Elevated fasting glucose levels in obese children and adolescents : prevalence and long-term consequences

Background: Obesity in childhood and adolescents is a major concern in Sweden, as in many parts of the world. Already during the pediatric years is obesity associated with several metabolic complications, which often persists into adulthood. An important metabolic concern is the disturbance of the glucose-insulin homeostasis. One early sign is impaired fasting glycaemia (IFG) which is considered a prediabetic stage as IFG is associated with markedly increased risk for development of type 2 diabetes mellitus (T2DM) in adults. IFG refers to elevated, but not yet diabetic, glucose levels in the fasting state. At present, two different cut-off values for IFG are used in parallel; the American Diabetes Association (ADA) suggest 5.6 mmol/L and the World Health Organization (WHO) promotes 6.1 mmol/L as the cut-off for IFG. In adults, IFG has been associated with increased risk for cardiovascular disease, cancer, and premature also in the absence of the development of T2DM. The prevalence of IFG in the obese pediatric population has been reported with vast differences across different countries and populations. Further, the long-term consequences of IFG in the obese pediatric population are not clear. However, obesity as well as obesity-induced dysglycemia, may affect several brain functions important for schooling. The aim of this thesis is to investigate the prevalence, risk groups, and consequences of IFG in obese children and adolescents. Method: All studies included in this thesis contains data from the Swedish Childhood Obesity Register – BORIS (Barn Obesitas Register I Sverige). BORIS is a national quality register for obesity treatment in childhood and adolescence and was initiated in 2005. In addition, data from Germany and Poland regarding children and adolescents who have been undergoing obesity treatment are included. Study I and II are cross-sectional observational studies and Study III and IV are prospective cohort studies, which in addition to BORIS data using data from several national registries. Results: The total prevalence of IFG among obese children in the German cohort according to the ADA was 5.7% and according to the WHO it was 1.1%. In Sweden, the corresponding prevalence was 17.1% and 3.9%, respectively. IFG risk was associated with increasing age, male sex and degree of obesity. Further, Swedish obese young children had higher glucose levels than Polish obese young children. The use of T2DM medication retrieved from the national prescribed drug registry was used as a proxy for the diagnosis of T2DM. The pediatric obese population in Sweden, based on the BORIS cohort, had a 24 times increased use of T2DM medications in early adulthood in relation to a population-based comparison group, regardless of gender and ethnicity. While the WHO-defined IFG predicted future use of T2DM medication in early adulthood with an adjusted hazard ratio of 3.84 compared with those who had fasting glucose levels <5.6mmol/L. A fasting glucose level of 5.6-6.0 mmol/L, i.e. the IFG glucose interval added by ADA, did not increase the use of T2DM medication in young adults more than pediatric obesity itself. Female gender and more severe degree of obesity increased the risk for future T2DM medication. In the obese cohort, 55.4% completed ≥12 years in school, compared with 76.2% in the comparison group. IFG did not correlate significantly with school completion; 50.8% for those with IFG according to ADA and 48.4% for those with IFG according to WHO completed school compared with 55.8% for non-IFG. When analyzing glucose as a continuous variable, a non-significant tendency on school completion could be seen (adjusted p=0.06). Conclusion: IFG is highly prevalent among obese children in Sweden compared with Poland and Germany. There are no known explanations for the large regional differences in both IFG prevalence and fasting glucose levels. IFG according to WHO, but not the additional interval added by ADA (5.6-6.0 mmol/L) can be considered as a prediabetic stage in the obese pediatric population. Thus, these studies indicate that risk markers identified in adults can not directly be transferred to children. Obesity in childhood and adolescence was associated with low educational level in early adulthood but IFG did not statistically significantly increase the risk for low education in obese individuals

Adenovirus-36 Is Associated with Obesity in Children and Adults in Sweden as Determined by Rapid ELISA

Background Experimental and natural human adenovirus-36 (Adv36) infection of multiple animal species results in obesity through increasing adipogenesis and lipid accumulation in adipocytes. Presence of Adv36 antibodies detected by serum neutralization assay has previously been associated with obesity in children and adults living in the USA, South Korea and Italy, whereas no association with adult obesity was detected in Belgium/the Netherlands nor among USA military personnel. Adv36 infection has also been shown to reduce blood lipid levels, increase glucose uptake by adipose tissue and skeletal muscle biopsies, and to associate with improved glycemic control in non-diabetic individuals. Principal Findings Using a novel ELISA, 1946 clinically well-characterized individuals including 424 children and 1522 non-diabetic adults, and 89 anonymous blood donors, residing in central Sweden representing the population in Stockholm area, were studied for the presence of antibodies against Adv36 in serum. The prevalence of Adv36 positivity in lean individuals increased from ~7% in 1992–1998 to 15–20% in 2002–2009, which paralleled the increase in obesity prevalence. We found that Adv36-positive serology was associated with pediatric obesity and with severe obesity in females compared to lean and overweight/mildly obese individuals, with a 1.5 to 2-fold Adv36 positivity increase in cases. Moreover, Adv36 positivity was less common among females and males on antilipid pharmacological treatment or with high blood triglyceride level. Insulin sensitivity, measured as lower HOMA-IR, showed a higher point estimate in Adv36-positive obese females and males, although it was not statistically significant (p = 0.08). Conclusion Using a novel ELISA we show that Adv36 infection is associated with pediatric obesity, severe obesity in adult females and lower risk of high blood lipid levels in non-diabetic Swedish individuals

Palveluyrityksen brändi-identiteetin ja imagon vastaavuus : Case: Peurunka

Tutkimuksen tavoitteena oli selvittää vastaako Peurungan imago sen brändi-identiteettiä. Imagoa tutkittiin kuluttajien näkökulmasta. Tutkimuksen toimeksiantaja, Peurunka on palvelualan yritys, joka tarjoaa laajan valikoiman hyvinvoinnin palveluita mukaan lukien kylpylä- ja kuntoutuspalvelut. Teoreettinen viitekehys muodostui käsitteiden palvelu, brändi, brändi-identiteetti ja imago määrittelystä. Tutkimuksessa käytettiin sekä kvalitatiivista, että kvantitatiivista tutkimus-otetta. Tutkimuksen kvalitatiivisessa osiossa selvitettiin, millainen on Peurungan brändi-identiteetti haastattelemalla Peurungan markkinointijohtajaa. Tutkimuksen kvantitatiivisessa osiossa tutkittiin, millaiseksi Peurungan digitaalisten markkinointikanavien seuraajat kokivat imagon. Aineistonkeruuseen käytettiin verkkokyselyä. Tuloksista selvisi, että imago oli pääosin lähellä brändi-identiteettiä. Peurungan arvot, missio ja visio olivat osa brändi-identiteettiä sekä imagoa. Lisäksi brändin ydinidentiteetti tuli vahvasti esiin imagossa. Kuitenkin joidenkin brändi-identiteetin ja imagon osien välillä oli eroja. Etenkin vastaukset eri taustamuuttujien välillä vaihtelivat joissain tapauksissa. Peurungan brändi-identiteetti ei ollut aikaisemmin kirjallisessa muodossa, eikä se ollut alaisten tiedossa. Tulosten mukaan syy siihen, miksi imago ei kuitenkaan vastaa täysin brändi-identiteettiä, saattaa hyvinkin johtua siitä, ettei brändi-identiteettiä ollut saatettu koko henkilökunnan tietoon. Ulkoinen markkinointi ei ole välttämättä tavoittanut haluttuja kohderyhmiä ja antanut oikeaa viestiä. Myös itse palvelukokemus on saattanut vaikuttaa väärällä tavalla imagoon, koska asiakaspalvelijat eivät ole tienneet, millaista viestiä asiakkaille halutaan lähettää.The objective of the study was to examine if Peurunkas’s brand image is similar to its brand identity. The brand image was investigated from the consumers’ perspective. The research subject is Peurunka, a service company which provides a wide range of wellness services including a spa and rehabilitation services. The literature review consisted of defining the concepts of service, brand, brand image and brand identity. Both quantitative and qualitative research methods were used in the study. In the qualitative part of the study Peurunka’s brand identity was examined by interviewing the marketing manager of Peurunka. The quantitative part looked into how the followers of Peurunka’s digital marketing channels viewed the company’s brand image. The data was collected via an online survey. The results revealed that the brand image was mainly similar to the brand identity. Peurunka’s values, mission and vision were part of the brand identity and brand image as well. Additionally, the core identity of the brand came across strongly in the brad image. Nevertheless, there were some differences between some attributes of the brand identity and the brand image. Especially the answers regarding different background variables varied in some cases. Peurunka’s brand identity was not written down earlier and employees were not aware of it. Based on the results the brand identity that was unfamiliar to the staff members may be one reason why the brand image and brand identity did not match perfectly. External marketing may not have reached the right audience or given the right message. Also the service experience may have affected the brand image in the wrong way since the customer service persons were not aware of what kind of message to send to the customers

Prevalence of increased transaminases and its association with sex, age, and metabolic parameters in children and adolescents with obesity – a nationwide cross-sectional cohort study

Abstract Background Childhood obesity increases the risk of non-alcoholic fatty liver disease marked by elevated alanine aminotransferase (ALT). This study investigated the prevalence of increased ALT in children and adolescents with obesity, and its associations with sex, age, degree of obesity, and metabolic parameters. Methods Individuals between 5 and 17.99 years of age enrolled in the Swedish Childhood Obesity Treatment Register (BORIS) before March 2020 were included. Mildly increased ALT was defined by ALT 27–51 U/L (males) and 23–43 U/L (females), while markedly increased ALT by levels above. Multiple logistic regression models were used for statistical analysis. Results Among 11,776 individuals (age 11.0 ± 3.3 years, 53.5% males), the prevalence of mildly and markedly increased ALT were 37.9 and 10.6%, respectively. A sex-age interaction was found, where increasing age strengthened the odds of markedly increased ALT in males (OR, 99% CI: 1.34, 1.29–1.4 for each year) while the corresponding pattern in females with was minuscule (1.09, 1.02–1.10). Compared to class I obesity, class II and III obesity had greater odds ratios for mildly increased ALT (class II obesity OR, 99% CI: 1.51, 1.35–1.70; class III obesity OR, 99% CI: 2.17, 1.66–2.61) and for markedly increased ALT (class II obesity OR, 99% CI: 1.82, 1.51–2.20; class III obesity OR, 99% CI 3.38, 2.71–4.23). Dyslipidemia was associated with both mildly and markedly increased ALT, all p < 0.001. Prevalence of impaired fasting glucose was 19.1% in normal ALT group, 20.4% in mildly increased ALT group, and 29.0% in markedly increased ALT group. Conclusions The risk of markedly increased ALT increased exponentially with age among boys, but not among girls. Higher degree of obesity was observed in individuals with mildly and markedly increased ALT. Further, metabolic derangements were more prevalent among individuals with mildly and markedly increased ALT

Obesity in childhood, socioeconomic status, and completion of 12 or more school years: a prospective cohort study

Objectives Children with obesity achieve lower educational level compared with normal-weight peers. Parental socioeconomic status (SES) impacts both a child’s academic achievement and risk of obesity. The degree to which the association between obesity and education depends on parental SES is unclear. Therefore, the primary aim is to investigate if individuals with obesity in childhood are less likely to complete ≥12 years of schooling, independently of parental SES. The secondary aim is to study how weight loss, level of education and parental SES are associated.Design Nationwide prospective cohort study.Setting Swedish national register data.Participants Children aged 10–17 years, recorded in the Swedish Childhood Obesity Treatment Register, and aged 20 years or older at follow-up were included (n=3942). A comparison group was matched by sex, year of birth and living area (n=18 728). Parental SES was based on maternal and paternal level of education, income and occupational status.Primary outcome measure Completion of ≥12 years of schooling was analysed with conditional logistic regression, and adjusted for group, migration background, attention deficit disorder with or without hyperactivity, anxiety/depression and parental SES.Results Among those with obesity in childhood, 56.7% completed ≥12 school years compared with 74.4% in the comparison group (p&lt;0.0001). High parental SES compared with low SES was strongly associated with attained level of education in both children with and without obesity, adjusted OR (aOR) (99% CI)=5.40 (4.45 to 6.55). However, obesity in childhood remains a strong risk factor of not completing ≥12 school years, independently of parental SES, aOR=0.57 (0.51 to 0.63). Successful obesity treatment increased the odds of completing ≥12 years in school even when taking parental SES into account, aOR=1.34 (1.04 to 1.72).Conclusions Individuals with obesity in childhood have lower odds of completing ≥12 school years, independently of parental SES. Optimised obesity treatment may improve school results in this group

Association of childhood obesity with risk of early all-cause and cause-specific mortality: A Swedish prospective cohort study.

BACKGROUND:Pediatric obesity is associated with increased risk of premature death from middle age onward, but whether the risk is already increased in young adulthood is unclear. The aim was to investigate whether individuals who had obesity in childhood have an increased mortality risk in young adulthood, compared with a population-based comparison group. METHODS AND FINDINGS:In this prospective cohort study, we linked nationwide registers and collected data on 41,359 individuals. Individuals enrolled at age 3-17.9 years in the Swedish Childhood Obesity Treatment Register (BORIS) and living in Sweden on their 18th birthday (start of follow-up) were included. A comparison group was matched by year of birth, sex, and area of residence. We analyzed all-cause mortality and cause-specific mortality using Cox proportional hazards models, adjusted according to group, sex, Nordic origin, and parental socioeconomic status (SES). Over 190,752 person-years of follow-up (median follow-up time 3.6 years), 104 deaths were recorded. Median (IQR) age at death was 22.0 (20.0-24.5) years. In the childhood obesity cohort, 0.55% (n = 39) died during the follow-up period, compared to 0.19% (n = 65) in the comparison group (p < 0.001). More than a quarter of the deaths among individuals in the childhood obesity cohort had obesity recorded as a primary or contributing cause of death. Male sex and low parental SES were associated with premature all-cause mortality. Suicide and self-harm with undetermined intent were the main cause of death in both groups. The largest difference between the groups lay within endogenous causes of death, where children who had undergone obesity treatment had an adjusted mortality rate ratio of 4.04 (95% CI 2.00-8.17, p < 0.001) compared with the comparison group. The main study limitation was the lack of anthropometric data in the comparison group. CONCLUSIONS:Our study shows that the risk of mortality in early adulthood may be higher for individuals who had obesity in childhood compared to a population-based comparison group

Patterns and correlates of objectively measured physical activity in 3-year-old children

BACKGROUND: To increase the knowledge about physical activity (PA) patterns and correlates among children under the age of 4, there is a need for study's using objective measurements. The aim of this study was therefore to investigate if objectively measured PA among 3-year-old children differed between day of week and time of day and whether it correlated to child weight status and sex as well as parental weight status and education. METHODS: Totally 61 children (51% girls) aged 3, participating in Early Stockholm Obesity Prevention Project were included. PA was measured with a tri-axial accelerometer (ActiGraph GT3X+) worn on the non-dominant wrist for one week. The main outcome was average PA expressed as counts per minute from the vector magnitude. PA and demographics/family-related factors were collected at baseline and at age 3. To analyze the results simple linear regression, ANOVA and paired t-tests were performed. RESULTS: The mean number of valid days was 6.7 per child. The children were more active on weekdays than weekends (p &lt; 0.01) and the hourly pattern differed over the day with children being most active midmorning and midafternoon (p = 0.0001). Children to parents with low education were more active (p = 0.01) than those with highly educated parents. No differences in PA by child weight status, sex nor parental weight status were found. CONCLUSIONS: PA in 3-year-old children was lower during weekends than weekdays and varied over the day. Boys and girls had similar PA patterns, these patterns were independent of child or parental weight status. Children to parents with low education were more active than their counterparts. The fact that PA differed between weekdays and weekends indicates that PA might be affectable in 3-year-old children

Predictors of responses to clinic-based childhood obesity care

Background/Objective: Lifestyle modification is the therapy of choice for childhood obesity, yet the response rate is variable and may be affected by genetic factors. We aimed to investigate predictors of poor response to lifestyle modification obesity treatment in children. Methods: A prospective cohort study of 434 youths (64.5% females) between 4 and 20 years of age undergoing a standard care of lifestyle modification obesity management for 35.9 ± 20.8 months at Yale Childhood Obesity Clinic, USA. The primary outcome was a “poor response,” defined as the quintile with the largest increase in BMI Z-score over time. The secondary outcome was the endpoint BMI Z-score. Covariates investigated were sex, baseline pubertal status and degree of obesity, race, biochemical profile, and family history of overweight. A subsample (n = 214) had FTO genotyping (SNP rs8050136) tested. Results: Males (hazard ratio [HR] = 5.35, 95% confidence interval [CI] [3.32-8.61], P < 0.0001) and pubertal adolescents (HR = 2.78, [1.40-5.50], P = 0.003) compared to prepubertal children were more prone to respond poorly. Baseline degree of obesity was associated with relative protection from responding poorly (HR per BMI Z-score unit = 0.32, [0.17-0.61], P = 0.0006). Carriers of the FTO obesity-predisposing allele (AA genotype) were protected from responding poorly compared to non-carriers (CC genotype) (HR = 0.33, [0.12-0.88], P = 0.028). Conclusions: Boys and pubertal adolescents are more prone to respond poorly to standard obesity care while those with greater baseline degree of obesity and carriers of the FTO obesity-predisposing allele are not

Oral intake of mesoporous silica is safe and well tolerated in male humans.

BackgroundPrecisely engineered mesoporous silica has been shown to induce weight loss in mice, but whether it is safe to use in humans have not investigated.ObjectiveThe aim was to determine whether oral dosing, up to 9 grams/day, of precisely engineered mesoporous silica as a food additive can be used safely in male humans.DesignThis single blinded safety study consisted of two study arms including 10 males each (18-35 years). One arm consisted of participants with normal weight and one with obesity. After a placebo run-in period, all subjects were given porous silica three times daily, with increasing dose up to 9 grams/day (Phase 1). Subjects with obesity continued the study with highest dose for additional 10 weeks (Phase 2).ResultsAll participants completed Phase 1 and 90% completed Phase 2, with approximately 1% missed doses. Participants reported no abdominal discomfort, and changes in bowel habits were minor and inconsistent. The side effects observed were mild and tolerable, biomarkers did not give any safety concern, and no severe adverse events occurred.ConclusionMesoporous silica intake of up to 9 grams/day can be consumed by males without any major adverse events or safety concerns