Child Mental Disorders, Obesity, Metabolic Syndrome
Conditions
Keywords
Child Psychiatry, Obesity, Antipsychotic
Brief summary
The US prevalence of childhood-onset obesity and type 2 diabetes, both predictors of cardiovascular risk, have increased to epidemic proportions in recent decades. Children with mental illness, especially those treated with antipsychotic medications, are at additional risk for obesity (adiposity) and related risk conditions. A variety of noninvasive techniques to assess cardiometabolic risk have begun to be applied in children, including body composition measured with dual energy x-ray absorptiometry (DEXA), carotid intima media thickness (CIMT) measured by ultrasound, and hepatic triglyceride content measured using magnetic resonance (MR) imaging-estimated proton density fat fraction (PDFF). These measures allow for the early, noninvasive study of adiposity-related metabolic risk. The overall aim of this two-study research plan is to characterize the level of measurable risk using these sensitive markers in treated and untreated children with mental health disorders, and to evaluate the magnitude of change in risk that can be observed using these biomarkers in children receiving a well established behavioral weight-loss intervention.
Detailed description
This project will utilize sensitive, early biomarkers of disease risk, including whole body adiposity with DEXA, PDDF and CIMT, directly relevant to diabetes and cardiovascular disease risk. The primary goals of this study are to deliver an evidence-based weight loss intervention to the population of youth who are overweight or obese as a result of antipsychotic treatment, to characterize metabolic risk associated with weight using sensitive biomarkers, and to evaluate the magnitude of change observed in these biomarkers in children receiving an established behavioral weight-loss intervention. Aim 1: To evaluate the main effect of time of 16 weeks of a Behavioral Weight Loss (BWL) intervention on DEXA-measured whole body adiposity in overweight/obese antipsychotic (AP)-treated children compared to nonpsychiatric (NP) overweight or obese healthy controls, and in AP-treated youth randomized to monthly Usual Care (UC). Aim 2: To evaluate the main effect of time of 16 weeks of a BWL intervention on PDFF in overweight/obese AP-treated children compared to NP overweight or obese healthy controls, and in AP-treated youth randomized monthly UC. Aim 3: To evaluate the main effect of time of 16 weeks of a weekly behavioral weight loss intervention on CIMT in overweight/obese AP-treated children compared to NP overweight or obese healthy controls, and in AP-treated youth randomized monthly UC.
Interventions
BEHAVIORALBehavioral Weight Loss
This intervention is a family-based, behavioral weight loss program that has been employed in studies with overweight and obese children, as well as with children who have diabetes. For the proposed study, the program has been modified to fit the needs of disruptive and behaviorally disturbed youth and their families. The modified program includes 16 weeks of weekly visits with a study interventionist, and supplemental phone contacts as needed. Phone contacts will only replace in-person visits if absolutely necessary to achieve the visit.
BEHAVIORALDiet and Exercise Education
Participants assigned to this arm will receive monthly medically validated, individualized diet and exercise education by a trained research professional.
Sponsors
National Institute of Mental Health (NIMH)
Washington University School of Medicine
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
6 Years to 18 Years
Healthy volunteers
Yes
Inclusion criteria
* 6-18 years old (at any point during study participation) * BMI percentile \> 85 * Meet DSM-IV criteria for one or more childhood onset psychiatric disorders including disruptive behavior disorders (attention deficit disorder, conduct disorder, oppositional defiant disorder and disruptive behavior disorder not otherwise specified), affective disorders (bipolar affective disorder, major depressive disorder and mood disorder not otherwise specified), anxiety disorders (generalized anxiety disorder, obsessive compulsive disorder, separation anxiety, social and other specific phobias) as well as other disorders, including autism spectrum disorders (autistic disorder, Asperger's Syndrome and pervasive developmental disorder not otherwise specified), psychotic disorders (schizophreniform disorder, schizophrenia and psychotic disorder not otherwise specified) and movement disorders (tic disorder, Tourette's Syndrome) as determined by semi-structured diagnostic interview (EXCEPT for the Obese or Overweight Control Group, none of whom can meet criteria for any DSM-IV Axis I psychiatric illness) * Currently treated with an atypical antipsychotic medication (EXCEPT for the Obese or Overweight Healthy Control Group, none of whom can be treated with any psychotropic medications Participants treated with any psychotropic medication may not have any medication changes for 1 month prior to study enrollment at the discretion of the PI, and Antipsychotic-Treated Participants must be treated with an antipsychotic \> approximately 12 weeks with no antipsychotic medication dose changes for 1 month * The Healthy Overweight or Obese Control Group may not be currently taking any prescription medications (multivitamins, over the counter medications, glucocorticoid nasal spray and inhalers are permitted, as well as non-sedating antihistamines such as but not limited to Claritin (loratadine) and Zyrtec (cetirizine) * Participants between 6-17 years old will be able to give assent and have a parent/guardian that can provide written informed consent, and 18 year-old participants will be able to provide written informed consent.
Exclusion criteria
* Do not meet DSM-IV criteria for any Axis I psychiatric illness per PI discretion (EXCEPT for Overweight or Obese Healthy reference group) * Any lifetime use of antipsychotics (EXCEPT for Antipsychotic-Treated Participants, with the individuals in the latter group possibly having a remote, brief prior antipsychotic exposure that may be considered for enrollment on a case by case basis by the PI) * The presence of any serious medical disorder that may confound the assessment of relevant biologic measures or diagnoses, including: significant organ system dysfunction; endocrine disease, including type 1 or type 2 diabetes mellitus; coagulopathy; anemia; or acute infection; all based on PI discretion Participants regularly taking within the last 3 months any glucose lowering agent, lipid lowering agent, exogenous testosterone, recombinant human growth hormone, or any other endocrine agent that might confound substrate metabolism, oral glucocorticoids (glucocorticoid nasal spray and inhalers are permitted), sedating antihistamines (non-sedating antihistamines such as but not limited to Claritin (loratadine) and Zyrtec (cetirizine) are permitted), and certain mood stabilizing agents including antiepileptic medications (lamotrigine is permitted) and Lithium, as these medications may themselves worsen or otherwise alter weight gain, glucose and lipid regulation or otherwise make it difficult to assess the effects of the antipsychotic alone; (note that exposure to many psychotropic agents including stimulants, SSRI's and SNRI's are permitted in the Antipsychotic-Treated and Non-Antipsychotic Treated Groups in Study 1 in order to maintain the generalizability of the sample) * IQ \< 70 (based on school records and/or evaluation by clinician and at the discretion of the PI) * Current DSM IV diagnosed substance abuse or dependence * Past history of, or current dyskinesia * Stimulant dosage significantly higher (per PI judgment) than the equivalent of approximately 2 mg/kg/day methylphenidate equivalent dose (EXCEPT in the Obese or Overweight Control Group, none of whom can be taking stimulant medications) * Unable to provide assent or informed consent * Active suicidality or a primary diagnosis of depression * Unwilling to allow study staff to contact subject's primary care physician to alert to any significant, abnormal clinical findings or test results obtained as part of study participation
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Proton Density Fat Fraction (PDFF) | Baseline and 16 weeks | 1H Magnetic Resonance Spectroscopy (MRS) of liver will be used to assess intracellular triglyceride content at baseline and following 16 weeks of participation in a behavioral weight loss intervention. |
| DEXA-measured Adiposity | Baseline and 16 weeks | Dual-Energy X-Ray Absorptiometry (DEXA) will be used to assess body fat at baseline and following 16 weeks of participation in a behavioral weight loss intervention. |
| Carotid Artery Intima Media Thickness (CIMT) | Baseline and 16 weeks | 9-13-MHZ B-mode Carotid Ultrasound will be used to assess intima media thickness at baseline and following 16 weeks of participation in a behavioral weight loss intervention. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Aberrant Behavior Checklist (ABC) | Baseline and 16 weeks | Change From Baseline in Aberrant Behavior Checklist - Irritability Subscale at 16 Weeks |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Antipsychotic Treated Educational Control Antipsychotic treated participants randomized to this arm will receive diet and exercise education at monthly intervals with a study clinician or coordinator.
Diet and Exercise Education: Participants assigned to this arm will receive monthly medically validated, individualized diet and exercise education by a trained research professional. | 7 |
| Antipsychotic Treated Weekly Behavioral Weight Loss Antipsychotic treated participants randomized to this arm will engage in an evidence-based, 16 week manualized behavioral weight loss intervention that includes weekly meetings and phone check-ins with a trained study therapist.
Behavioral Weight Loss: This intervention is a family-based, behavioral weight loss program that has been employed in studies with overweight and obese children, as well as with children who have diabetes. For the proposed study, the program has been modified to fit the needs of disruptive and behaviorally disturbed youth and their families. The modified program includes 16 weeks of weekly visits with a study interventionist, and supplemental phone contacts as needed. Phone contacts will only replace in-person visits if absolutely necessary to achieve the visit. | 19 |
| Non-antipsychotic Treated Weekly Behavioral Weight Loss Participants assigned to this arm will engage in an evidence-based, 16 week manualized behavioral weight loss intervention that includes weekly meetings and phone check-ins with a trained study therapist.
Behavioral Weight Loss: This intervention is a family-based, behavioral weight loss program that has been employed in studies with overweight and obese children, as well as with children who have diabetes. For the proposed study, the program has been modified to fit the needs of disruptive and behaviorally disturbed youth and their families. The modified program includes 16 weeks of weekly visits with a study interventionist, and supplemental phone contacts as needed. Phone contacts will only replace in-person visits if absolutely necessary to achieve the visit. | 21 |
| Total | 47 |
Baseline characteristics
| Characteristic | Total | Antipsychotic Treated Educational Control | Antipsychotic Treated Weekly Behavioral Weight Loss | Non-antipsychotic Treated Weekly Behavioral Weight Loss |
|---|---|---|---|---|
| Aberrant Behavior Checklist (ABC) Irritability | 8.15 units on a scale STANDARD_DEVIATION 9.13 | 18.57 units on a scale STANDARD_DEVIATION 8.75 | 11.06 units on a scale STANDARD_DEVIATION 8.3 | 2.19 units on a scale STANDARD_DEVIATION 4.81 |
| Aberrant Behavior Checklist (ABC) Total Score | 25.17 units on a scale STANDARD_DEVIATION 26.11 | 53.43 units on a scale STANDARD_DEVIATION 20.14 | 35.61 units on a scale STANDARD_DEVIATION 24.29 | 6.81 units on a scale STANDARD_DEVIATION 13.39 |
| Age, Continuous | 13.30 years STANDARD_DEVIATION 2.43 | 12.80 years STANDARD_DEVIATION 2.21 | 13.35 years STANDARD_DEVIATION 2.57 | 13.42 years STANDARD_DEVIATION 2.46 |
| Baseline Fasting Laboratory Values Glucose | 90.02 mg/dl STANDARD_DEVIATION 7.13 | 93.71 mg/dl STANDARD_DEVIATION 10.01 | 91.32 mg/dl STANDARD_DEVIATION 7.42 | 87.62 mg/dl STANDARD_DEVIATION 4.99 |
| Baseline Fasting Laboratory Values HDL Cholesterol | 48.34 mg/dl STANDARD_DEVIATION 10.04 | 45.00 mg/dl STANDARD_DEVIATION 6.16 | 46.95 mg/dl STANDARD_DEVIATION 10.2 | 50.71 mg/dl STANDARD_DEVIATION 10.74 |
| Baseline Fasting Laboratory Values LDL Cholesterol | 95.32 mg/dl STANDARD_DEVIATION 24.49 | 102.29 mg/dl STANDARD_DEVIATION 10.95 | 101.68 mg/dl STANDARD_DEVIATION 27.32 | 87.24 mg/dl STANDARD_DEVIATION 23.4 |
| Baseline Fasting Laboratory Values Total Cholesterol | 164.36 mg/dl STANDARD_DEVIATION 31.1 | 170.14 mg/dl STANDARD_DEVIATION 9.67 | 169.47 mg/dl STANDARD_DEVIATION 37.55 | 157.81 mg/dl STANDARD_DEVIATION 29.09 |
| Baseline Fasting Laboratory Values Triglycerides | 104.30 mg/dl STANDARD_DEVIATION 57.35 | 114.43 mg/dl STANDARD_DEVIATION 44.49 | 106.26 mg/dl STANDARD_DEVIATION 59.11 | 99.14 mg/dl STANDARD_DEVIATION 61.3 |
| Body Mass Index (BMI) | 30.52 kilograms per meter-squared STANDARD_DEVIATION 5.69 | 28.72 kilograms per meter-squared STANDARD_DEVIATION 2.09 | 29.70 kilograms per meter-squared STANDARD_DEVIATION 6.83 | 31.86 kilograms per meter-squared STANDARD_DEVIATION 5.25 |
| Body Mass Index (BMI) Percentile | 97.24 percentile STANDARD_DEVIATION 2.6 | 97.77 percentile STANDARD_DEVIATION 1.03 | 96.55 percentile STANDARD_DEVIATION 3.3 | 97.69 percentile STANDARD_DEVIATION 2.16 |
| Body Mass Index (BMI) Z-Score | 2.06 z-score STANDARD_DEVIATION 0.4 | 2.05 z-score STANDARD_DEVIATION 0.23 | 1.99 z-score STANDARD_DEVIATION 0.47 | 2.13 z-score STANDARD_DEVIATION 0.38 |
| Carotid Intima Media Thickness | 0.0484 centimeters STANDARD_DEVIATION 0.007 | 0.0494 centimeters STANDARD_DEVIATION 0.0058 | 0.0451 centimeters STANDARD_DEVIATION 0.0074 | 0.0504 centimeters STANDARD_DEVIATION 0.0065 |
| Child Behavior Checklist (CBCL) | 40.61 units on a scale STANDARD_DEVIATION 31.8 | 70.14 units on a scale STANDARD_DEVIATION 26.34 | 57.06 units on a scale STANDARD_DEVIATION 28.39 | 16.67 units on a scale STANDARD_DEVIATION 15.2 |
| DEXA-Measured Body Composition DEXA Total Percent Fat | 42.51 percentage of body composition STANDARD_DEVIATION 6.97 | 45.40 percentage of body composition STANDARD_DEVIATION 6.76 | 41.76 percentage of body composition STANDARD_DEVIATION 8.53 | 42.24 percentage of body composition STANDARD_DEVIATION 5.38 |
| DEXA-Measured Body Composition DEXA Total Percent Lean | 54.77 percentage of body composition STANDARD_DEVIATION 6.73 | 52.12 percentage of body composition STANDARD_DEVIATION 6.81 | 55.48 percentage of body composition STANDARD_DEVIATION 8.23 | 55.01 percentage of body composition STANDARD_DEVIATION 5.15 |
| Ethnicity (NIH/OMB) Hispanic or Latino | 1 Participants | 0 Participants | 0 Participants | 1 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 46 Participants | 7 Participants | 19 Participants | 20 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Height | 1.60 meters STANDARD_DEVIATION 0.14 | 1.58 meters STANDARD_DEVIATION 0.17 | 1.58 meters STANDARD_DEVIATION 0.15 | 1.63 meters STANDARD_DEVIATION 0.11 |
| Primary Diagnosis Anxiety Disorder | 1 Participants | 0 Participants | 1 Participants | 0 Participants |
| Primary Diagnosis Attention Deficit Hyperactivity Disorder (ADHD) | 5 Participants | 1 Participants | 4 Participants | 0 Participants |
| Primary Diagnosis Autism | 15 Participants | 4 Participants | 11 Participants | 0 Participants |
| Primary Diagnosis Mood Disorder | 3 Participants | 1 Participants | 2 Participants | 0 Participants |
| Primary Diagnosis Pervasive Development Disorder (PDD) | 1 Participants | 1 Participants | 0 Participants | 0 Participants |
| Primary Diagnosis Psychosis | 1 Participants | 0 Participants | 1 Participants | 0 Participants |
| Proton Density Fat Fraction (PDFF) | 6.58 percentile STANDARD_DEVIATION 8.54 | 12.01 percentile STANDARD_DEVIATION 7.82 | 6.52 percentile STANDARD_DEVIATION 8.21 | 4.72 percentile STANDARD_DEVIATION 8.61 |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 9 Participants | 0 Participants | 3 Participants | 6 Participants |
| Race (NIH/OMB) More than one race | 3 Participants | 0 Participants | 1 Participants | 2 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) White | 35 Participants | 7 Participants | 15 Participants | 13 Participants |
| Sex: Female, Male Female | 21 Participants | 1 Participants | 5 Participants | 15 Participants |
| Sex: Female, Male Male | 26 Participants | 6 Participants | 14 Participants | 6 Participants |
| Waist Circumference | 100.83 centimeters STANDARD_DEVIATION 16.58 | 99.86 centimeters STANDARD_DEVIATION 10.35 | 99.45 centimeters STANDARD_DEVIATION 19.35 | 102.40 centimeters STANDARD_DEVIATION 16.07 |
| Weight | 80.26 kilograms STANDARD_DEVIATION 26.62 | 72.37 kilograms STANDARD_DEVIATION 16.11 | 77.08 kilograms STANDARD_DEVIATION 32.6 | 85.76 kilograms STANDARD_DEVIATION 23.07 |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk |
|---|---|---|---|
| deaths Total, all-cause mortality | 0 / 7 | 0 / 19 | 0 / 21 |
| other Total, other adverse events | 0 / 7 | 0 / 19 | 0 / 21 |
| serious Total, serious adverse events | 0 / 7 | 0 / 19 | 0 / 21 |
Outcome results
Primary
Carotid Artery Intima Media Thickness (CIMT)
9-13-MHZ B-mode Carotid Ultrasound will be used to assess intima media thickness at baseline and following 16 weeks of participation in a behavioral weight loss intervention.
Time frame: Baseline and 16 weeks
Population: Modified Intent to Treat (ITT) sample with week 0 and week 16 data.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Antipsychotic Treated Educational Control | Carotid Artery Intima Media Thickness (CIMT) | -0.0014 millimeters | Standard Deviation 0.0045 |
| Antipsychotic Treated Weekly Behavioral Weight Loss | Carotid Artery Intima Media Thickness (CIMT) | 0.0032 millimeters | Standard Deviation 0.0098 |
| Non-antipsychotic Treated Weekly Behavioral Weight Loss | Carotid Artery Intima Media Thickness (CIMT) | 0.0004 millimeters | Standard Deviation 0.0064 |
Comparison: An ANCOVA was used to test for differences between groups at endpoint, controlling for baseline values.p-value: 0.7ANCOVA
Primary
DEXA-measured Adiposity
Dual-Energy X-Ray Absorptiometry (DEXA) will be used to assess body fat at baseline and following 16 weeks of participation in a behavioral weight loss intervention.
Time frame: Baseline and 16 weeks
Population: Modified Intent to Treat (ITT) sample with week 0 and week 16 data.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Antipsychotic Treated Educational Control | DEXA-measured Adiposity | 0.76 kilograms | Standard Deviation 2.05 |
| Antipsychotic Treated Weekly Behavioral Weight Loss | DEXA-measured Adiposity | -0.43 kilograms | Standard Deviation 3.13 |
| Non-antipsychotic Treated Weekly Behavioral Weight Loss | DEXA-measured Adiposity | -2.79 kilograms | Standard Deviation 3.35 |
Comparison: An ANCOVA was used to test for differences between groups at endpoint, controlling for baseline values.p-value: 0.01ANCOVA
Primary
Proton Density Fat Fraction (PDFF)
1H Magnetic Resonance Spectroscopy (MRS) of liver will be used to assess intracellular triglyceride content at baseline and following 16 weeks of participation in a behavioral weight loss intervention.
Time frame: Baseline and 16 weeks
Population: Modified Intent to Treat (ITT) sample with week 0 and week 16 data.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Antipsychotic Treated Educational Control | Proton Density Fat Fraction (PDFF) | -0.62 percent | Standard Deviation 1.57 |
| Antipsychotic Treated Weekly Behavioral Weight Loss | Proton Density Fat Fraction (PDFF) | -0.41 percent | Standard Deviation 4.95 |
| Non-antipsychotic Treated Weekly Behavioral Weight Loss | Proton Density Fat Fraction (PDFF) | -1.75 percent | Standard Deviation 4.93 |
Comparison: An ANCOVA was used to test for differences between groups at endpoint, controlling for baseline values.p-value: 0.04ANCOVA
Other Pre-specified
Aberrant Behavior Checklist (ABC)
Change From Baseline in Aberrant Behavior Checklist - Irritability Subscale at 16 Weeks
Time frame: Baseline and 16 weeks
Population: Modified Intent to Treat (ITT) sample with week 0 and week 16 data.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Antipsychotic Treated Educational Control | Aberrant Behavior Checklist (ABC) | 3.00 units on a scale | Standard Deviation 4.65 |
| Antipsychotic Treated Weekly Behavioral Weight Loss | Aberrant Behavior Checklist (ABC) | -1.27 units on a scale | Standard Deviation 5.82 |
| Non-antipsychotic Treated Weekly Behavioral Weight Loss | Aberrant Behavior Checklist (ABC) | -1.38 units on a scale | Standard Deviation 4.32 |
Comparison: An ANCOVA was used to test for differences between groups at endpoint, controlling for baseline values.p-value: 0.003ANCOVA