Childhood Obesity Management at the 9-11 Year Well Child Check-An Opportunity for Expert Committee Recommended Comorbidity Screening

Our study assessed how primary care providers in a large outpatient network follow ECR guidelines with regards to laboratory screening for comorbidities of obese patients in the 9 to 11 year age group. This retrospective cohort study included 706 patients seen in an outpatient network with a 10 year well child check from 7/1/17 to 7/1/18 and a BMI greater than or equal to the 95th percentile. Our study found 42% of patients, who met ECR guidelines, had no lipid screening or obesity co-morbidity screening obtained. The most frequently abnormal test was the lipid panel, at 23%, and notably 16 % of Hemoglobin A1C screening resulted pre-diabetic range. Our study serves as an updated review of ECR compliance in a large primary care network and suggests an opportunity to enhance education on screening recommendations.

Discrimination Associated with Metabolic Syndrome among African Americans from the Jackson Heart Study

We enthusiastically read the paper entitled “Experiences of Discrimination Are Associated with Worse Metabolic Syndrome Severity Among African Americans in the Jackson Heart Study” by Cardel et al. [1]. Despite the detected association between experiences of discrimination and metabolic syndrome (MetS) severity (using the Z-score described), some limitations in the methodology should be further discussed. First, the validity of the MetS Z-score used remains debatable. The underlying assumption in the calculation of this Z-score is based on simultaneous use of the known five biomarkers namely blood pressure, fasting blood glucose, abdominal fat/circumference, fasting blood triglycerides, and fasting blood high-density cholesterol as a cluster of circumstances that bundle together to define MetS by Adult Treatment Panel III (ATP III) criteria [2]. Even though previous research may be in support of this approach [3-6], the assumption has major limitations. Each biomarker has a defined threshold, with the value above that threshold showing a certain amount of future cardiovascular and metabolic disease risk. However, the value below that threshold has no distinct risk prediction capability. In other words, adding these biomarker scores together has more limited prediction ability because any increase risk detected by these individual biomarkers only increases the opportunity of creating a new parameter with relatively lower prediction ability. As an exemplification; in this study, there are higher baseline MetS scores among the older / aging participants, especially in 46 to 64 years group. Nevertheless this phenomenon is expected given that 1) interaction with time will enhance the correlation; and 2) the MetS older individuals criteria is determined by extreme measurements of at least three MetS biomarkers [2]. Second, although the prevalence of MetS diagnosed by ATP III is ascertained, the authors did not provide any data to compare proposed MetS Z-score with traditional ATP III dichotomous criteria to see whether the effect of discrimination on MetS is different. If there is no significantly better prediction of discrimination for MetS between the two methods, why MetS Z-score should be calculated and used? Third, the linkage between discrimination and MetS remains unclear (and underdeveloped) because 1) MetS is the risk predictor for later cardiovascular and metabolic disease instead of the health outcome caused by certain psychological factor like discrimination [2]; and 2) the process that affects MetS development is complex. Both intrapersonal determinants like awareness and interpersonal factors like social network may contribute to MetS progression. Therefore, a theoretical mechanism/model for discrimination associated with MetS is needed to unravel the interplay with personal and societal correlates that can holistically describe how MetS progresses among African Americans. Clearly, the statistical approach used to generate MetS Z-score warrants further validation. A theorized framework supporting the relationship between the MetS and its predictive ability is needed in order to explain how MetS’ consequences develop and inform future use of MetS per se or its derived Z-score for risk assessment.

Influence of the Basal Metabolic Profile on the Evolution of the Pediatric Patient with Obesity

Purpose: To study how basal metabolism influences the somatometric evolution of the child and adolescent population with obesity in a pediatric endocrinology clinic. Material and Methods: Study of the entire population diagnosed with childhood obesity in a tertiary hospital by means of a multichannel impedanceometry study, TANITA BF 430. Results: 100 patients were selected by chance and studied from a database with 1400 records. Most of the patients who attend to these consultations for obesity are girls, between 8 and 11 years old. All the patients studied had a basal metabolism lower than the calculated theoretical ideal. The group of boys at the beginning of their follow-up showed a higher basal metabolism and more similar than the group of girls. Girls had a higher amount of fat mass compared to boys at the beginning of their follow up. After their first year of follow-up, both groups achieved a decrease in the percentage of fat mass, double in the case of boys compared to girls. After three years of the study, it was observed that 54% of the boys achieved a reduction in their FM compared to 36% of the girls. In overall terms, weight reduction is not achieved in this pediatric population. However it is observed a decrease in fat content in the medium term (1-3 years). The reduction of this fat mass could be a protection factor against cardiovascular diseases in adults. Given the same adherence to nutritional programs, it is believed that physical exercise rates influence this reduction. It was also observed that the most relevant data in the evolution of obesity in these patients is the basal metabolism that they present at the beginning of their follow-up. Discussion: Childhood obesity is a problem of increasing importance in our society. Understanding its characteristics would allow different strategies to be taken for a better treatment and diagnosis of these cases. Boys, in general, achieve a greater reduction in fat mass in the same follow-up time. Due to sexual dimorphism, or a higher rate of physical activity. Bioelectrical impedanceometry measurement is a simple, cheap and easy to use method in clinical practice to evaluate the energy consumption and the body composition of the patient. In “healthy child” health programs and even in schools, an impedanceometry machine could be purchased to focus physical activity efforts on those boys and girls with a lower basal metabolism, adding a greater consumption factor such as physical exercise. Thus, it would be possible to increase the requirements and the basal metabolism of the patient would increase, favoring the loss of fat mass. Regarding the use of conventional scales, in this type of patients, if we only look at the weight variable, a bias could be created since it would not be noticed that there has been a decrease in fat content at the cost of an increase in muscle mass. Conclusion: We consider that it should be recommendable to supply with a multichannel impedanceometry every pediatric endocrine consultation room as it is a non-invasive, and easy-to-use test that can provide a great amount of information about the evolution of these patients, since we believe that focusing efforts on those boys and girls who have a worse basal metabolism could contribute to improving the efficiency and effectiveness of the scarce health resources that we have.

A Multi-Center Study Exploring the Association of Metabolic Syndrome and Non-Alcoholic Fatty Liver Disease in Cuban Patients

Aim: There is a paucity of data on Non-Alcoholic Fatty Liver Disease (NAFLD) and Metabolic Syndrome (MetS) among native Cubans. We aimed to assess the prevalence of MetS in Cubans with NAFLD and the outcomes and predictors for advanced fibrosis. Methods: A multicenter (outpatient clinics of nine hospitals in seven Cuban provinces) cross-sectional study of adults with NAFLD between September 2018 and May 2019. MetS was defined by the National Cholesterol Education Program Adult Treatment Panel III (NCEP: ATPIII) criteria. Advanced fibrosis was defined using AST to Platelet Ratio Index (APRI) ≥1 and Fibrosis-4 score (FIB-4) ≥2.67. Results: 819 patients enrolled, 563 (68.7%) had MetS; mean age 54.9 years, 60.3% female, 65.8% white, 95.1% from urban residency, mean BMI 30.7 kg/m². Fibrosis was present in 114 (13.9%); 94 (82.5%) had APRI ≥1; 77 (67.5%) had FIB-4 ≥ 2.67; 57 (50%) both scores were elevated. MetS group had significantly more fibrosis than no MetS, [17% vs. 7% (p=0.0001)]. Patients with fibrosis were older (57.7 vs. 54.5, P=0.0015), of Mestizos ethnicity (36.8% vs. 16.9%, P<0.0001), and from rural residency (17.5% vs. 2.8%, P<0.0001). MetS was independently associated with fibrosis: Odds Ratio (OR) = 2.05 (95% CI 1.10-3.81) (p=0.024), but, rural residency was the strongest fibrosis predictor [OR: 5.30 (95% CI 2.45-11.47, (P<0.0001)]. Other fibrosis predictors were male gender, sedentary life-style, NAFLD family history, and lower estimated glomerular filtration rate (p<0.05). Risk of fibrosis was not associated with age, ethnicity, or smoking (all p>0.05). Conclusion: Cuban NAFLD patients with MetS have substantial clinical impairment and a higher risk for fibrosis.