目的:下丘脑功能失调可能会导致饱腹感(食欲不振)下降,减少能量消耗,和高胰岛素血症导致的脂肪储存增加。因此,下丘脑功能障碍可能导致病态肥胖,并可能在儿童时期由于先天性而遇到,遗传,或获得性障碍。目前没有有效的治疗下丘脑肥胖(HO)。然而,与消化性肥胖相比,饮食和生活方式干预可能被认为是肥胖治疗的基石.我们质疑饮食或生活方式干预对HO的影响,并系统地搜索文献中的可行性证据,安全,或饮食或生活方式干预对儿童下丘脑超重或肥胖的疗效。
方法:在MEDLINE(包括Cochrane库)中进行了系统搜索,EMBASE,和CINAHL(2023年5月)。评估可行性的研究,安全,或任何饮食或生活方式干预对下丘脑超重或肥胖儿童的疗效,包括在内。动物研究,关于非饮食干预的研究,并且没有全文可用的研究被排除.因为纳入的研究数量很少,对患有下丘脑超重或肥胖的成年人重复进行了搜索.使用适应性Cochrane偏差风险工具评估偏差风险。使用GRADE系统评估证据水平。描述了描述性数据,由于纳入研究的异质性,无法进行汇总数据分析.
结果:总计,包括12项研究,共有118名患者(1-19岁),其中1名患有颅咽管瘤,一个患有ROHHAD-NET综合征,50例单基因肥胖,66患有Prader-Willi综合征(PWS)。四项研究报告说饮食干预是可行的。然而,父母确实遇到了孩子仍然偷食物的困难,特别是降低碳水化合物被认为是具有挑战性的。七项研究报告了饮食干预的功效:均衡的限制性热量饮食(30%脂肪,45%的碳水化合物,和25%蛋白质)和各种低热量饮食(8-10kcal/cm/天)被认为在体重稳定或减轻方面是有效的。没有报道对线性生长的负面影响。四项研究报告了特定的生活方式干预,其中三个还包括饮食干预。联合饮食和生活方式干预导致BMI下降,尽管长期BMI恢复到基线值。在脑外伤后的成年人中发现了另一项研究,并显示在饮食和生活方式综合干预后,八分之一的患者的BMI显着降低。
结论:低碳水化合物百分比的低热量饮食或限制性常量营养素饮食似乎对儿童HO可行且有效,尽管大多数研究有很高的偏倚风险,没有对照组的小组,并且仅在患有PWS的儿童中进行,损害了普适性。生活方式干预仅在短期内导致BMI下降,这表明需要额外的指导来维持其长期效果。关于下丘脑超重或肥胖的饮食或生活方式干预的可行性和有效性的文献很少,尤其是在患有获得性HO的儿童中(对鞍上肿瘤进行治疗后)。需要进行前瞻性(对照)研究,以确定哪种饮食和生活方式干预对该特定患者组最有帮助。
OBJECTIVE: A dysfunctional hypothalamus may result in decreased feelings of satiety (hyperphagia), decreased energy expenditure, and increased fat storage as a consequence of hyperinsulinemia. Hypothalamic dysfunction may thus lead to morbid obesity and can be encountered in childhood as a consequence of congenital, genetic, or acquired disorders. There is currently no effective treatment for hypothalamic obesity (HO). However, comparable to alimentary obesity, dietary and lifestyle interventions may be considered the cornerstones of obesity treatment. We questioned the effect of dietary or lifestyle interventions for HO and systematically searched the literature for evidence on feasibility, safety, or efficacy of dietary or lifestyle interventions for childhood hypothalamic overweight or obesity.
METHODS: A systematic search was conducted in MEDLINE (including Cochrane Library), EMBASE, and CINAHL (May 2023). Studies assessing feasibility, safety, or efficacy of any dietary or lifestyle intervention in children with hypothalamic overweight or obesity, were included. Animal studies, studies on non-diet interventions, and studies with no full text available were excluded. Because the number of studies to be included was low, the search was repeated for adults with hypothalamic overweight or obesity. Risk of bias was assessed with an adapted Cochrane Risk of Bias Tool. Level of evidence was assessed using the GRADE system. Descriptive data were described, as pooled-data analysis was not possible due to heterogeneity of included studies.
RESULTS: In total, twelve studies were included, with a total number of 118 patients (age 1-19 years) of whom one with craniopharyngioma, one with ROHHAD-NET syndrome, 50 with monogenic obesity, and 66 with Prader-Willi syndrome (PWS). Four studies reported a dietary intervention as feasible. However, parents did experience difficulties with children still stealing food, and especially lowering carbohydrates was considered to be challenging. Seven studies reported on efficacy of a dietary intervention: a well-balanced restrictive caloric diet (30% fat, 45% carbohydrates, and 25% protein) and various hypocaloric diets (8-10 kcal/cm/day) were considered effective in terms of weight stabilization or decrease. No negative effect on linear growth was reported. Four studies reported on specific lifestyle interventions, of which three also included a dietary intervention. Combined dietary and lifestyle intervention resulted in decreased BMI, although BMI returned to baseline values on long-term. One additional study was identified in adults after brain trauma and showed a significant reduction in BMI in one out of eight patients after a combined dietary and lifestyle intervention.
CONCLUSIONS: Hypocaloric diet or restrictive macronutrient diet with lower percentage of carbohydrates seems feasible and effective for childhood HO, although most of the studies had a high risk of bias, small cohorts without control groups, and were conducted in children with PWS only, compromising the generalizability. Lifestyle interventions only resulted in BMI decrease in short-term, indicating that additional guidance is needed to sustain its effect in the long-term. Literature on feasibility and efficacy of a dietary or lifestyle intervention for hypothalamic overweight or obesity is scarce, especially in children with acquired HO (following treatment for a suprasellar tumor). There is need for prospective (controlled) studies to determine which dietary and lifestyle intervention are most helpful for this specific patient group.