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* Ways of Treating Adolescent Obesity


* Foodborne Illness Update



As rates of adolescent obesity continue to rise, choice of treatment needs to be guided by the severity of obesity, psychosocial factors, comorbidities, and patient's age and pubertal status, according to a new article published online in the Journal of the American Medical Association (JAMA) that addresses the evidence behind behavioral intervention, pharmacological, and weight loss options. For the behavioral intervention, it recommends the following:


* Delivery of at least 26 contact hours over 2 to 12 months by an interdisciplinary team including a pediatrician, a registered dietician, an exercise physiologist, and/or a psychologist.


* Targeting home environment, eating with the family, and involving the family.


* Dietary change such as decreased portion sizes, fewer ultra-processed foods, sugar-sweetened beverages, and other added sugars and eating more fruits, vegetables, and fiber-rich foods.



With respect to pharmacology, the FDA has approved 2 medications for adolescent obesity:


* Orlistat, a lipase inhibitor for long-term use


* Phentermine, a norepinephrine and a reuptake inhibitor for short-term use



In the largest randomized clinical trial, takers of orlistat experienced mild to moderate gastrointestinal problems. No randomized clinical trials of phentermine have been conducted in individuals younger than 17 years. Bariatric surgery is effective for adolescents with severe obesity. The TEEN Longitudinal Assessment of Bariatric Surgery reported a 3-year mean body mass index (BMI) reductions of 29% with Roux-en-Y gastric bypass and 27% with vertical sleeve gastrectomy among individuals aged 19 years or younger. The 5-year outcomes in the Roux-en-Y gastric bypass group demonstrated that the BMI reduction was largely sustained. However, long-term safety and effectiveness data in patients undergoing bariatric surgery during adolescence are lacking.


In summary, with respect to dealing with obesity, rather than proceeding by chronological stages or phases, treatment should occur as an integrated continuum of care that begins with the least invasive yet appropriately intensive treatment. In addition, all options should be discussed with the family, and it is critical to use patient-first language and terms preferred by adolescents, such as BMI, and to avoid terms such as fat. Almost 21% of adolescents aged 12 to 19 years have obesity; the challenge remains not only what to do and how to do it once obesity is present but also how to prevent it in the first place.


Source: Michelle I. Cardel, PhD, MS, RD1; Ania M. Jastreboff, MD, PhD2; Aaron S. Kelly, PhD3 Treatment of adolescent obesity in 2020, JAMA. Published online September 30, 2019. doi:10.1001/jama.2019.14725



Just because a little is good, it does not mean a lot is better. Vitamin D might not be much help for strengthening bones among healthy adults without osteoporosis, Canadian researchers reported, even at doses far higher than recommended daily allowances. In a clinical trial assessing 3 levels of daily vitamin D supplementation-400, 4000, and 10 000 IU-radial volumetric bone mineral density was significantly lower among those (aged 55-70 years) taking higher doses for 3 years.


400 IU: reference


4000 IU: -3.9-mg calcium hydroxyapatite/cm3 (95% confidence interval [CI], -6.5 to -1.3)


10 000 IU: -7.5-mg hydroxyapatite/cm3 (95% CI, -10.1 to -5.0)


No dose of vitamin D supplementation was able to prevent bone loss, as each dose saw a drop in the percentage of radial volumetric bone mineral density for 3 years, as they reported in JAMA:


400 IU: -1.2%


4000 IU: -2.4%


10 000 IU: -3.5%


A total of 311 Canadian adults were included in the randomized trial, all of whom were free of osteoporosis at baseline and were ages 55 to 70 years. All participants had baseline serum 25-hydroxyvitamin D levels of between 12 and 50 ng/mL (30-125 nmol/L) and baseline serum calcium levels between 8.4 and 10.2 mg/dL (2.10-2.55 mmol/L). Vitamin D supplements were provided in the form of drops, and all participants were instructed to take no more than 200 IU of additional vitamin D each day, such as the amount in many multivitamins. Only those who were not taking in the recommended level of calcium (1200 mg/d) were provided with calcium citrate tablets. Study limitations included the exclusion of people with osteoporosis or with 25(OH)D levels of less than 30 nmol/L, who might respond differently to high-dose vitamin D supplementation. In addition, the study did not include a placebo control group. The findings were unexpected, and outcomes were opposite of what they were anticipating. The authors caution that "this evidence of high-dose vitamin D having a negative effect on bone should be regarded as hypothesis generating, requiring confirmation with further research." Therefore, the interpretation of this study is that, for maintenance of bone quality in healthy vitamin D-sufficient adults, these results do not support a skeletal benefit of vitamin D doses well above the recommended dietary allowance.


Source: Burt LA, et al. Effect of high-dose vitamin D supplementation on volumetric bone density and bone strength. JAMA. 2019. doi:10.1001/jama.2019.11889.



Compared with high-income countries, people in low-income countries are more likely to experience dual burdens of malnutrition-both overnourishment and undernourishment-often in the same persons over time. Both ends of this spectrum have been associated with an increased risk of obesity and adult-onset cardiometabolic diseases such as type 2 diabetes and cardiovascular disease. Although studies have shown that these outcomes are associated with early childhood growth patterns, very few studies have explored the relationship between distinct growth trajectories and cardiometabolic markers in a low-income urban population. In a recent study, researchers examined distinct trajectories of adiposity-related BMI in the first years of life and subsequent implications on markers of cardiometabolic risk and body composition in early childhood. Study results highlight the importance of timely interventions targeted at young children from low-income countries with unfavorable growth patterns. In the prospective birth cohort study, a total of 453 healthy and full-term Ethiopian children were included in the modeling of BMI trajectories. Four distinct BMI growth paths or trajectories from birth to 5 years old were identified: stable low BMI, normal BMI, rapid catch-up to high BMI, and slow catch-up to high BMI. Associations of the identified growth trajectories with cardiometabolic markers and body composition at 5 years old were analyzed.


Compared with the "normal BMI" trajectory, children in the "rapid catch-up to high BMI" trajectory had higher triglycerides, insulin production, fat mass, and fat-free mass. Children in the "stable low BMI" class had lower low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, fat mass, and fat-free mass but higher triglycerides at 5 years old. The generalizability of these trajectories was supported by their similarity to BMI trajectories identified in studies from high-income countries using similar data-driven modeling. The researchers hypothesized that rapid BMI growth during a critical window of the first 6 months of life accelerates an increase of fat mass in relation to fat-free mass, which may result in unfavorable cardiometabolic changes early in childhood. Thus, the development of obesity and cardiometabolic risk may be established already in early childhood. Interventions should begin early in life and target young children from low-income countries with unfavorable growth patterns.




Wibaek R, Vistisen D, Girma T, et al. Body mass index in early childhood in relation to cardiometabolic risk profile and body composition at 5 years of age. The American Journal of Clinical Nutrition. nqz170.