Significado de la hipertensión arterial enmascarada en niños y adolescentes

La Hipertensión Arterial Enmascarada (HTAe) en niños y adolescentes es una condición prevalente, persistente y con impacto clínico. Las características clínicas que presentan los jóvenes en riesgo de sufrir HTAe no están definidas. Además, hasta el momento, no ha sido establecido cuál es el riesgo de desarrollar hipertensión arterial persistente (HTAp) de los niños y adolescentes con HTAe, ni los factores de riesgo asociados a esta condición. Con el objetivo de estudiar estos aspectos, se ha realizado un estudio prospectivo a largo plazo, evaluando la progresión de los valores de presión arterial clínica y ambulatoria así como la antropometría de un grupo de niños y adolescentes normotensos (NT) y otro con HTAe. Las características clínicas que podrían identificar a los niños y jóvenes en riesgo de sufrir HTAe y el potencial dimorfismo sexual en la incidencia y momento de aparición de HTAp han sido analizados. En este estudio prospectivo a largo plazo (seguimiento medio de 36 meses), participaron 272 niños y adolescentes sanos (edad entre 6 y 18 años, 55,8% niñas), normotensos por determinación de presión arterial clínica, de los cuáles 39, presentaban HTAe al inicio del estudio. Cuando se comparan las características clínicas de ambos grupos al inicio del estudio no encontramos diferencias en cuanto a edad, sexo, valor de PA o antropometría, pero los antecedentes familiares de primer grado de HTA eran significativamente mayores en los varones con HTAe frente a los NT (50% vs 23,1%, p<0,05) y también en mujeres (21,7% Vs 18,6%, p=ns), pero no de forma significativa. El desarrollo de HTAp (HTA tanto por PA clínica como por presión arterial ambulatoria (MAPA)) en los participantes, fue registrado. LA PA sistólica clínica, desde la determinación inicial hasta la última medición realizada en el seguimiento se incrementó significativamente en los varones (3,2 mmHg por año, p<0,0001), pero no en las mujeres (1,2 mmHg por año, p=0,062). Algo similar ocurrió con la PA sistólica diurna determinada por MAPA, varones (1,14 mmHg por año, p<0.05) Vs mujeres (-0,23 mmHg, anuales, p=ns), lo que denota una diferencia significativa entre sexos (p=0,0022). La incidencia de HTAp fue de 7/100 sujetos anual (n=12)entre los HTAe y de 0,6/100 sujetos anual (n=4) entre los NT. Los varones con HTAe desarrollaron HTAp en una proporción significativamente mayor que las mujeres con HTAe (50% versus 17,4%; p=0,041). La presencia de HTAe en la valoración basal fue el determinante más importante para desarrollar HTAp (HR 15,6; 95th CI 4,91-49,7; p<0,0001). También el sexo masculino implicó mayor riesgo (HR 3,25; CI 1,12-9,39; p=0,0295). En niños y adolescentes, la HTAe es una precursora de HTAp. Los antecedentes parentales de HTA podrían ser un marcador clínico de riesgo de presentar HTA e por lo que estos niños serían candidatos de estudiarse mediante MAPA. El riesgo de desarrollar HTAp es superior en varones que en mujeres. El hecho de que la HTAe no sea una condición inocente, incrementa la necesidad de su diagnóstico precoz y un seguimiento adecuado, por lo que proponemos un algoritmo de diagnóstico y seguimiento de estos pacientes.Masked Hypertension (MK) in children and adolescents is prevalent, persistent and with clinical significance condition. Clinical characteristics of youth at risk of MK are not defined. Also, so far, has not been established what is the risk of developing sustained hypertension (SH) in children and adolescents with MK or the risk factors associated with. In order to study these aspects, we performed a long-term follow-up study assessing how hypertension develops over time in healthy, masked hypertensive youths.The clinical characteristics that could identify children and youth at risk of MK and the potential sexual dimorphism in the incidence and timing of the development of SH have been analyzed. In this prospective long-term study (mean follow-up of 36 months), we enrolled 272 healthy conventional normotensive children and adolescents (aged 6 to 18 years, 55.8% female), of whom 39 had MK at baseline. Clinical characteristics of both groups were compared at baseline founding no differences in age, sex, anthropometry and BP value, but the first-degree family history of hypertension was significantly higher in boys with HTAe compared to NT (50% vs 23.1%, p <0.05) and in girls (21.7% vs. 18.6%, p = ns), but not significantly. Development of SH (HTN both clinic BP and ambulatory blood pressure (ABPM) in participants was recorded. Clinic systolic BP, from baseline to the last avaliable follow-up significantly increased in boys (3.2 mmHg per year, p <0.0001) but not in girls (1.2 mm Hg per year , p = 0.062). Something similar happened with daytime systolic BP determined by ABPM, boys (1.14 mmHg per year, p <0.05) vs girls (-0.23 mmHg, year, p = ns), leading to a significant between-sex difference (p = 0.0022). The incidence of sustained hypertension was 7.0/100 subjects/y (n=12) in masked hypertensives and 0.6/100 subjects/y (n=4) in normotensives. Masked hypertensive boys more frequently proceeded to sustained hypertension as compared with masked hypertensive girls (50.0% versus 17.4%; P =0.041). Masked hypertension at baseline (hazard ratio, 15.6; 95% confi dence interval, 4.91 – 49.7; P < 0.0001) and male sex (hazard ratio, 3.25; 95% confi dence interval, 1.12 – 9.39; P =0.0295) were independent factors associated with the incidence of sustained hypertension during the follow-up. In children and adolescents, MK is a precursor of SH. Parental history of hypertension may be a clinical marker of risk for hMK and so, these children would be candidates for study by ABPM The risk of developing SH is higher in boys than in girls. The fact that MK not prognostically innocent, increases the need for early diagnosis and appropriate monitoring. We propose an algorithm for diagnosis and management of these patients

Innovations In infant feeding : future challenges and opportunities in obesity and cardiometabolic disease

The field of nutrition in early life, as an e ective tool to prevent and treat chronic diseases, has attracted a large amount of interest over recent years. The vital roles of food products and nutrients on the body's molecular mechanisms have been demonstrated. The knowledge of the mechanisms and the possibility of controlling them via what we eat has opened up the field of precision nutrition, which aims to set dietary strategies in order to improve health with the greatest e ectiveness. However, this objective is achieved only if the genetic profile of individuals and their living conditions are also considered. The relevance of this topic is strengthened considering the importance of nutrition during childhood and the impact on the development of obesity. In fact, the prevalence of global childhood obesity has increased substantially from 1990 and has now reached epidemic proportions. The current narrative review presents recent research on precision nutrition and its role on the prevention and treatment of obesity during pediatric years, a novel and promising area of research

Opciones alternativas para prescribir actividad física entre niños y adolescentes obesos: marcha rápida con el apoyo de videojuegos activos

Background: Physical inactivity has been identified as an important public health concern for children. An increasing sedentary way of life is directly related to obesity; hence, prevention and management of childhood obesity are commonly based on lifestyle interventions wherein increasing physical activity is one of the main targets. The use of exergames can be useful in promoting physical activity, but it is necessary more research. This study analyzes the effects of an exergaming platform that involves brisk walking, on perceived exertion, self-efficacy, positive expectations and satisfaction in a sample of clinically obese children, as compared with normal weight children. Physiological variables like heart rate, oxygen consumption and energy expenditure were also measured. Method: A total sample of 42 children was recruited. Children were randomized into those walking on a treadmill and those using a treadmill with the support of the exergaming platform (Wii-Fit). Results: The obese children scored significantly higher in expectations and satisfaction in the exergame condition but not in self-efficacy, perceived exertion or physiological measures. Conclusions: These results suggest that this exergaming platform could be a tool to assist obese children in the practice of brisk walking as part of a programme designed to treat obesity.Introducción: La inactividad de los niños se ha identificado como un problema importante de salud pública. La generalización del sedentarismo está directamente relacionada con el aumento de la obesidad, por ello, el tratamiento de la obesidad infantil se basa en la intervención en estilos de vida siendo el aumento de actividad física uno de los objetivos principales. Los videojuegos activos podrían ser útiles para incrementar la actividad física, pero aún sería necesaria más investigación en este campo. Este estudio analiza los efectos de un videojuego activo que implica marcha rápida sobre el esfuerzo percibido, la auto-eficacia, las expectativas positivas y la satisfacción de un grupo de niños obesos y se compara con la respuesta de un grupo de niños normopeso. Se registraron también variables fisiológicas como la frecuencia cardiaca, el consumo de oxígeno y el gasto metabólico. Método: Una muestra de 42 niños fue estudiada. Los jóvenes fueron distribuidos de forma aleatoria en las dos opciones de ejercicio, marcha rápida en tapiz rodante con o sin el apoyo del videojuego activo (Wii-Fit). Resultados: Los niños obesos tuvieron puntuaciones significativamente más altas que los normopeso en las expectativas y la satisfacción que les producía la marcha rápida con apoyo del videojuego activo, pero en cambio no hubo diferencias significativas en cuanto a la auto-eficacia, el esfuerzo percibido o en las variables fisiológicas. Conclusiones: Estos resultados sugieren que esta plataforma de videojuego activo podría ser una herramienta útil para facilitar la práctica de la marcha rápida en niños obesos, como parte de una intervención para tratar la obesidad.CIBEROBN is an initiative of ISCIII (Instituto de Salud Carlos III). Thanks are extended to the Ministerio de Economía y Competitividad (Plan Nacional I+D+I 2008-2011), en el proyecto (PSI2011-25767); y la red de investigación en excelencia PROMETEO 2013 Fase II (PROMETEOII/2013/003

Prevalencia del trastorno por atracón en una muestra clínica de obesos

Introduction: Binge eating disorder is characterized by the presence of recurrent binge eating episodes in a short period of time, accompanied by loss of control. This disorder is the most frequent of all eating disorders in obese people, both adults and children. Objective: The objective of this study was to obtain prevalence data for binge eating disorder in a sample of obese children, users of a specialized pediatric unit in the treatment of childhood obesity. Material and Methods: A sample had 70 children and adolescents aged 9 to 16, with a mean age of 12 years attending a pediatric ward in the General Hospital of Valencia. To carry out the evaluation the following instruments were used, Diagnostic Interview for Binge Eating Disorder (SCID-IV), Binge Eating Disorder Scale Child (C-BED) and Questionnaire of eating patterns and weight (QEWP). Results: After the assessment, 6% of the clinical sample was diagnosed with binge eating disorder according to criteria established by the DSM-IVTR, and 14% showed subclinical forms of the diagnosis. Conclusions: The results are in line with previous studies that highlight the necessity of assessing these disorders in specialized units in the treatment of obesity

An electronic system (PDA) to record dietary and physical activity in obese adolescents; data about efficiency and feasibility

Introduction: Recently, the prevalence of childhood obesity is increasing significantly. Dietary and physical activity registers are frequently referred to as the “cornerstone" of behavioral weight control programs. Mobile devices such as Personal Digital Assistants (PDAs) are showing their usefulness to facilitate these self-registers. Objective: This study is aimed to analyze and compare the efficiency and feasibility of a PDA and Paper and Pencil (P&P) registers to record dietary and physical activity in a sample of Spanish adolescents with overweight. Methods: Sample was composed by 30 overweight participants aged 9-15 years seeking for obesity treatment. This is a counterbalance study, all participants completing both experimental conditions: PDA and P&P registers. Results: For dietary records, participants filled out more records using P&P than PDA when “total" number of self-registers was considered, but when “complete" records were taken into account, these differences disappeared, and when percentages of “complete" records were analyzed, PDA produced more accurate registers than P&P. For physical activity, PDA produced more records than P&P. PDA was the preferred system. According to participants, the PDA s strengths are the comfort, easiness to use and to transport. Conclusions: Results showed that P&P produced more incomplete dietary records than PDA. PDA is a reliable system that allows the clinician to be confident in the data recorded. Recently, several applications for mobile devices have been developed, but there are few studies supporting evidence of their efficacy and feasibility in assessment and treatment of childhood obesity. This study tries to provide some evidence in this field.INTRODUCCIÓN: En los últimos años, la prevalencia de la obesidad infantil se ha incrementado de forma significativa. Los registros de ingesta y actividad física son considerados la “piedra angular” de los programas comportamentales de control del peso. Los dispositivos móviles, como las Personal Digital Assistant (PDAs), están mostrando su utilidad en la realización de estos registros. OBJETIVO: El presente estudio tiene como objetivo analizar y comparar la eficiencia y viabilidad de un sistema PDA y un sistema de Lápiz y Papel (P&P) para el registro de ingesta y movimiento físico en una muestra de adolescentes españoles con sobrepeso. MÉTODO: La muestra estuvo compuesta por 30 niños de entre 9 y 15 años con sobrepeso que asisten a un tratamiento para obesidad infantil. Se trata de un estudio contrabalanceado, por lo que los participantes completaron ambas condiciones experimentales: PDA y P&P. RESULTADOS: Considerando los registros de ingesta, cuando se consideran los registros “totales” los participantes realizaron más registros utilizando el sistema P&P que el sistema PDA, pero cuando se consideran los registros “completos”, estas diferencias desaparecieron y al considerar el porcentaje de registros “completos”, el sistema en PDA produjo más registros que el sistema P&P. Respecto a los registros de actividad física, el sistema PDA produjo más registros que el sistema P&P. La PDA fue considerada el sistema preferido por los participantes. De acuerdo con las opiniones de éstos, las potencialidades de la PDA es su comodidad, su facilidad de uso y de transporte. CONCLUSIONES: Los resultados obtenidos indican que el sistema P&P produce mayor cantidad de registros de ingesta incompletos que el sistema en PDA. La PDA es un sistema fiable que permite al clínico confiar en los datos registrados por los niños respecto a la ingesta y a la actividad física. Recientemente, se han desarrollado diversas aplicaciones para llevar a cabo registros en dispositivos móviles, pero aún son escasos los estudios disponibles que avalan la eficacia y viabilidad de estos sistemas para la evaluación y el tratamiento de la obesidad infantil. Este estudio pretende proporcionar evidencia al respeto

Sympathetic neural activity, metabolic parameters and cardiorespiratory fitness in obese youths.

OBJECTIVE: The main objective of this cross-sectional study is to assess the cardiac autonomic neural activity in the presence of abnormally increased body weight in youths and its relationship to metabolic risk factors and cardiorespiratory fitness (CRF). METHODS: Sixty-four overweight and obese patients, aged 9-17 years, of both sexes, stratified according to the international BMI cut-off, were enrolled. Continuous ECG was recorded during 15 min in resting conditions, and the heart rate variability (HRV) was measured in the time domain, frequency domain and for nonlinear dynamics. In addition, cardiometabolic risk factors and CRF in effort conditions were assessed. RESULTS: Among the overweight and obese youths, no significant differences were observed regarding metabolic parameters and heart rate, although CRF was the lowest in the severely obese youths. Likewise, no significant differences were observed in HRV, independent of how it was assessed. A positive and significant relationship, independent of the degree of obesity, pubertal stage and breathing rate under resting conditions, has been observed among sympathovagal balance, insulin and the homeostatic model assessment index. Furthermore, CRF assessed by volume oxygen peak was associated with insulin levels (r = -0.273; P < 0.05), the SD of the NN interval series (r = 0.268, P < 0.05) and the long-term variation using the Poincaré plot (PS1: r = 0.275, P < 0.05; PS2: r = 0.273, P < 0.05). CONCLUSION: The key findings of the present study were the presence of a link among fasting insulin, HRV and CRF independent of the degree of obesity, indicating the heterogeneity of obese children and adolescents

Obesity and Cardiometabolic Risk Factors : from Childhood to Adulthood

Obesity has become a major epidemic in the 21st century. It increases the risk of dyslipidemia, hypertension, and type 2 diabetes, which are known cardiometabolic risk factors and components of the metabolic syndrome. Although overt cardiovascular (CV) diseases such as stroke or myocardial infarction are the domain of adulthood, it is evident that the CV continuum begins very early in life. Recognition of risk factors and early stages of CV damage, at a time when these processes are still reversible, and the development of prevention strategies are major pillars in reducing CV morbidity and mortality in the general population. In this review, we will discuss the role of well-known but also novel risk factors linking obesity and increased CV risk from prenatal age to adulthood, including the role of perinatal factors, diet, nutrigenomics, and nutri-epigenetics, hyperuricemia, dyslipidemia, hypertension, and cardiorespiratory fitness. The importance of 'tracking' of these risk factors on adult CV health is highlighted and the economic impact of childhood obesity as well as preventive strategies are discussed

Blood cell transcript levels in 5-year-old children as potential markers of breastfeeding effects in those small for gestational age at birth

BACKGROUND: Nutrition of the newborn during the early postnatal period seems to be of capital importance and there is clinical evidence showing the protective effect of breastfeeding compared with formula feeding on childhood obesity and its comorbidities. Infants born small for gestation age may be more sensitive to the type of feeding during lactation. Here, we aimed to analyze the impact of birth weight and the type of infant feeding on the expression levels in peripheral blood cells of selected candidate genes involved in energy homeostasis in 5-year-old children, to find out potential early biomarkers of metabolic programming effects during this period of metabolic plasticity. METHODS: Forty subjects were recruited at birth and divided in four groups according to birth weight (adequate or small for gestational age) and type of infant feeding (breastfeeding or formula feeding). They were followed from birth to the age of 5 years. RESULTS: At 5 years, no significant differences regarding anthropometric parameters were found between groups, and all children had normal biochemical values. Expression levels of UCP2 and MC4R in peripheral blood cells were lower and higher, respectively, in formula feeding children compared with breastfeeding ones (P = 0.002 and P = 0.064, two-way ANOVA). Differences were more marked and significant by Student's t test in small for gestation age children (P < 0.001 and P = 0.017, respectively). Transcript levels of FASN and FTO in peripheral blood cells were also different according to the type of infant feeding, but only in small for gestation age children. CONCLUSIONS: Altogether, these results suggest that small for gestation age infants are more sensitive to the type of feeding during lactation, and transcript levels of particular genes in peripheral blood cells, especially the MC4R/UCP2 mRNA ratio, may precisely reflect these effects in the absence of clear differences in phenotypic traits

Are Peripheral Biomarkers Determinants of Eating Styles in Childhood and Adolescence Obesity? A Cross-Sectional Study

Disturbances in eating behaviors have been widely related to obesity. However, little is known about the role of obesity-related biomarkers in shaping habitual patterns of eating be haviors (i.e., eating styles) in childhood. The objective of the present study was to explore the relationships between several biomarkers crucially involved in obesity (ghrelin, insulin resistance, and leptin/adiponectin ratio) and eating styles in children and adolescents with obesity. Seventy participants aged between 8 and 16 (56.2% men) fulfilled the Spanish version of the Dutch Eating Behavior Questionnaire for Children to measure external, emotional, and restrained eating styles. In addition, concentrations of ghrelin, leptin, adiponectin, insulin, and glucose were obtained through a blood test. Hierarchical multiple regression analyses controlling for age and sex were computed for each eating style. Results indicated that individuals with higher ghrelin concentration levels showed lower scores in restrained eating (β = −0.61, p < 0.001). The total model explained 32% of the variance of the restrained pattern. No other relationships between obesity-related biomarkers and eating behaviors were found. This study highlights that one of the obesity-risk factors, namely lower plasma ghrelin levels, is substantially involved in a well-known maladaptive eating style, restraint eating, in childhood obesity

Longitudinal genome-wide DNA methylation analysis uncovers persistent early-life DNA methylation changes

BACKGROUND: Early life is a period of drastic epigenetic remodeling in which the epigenome is especially sensitive to extrinsic and intrinsic influence. However, the epigenome-wide dynamics of the DNA methylation changes that occur during this period have not been sufficiently characterized in longitudinal studies. METHODS: To this end, we studied the DNA methylation status of more than 750,000 CpG sites using Illumina MethylationEPIC arrays on 33 paired blood samples from 11 subjects at birth and at 5 and 10 years of age, then characterized the chromatin context associated with these loci by integrating our data with histone, chromatin-state and enhancer-element external datasets, and, finally, validated our results through bisulfite pyrosequencing in two independent longitudinal cohorts of 18 additional subjects. RESULTS: We found abundant DNA methylation changes (110,726 CpG sites) during the first lustrum of life, while far fewer alterations were observed in the subsequent 5 years (460 CpG sites). However, our analysis revealed persistent DNA methylation changes at 240 CpG sites, indicating that there are genomic locations of considerable epigenetic change beyond immediate birth. The chromatin context of hypermethylation changes was associated with repressive genomic locations and genes with developmental and cell signaling functions, while hypomethylation changes were linked to enhancer regions and genes with immunological and mRNA and protein metabolism functions. Significantly, our results show that genes that suffer simultaneous hyper- and hypomethylation are functionally distinct from exclusively hyper- or hypomethylated genes, and that enhancer-associated methylation is different in hyper- and hypomethylation scenarios, with hypomethylation being more associated to epigenetic changes at blood tissue-specific enhancer elements. CONCLUSIONS: These data show that epigenetic remodeling is dramatically reduced after the first 5 years of life. However, there are certain loci which continue to manifest DNA methylation changes, pointing towards a possible functionality beyond early development. Furthermore, our results deepen the understanding of the genomic context associated to hyper- or hypomethylation alterations during time, suggesting that hypomethylation of blood tissue-specific enhancer elements could be of importance in the establishment of functional states in blood tissue during early-life