Objective: The prevalence of overweight and obesity was estimated among the school children and adolescents of three provinces of central Italy, and the role of several possible influencing factors was analysed. Design, subjects and measurements: Body mass index (BMI) was measured in 44 231 subjects, age 3-17.5 y, and a household questionnaire was filled out by the parents of 12 143 subjects to collect the following data: subjects, only child or firstborn status, prematurity, birth weight, type of feeding until the fifth month, menarche status in girls; parents, age at the time of the subject's birth; BMI (mean of the two parents) at the time the subject was measured, mother's age of menarche, socioeconomic status. BMI was measured in a subgroup of 10 795 subjects 1 y later to study the yearly sex-and age-related variations from the categories of normal weight to overweight or obesity and vice versa. All females aged 11-14 y were asked if they had their menarche. Results: Striking differences in the proportions of overweight and obesity resulted from the use of two different criteria for defining cutoff points. The overall prevalence of overweight was 13.2 and 20.7% in males, and 13.7 and 18.6% in females, and the overall prevalence of obesity varied between 24.2 and 6.3% in males, and between 22.9 and 6.1% in females, respectively. Parents' BMI, birth weight, firstborn status and post-menarche status in girls showed a significant association with overweight and/or obesity in logistic regression models. Conclusions: A large prevalence of overweight and obesity was observed in school subjects from three provinces of central Italy. From the comparisons of the prevalence rate, the new internationally agreed criteria seem more appropriate for epidemiological studies in this population.

Eating problems in adolescents with type 1 diabetes (T1D) can be divided into two groups. The first includes the diagnosed eating disorders (EDs), i.e., diseases specifically identified by defined signs and symptoms for which a degree of severity has been established, such as anorexia nervosa, bulimia nervosa, binge-eating disorder, pica, and rumination. The second is the group of disordered eating symptoms (DES), which include behaviors such as dieting for weight loss, binge eating, self-induced vomiting, excessive exercise, and laxative or diuretic use; these behaviors cannot be categorized as complete diseases, and, although apparently mild, they must be closely evaluated because they can evolve into true EDs. In this review, present knowledge about the clinical relevance of EDs and DES and the possible preventive and therapeutic measures used to reduce their impact on the course of T1D will be discussed. As adolescents with diabetes are at higher risk of eating disturbances and consequently for higher rates of disease complications, care providers should pay attention to clinical warning signs that raise suspicion of disturbed eating to refer these patients early to an expert in nutrition and mental health disorders. To ensure the best care for adolescents with T1D, diabetes teams should be multidisciplinary and include a pediatric diabetologist, a skilled nurse, a dietician, and a psychologist.

Objective: To evaluate the dependence of body mass index (BMI) values on pubertal stage in subjects similar in age. Design, subjects and measurements: Height and weight were recorded cross-sectionally in school subjects from three provinces in central Italy. The subjects were subdivided into three groups: (1) 4271 school subjects (2125 males and 2146 females; 8.5 ± 15.5 y old), in whom the pubertal development was also recorded, were selected to subdivide BMI values according to pubertal stage and age; (2) 6345 females (10.5 ± 14.5 y old), who were asked whether or not they had had their ®rst menstrual period, were selected to subdivide BMI values according to age in pre-menarche and post-menarche girls, separately; and (3) 1919 females (10.5 ± 14.5 y old), who had presented their menarche within the previous 6 months, were selected to subdivide short-term postmenarche BMI values according to age. Results: The medians and interquartile ranges of BMI varied according to age and pubertal stage. Kruskall ± Wallis test performed in subjects similar in age demonstrated that signi®cant differences existed among the medians of BMI values of subjects at different pubertal stages in 12 ± 14-y-old males (P`0.05), and in 11 ± 14-yold females (P`0.001). The difference also proved to be signi®cant between stage I and stage II (P`0.05) in 10-y-old females, but not in 10 ± 11-y-old males. The Kruskal ± Wallis test performed in subjects similar in pubertal stage demonstrated that signi®cant differences among the medians of BMI at different ages existed only in females at stages II and III. A signi®cant positive trend was observed in both genders according to pubertal stage for BMI values of subjects similar in age (z-test for trend, P`0.01). On the contrary, a negative age trend proved to be signi®cant in females at stages I (P`0.01), II (P`0.01) and III (P`0.001), but not in males when the subdivision of BMI was made according to age in subjects similar in pubertal stage. BMI values were signi®cantly higher in post-menarche girls as compared to pre-menarche girls similar in age (P`0.001). However, at partial regression analysis BMI values were in¯uenced by pubertal stage and, to a lesser extent, by age, but not by menarcheal status. An inverse association between short-term post-menarche BMI and age was observed, with the highest values in girls presenting menarche at 11 y of age (P`0.05). The negative trend was demonstrated at the z-test for trend (P`0.001). Conclusions: BMI values depend on pubertal degree of maturation, especially in girls. This in¯uence should be taken into account when BMI is evaluated in adolescents.

Carbohydrate counting (CC) is a meal-planning tool for patients with type 1 diabetes (T1D) treated with a basal bolus insulin regimen by means of multiple daily injections or continuous subcutaneous insulin infusion. It is based on an awareness of foods that contain carbohydrates and their effect on blood glucose. The bolus insulin dose needed is obtained from the total amount of carbohydrates consumed at each meal and the insulin-to-carbohydrate ratio. Evidence suggests that CC may have positive effects on metabolic control and on reducing glycosylated haemoglobin concentration (HbA1c). Moreover, CC might reduce the frequency of hypoglycaemia. In addition, with CC the flexibility of meals and snacks allows children and teenagers to manage their T1D more effectively within their own lifestyles. CC and the bolus calculator can have possible beneficial effects in improving post-meal glucose, with a higher percentage of values within the target. Moreover, CC might be integrated with the counting of fat and protein to more accurately calculate the insulin bolus. In conclusion, in children and adolescents with T1D, CC may have a positive effect on metabolic control, might reduce hypoglycaemia events, improves quality of life, and seems to do so without influencing body mass index; however, more high-quality clinical trials are needed to confirm this positive impact.

Type 1 diabetes (T1D) is a chronic autoimmune disorder that leads to progressive pancreatic ß-cell destruction and culminates in absolute insulin deficiency and stable hyperglycaemia. It is very likely that environmental factors play a role in triggering islet autoimmunity. Knowing whether they have true relevance in favoring T1D development is essential for the effective prevention of the disease. Moreover, prevention could be obtained directly interfering with the development of autoimmunity through autoantigen-based immunotherapy. In this narrative review, the present possibilities for the prevention of T1D are discussed. Presently, interventions to prevent T1D are generally made in subjects in whom autoimmunity is already activated and autoantibodies against pancreatic cell components have been detected. Practically, the goal is to slow down the immune process by preserving the normal structure of the pancreatic islets for as long as possible. Unfortunately, presently methods able to avoid the risk of autoimmune activation are not available. Elimination of environmental factors associated with T1D development, reverse of epigenetic modifications that favor initiation of autoimmunity in subjects exposed to environmental factors and use of autoantigen-based immunotherapy are possible approaches, although for all these measures definitive conclusions cannot be drawn. However, the road is traced and it is possible that in a not so distant future an effective prevention of the disease to all the subjects at risk can be offered.

OBJECTIVE: Leptin, the product of the ob gene, is present in higher concentrations in blood of obese subjects than of lean subjects. There is scarce information on the role of leptin in the pathogenesis of human obesity and little is known about leptin serum levels in obese children. DESIGN, SUBJECTS AND MEASUREMENTS: To evaluate the in¯uences of age, sex, pubertal development and weight excess on serum leptin levels, we have studied 390 obese subjects (OS) and 320 normal weight subjects (NWS) aged 5±16 y. Fasting insulin concentrations were assayed in NWS, and an oral glucose tolerance test was carried out in OS and total insulin area under the curve (TIA) was calculated. RESULTS: Log-transformed values of leptin serum concentrations appeared to be distributed according to an acceptable Gaussian pattern. As observed in adults, serum leptin concentrations in children and adolescents were also increased (4±5 times) in OS as compared to NWS. In both males and females, subdivided according to pubertal stages, serum leptin varied signi®cantly in stage IV±V as compared to the lower stages, with a reduction in males and an increase in females. On comparing the two sexes, greater serum leptin concentrations were observed in females of both NWS and OS. A signi®cant linear correlation was found in both groups, subdivided according to sex and pubertal stage, between log values of serum leptin and standard deviation scores (SDS) of body mass index (BMI), and logtransformed relative body weight (RBW). Using partial correlation analysis in subjects subdivided according to sex and pubertal stages, log values of serum leptin and fasting insulin values, adjusted by age and SDS of BMI, correlated signi®cantly with a weaker correlation in males than in females. In OS, the leptin concentrations correlated better with TIA than with fasting insulin. A weight reduction program (WRP) was carried out in 141 OS and signi®cant reductions of serum leptin and fasting insulin were observed, showing a reduction of RBW. There was a correlation between the reduction of RBW and of serum leptin, but not of fasting insulin. No variation was found in non-responsive OS. RBW reduction correlated with leptin, but not with insulin (fasting and TIA), evaluated before the therapeutic program started. CONCLUSION: As observed in adults, obese children and adolescents have higher serum leptin concentrations. However, several conditions should be taken into account when evaluating leptin concentrations in children. There are differences, independent of BMI, relative to pubertal stage and sex, females having greater leptin concentrations than males. There is evidence of a possible role for leptin in the effectiveness of a weight reduction program in OS.

A defect in indoleamine 2,3-dioxygenase 1 (IDO1), which is responsible for immunoregulatory tryptophan catabolism, impairs development of immune tolerance to autoantigens in NOD mice, a model for human autoimmune type 1 diabetes (T1D). Whether IDO1 function is also defective in T1D is still unknown. We investigated IDO1 function in sera and peripheral blood mononuclear cells (PBMCs) from children with T1D and matched controls. These children were further included in a discovery study to identify SNPs in IDO1 that might modify the risk of T1D. T1D in children was characterized by a remarkable defect in IDO1 function. A common haplotype, associated with dysfunctional IDO1, increased the risk of developing T1D in the discovery and also confirmation studies. In T1D patients sharing such a common IDO1 haplotype, incubation of PBMCs in vitro with tocilizumab (TCZ) - an IL-6 receptor blocker - would, however, rescue IDO1 activity. In an experimental setting with diabetic NOD mice, TCZ was found to restore normoglycemia via IDO1-dependent mechanisms. Thus, functional SNPs of IDO1 are associated with defective tryptophan catabolism in human T1D, and maneuvers aimed at restoring IDO1 function would be therapeutically effective in at least a subgroup of T1D pediatric patients.

In people with type 1 diabetes mellitus (T1DM), obtaining good glycemic control is essential to reduce the risk of acute and chronic complications. Frequent glucose monitoring allows the adjustment of insulin therapy to improve metabolic control with near-normal blood glucose concentrations. The recent development of innovative technological devices for the management of T1DM provides new opportunities for patients and health care professionals to improve glycemic control and quality of life. Currently, in addition to traditional self-monitoring of blood glucose (SMBG) through a glucometer, there are new strategies to measure glucose levels, including the detection of interstitial glucose through Continuous Glucose Monitoring (iCGM) or Flash Glucose Monitoring (FGM). In this review, we analyze current evidence on the efficacy and safety of FGM, with a special focus on T1DM. FGM is an effective tool with great potential for the management of T1DM both in the pediatric and adult population that can help patients to improve metabolic control and quality of life. Although FGM might not be included in the development of an artificial pancreas and some models of iCGM are more accurate than FGM and preferable in some specific situations, FGM represents a cheaper and valid alternative for selected patients. In fact, FGM provides significantly more data than the intermittent results obtained by SMBG, which may not capture intervals of extreme variability or nocturnal events. With the help of a log related to insulin doses, meal intake, physical activity and stress factors, people can achieve the full benefits of FGM and work together with health care professionals to act upon the information provided by the sensor. The graphs and trends available with FGM better allow an understanding of how different factors (e.g., physical activity, diet) impact glycemic control, consequently motivating patients to take charge of their health.