclusion
Our findings suggest that the risk factors and self- or parent-reported risk behaviors routinely assessed by pediatric clinicians have limited ability to predict future growth trends, demonstrating the difficulty in determining which patients have the greatest risk of progression of obesity.
doi:10.1016/j.jpeds.2010.04.062
PMCID: PMC2936814  PMID: 20542293
obesity; community health centers; healthcare delivery; child; adolescent
9.  Dyslipidemia in Iranian overweight and obese children 
Objective:
To evaluate the frequency and patterns of dyslipidemia in overweight and obese children and to determine the extent of blood lipid abnormality in overweight and obese children.
Methods:
A prospective matched case control study on 230 overweight and obese children and adolescents (body mass index [BMI] > 85th percentile) aged 4 to 18 years undertaken at the outpatient endocrine clinic of the Childrens’ Hospital at Tabriz University between 2006–2008. This study was conducted to compare the frequency of abnormal plasma lipid levels in overweight and obese children compared with 50 nonobese children (BMI = 50th–85th percentile).
Results:
The total frequency of dyslipidemia was 69.58%. The prevalence of dyslipidemia increased with severity of obesity and reached 76.9% in the severely obese (P < 0.005). High triglycerides was the most common dyslipidemia in combination (26.08%) and in isolation (18.6%). There was a significant difference in mean of triglycerides between the severely obese and other groups (P < 0.004).
Conclusion:
In the present study, dyslipidemia is more common in severely obese children and the most common component of dyslipidemia is a high triglyceride level.
PMCID: PMC2754088  PMID: 19816572
dyslipidemia; lipid profile; obesity; overweight; children; adolescents
10.  Physical Activity and Obesity in Canadian Women 
BMC Women's Health  2004;4(Suppl 1):S6.
Health Issue
Overweight and obesity have been recognized as major public health concern in Canada and throughout the world. Lack of physical activity, through its impact on energy balance, has been identified as an important modifiable risk factor for obesity. Physical activity and obesity are also important risk factors for a variety of chronic diseases. This chapter provides an overview of the current state of physical activity and overweight/obesity among Canadian women.
Key Findings
For all ages combined more women (57%) than men (50%) are physically inactive (energy expenditure <1.5 KKD). Physical activity increases as income adequacy and educational level decrease. Physical inactivity also varies by ethnicity. The prevalence of both overweight (BMI 25.0 – 29.9 kg/m2) and obese (BMI ≥ 30 kg/m2) Canadian women has increased 7% since 1985. Obesity increases with age and is highest among women reporting low and lower middle incomes and lower levels of education. The prevalence of obesity is highest among Aboriginal women and men (28% and 22% respectively).
Data Gaps and Recommendations
There is currently no surveillance system in Canada to monitor the level of physical activity among children, those performing activity at work, at school or in the home. There is a gap in the knowledge surrounding socio-cultural and ecological determinants of physical activity and obesity and the associations of these to chronic disease among women and minority populations. Multi-sectoral policy interventions that act to decrease the broad systemic barriers to physical activity and healthy weights among all women are needed.
doi:10.1186/1472-6874-4-S1-S6
PMCID: PMC2096675  PMID: 15345069
11.  Utility of waist-to-height ratio in assessing the status of central obesity and related cardiometabolic risk profile among normal weight and overweight/obese children: The Bogalusa Heart Study 
BMC Pediatrics  2010;10:73.
Background
Body Mass Index (BMI) is widely used to assess the impact of obesity on cardiometabolic risk in children but it does not always relate to central obesity and varies with growth and maturation. Waist-to-Height Ratio (WHtR) is a relatively constant anthropometric index of abdominal obesity across different age, sex or racial groups. However, information is scant on the utility of WHtR in assessing the status of abdominal obesity and related cardiometabolic risk profile among normal weight and overweight/obese children, categorized according to the accepted BMI threshold values.
Methods
Cross-sectional cardiometabolic risk factor variables on 3091 black and white children (56% white, 50% male), 4-18 years of age were used. Based on the age-, race- and sex-specific percentiles of BMI, the children were classified as normal weight (5th - 85th percentiles) and overweight/obese (≥ 85th percentile). The risk profiles of each group based on the WHtR (<0.5, no central obesity versus ≥ 0.5, central obesity) were compared.
Results
9.2% of the children in the normal weight group were centrally obese (WHtR ≥0.5) and 19.8% among the overweight/obese were not (WHtR < 0.5). On multivariate analysis the normal weight centrally obese children were 1.66, 2.01, 1.47 and 2.05 times more likely to have significant adverse levels of LDL cholesterol, HDL cholesterol, triglycerides and insulin, respectively. In addition to having a higher prevalence of parental history of type 2 diabetes mellitus, the normal weight central obesity group showed a significantly higher prevalence of metabolic syndrome (p < 0.0001). In the overweight/obese group, those without central obesity were 0.53 and 0.27 times less likely to have significant adverse levels of HDL cholesterol and HOMA-IR, respectively (p < 0.05), as compared to those with central obesity. These overweight/obese children without central obesity also showed significantly lower prevalence of parental history of hypertension (p = 0.002), type 2 diabetes mellitus (p = 0.03) and metabolic syndrome (p < 0.0001).
Conclusion
WHtR not only detects central obesity and related adverse cardiometabolic risk among normal weight children, but also identifies those without such conditions among the overweight/obese children, which has implications for pediatric primary care practice.
doi:10.1186/1471-2431-10-73
PMCID: PMC2964659  PMID: 20937123
12.  Healthy Weight Regulation and Eating Disorder Prevention in High School Students: A Universal and Targeted Web-Based Intervention 
Background
Given the rising rates of obesity in children and adolescents, developing evidence-based weight loss or weight maintenance interventions that can be widely disseminated, well implemented, and are highly scalable is a public health necessity. Such interventions should ensure that adolescents establish healthy weight regulation practices while also reducing eating disorder risk.
Objective
This study describes an online program, StayingFit, which has two tracks for universal and targeted delivery and was designed to enhance healthy living skills, encourage healthy weight regulation, and improve weight/shape concerns among high school adolescents.
Methods
Ninth grade students in two high schools in the San Francisco Bay area and in St Louis were invited to participate. Students who were overweight (body mass index [BMI] >85th percentile) were offered the weight management track of StayingFit; students who were normal weight were offered the healthy habits track. The 12-session program included a monitored discussion group and interactive self-monitoring logs. Measures completed pre- and post-intervention included self-report height and weight, used to calculate BMI percentile for age and sex and standardized BMI (zBMI), Youth Risk Behavior Survey (YRBS) nutrition data, the Weight Concerns Scale, and the Center for Epidemiological Studies Depression Scale.
Results
A total of 336 students provided informed consent and were included in the analyses. The racial breakdown of the sample was as follows: 46.7% (157/336) multiracial/other, 31.0% (104/336) Caucasian, 16.7% (56/336) African American, and 5.7% (19/336) did not specify; 43.5% (146/336) of students identified as Hispanic/Latino. BMI percentile and zBMI significantly decreased among students in the weight management track. BMI percentile and zBMI did not significantly change among students in the healthy habits track, demonstrating that these students maintained their weight. Weight/shape concerns significantly decreased among participants in both tracks who had elevated weight/shape concerns at baseline. Fruit and vegetable consumption increased for both tracks. Physical activity increased among participants in the weight management track, while soda consumption and television time decreased.
Conclusions
Results suggest that an Internet-based, universally delivered, targeted intervention may support healthy weight regulation, improve weight/shape concerns among participants with eating disorders risk, and increase physical activity in high school students. Tailored content and interactive features to encourage behavior change may lead to sustainable improvements in adolescent health.
doi:10.2196/jmir.2995
PMCID: PMC3962843  PMID: 24583683
healthy weight regulation; universal and targeted delivery; school-based intervention; prevention; adolescents
13.  Obesity in children & adolescents 
Worldwide, obesity trends are causing serious public health concern and in many countries threatening the viability of basic health care delivery. It is an independent risk factor for cardiovascular diseases and significantly increases the risk of morbidity and mortality. The last two decades have witnessed an increase in health care costs due to obesity and related issues among children and adolescents. Childhood obesity is a global phenomenon affecting all socio-economic groups, irrespective of age, sex or ethnicity. Aetiopathogenesis of childhood obesity is multi-factorial and includes genetic, neuroendocrine, metabolic, psychological, environmental and socio-cultural factors. Many co-morbid conditions like metabolic, cardiovascular, psychological, orthopaedic, neurological, hepatic, pulmonary and renal disorders are seen in association with childhood obesity. The treatment of overweight and obesity in children and adolescents requires a multidisciplinary, multi-phase approach, which includes dietary management, physical activity enhancement, restriction of sedentary behaviour, pharmacotherapy and bariatric surgery. A holistic approach to tackle the childhood obesity epidemic needs a collection of activities including influencing policy makers and legislation, mobilizing communities, restructuring organizational practices, establishing coalitions and networks, empowering providers, imparting community education as well as enriching and reinforcing individual awareness and skills. The implications of this global phenomenon on future generations will be serious unless appropriate action is taken.
PMCID: PMC3028965  PMID: 21150012
Adolescents; children; dietary management; obesity; overweight
14.  Effects of a recreational physical activity and healthy habits orientation program, using an illustrated diary, on the cardiovascular risk profile of overweight and obese schoolchildren: a pilot study in a public school in Brasilia, Federal District, Brazil 
Introduction
Educative strategies need to be adopted to encourage the consumption of healthy foods and to promote physical activity in childhood and adolescence. The effects of recreational physical activity and a health-habit orientation program using an illustrated diary on the cardiovascular risk profile of overweight and obese children was investigated.
Methods
The weight and height of 314 schoolchildren aged between 9 and 11 years old, in a public school in Brasilia, Federal District, Brazil, were recorded. According to the body mass index (BMI) classification proposed by the World Health Organization, 84 were overweight or obese for their age and sex. Of these children, 34 (40%) participated in the study. Students were divided into two groups matched for sex, age, BMI, percent body fat (%BF): the intervention group (IG, n = 17) and the control group (CG, n = 17). The IG underwent a program of 10 weeks of exercise with recreational activities and health-habit orientation using an illustrated diary of habits, while no such interventions were used with the CG during the study period. Before and after the intervention, the children’s weight, height, BMI, %BF, waist circumference (WC), maximum oxygen intake (VO2max), total cholesterol (TC), high density lipoprotein (HDL), low density lipoprotein (LDL), triglycerides, glucose, eating habits, and physical activity level (PAL) were assessed. In analyzing the data, we used descriptive statistics and paired and unpaired t-tests, using a significance level of 0.05. For assessment of dietary habits, a questionnaire, contingency tables, and the chi-squared test were used, with <0.05 set as the significance level.
Results
After 10 weeks of intervention, the IG showed a reduction in BMI (pre: 22.2 ± 2.1 kg/m2 versus [vs] post: 21.6 ± 2.1 kg/m2, P < 0.01); WC (pre: 70.1 ± 6.1 cm vs post: 69.1 ± 5.8 cm, P < 0.01); %BF (pre: 29.2% ± 4.6% vs post: 28.0% ± 4.8%, P < 0.01); systolic blood pressure (P < 0.01); VO2max (P = 0.014); TC (P < 0.01); LDL (P < 0.01); triglycerides (P < 0.01); and intake of candy (P < 0.01) and soda drinks (P < 0.01), while an increase in the consumption of fruit (P < 0.01) and PAL (P < 0.01) were observed. The CG did not show any change in the health parameters assessed.
Conclusion
The program was effective in reducing risk factors for cardiovascular disease and the use of an illustrative diary may have been the key to this result, since students were motivated to change their poor eating habits and to increase their physical activity level.
doi:10.2147/DMSO.S52166
PMCID: PMC3848643  PMID: 24348058
obesity; cardiovascular disease; physical activity level; body mass index; risk factor; motivation; children; change of habits
15.  Fatness, Fitness, and Cardiometabolic Risk Factors among Sixth-Grade Youth 
Purpose
Examine whether cardiometabolic risk factors are predicted by fitness or fatness among adolescents.
Methods
Participants are 4955 (2614 female) sixth-grade students with complete data from 42 US middle schools. Fasting blood samples were analyzed for total cholesterol, HDL- and LDL-cholesterol, triglyceride, glucose, and insulin concentrations. Waist circumference and blood pressure were assessed. Body mass index (BMI) was categorized as normal weight, overweight, or obese as a measure of fatness. Fitness was assessed using the multistage shuttle test and was converted into gender-specific quintiles. Gender-specific regression models, adjusted for race, pubertal status, and household education, were run to identify whether BMI group predicted risk factors. Models were repeated with fitness group and both fitness and fatness groups as predictors.
Results
Means for each risk factor (except HDL, which was the reverse) were significantly higher (P < 0.0001) with increased fatness and differed across all BMI groups (P < 0.001). Waist circumference, LDL-cholesterol, triglycerides, diastolic blood pressure, and insulin were inversely associated with fitness (P < 0.001). When both fatness and fitness were included in the model, BMI was associated (P < 0.001) with almost all cardiometabolic risk factors; fitness was only associated with waist circumference (both genders), LDL-cholesterol (males), and insulin (both genders). Other associations between fitness and cardiometabolic risk factors were attenuated after adjustment for BMI group.
Conclusions
Both fatness and fitness are associated with cardiometabolic risk factors among sixth-grade youth, but stronger associations were observed for fatness. Although maintaining high levels of fitness and preventing obesity may positively affect cardiometabolic risk factors, greater benefit may be obtained from obesity prevention.
doi:10.1249/MSS.0b013e3181d322c4
PMCID: PMC2921216  PMID: 20139783
FIT; OBESITY; CHILDREN; ADOLESCENTS; CARDIOVASCULAR DISEASE
16.  Severe Obesity and Cardiometabolic Risk in Children: Comparison from Two International Classification Systems 
PLoS ONE  2013;8(12):e83793.
Objectives
There is no agreed-upon definition for severe obesity (Sev-OB) in children. We compared estimates of Sev-OB as defined by different cut-points of body mass index (BMI) from the Centers for Disease Control and Prevention (CDC) or the World Health Organization (WHO) curves and the ability of each set of cut-points to screen for the presence of cardiometabolic risk factors.
Research Design and Methods
Cross-sectional, multicenter study involving 3,340 overweight/obese young subjects. Sev-OB was defined as BMI ≥99th percentile or ≥1.2 times the 95th percentile of the CDC or the WHO curves. High blood pressure, hypertriglyceridemia, low High Density Lipoprotein -cholesterol and impaired fasting glucose were considered as cardiometabolic risk factors.
Results
The estimated prevalence of Sev-OB varied widely between the two reference systems. Either using the cut-point ≥99th percentile or ≥1.2 times the 95th percentile, less children were defined as Sev-OB by CDC than WHO (46.8 vs. 89.5%, and 63.3 vs. 80.4%, respectively p<0.001). The CDC 99th percentile had lower sensitivity (58.5 vs 94.2), higher specificity (57.6 vs 12.3) and higher positive predictive value (34.4 vs 28.9) than WHO in identifying obese children with ≥2 cardiometabolic risk factors. These differences were mitigated using the 1.2 times the 95th percentile (sensitivity 73.9 vs. 88.1; specificity 40.7 vs. 22.5; positive predictive value 32.1 vs. 30.1). Substantial agreement between growth curves was found using the 1.2 times the 95th percentile, in particular in children ≤10 years.
Conclusions
Estimates of Sev-OB and cardiometabolic risk as defined by different cut-points of BMI are influenced from the reference systems used. The 1.2 times the 95th percentile of BMI of either CDC or WHO standard has a discriminatory advantage over the 99th percentile for identifying severely obese children at increased cardiometabolic risk, particularly under 10 years of age.
doi:10.1371/journal.pone.0083793
PMCID: PMC3873982  PMID: 24386280
17.  Glycolipid metabolic status of overweight/obese adolescents aged 9- to 15-year-old and the BMI-SDS/BMI cut-off value of predicting dyslipidemiain boys, Shanghai, China: a cross-sectional study 
Background
The prevalence of adolescents’ obesity and overweight has dramatically elevated in China. Obese children were likely to insulin resistance and dyslipidemia, which are risk factors of cardiovascular diseases. However there was no cut-off point of anthropometric values to predict the risk factors in Chinese adolescents. The present study was to investigate glycolipid metabolism status of adolescents in Shanghai and to explore the correlations between body mass index standard deviation score (BMI-SDS) and metabolic indices, determine the best cut-off value of BMI-SDS to predict dyslipidemia.
Methods
Fifteen schools in Shanghai’s two districts were chosen by cluster sampling and primary screening was done in children aged 9-15 years old. After screening of bodyweight and height, overweight and obese adolescents and age-matched children with normal body weight were randomly recruited in the study. Anthropometric measurements, biochemical measurements of glycolipid profiles were done. SPSS19.0 was used to analyze the data. Receiver operating characteristic (ROC) curves were made and the best cut-off values of BMI-SDS to predict dyslipidemia were determined while the Youden indices were maximum.
Results
Five hundred and thirty-eight adolescents were enrolled in this research, among which 283 have normal bodyweight, 115 were overweight and 140 were obese. No significant differences of the ages among 3 groups were found. There were significant differences of WC-SDS (p<0.001), triacylglycerol (p<0.05), high and low density lipoprotein cholesterol (p<0.01), fasting insulin (p<0.01) and C-peptide (p<0.001) among 3 groups. Significant difference of fasting glucose was only found between normal weight and overweight group. Significant difference of total cholesterol was found between obese and normal weight group. There was no significant difference of glycated hemoglobin among 3 groups. The same tendency was found in boys but not in girls. Only HDL-C reduced and TG increased while BMI elevated in girls. The best cut-off value of BMI-SDS was 1.22 to predict dyslipidemia in boys. The BMI cut-off was 21.67 in boys.
Conclusion
Overweight and obese youths had reduced insulin sensitivity and high prevalence of dyslipidemia.When BMI-SDS elevated up to 1.22 and BMI was higher than 21.67 in boys, dyslipidemia may happen.
doi:10.1186/1476-511X-12-129
PMCID: PMC3766195  PMID: 23984682
Adolescents; Children; Lipid metabolism; Obesity; Overweight; BMI-SDS; China
18.  HEALTH-RELATED QUALITY OF LIFE IN OVERWEIGHT AND NONOVERWEIGHT BLACK AND WHITE ADOLESCENTS 
The Journal of pediatrics  2005;147(4):443-450.
Objectives
To assess the impact of obesity on quality of life (QOL) in black and white adolescents.
Study design
One hundred ten overweight (body mass index [BMI], 41.7 ± 8.9 kg/m2) and 34 nonoverweight adolescents (BMI, 20.6 ± 2.9 kg/m2) and their parents completed measures of QOL.
Results
Overweight was associated with poorer adolescent-reported QOL and parent reports of their children’s QOL. Examining groups by weight status and race, overweight whites reported the greatest impairment on Social/Interpersonal, Self-Esteem, and Physical Appearance QOL (all P < .01), whereas parents of overweight blacks reported the poorest General Health Perceptions scores regarding their children. Interactions between BMI z-score and race were detected for Social/Interpersonal, Self-esteem, Daily Living, Self-Efficacy, Self-regard, and Physical Appearance QOL (all P < .05): Higher BMI in whites was associated with greater impairments in QOL than in blacks. Parents reported similar relations for their children.
Conclusions
According to adolescent and parent reports, overweight is associated with poorer QOL in adolescence, regardless of race; however, compared with overweight white adolescents, blacks report less impairment in QOL. Future research is required to determine whether differences in QOL are predictive of treatment success.
doi:10.1016/j.jpeds.2005.05.039
PMCID: PMC2266889  PMID: 16227028
19.  Potential determinants of obesity among children and adolescents in Germany: results from the cross-sectional KiGGS study 
BMC Public Health  2009;9:46.
Background
Obesity among children and adolescents is a growing public health problem. The aim of the present paper is to identify potential determinants of obesity and risk groups among 3- to 17-year old children and adolescents to provide a basis for effective prevention strategies.
Methods
Data were collected in the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), a nationally representative and comprehensive data set on health behaviour and health status of German children and adolescents. Body height and weight were measured and body mass index (BMI) was classified according to IOTF cut-off points. Statistical analyses were conducted on 13,450 non-underweight children and adolescents aged 3 to 17 years. The association between overweight, obesity and several potential determinants was analysed for this group as well as for three socio-economic status (SES) groups. A multiple logistic regression model with obesity as the dependent variable was also calculated.
Results
The strongest association with obesity was observed for parental overweight and for low SES. Furthermore, a positive association with both overweight (including obesity) and obesity was seen for maternal smoking during pregnancy, high weight gain during pregnancy (only for mothers of normal weight), high birth weight, and high media consumption. In addition, high intakes of meat and sausages, total beverages, water and tea, total food and beverages, as well as energy-providing food and beverages were significantly associated with overweight as well as with obesity. Long sleep time was negatively associated with obesity among 3- to 10-year olds. Determinants of obesity occurred more often among children and adolescents with low SES.
Conclusion
Parental overweight and a low SES are major potential determinants of obesity. Families with these characteristics should be focused on in obesity prevention.
doi:10.1186/1471-2458-9-46
PMCID: PMC2642815  PMID: 19187531
20.  The Epidemiological Boehringer Ingelheim Employee Study—Part I: Impact of Overweight and Obesity on Cardiometabolic Risk 
Journal of Obesity  2013;2013:159123.
Objective. Obesity-dependent diseases cause economic burden to companies. Large-scale data for working populations are lacking. Prevalence of overweight and obesity in the Boehringer Ingelheim (BI) Employee cohort and the relationship between body mass index (BMI) and cardiometabolic risk factors and diseases were estimated. Design and Methods. Employees (≥38 years, employed in Ingelheim ≥2 years; n = 3151) of BI Pharma GmbH & Co. KG were invited by the medical corporate department to participate in intensive health checkups. Cross-sectional analysis of baseline data collected through 2006–2011 was performed. Results. 90% of eligible subjects participated (n = 2849). Prevalences of overweight and obesity were 40% and 18% and significantly higher in men and participants ≥50 years. Cardiometabolic risk factor levels and prevalences of cardiometabolic diseases significantly increased with BMI and were higher in overweight and obese participants. Cut-points for increased risk estimated from ROC curves were ≈25 kg/m2 for hypertension, hypercholesterolemia, arteriosclerosis, and hypertriglyceridemia and 26.7–28.0 kg/m2 for the metabolic syndrome, insulin resistance, hyperinsulinemia, increased intima media thickness, and type 2 diabetes. Conclusion. This is the first large-scale occupational health care cohort from a single company. Cardiometabolic risk factors and diseases accumulate with increasing BMI. Occupational weight reduction programs seem to be reasonable strategies.
doi:10.1155/2013/159123
PMCID: PMC3753749  PMID: 23997947
21.  Swedish Child Health Care nurses conceptions of overweight in children: a qualitative study 
BMC Family Practice  2012;13:57.
Background
Registered Sick Children’s Nurses and District Nurses employed at Child Health Care centres are in a position to help prevent childhood overweight and obesity. Prevention of this challenging public health threat could be improved through having a better understanding of how this group of nurses perceives childhood obesity. The aim of this study was to elucidate the conceptions of childhood overweight, including obesity, among nurses working in Child Health Care.
Method
A qualitative study using a phenomenographic approach, based on open-ended interviews with 18 Child Health Care nurses (CHC-nurses) strategically selected from 17 Child Health Care Centres in the southern part of Sweden.
Results
Four categories of description emerged from the data: Perception of childhood overweight changes, Overweight in younger children a neglected concern, Overweight a delicate issue and Importance of family lifestyle. The participating CHC-nurses conceived overweight in children, primarily obesity in children to be an extensive and serious problem which affects children, families and the surrounding society. Overweight in children was further perceived as a consequence of their parent’s lifestyle and their awareness of the problem, which was considered by the CHC-nurses as a sensitive and a provoking issue. It was also perceived that overweight in children is not taken seriously during the pre-school period and that concerns regarding overweight in younger children were mainly about the appearance and not the health of the child. The CHC-nurses perceived that the proportion of overweight children has increased, which Swedish society and the CHC-nurses have adapted to. This adaptation makes it difficult for CHC-nurses to define those children who are overweight.
Conclusion
CHC-nurses provide a comprehensive and complex picture of childhood overweight, which includes several difficulties dealing with this issue. Attention to CHC-nurse’s conceptions of overweight in children is important since it can affect the parent-nurse relationship and thereby the nurse’s, as well as the parent’s efforts to influence the children’s weight. It is suggested that CHC- nurses should work with person centered counseling and empowerment concerning parent to child relations in cases involving overweight.
doi:10.1186/1471-2296-13-57
PMCID: PMC3426496  PMID: 22697580
Child; Conceptions; Nurses; Overweight; Perceptions; Primary health care; Qualitative research
22.  A Review of the Potential for Cardiometabolic Dysfunction in Youth with Spina Bifida and the Role for Physical Activity and Structured Exercise 
Children and adolescents who have decreased mobility due to spina bifida may be at increased risk for the components of metabolic syndrome, including abdominal obesity, insulin resistance, and dyslipidemia due to low physical activity. Like their nondisabled peers, adolescents with spina bifida that develop metabolic risk factors early in life have set the stage for adult disease. Exercise interventions can improve metabolic dysfunction in nondisabled youth, but the types of exercise programs that are most effective and the mechanisms involved are not known. This is especially true in adolescents with spina bifida, who have impaired mobility and physical function and with whom there have been few well-controlled studies. This paper highlights the current lack of knowledge about the role of physical activity and the need to develop exercise strategies targeting the reduction of cardiometabolic risk and improving quality of life in youth with spina bifida.
doi:10.1155/2012/541363
PMCID: PMC3384902  PMID: 22778758
23.  Differences in lifestyle behaviors, dietary habits, and familial factors among normal-weight, overweight, and obese Chinese children and adolescents 
Background
Pediatric obesity has become a global public health problem. Data on the lifestyle behaviors, dietary habits, and familial factors of overweight and obese children and adolescents are limited. The present study aims to compare health-related factors among normal-weight, overweight, and obese Chinese children and adolescents.
Methods
We conducted a cross-sectional study consisted of 4262 children and adolescents aged 5–18 years old from rural areas of the northeast China. Anthropometric measurements and self-reported information on health-related variables, such as physical activities, sleep duration, dietary habits, family income, and recognition of weight status from the views of both children and parents, were collected by trained personnel.
Results
The prevalence rates of overweight and obesity were 15.3 and 6.4%, respectively. Compared to girls, boys were more commonly overweight (17.5% vs. 12.9%) and obese (9.5% vs. 3.1%). Approximately half of the parents with an overweight or obese child reported that they failed to recognize their child’s excess weight status, and 65% of patients with an overweight child reported that they would not take measures to decrease their child’s body weight. Obese children and adolescents were more likely to be nonsnackers [odds ratio (OR): 1.348; 95% confidence interval (CI): 1.039–1.748] and to have a family income of 2000 CNY or more per month (OR: 1.442; 95% CI: 1.045–1.99) and less likely to sleep longer (≥7.5 h) (OR: 0.475; 95% CI: 0.31–0.728) than the normal-weight participants.
Conclusions
Our study revealed a high prevalence of overweight and obesity in a large Chinese pediatric population. Differences in sleep duration, snacking, family income, and parental recognition of children’s weight status among participants in different weight categories were observed, which should be considered when planning prevention and treatment programs for pediatric obesity.
doi:10.1186/1479-5868-9-120
PMCID: PMC3522535  PMID: 23031205
Overweight; Obesity; Children; Adolescents; Health-related factors
24.  Prevention of gestational diabetes through lifestyle intervention: study design and methods of a Finnish randomized controlled multicenter trial (RADIEL) 
Background
Maternal overweight, obesity and consequently the incidence of gestational diabetes are increasing rapidly worldwide. The objective of the study was to assess the efficacy and cost-effectiveness of a combined diet and physical activity intervention implemented before, during and after pregnancy in a primary health care setting for preventing gestational diabetes, later type 2 diabetes and other metabolic consequences.
Methods
RADIEL is a randomized controlled multi-center intervention trial in women at high risk for diabetes (a previous history of gestational diabetes or prepregnancy BMI ≥30 kg/m2). Participants planning pregnancy or in the first half of pregnancy were parallel-group randomized into an intervention arm which received lifestyle counseling and a control arm which received usual care given at their local antenatal clinics. All participants visited a study nurse every three months before and during pregnancy, and at 6 weeks, 6 and 12 months postpartum. Measurements and laboratory tests were performed on all participants with special focus on dietary and exercise habits and metabolic markers.
Of the 728 women [mean age 32.5 years (SD 4.7); median parity 1 (range 0-9)] considered to be eligible for the study 235 were non-pregnant and 493 pregnant [mean gestational age 13 (range 6 to 18) weeks] at the time of enrollment. The proportion of nulliparous women was 29.8% (n = 217). Out of all participants, 79.6% of the non-pregnant and 40.4% of the pregnant women had previous gestational diabetes and 20.4% of the non-pregnant and 59.6% of the pregnant women were recruited because of a prepregnancy BMI ≥30 kg/m2. Mean BMI at first visit was 30.1 kg/m2 (SD 6.2) in the non-pregnant and 32.7 kg/m2 (SD 5.6) in the pregnant group.
Discussion
To our knowledge, this is the first randomized lifestyle intervention trial, which includes, besides the pregnancy period, both the prepregnancy and the postpartum period. This study design also provides an opportunity to focus upon the health of the next generation. The study is expected to produce novel information on the optimal timing and setting of interventions and for allocating resources to prevent obesity and diabetes in women of reproductive age.
Trial registration
Clinicaltrials.gov Identifier: NCT01698385
doi:10.1186/1471-2393-14-70
PMCID: PMC3928878  PMID: 24524674
Gestational diabetes; Type 2 diabetes; Diet and exercise intervention; Obesity; BMI; Pregnancy
25.  Is ideal body image related to obesity and lifestyle behaviors in African-American adolescents? 
Child  2011;38(2):219-228.
Background
Childhood obesity epidemic has become a public health issue in the U.S., especially among African-American youths. Research on the association between ideal body image (IBI) and obesity and related lifestyle factors among African-American children and adolescents is limited.
Methods
Data collected from 402 low-income African-American adolescents aged 10-14 years in four Chicago public schools were used. Questionnaires were used to assess IBI, weight perception, weight control practices, and self-efficacy towards food and physical activity. Body mass index (BMI) was calculated using measured weight and height. Associations between IBI and weight perception, overweight/obesity, and lifestyle behaviors were assessed using linear and logistic regression models.
Results
The most frequently chosen ideal body size was the fourth of 8 silhouettes (from thinnest to heaviest) for boys (55%) and girls (49%). Overweight and obese girls selected larger ideal body figures than the others (trend test: P< 0.001). Compared to those with middle ideal body figures, girls who selected smaller ones were twice more likely to have an unhealthy diet as indicated by less fruit and milk consumption, the odd ratios (ORs) and 95% confidence intervals (95% CI) were 2.40 (1.15-5.02) for fruits intake (
Conclusions
Ideal body image is associated with weight status, food self-efficacy, and lifestyle behaviors among low-income African-American adolescents.
doi:10.1111/j.1365-2214.2011.01227.x
PMCID: PMC3138864  PMID: 21434968
ideal body image; obesity; weight perception; weight control; African-American; adolescent

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