Alan R Sinaiko

University of Minnesota Duluth, Duluth, Minnesota, United States

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Publications (136)685.9 Total impact

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    ABSTRACT: Along with other childhood cancer survivors (CCS), hematopoietic cell transplantation (HCT) survivors are at high risk of treatment-related late effects, including cardiovascular disease and diabetes. Cardiometabolic risk factor abnormalities may be exacerbated by inadequate physical activity (PA). Relationships between PA and cardiometabolic risk factors have not been well described in CCS with HCT. PA (self-report), mobility (Timed Up and Go test), endurance (six-minute walk test), handgrip strength, and cardiometabolic risk factors were measured in 119 HCT survivors and 66 sibling controls aged ≥18 years. Adjusted comparisons between HCT survivors and controls and between categories of low and high PA, mobility, endurance, and strength were performed with linear regression. Among HCT survivors, the high PA group had lower waist circumference (WC) (81.9±2.5 v 88.6±3.1 cm±standard error (SE), P=.009) than the low PA group, while the high endurance group had lower WC (77.8±2.6 v 87.8±2.5 cm±SE, P=.0001) and percent fat mass (33.6±1.8 v 39.4±1.7 %±SE, P=.0008) and greater insulin sensitivity (IS) (10.9±1.0 v 7.42±1.14 mg/kg/min±SE via euglycemic insulin clamp, P=.001) than the low endurance group. Differences were greater in HCT survivors than in controls for WC between low and high PA groups, triglycerides between low and high mobility groups, and WC, systolic blood pressure, and IS between low and high endurance groups (all Pinteraction <.05). Higher endurance was associated with a more favorable cardiometabolic profile in HCT survivors, suggesting that interventions directed to increase endurance in survivors may reduce the risk of future cardiovascular disease. Copyright © 2015 American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.
    Biology of blood and marrow transplantation: journal of the American Society for Blood and Marrow Transplantation 04/2015; 21(7). DOI:10.1016/j.bbmt.2015.04.007 · 3.35 Impact Factor
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    ABSTRACT: Decreased insulin sensitivity, also referred to as insulin resistance (IR), is a fundamental abnormality in patients with type 2 diabetes and a risk factor for cardiovascular disease. While IR predisposition is heritable, the genetic basis remains largely unknown. The GENEticS of Insulin Sensitivity consortium conducted a genome-wide association study (GWAS) for direct measures of insulin sensitivity, such as euglycemic clamp or insulin suppression test, in 2,764 European individuals, with replication in an additional 2,860 individuals. The presence of a nonsynonymous variant of N-acetyltransferase 2 (NAT2) [rs1208 (803A>G, K268R)] was strongly associated with decreased insulin sensitivity that was independent of BMI. The rs1208 "A" allele was nominally associated with IR-related traits, including increased fasting glucose, hemoglobin A1C, total and LDL cholesterol, triglycerides, and coronary artery disease. NAT2 acetylates arylamine and hydrazine drugs and carcinogens, but predicted acetylator NAT2 phenotypes were not associated with insulin sensitivity. In a murine adipocyte cell line, silencing of NAT2 ortholog Nat1 decreased insulin-mediated glucose uptake, increased basal and isoproterenol-stimulated lipolysis, and decreased adipocyte differentiation, while Nat1 overexpression produced opposite effects. Nat1-deficient mice had elevations in fasting blood glucose, insulin, and triglycerides and decreased insulin sensitivity, as measured by glucose and insulin tolerance tests, with intermediate effects in Nat1 heterozygote mice. Our results support a role for NAT2 in insulin sensitivity.
    The Journal of clinical investigation 03/2015; DOI:10.1172/JCI74692 · 13.77 Impact Factor
  • Molecular Genetics and Metabolism 02/2015; 114(2):S123-S124. DOI:10.1016/j.ymgme.2014.12.284 · 2.83 Impact Factor
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    ABSTRACT: Although paediatric growth charts are recommended for weight assessment prior to age 20, many teenagers transition earlier to adult care where absolute body mass index (BMI) is used. This study examines concordance of weight classification in older teenagers using paediatric percentiles and adult thresholds. BMI from 23 640 US teens ages 18-19 years were classified using paediatric BMI percentile criteria for underweight (< 5th), normal (5th to < 85th), overweight (85th to < 95th), obesity (≥ 95th) and severe obesity (≥ 120% × 95th percentile) and adult BMI (kg m(-2) ) criteria for underweight (< 18.5), normal (18.5-24.9), overweight (25-29.9) and obesity: class I (30-34.9), class II (35-39.9) and class III (≥ 40). Concordance was examined using the kappa (κ) statistic. Blood pressure (BP) from the same visit was classified hypertensive for BP ≥ 140/90. The majority of visits (72.8%) occurred in adult primary care. Using paediatric/adult criteria, 3.4%/5.2% were underweight, 66.6%/58.8% normal weight, 15.7%/21.7% overweight, 14.3%/14.3% obese and 4.9%/6.0% severely/class II-III obese, respectively. Paediatric and adult classification for underweight, normal, overweight and obesity were concordant for 90.3% (weighted κ 0.87 [95% confidence interval, 0.87-0.88]). For severe obesity, BMI ≥ 120% × 95th percentile showed high agreement with BMI ≥ 35 kg m(-2) (κ 0.89 [0.88-0.91]). Normal-weight males and moderately obese females by paediatric BMI percentile criteria who were discordantly classified into higher adult weight strata had a greater proportion with hypertensive BP compared with concordantly classified counterparts. Strong agreement exists between US paediatric BMI percentile and adult BMI classification for older teenagers. Adult BMI classification may optimize BMI tracking and risk stratification during transition from paediatric to adult care. © 2015 World Obesity.
    Pediatric Obesity 01/2015; DOI:10.1111/ijpo.274 · 2.42 Impact Factor
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    ABSTRACT: We sought to determine whether childhood wrist circumference predicts insulin resistance in adulthood. Measures were taken in prepubertal children and then approximately 30 years later in the same subjects as adults. Our findings suggest that wrist circumference in childhood is not a predictor of insulin resistance in adulthood. Copyright © 2015 Elsevier Inc. All rights reserved.
    Journal of Pediatrics 01/2015; 166(4). DOI:10.1016/j.jpeds.2014.12.011 · 3.74 Impact Factor
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    ABSTRACT: Objective The purpose of this study was to measure the linearity of visceral adipose tissue (VAT) accumulation with measures of total body adiposity to determine whether a threshold exists and to explore the association with cardiometabolic risk factors in adults.Methods Using a cross-sectional design, data were obtained from 723 adults (324 females) age 19-47 years. Body mass index ranged from 15 to 52 kg/m2. Segmented linear regression was used to identify sex-specific percent body fat thresholds at which VAT slope changes. Linear regression measured the association of VAT mass, total fat mass, and subcutaneous fat with cardiometabolic risk factors above and below each threshold.ResultsAdiposity thresholds were identified at 23.4% body fat in males and 38.3% body fat in females beyond which the slope of VAT per unit of percent body fat increased to strongly positive. Males and females above these adiposity thresholds had significant dyslipidemia (P < 0.001), increased insulin resistance (P < 0.001), and higher fat mass across all depots.Conclusions From these cross-sectional data, the following were inferred: the accumulation of VAT mass is not linear with increasing adiposity; increases in visceral accumulation above threshold are associated with decreased insulin sensitivity and cardiovascular risk in males and females independent of total body fat.
    Obesity 12/2014; 23(2). DOI:10.1002/oby.20961 · 4.39 Impact Factor
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    ABSTRACT: Background Childhood cancer survivors (CCS) are at high risk of developing treatment-related late effects, including cardiovascular disease and diabetes. Late effects can be exacerbated by low physical activity (PA) levels. Relationships between PA and cardiovascular risk factors during childhood have not been well described in CCS.ProcedurePA and cardiovascular risk factors were measured cross-sectionally in 319 CCS and 208 sibling controls aged 9–18 years. Comparisons between CCS and controls and associations of outcomes with PA (dichotomized at 60 min/day or treated as continuous) were performed with linear regression.ResultsAmong CCS, the high PA group had lower percent fat mass (24.4% vs. 29.8%, P < 0.0001), abdominal subcutaneous fat (67.9 vs. 97.3 cm3, P = 0.0004), and abdominal visceral fat (20.0 vs. 24.9 cm3, P = 0.007) and greater lean body mass (41.3 vs. 39.5 kg, P = 0.009) than the low PA group. Comparing CCS to controls, differences in waist circumference (Pinteraction = 0.04), percent fat mass (Pinteraction = 0.04), and abdominal subcutaneous (Pinteraction = 0.02) and visceral (Pinteraction = 0.004) fat between low and high PA groups were greater in CCS than controls, possibly due to greater overall adiposity in CCS.Conclusions High PA in CCS resulted in an improved cardiovascular profile, consisting primarily of lower fat mass and greater lean mass, similar to that observed in controls. This suggests interventions directed to increase PA in CCS may reduce the risk of future cardiovascular disease. Pediatr Blood Cancer © 2014 Wiley Periodicals, Inc.
    Pediatric Blood & Cancer 10/2014; DOI:10.1002/pbc.25276 · 2.56 Impact Factor
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    ABSTRACT: Objectives To describe changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), and body mass index (BMI) associated with initiation and continued use of combined oral contraceptives (COCs) in healthy adolescents. Study design This observational, matched cohort study was conducted in 2 large health systems. Utilizing claims and electronic medical records, we identified adolescents 14-17.9 years of age initiating medium-dose COCs (containing 30 or 35 (mu g of ethinyl estradiol or equivalent and a progestin) between July 1, 2007 and December 31, 2009 with a baseline and at least 1 follow-up blood pressure (BP) and BMI. COC-users were matched 1:2 by age, race/ethnicity, and site to controls (COC-nonusers). All BPs and BMIs recorded during outpatient visits starting 1 month prior to COC initiation (index date for controls), through December 31, 2010 were collected. Mixed model linear regression with random intercepts and slopes were then used to estimate changes in SBP, DBP, and BMI over time. Results The 510 adolescent COC-users and 912 controls did not differ significantly by age, race/ethnicity, insurance, and baseline SBP, DBP, or BMI. After adjusting for baseline values, over a median of 18 months follow-up, COC-users had an decrease in SBP of 0.07 mm Hg/mo, and controls had an increase of 0.02 mm Hg/mo (P = .65). Similarly, DBP decreased by 0.007 mm Hg/mo in COC-users vs 0.006 mm Hg/mo in controls (P = .99). BMI increased by 0.04 (kg/m(2))/mo in COC-users vs 0.025 (kg/m(2))/mo in controls (P = .09). Conclusions These data should provide reassurance to patients and providers regarding the lack of significant associations between COC-use and BMI or BP changes in adolescents.
    Journal of Pediatrics 09/2014; 165(5). DOI:10.1016/j.jpeds.2014.07.048 · 3.74 Impact Factor
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    ABSTRACT: Background-Integrated guidelines on cardiovascular health and risk reduction in children issued in 2011 newly recommended universal screening for dyslipidemia in children at 9 to 11 years and 17 to 21 years. Methods and Results-We determined the frequency and results of lipid testing in 301 080 children and adolescents aged 3 to 19 enrolled in 3 large US health systems in 2007 to 2010 before the 2011 guidelines were issued. Overall, 9.8% of the study population was tested for lipids. The proportion tested varied by body mass index percentile (5.9% of normal weight, 10.8% of overweight, and 26.9% of obese children) and age (8.9% of 9- to 11-year olds and 24.3% of 17- to 19-year olds). In normal weight individuals, 2.8% of 9- to 11-year olds and 22.0% of 17- to 19-year olds were tested. In multivariable models, age and body mass index category remained strongly associated with lipid testing. Sex, race, ethnicity, and blood pressure were weakly associated with testing. Abnormal lipid levels were found in 8.6% for total cholesterol, 22.5% for high-density lipoprotein-cholesterol, 12.0% for non-high-density lipoprotein-cholesterol, 8.0% for low-density lipoprotein-cholesterol, and 21% for triglycerides (age, 10-19 years). There was a strong and graded association of abnormal lipid levels with body mass index, particularly for high-density lipoprotein-cholesterol and triglycerides (2- to 6-fold higher odds ratio in obese when compared with that in normal weight children). Conclusions-Lipid screening was uncommon in 9- to 11-year olds and was performed in a minority of 17- to 19-year olds during 2007 to 2010. These data serve as a benchmark for assessing change in practice patterns after the new recommendations for pediatric lipid screening and management.
    Circulation Cardiovascular Quality and Outcomes 08/2014; 7(5). DOI:10.1161/CIRCOUTCOMES.114.000842 · 5.66 Impact Factor
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    ABSTRACT: Background Visceral adipose tissue (VAT) generally demonstrates a stronger relationship with cardiometabolic risk factors than total body fat or subcutaneous adipose tissue.Objectives The purpose of this study was to compare VAT estimated in children by total volume dual-energy X-ray absorptiometry (DXA) with a gold standard measurement, single slice (L4–L5) computed tomography (CT).MethodsA total of 329 (152 females, 177 males) children ages 6–18 years (mean age 12.3 ± 3.6) and with average body mass index percentile of 54.9% (3–99%) had their VAT estimated by both CT and DXA. Linear association between methods was measured using Pearson's correlation. Multiple linear regressions compared the associations between cardiometabolic risk factors and both CT-VAT and DXA-VAT, respectively.ResultsIn children, DXA-VAT was correlated significantly with CT-VAT, with a stronger relationship in overweight and obese children. Multiple regression analysis showed that both estimates of VAT were significantly associated with lipids and insulin sensitivity, measured by euglycaemic-hyperinsulinaemic clamp. Additionally, DXA-VAT was associated with diastolic blood pressure, homeostasis model of insulin resistance and fasting insulin, but CT-VAT was not.Conclusion In children, total volume DXA-VAT and single slice CT-VAT are significantly correlated and each demonstrates similar associations with cardiometabolic risk factors. This suggests that DXA is a useful and valid method for estimation of VAT in children.
    Pediatric Obesity 08/2014; 10(3). DOI:10.1111/ijpo.249 · 2.42 Impact Factor
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    ABSTRACT: Objectives Despite the significant prevalence of elevated blood pressure (BP) and body mass index (BMI) in children, few studies have assessed their combined impact on healthcare costs. This study estimates healthcare costs related to BP and BMI in children and adolescents. Study Design Prospective dynamic cohort study of 71,617 children aged 3 to 17 years with 208,800 child years of enrollment in integrated health systems in Colorado or Minnesota between January 1, 2007, and December 31, 2011. Methods Generalized linear models were used to calculate standardized annual estimates of total, inpatient, outpatient, and pharmacy costs, outpatient utilization, and receipt of diagnostic and evaluation tests associated with BP status and BMI status. Results Total annual costs were significantly lower in children with normal BP ($736, SE = $15) and prehypertension ($945, SE = $10) than children with hypertension ($1972, SE = $74) (P <.001, each comparison), adjusting for BMI. Total annual cost for children below the 85th percentile of BMI ($822, SE = $8) was significantly lower than for children between the 85th and 95th percentiles ($954, SE = $45) and for children at or above the 95th percentile ($937, SE = $13) (P <.001, each), adjusting for HT. Conclusions This study shows strong associations of prehypertension and hypertension, independent of BMI, with healthcare costs in children. Although BMI status was also statistically significantly associated with costs, the major influence on cost in this large cohort of children and adolescents was BP status. Costs related to elevated BMI may be systematically overestimated in studies that do not adjust for BP status.
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    ABSTRACT: Evaluate the association of abdominal visceral and subcutaneous fat, independent of total body fat, with cardiometabolic risk factors and insulin resistance among youth. Visceral and subcutaneous fat, percent total body fat, insulin resistance (adjusted for lean body mass: Mlbm), blood pressure, glucose, insulin, and lipids were obtained in 472 youth ages 6-18 years. Linear regression, adjusted for age, sex, race, Tanner stage, and percent total body fat, was used to evaluate associations of visceral and subcutaneous fat with cardiometabolic risk factors. Visceral fat was associated inversely with Mlbm (p=0.003) and positively with fasting insulin (p=0.002) and triglycerides (p=0.002). Visceral fat levels above the mean were associated inversely with HDL cholesterol (p=0.002), and positively systolic blood pressure (p<0.0001) and non-HDL cholesterol (p<0.0001). Subcutaneous fat was associated inversely with Mlbm (p=0.003) and HDL cholesterol (p<0.05), and positively with fasting glucose (p<0.05), fasting insulin (p=0.0003), systolic blood pressure (p=0.005), and triglycerides (p=0.003). Subcutaneous fat levels above the mean were associated with non-HDL cholesterol (p=0.0002). These findings suggest that there may be a threshold level of visceral and subcutaneous fat (regardless of total body fat), that when exceeded in childhood, is more likely to be associated with many cardiometabolic risk factors. Triglycerides and insulin resistance appear to be associated with these fat depots at even lower thresholds of abdominal adiposity.
    04/2014; 4(2):101-107. DOI:10.1111/cob.12044
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    ABSTRACT: Newer approaches for classifying gradations of pediatric obesity by level of body mass index (BMI) percentage above the 95th percentile have recently been recommended in the management and tracking of obese children. Examining the prevalence and persistence of severe obesity using such methods along with the associations with other cardiovascular risk factors such as hypertension is important for characterizing the clinical significance of severe obesity classification methods. This retrospective study was conducted in an integrated healthcare delivery system to characterize obesity and obesity severity in children and adolescents by level of body mass index (BMI) percentage above the 95th BMI percentile, to examine tracking of obesity status over 2-3 years, and to examine associations with blood pressure. Moderate obesity was defined by BMI 100-119 % of the 95th percentile and severe obesity by BMI >=120 % x 95th percentile. Hypertension was defined by 3 consecutive blood pressures >=95th percentile (for age, sex and height) on separate days and was examined in association with obesity severity. Among 117,618 children aged 6-17 years with measured blood pressure and BMI at a well-child visit during 2007-2010, the prevalence of obesity was 17.9 % overall and was highest among Hispanics (28.9 %) and blacks (20.5 %) for boys, and blacks (23.2 %) and Hispanics (21.5 %) for girls. Severe obesity prevalence was 5.6 % overall and was highest in 12-17 year old Hispanic boys (10.6 %) and black girls (9.5 %). Subsequent BMI obtained 2-3 years later also demonstrated strong tracking of severe obesity. Stratification of BMI by percentage above the 95th BMI percentile was associated with a graded increase in the risk of hypertension, with severe obesity contributing to a 2.8-fold greater odds of hypertension compared to moderate obesity. Severe obesity was found in 5.6 % of this community-based pediatric population, varied by gender and race/ethnicity (highest among Hispanics and blacks) and showed strong evidence for persistence over several years. Increasing gradation of obesity was associated with higher risk for hypertension, with a nearly three-fold increased risk when comparing severe to moderate obesity, underscoring the heightened health risk associated with severe obesity in children and adolescents.
    International Journal of Pediatric Endocrinology 03/2014; 2014(1):3. DOI:10.1186/1687-9856-2014-3
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    ABSTRACT: Background: Childhood cancer survivors (CCS) are more insulin resistant (IR) and have higher levels of several cardiovascular (CV) risk factors even while still children. This study examines specific treatment exposures associated with CV risk factors and IR. Methods: CCS age 9-18 years at study entry and in remission >5 years from diagnosis (n=319) and 208 sibling controls were recruited into this cross-sectional study that included physiologic assessment of IR (hyperinsulinemic euglycemic clamp) and assessment of CV risk factors.. Regression and recursive tree modeling were used to ascertain treatment combinations associated with IR and CV risk. Results: Mean current age of CCS was 14.5yr, 54% were male (siblings 13.6yr, 54% male). Diagnoses included leukemia (35%), brain tumors (36%), solid tumors (33%) or lymphoma (6%). Among CCS, analysis of individual chemotherapy agents failed to find associations with CV risk factors or IR. Compared to siblings, IR was significantly higher in CCS who received platinum plus cranial radiation (CRT, 92% brain tumors) and in those who received steroids but no platinum (majority leukemia). IR did not differ between CCS who received surgery alone vs. siblings. Within survivor comparisons failed to elucidate treatment combinations that increased IR compared to those who received surgery only. Conclusions: Exposure to platinum, CRT or steroids is associated with IR and CV risk factors and should be taken into consideration in the development of screening recommendations for CV risk. Impact: Earlier identification of CCS who may benefit from targeted prevention efforts may reduce their future risk of CV disease.
    Cancer Epidemiology Biomarkers & Prevention 09/2013; 22(11). DOI:10.1158/1055-9965.EPI-13-0610 · 4.32 Impact Factor
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    ABSTRACT: Few studies have examined the relations of adiposity and lifestyle factors in young offspring with their parents as children (parentschild) or at their current age (parentsadult). Therefore, we compared measures of adiposity and lifestyle in parentschild and parentsadult with their offspring. Two generations (one parent and his/her offspring) participated in this study: 234 parents from a previously established cohort and 382 offspring. Parentsadult and offspring underwent measurements for height, weight, waist circumference, % body fat, visceral fat, and lifestyle habits. Participants were classified as normal weight, overweight, obese based on age-specific BMI criteria. Mixed model linear regression analysis evaluated the associations of adiposity and lifestyle factors of parentschild and parentsadult with that of their offspring, adjusting for age, sex, race, and family membership. The prevalence of obesity was greater among offspring mean age 12.3 years compared to their parentschild mean age 12.6 years (18.4% vs 10.1%, p<0.001) even though hours of television (TV) watching were similar between the two generations as children (p=0.80). Sixty percent of parents (as children and adults) and offspring reported more than 2 hours of TV/day. Offspring of parents who were overweight and obese as children had greater BMI (all p<0.001) than offspring of parents who were normal weight as children. For both parentadult and offspring, adiposity was greater with greater total screen time. Identifying high-risk families is important for early intervention of overweight, especially in children.
    BMC Pediatrics 09/2013; 13(1):133. DOI:10.1186/1471-2431-13-133 · 1.92 Impact Factor
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    ABSTRACT: Background/Aims Overweight and obesity among US children and adolescents is an important public health problem. Conditions associated with obesity, such as type 2 diabetes, hypertension, and hypercholesterolemia, are becoming more common in children. This study examined the relationship between changes in BMI percentile and incident prehypertension and hypertension in a cohort of children and adolescents. Methods Study subjects were 23,578 patients, ages 3-17, with three or more outpatient primary care visits between 2007 and 2010 at HealthPartners Medical Group, Kaiser Permanente Colorado, or Kaiser Permanente Northern California. Data were extracted from electronic health records (EHR). Change in BMI was defined as: increase, decrease, stayed obese, stayed overweight, and stayed healthy weight using established BMI percentile cut-points. Incident prehypertension and hypertension were defined using blood pressures and diagnosis codes from the EHR. We used time-dependent Cox proportional hazards models to estimate the hazard of change in BMI percentile with incident prehypertension and hypertension. Results Over a median 2.6 years follow-up, there were 7,232 cases of incident prehypertension, 148 diagnoses of incident hypertension, and 107 additional cases of incident hypertension based on blood pressure data from the EHR. Seventy-one prehypertensives went on to develop hypertension. Those who stayed obese, stayed overweight, and increased BMI had increased hazard of incident prehypertension (1.96, 1.39, and 1.49, respectively) and increased hazard of incident hypertension (3.61, 1.21, and 1.83, respectively) compared with those who stayed healthy weight. Conclusions Persistently high BMI or increasing BMI over time was associated with pronounced increase in risk of both incident prehypertension and hypertension. Future research should examine factors associated with the development and recognition of hypertension.
    Clinical Medicine &amp Research 09/2013; 11(3):139. DOI:10.3121/cmr.2013.1176.ps3-29
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    ABSTRACT: Background/Aims The aim of the study was to ascertain frequency of glucose screening in children and adolescents, in predefined age, gender, BMI, and race strata. Methods Study subjects included 68,322 individuals age 3-17 years at cohort entry and followed for a median of 37 months. Subjects had at least one office visit at HealthPartners Medical Group (HPMG). Subjects had their laboratory data examined for date and results of any fasting or random glucose, glycated hemoglobin (A1c), or oral glucose tolerance tests done in an outpatient setting. We report descriptive statistics on rate of glucose testing and rate of tests indicating pre-diabetes by age, gender, BMI, race/ethnicity group, and calendar year. Results Overall rate of glucose screening was 10.7% (7278/68322). Rates increased in recent years compared to earlier years, were similar in males and females, and were greater in older subjects, those with obesity, and those of minority race or Hispanic ethnicity. The test rate was 4.4% (1145/26245) per year in 2007 compared to 19.7% (1687/8563) in 2010. Glucose screening was most often done with fasting or random glucose, but 7.7% (560/7278) of tests were glycated hemoglobin (A1c). About 13.9% (1013/7278) of tests showed results indicating pre-diabetes. Of the 1013 with a test result indicating pre-diabetes, 79.1% (801/1013) were age 12 and older, 60% (608/1013) were of minority race or Hispanic ethnicity, and 30.9% (313/1013) were obese. Diabetes diagnosis (250.xx) was present in 2.2% (161/7278) of the subjects with one or more glucose/A1c tests. Conclusions Rates of glucose testing are highest in demographic subgroups with the highest risk, and have increased markedly in recent years. As the rate of screening increases further, it is likely that the proportion that screen positive for pre-diabetes or diabetes will decline. A substantial number of adolescents have recently been identified as having pre-diabetes, and further work is needed to characterize care subsequently provided to these subjects, and to characterize other CV risk factors.
    Clinical Medicine &amp Research 09/2013; 11(3):145. DOI:10.3121/cmr.2013.1176.ps2-2
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    ABSTRACT: Background/Aims The National High Blood Pressure Education Program (NHBPEP) guidelines define hypertension (HT) in children and adolescents as blood pressure (BP) measures above the 95th percentile on three consecutive clinic visits. In contrast, the Expert Panel of Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents (Expert Panel) clinical practice guidelines define HT as the average of three consecutive BP measures above the 95th percentile. Here we quantify the impact of these two different case definitions of HT on occurrence of HT in a defined population of children and adolescents. Methods Study subjects were a cohort of 117,329 pediatric primary care patients, drawn from three large, geographically dispersed health systems. Subjects were 3-17 years old at entry between January 1, 2007 and December 31, 2010. Subjects having an elevated initial BP were not excluded, nor were subjects having BP diagnosis codes at baseline or follow-up. We estimated the period prevalence rate of HT using NHBPEP and Expert Panel definitions, applying a rolling window to the longitudinal BP measurements to consider each successive block of three BP measures. Analyses were performed separately for children (3-11 years) and adolescents (12-17 years). Data were analyzed by Poisson regression to estimate annual rates of HT. Results Subjects were followed for an average of 2.1 years. HT defined by elevated BP ≥95th percentile on 3 consecutive clinic visits occurred at a rate of 0.25%/year in children, and 0.42%/year in adolescents. HT defined as the average BP ≥95th percentile from 3 successive clinic visits occurred at higher rates; 0.49%/year in children (P ≤0.00005) and 0.75%/year in adolescents (P ≤0.00005). For subjects with HT defined by elevated BP ≥95th percentile on 3 consecutive clinic visits, the average time between elevated measurements was 19 weeks (s.d. 25 weeks). Conclusions HT rates in children and adolescents were twice as high when using an average of 3 consecutive measures (Expert Panel method) as when using 3 consecutive hypertensive levels (NHBPEP definition). The impact of these differences in HT rates on downstream risk of persistent HT and CV events later in life requires further investigation.
    Clinical Medicine &amp Research 09/2013; 11(3):137. DOI:10.3121/cmr.2013.1176.ps1-52
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    ABSTRACT: Background/Aims The aim of the study was to examine the prevalence of obesity and extreme obesity in school-aged children using three classifications based on body mass index (BMI): BMI percentile, percentage above the 95th percentile and Z score, and the association of BMI stratification with elevated blood pressure. Methods This was a retrospective study of 117,618 children aged 6-17 years receiving well-child care in Kaiser Permanente Northern California between July 2007 and December 2010. Blood pressure, BMI and other data were extracted from electronic records. Results The prevalence of BMI >95th percentile ranged from 14.5% (4,395 of 30,235) in whites and 14.3% (2,287 of 16,033) in Asians to 22.3% (1,809 of 8,124) in blacks and 25.8% (5,734 of 22,187) in Hispanics. For boys, the highest prevalence was in Hispanics (29.2%, 3,346 of 11,452), followed by blacks (21.0%, 879 of 4,193); for girls, the highest prevalence was in blacks (23.7%, 930 of 3,931) and then Hispanics (22.2%, 2,388 of 10,735). For extreme obesity, a threshold of BMI ≥120% of the 95th BMI percentile identified the largest proportion of children (5.6%, 6,532 of 117,618) compared to BMI ≥99th percentile (3.8%, 4,488 of 117,618) and BMI Z score ≥3.0 (0.1%, 83 of 117,618). Stratification of BMI by percentage above the 95th percentile demonstrated a graded relationship between obesity severity and risk of elevated blood pressure. Conclusions The prevalence of obesity and extreme obesity in children varied by age, gender and race/ethnicity, with the highest prevalence among Hispanics followed by black children. Compared to BMI thresholds based on the 99th BMI percentile or BMI Z score of 3, classification by BMI ≥120% of the 95th BMI percentile identified a greater percentage of severely obese children in whom additional health risk-stratification was achieved by further categorizing based on percentage above the 95th BMI percentile. This classification approach may be useful for obesity management in clinical practice, public health surveillance, and research.
    Clinical Medicine &amp Research 09/2013; 11(3):138. DOI:10.3121/cmr.2013.1176.b2-5
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    ABSTRACT: Background/Aims Early childhood adiposity may have significant later health effects, highlighting the importance of early recognition in young children. This study examines the prevalence and recognition of obesity and severe obesity in preschool-aged children. Methods The electronic medical record was used to examine body mass index (BMI), height, sex, and race/ ethnicity in 42,559 children aged 3-5 years 2007-2010 within Kaiser Permanente Northern California. Normal BMI (BMI <85th percentile); overweight (BMI 85th-94th percentile); obesity (BMI ≥95th percentile); and extreme obesity (BMI ≥99th percentile or BMI ≥1.2×95th BMI percentile) were classified using the 2000 Center for Disease Control and Prevention growth charts. Provider recognition of elevated BMI was examined for obese children aged 5 years. Results Among 42,559 children, 12.4% (2,698 of 21,720) of boys and 10.0% (2,077 of 20,839) of girls had BMI ≥95th percentile. The prevalence was highest among Hispanics (18.2%, 982 of 5,397 boys and 15.2%, 760 of 4,988 girls), followed by blacks (12.4%, 161 of 1,138 boys and 12.7%, 154 of 1,216 girls). A positive trend existed between BMI category and median height percentile, with obesity rates highest in the highest height quintile. The proportion with BMI ≥99th percentile was 3.9% (1,670 of 42,559), nearly two-fold higher for boys (66.8%, 1,116 of 1,670) versus girls (33.2%, 554 of 1,670), and identified a larger proportion of children compared to BMI ≥1.2× 95th BMI percentile (1.6%, P <0.001). Among those aged 5 years, 77.9% of obese children (1082 of 1389) had provider diagnosis of obesity or elevated BMI, increasing to 84.5% (424 of 502) among the subset with severe obesity. Conclusions Obesity and severe obesity are evident as early as age 3-5 years, with race/ ethnic trends similar to older children. This study underscores the need for continued recognition and contextualization of early childhood obesity in order to develop effective strategies for early weight management.
    Clinical Medicine &amp Research 09/2013; 11(3):139. DOI:10.3121/cmr.2013.1176.ps3-20

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  • 1982–2015
    • University of Minnesota Duluth
      • Medical School
      Duluth, Minnesota, United States
  • 2005
    • University of Vermont
      Burlington, Vermont, United States
    • University of Wisconsin, Madison
      • Department of Ophthalmology and Visual Sciences
      Madison, MS, United States
  • 2003
    • McGill University
      • Department of Pediatrics
      Montréal, Quebec, Canada
  • 2002
    • University of Michigan
      • Division of Pediatric Genetics
      Ann Arbor, Michigan, United States
  • 2001
    • University of Cincinnati
      • Department of Pediatrics
      Cincinnati, Ohio, United States
  • 1998
    • University of Minnesota Twin Cities
      • Department of Pediatrics
      Minneapolis, MN, United States