Severe obesity during childhood is associated with cognitive deficits. Studies in adults have suggested improvements in executive functioning and memory after bariatric surgery. Our aim was to explore changes in cognitive function in adolescents over two years after bariatric surgery or intensive non-surgical treatment.
International and national guidelines recommend metabolic and bariatric surgery (MBS) as a treatment option for adolescents with severe obesity, but few countries offer MBS to adolescents in routine clinical care. This narrative review summarizes existing adolescent MBS guidelines and the available underpinning evidence. Two randomized trials and additional prospective studies have demonstrated efficacy and safety in adolescent MBS, and the health benefits appear to be similar or superior to outcomes in adults. However, there are specific challenges regarding the intervention during adolescence related to decision-making capacity and a peak in risk-taking behavior. Adolescents with severe obesity have—as a group—a mental health vulnerability, and specific nutritional concerns need to be addressed in relation to MBS. This review also describes how study findings can be translated into clinical care. We use Sweden as an example, where the National Board of Health and Welfare recommends MBS for selected adolescents with severe obesity aged 15 years or older. We present practical advice for implementing and integrating MBS in adolescents in the framework of multidisciplinary pediatric and adolescent care for obesity.
A systematic series of 89 single residue substitution analogs of the Mycobacterium leprae 65-kDa protein-derived peptide LQAAPALDKL were tested for stimulation of two HLA-DR2 restricted 65 kDa-reactive T cell clones from a tuberculoid leprosy patient. Some analogs with substitutions outside a "core" region showed enhanced stimulation of the T cell clones. This core region of seven or eight residues was essential for recognition, whereas substitution of amino acids outside this region did not affect T cell recognition although these residues could not be omitted. Thus these core residues interact directly with the presenting HLA-DR2 molecule and/or the TCR. Except for analogs of position 419 for clone 2B6, the majority of the nonstimulatory substitution analogs did not inhibit the presentation of LQAAPALDKL and thus probably failed to bind to the HLA-DR2 molecule. Unless all of the core residues are physically involved in binding to DR2, substitution at a position not directly involved in binding appears to have an influence on other residues that do bind to the DR2 molecule. Active peptide analogs with two or more internal prolines suggest that not all analogs need be helical for activity with clone 2F10.
Abstract Aim: Neuromuscular presentations are common in thyroid disease, although the mechanism is unclear. In the present study, we investigated the pathogenesis in a boy with autosomal‐dominant hyperthyroidism presenting with neuromuscular symptoms. Methods: The TSHr gene was investigated by direct sequencing. Functional properties of the mutant TSHr were investigated during transient expression in COS‐7 cells. Family members were investigated by clinical and biochemical examinations. Results: Sequence analysis revealed a previously reported heterozygous missense mutation Glycine 431 for Serine in the first transmembrane segment, leading to an increased specific constitutive activity. Three additional affected family members carried the same mutation. There was no indication of autoimmune disorder. All symptoms disappeared upon treatment with thacapzol and L‐thyroxine and subsequent subtotal thyroidectomy. Conclusion: The data imply that neuromuscular symptoms can be caused by excessive thyroid hormone levels rather than by autoimmunity.
In January 2025, a new classification of obesity was published in the Lancet Diabetes & Endocrinology [1]. It was developed by The Lancet Commission on the Definition and Diagnosis of Clinical Obesity, which comprised more than 50 researchers and experts in the field. The contributors should be praised for their enormous efforts and for including people living with obesity to ensure that the new classification included perspectives from patients. However, despite the appealing graphics that aim to explain the new criteria, the approach has left even insightful readers with doubts. So what does the new classification say? The first option is that people who used to fulfill the simple body mass index (BMI) criteria for overweight or obesity would no longer receive a diagnosis. The second is that, after careful consideration, they could meet the definitions for diagnoses of pre-clinical obesity or clinical obesity. Overweight, a general term that has often been used to describe both overweight and obesity in daily speech, but has lacked the status of a diagnosis, seems obsolete. The 42-page Commission's report will now challenge the printers in many obesity clinics. Having read it, I can summarise it as follows. It is not enough with a high BMI to be diagnosed with clinical obesity. Measurements that indicate increased body fat will be needed for a diagnosis, such as the patient's fat percentage, waist circumference, waist-to-height ratio or waist-to-hip ratio. In addition, symptoms that indicate problems, such as pain or affected blood tests, are needed. With all due respect to the Commission, the operational definitions are unclear for many of the 18 criteria for adults and 13 for children. Just consider this criterion for paediatric patients: 'cluster of hyperglycemia/glucose intolerance with abnormal lipid profile (high triglyceride levels or high LDL cholesterol or low HDL cholesterol)'. Note the word 'with' which tells us that glucose intolerance without lipid disturbances or even manifest type 2 diabetes is not included as a criterion. Similarly, a criterion like polycystic ovary syndrome is hard to define in girls. Another issue is that the prerequisites for diagnosing clinical obesity, namely body fat percentage or waist circumference, do not have clear and generally accepted cut-offs for children [2]. Those who like an academic battle could go on debating diagnostics, degrees and definitions forever, but that takes a lot of human power away from treating the patients we see in our clinics. The coverage in the general, non-medical media has been respectful, but two well-respected UK titles have raised concerns. The Guardian remarked that the health challenges of curbing obesity remain [3]. Meanwhile, The Economist saw the need to decide 'who is sick and who is not', [4] suggesting that there needs to be a distinction in the era of new and effective, but costly, anti-obesity drugs. The current definitions of overweight and obesity cover about a fifth of the children in Sweden [5] and a change in the diagnostic criteria will clearly matter. Today, we use the cut-offs that are visible in all growth charts to determine whether a child has a normal weight for their age and sex. These help us to diagnose overweight or obesity, and if needed, divide the latter into obesity grades 1–3 [6]. Using BMI charts to diagnose obesity is easy to do in clinics and it is also easy to teach. It takes 2 s to determine whether a child is above the cut-off points for overweight or obesity, but it takes skill and experience to communicate the diagnosis to the child and family. We make the diagnosis and take it from there. Many children with obesity are well, while others are more affected. But we make sure that we stress the positives and appreciate all signs of good health. We determine whether the child has uncomplicated obesity or whether complications are already present. And then we start to try and change the course of weight development and prevent the progression into more severe degrees of obesity and more complications. Health care providers will refer children with obesity grade 2 or 3, or complications, to higher levels of care for more intense treatments. Obesity hampers a child's ability to move, play, sleep and perform at school. Many children with obesity have concomitant diseases that make things more complex, such as neuropsychiatric comorbidities. Many have psychosocial challenges. These appear to be missing from the list of criteria produced by the Commission and they are often the most important aspects. Most children and adolescents with obesity remain with obesity during their adult years [7]. We also know that two children of the same height, sex, and age can have different BMIs and these can largely be explained by variations in the amount of body fat. Muscle growth is limited before puberty and cannot explain a high BMI. We try hard to cater to patients' individual needs and reduce stigma of all kinds. It is interesting that Putri et al. published a critical study in JAMA Paediatrics just after the Lancet Commission paper appeared. The study, which used data from the Swedish Childhood Obesity Treatment Register, illustrates the benefits of diagnosing obesity using established methods. It showed that children who had effective treatment for obesity in childhood had reduced risks of mortality and lower risks for diseases like type 2 diabetes in adulthood, unlike children for whom treatment was not as effective [8]. An editorial on the paper, by Epstein et al., concluded that the study was probably the first to demonstrate the impact of paediatric treatment for obesity on cardiometabolic disease and mortality in young adulthood [9]. Obesity per se can safely remain a diagnosis for children, and it should entitle them and their families to the care they need to help them preserve their future health. We need a straightforward and relevant classification that can be easily communicated to parents and other stakeholders. Instead of battling over criteria, we need to focus our attention on disseminating and following the most useful guidelines [10]. It would be great to agree on a global reference on overweight and obesity, as there are several international and national references that have been used to develop the different BMI charts used across the world. Having different references definitively makes international comparisons difficult. However, I believe there is no need to mystify and complicate things further for clinicians dealing with children's weight issues. While I applaud the scrutiny that the Lancet Commission experts have paid to this subject, I would rather stick to my present BMI growth charts for diagnosis. Annika Janson: conceptualization, writing – original draft. The author declares no conflicts of interest.
Many years ago, I waited behind a tall man at the coat check at a scientific congress. He handed in his coat, I left my jacket and then I suddenly I noticed his name tag. James M Tanner. This was before the word starstruck was invented, but I remember thinking “Of course, that is somebody's name!”. But not just any name. As a paediatrician, I use the Tanner stages test named after him to grade a child's pubertal development. I had never really thought about it, but suddenly the person who invented the pubertal staging was standing in front of me, greeting me politely. In spring 2020, another scientific conference held by a drug company in Boston turned into one of the first super-spreader events for COVID-19 in the USA. As I write this, a year after COVID-19 was declared a pandemic by the World Health Organization, we have got used to attending Web-based conferences. No more airline travel, with a fragile poster in a clumsy paper roll. No more feeling lost on the first day at an elaborate congress centre in a city that seems exciting, but we have no time to explore. No more sudden realisations that the picture being displayed in a dark lecture hall looks like my patient! No chance of seeing the great researchers present on stage, sometimes with the aura of rock stars. And no legendary players standing right next to us at the coat check. These days, we log into Web congresses and we do not need to choose between Hall A1 or Room E27. We can watch them all, one presentation after the other, and handle e-mails on the side if it gets boring. I can even decide to watch the recorded presentations tonight after work and do something more important now. It is a climate-smart, family-friendly, effective use of time. But it is also exceedingly dull. However, it does raise a serious point and that is how will all these changes, which have been forced on us by a global pandemic, affect future scientific interactions? Last year's Nobel Laureates in chemistry, Emanuelle Charpentier and Jennifer Doudna, who I always think of as do u DNA, first met in a corridor at a conference in Puerto Rico. That may be one of those Sliding Doors moments, when a decision can take our life in a completely different direction. If you haven't seen the film, it focuses on two scenarios, based on what would have happened if a character played by Gwyneth Paltrow had caught a train or not. Just think, if Charpentier and Doudna had not met in that corridor? One of the sharpest tools in genetics, the CRISPR-Cas9 genetic scissors, may not have been invented. Luck deserves respect. Or as the French scientist Louis Pasteur once said, chance favours the prepared mind. Impulses, ideas and joy are all based on humans interacting with each other. The unfriendly, lone researcher is a myth. Research is meeting, exchanging and sharing. Hard work, but sheer luck sometimes. Some anticipate that life after COVID-19 will resemble the 1920s, which was a time of glitter and glamour and a bright contrast to World War One and the Spanish flu. Others remind us that this is our chance to step up and make changes, cut down on travelling to limit fossil fuel emissions and use new virtual communication techniques instead. Congress halls will be refurbished into apartments. The phrase city weekend will become less common, as we no longer have the urge to come back and look at that really nice city that we glimpsed on our way to a busy conference hall. Fashion designers will focus on upper-body garments that look great during Zoom meetings. Restaurants will keep cooking takeaway meals. When the airline companies wake up from the shock of extended lockdowns, tickets will be unaffordable and we will not dare book them anyway. Will science survive by apps that continue the connections forged by those that used to bump into each other at meetings before COVID-19 dominated our lives? Will we wonder what the advantages were of meeting in real life, with our minds set on exploring, learning and curiosity, as we find that important email message hiding in one of our many inboxes during a normal busy day at home? In fact, will we even remember what we miss from the life we used to live as part of the international community of clinicians and scientists? I must admit that I am really longing to take off for a splendid conference as I connect on Zoom. I don't know whether we will ever get back to those days or whether we will need to adapt to a new normal. But if would be sad if random events, like my coat check moment with James M Tanner, or the meeting of two future Nobel Laureates in a conference corridor, were a thing of the past.
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