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MODEL
Journal of Pediatric Urology (2015) xx, 1.e1e1.e6
Obesity, overweight, and eating problems in children with incontinence Catharina Wagner, Monika Equit, Justine Niemczyk, Alexander von Gontard Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg/Saar, Germany Correspondence to: C. Wagner, Department of Child and Adolescent Psychiatry, Saarland University Hospital, 66421 Homburg, Germany, Tel.: þ49 6841 162 4148; fax: þ49 6841 162 4397 [email protected] (C. Wagner) Keywords Nocturnal enuresis; Daytime urinary incontinence; Fecal incontinence; Atypical eating disorders; Overweight; Obesity Received 24 November 2014 Accepted 18 May 2015 Available online xxx
Summary
Subjects and methods Forty-three consecutively presented children with incontinence, diagnosed to International Children’s Continence Society standards, and 44 matched continent controls were examined prospectively. All children received a physical examination, sonography, and a one-dimensional intelligence test. Child psychopathology was measured with the Child Behavior Checklist (CBCL/4e18). Eating problems were assessed with the German version of the Dutch Eating Behaviour Questionnaire for Children (DEBQC) and a 40-item-parental questionnaire referring to atypical eating problems.
problems (46.3% vs. 6.8%) in the clinical range (>90th percentile), as well as significantly lower mean IQ (105.5 vs. 120.6) than continent controls. Of the children with incontinence, 16.9% were affected by obesity (95th body mass index [BMI] percentile) compared with none of the continent controls. Especially in children with FI, the rate of obesity was significantly increased (23.5%). In addition, 46.5% of incontinent children, but none of the controls, had constipation. Again, children with FI (82.4%) had the highest rate of constipation (>DUI: 25% > NE only: 20%). “Food refusal” (FR) and “intense fear of gaining weight” (GW), but not other eating problems, were significantly more common among incontinent children (FR mean score 7.3; GW mean score 1.4) than in controls (FR mean score 5.6; GW mean score 0.7). After controlling for BMI percentiles, FR still was significantly higher in incontinent children. Children with FI had the highest score of FR among all subgroups of incontinence (mean score 9.1).
Results Of the 43 children with incontinence, 23.3% had nocturnal enuresis (NE) only, 37.2% had any form of daytime urinary incontinence (DUI) (isolated or combined with NE) and 39.5% had fecal incontinence (FI) (isolated or combined with NE and/or DUI). Incontinent children showed significantly more CBCL externalizing symptoms (35.7% vs. 6.8%) and total
Conclusions This study shows that overweight, obesity, behavioral and eating problems are especially associated with disorders of the gastrointestinal tract (FI and constipation), and only to a lesser degree with those of the urinary tract (DUI and NE). These problems should be addressed routinely in the clinical care of children with incontinence.
Objective The aim was to analyze the prevalence of eating problems and specific associations between overweight, obesity, and eating behavior in children with incontinence.
N (%) Boys: N (%) Age: mean (SD) IQ: mean (SD) Overweight + Obesity N: (%) CBCL Total score: mean T-values (SD) EDNOS-PQ Intense fear gaining weight: mean (SD) Food refusal: mean (SD)
Incontinent children
Continent controls
43 25 8.2 105 12 61.0
44 24 8.3 121 6 49.4
(100) (58.1) (2.1) (16.2) (38.6) (10.9)
1.4 (1.5) 7.3 (4.6)
(100) (54.5) (1.9) (17.5) (14.0) (9.9)
0.7 (1.1) 5.6 (3.0)
http://dx.doi.org/10.1016/j.jpurol.2015.05.019 1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Wagner C, et al., Obesity, overweight, and eating problems in children with incontinence, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.05.019
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1.e2
Introduction Functional incontinence, including nocturnal enuresis (NE), daytime urinary incontinence (DUI), and fecal incontinence (FI) are common disorders in childhood. According to the International Children’s Continence Society (ICCS), NE is defined as intermittent incontinence of discrete amounts of urine during sleep in a child aged 5 years or older after organic causes have been ruled out [1]. DUI is defined as incontinence of discrete amounts of urine during the day. Functional DUI comprises heterogeneous conditions, for example overactive bladder, voiding postponement, and dysfunctional voiding. The Rome III classification differentiates between functional constipation (with or without FI) and non-retentive FI (without constipation) from the age of 4 years onwards after excluding organic causes [2]. Prevalence rates of 9.1e18.2% for NE, 4.4e16.9% for DUI, and 1.4e5.4% for FI for 6e7.5-year-old children have been reported [3]. Overweight (>85th body mass index [BMI] percentile) and obesity (>95th BMI percentile) are also common in children and adolescents with prevalence rates between 15% for obesity and 34% for overweight (þobesity) among 2e19-year-old US-American children and adolescents. Similar rates were reported for other countries [4]. Classic eating disorders (ED) according to DSM-5, such as anorexia nervosa, bulimia nervosa, and binge eating disorder have their typical onset during adolescence and do not play a major role in early childhood [5]. In contrast, atypical eating disorders (e.g. selective eating, food avoidance or restrictive eating) affect 1e2% and atypical eating symptoms up to 25% of all typically developing children. In a population-based study, 23% of 6-year-old children showed symptoms of selective eating and 26% of aversion to new foods [5]. NE, DUI, overactive bladder (OAB), as well as FI and constipation are common in obese children [6e9]. Treatment efficacy among obese children with NE or dysfunctional voiding compared with normal-weighted incontinent children is lower [10]. In contrast, the prevalence of obesity among children with functional constipation is increased too [11]. High BMI was also associated with NE, DUI, and constipation [12,13]. Further, food refusal (FR) was reported more often among children with FI [14]. The aim of the present study was to assess associations between eating problems, BMI, and incontinence. Compared to continent controls, it was hypothesized that BMI is higher in children with incontinence and that children with incontinence show an increased rate of eating problems. Further, the aim was to analyze subgroups of incontinence (NE, DUI, and FI) regarding BMI, psychological comorbidity, and eating problems.
Subjects and methods The sample consisted of 43 children with different forms of functional incontinence (NE, DUI, FI, or any combination) (58.1% boys; mean age Z 8.2 years, SD Z 2.1, range 5.0e12.4 years) who presented consecutively at a specialized outpatient department for incontinence and 44 continent controls recruited from local schools (54.5% boys; mean age Z 8.3 years, SD Z 1.9, range 5.1e12.8 years),
C. Wagner et al. matched by age and gender. Exclusion criteria were an IQ < 70 or an organic disorder. The study was approved by the local ethics committee. Diagnoses of NE, DUI, and FI were made according to ICCS- [1] and Rome-III-criteria [2]. All children received a physical examination and sonography of the bladder and rectum. Additionally, weight and height were measured and BMI percentiles were calculated. According to the US Centers for Disease Control and Prevention, BMI percentiles were combined into four groups: underweight (
MODEL
Journal of Pediatric Urology (2015) xx, 1.e1e1.e6
Obesity, overweight, and eating problems in children with incontinence Catharina Wagner, Monika Equit, Justine Niemczyk, Alexander von Gontard Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg/Saar, Germany Correspondence to: C. Wagner, Department of Child and Adolescent Psychiatry, Saarland University Hospital, 66421 Homburg, Germany, Tel.: þ49 6841 162 4148; fax: þ49 6841 162 4397 [email protected] (C. Wagner) Keywords Nocturnal enuresis; Daytime urinary incontinence; Fecal incontinence; Atypical eating disorders; Overweight; Obesity Received 24 November 2014 Accepted 18 May 2015 Available online xxx
Summary
Subjects and methods Forty-three consecutively presented children with incontinence, diagnosed to International Children’s Continence Society standards, and 44 matched continent controls were examined prospectively. All children received a physical examination, sonography, and a one-dimensional intelligence test. Child psychopathology was measured with the Child Behavior Checklist (CBCL/4e18). Eating problems were assessed with the German version of the Dutch Eating Behaviour Questionnaire for Children (DEBQC) and a 40-item-parental questionnaire referring to atypical eating problems.
problems (46.3% vs. 6.8%) in the clinical range (>90th percentile), as well as significantly lower mean IQ (105.5 vs. 120.6) than continent controls. Of the children with incontinence, 16.9% were affected by obesity (95th body mass index [BMI] percentile) compared with none of the continent controls. Especially in children with FI, the rate of obesity was significantly increased (23.5%). In addition, 46.5% of incontinent children, but none of the controls, had constipation. Again, children with FI (82.4%) had the highest rate of constipation (>DUI: 25% > NE only: 20%). “Food refusal” (FR) and “intense fear of gaining weight” (GW), but not other eating problems, were significantly more common among incontinent children (FR mean score 7.3; GW mean score 1.4) than in controls (FR mean score 5.6; GW mean score 0.7). After controlling for BMI percentiles, FR still was significantly higher in incontinent children. Children with FI had the highest score of FR among all subgroups of incontinence (mean score 9.1).
Results Of the 43 children with incontinence, 23.3% had nocturnal enuresis (NE) only, 37.2% had any form of daytime urinary incontinence (DUI) (isolated or combined with NE) and 39.5% had fecal incontinence (FI) (isolated or combined with NE and/or DUI). Incontinent children showed significantly more CBCL externalizing symptoms (35.7% vs. 6.8%) and total
Conclusions This study shows that overweight, obesity, behavioral and eating problems are especially associated with disorders of the gastrointestinal tract (FI and constipation), and only to a lesser degree with those of the urinary tract (DUI and NE). These problems should be addressed routinely in the clinical care of children with incontinence.
Objective The aim was to analyze the prevalence of eating problems and specific associations between overweight, obesity, and eating behavior in children with incontinence.
N (%) Boys: N (%) Age: mean (SD) IQ: mean (SD) Overweight + Obesity N: (%) CBCL Total score: mean T-values (SD) EDNOS-PQ Intense fear gaining weight: mean (SD) Food refusal: mean (SD)
Incontinent children
Continent controls
43 25 8.2 105 12 61.0
44 24 8.3 121 6 49.4
(100) (58.1) (2.1) (16.2) (38.6) (10.9)
1.4 (1.5) 7.3 (4.6)
(100) (54.5) (1.9) (17.5) (14.0) (9.9)
0.7 (1.1) 5.6 (3.0)
http://dx.doi.org/10.1016/j.jpurol.2015.05.019 1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Wagner C, et al., Obesity, overweight, and eating problems in children with incontinence, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.05.019
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MODEL
1.e2
Introduction Functional incontinence, including nocturnal enuresis (NE), daytime urinary incontinence (DUI), and fecal incontinence (FI) are common disorders in childhood. According to the International Children’s Continence Society (ICCS), NE is defined as intermittent incontinence of discrete amounts of urine during sleep in a child aged 5 years or older after organic causes have been ruled out [1]. DUI is defined as incontinence of discrete amounts of urine during the day. Functional DUI comprises heterogeneous conditions, for example overactive bladder, voiding postponement, and dysfunctional voiding. The Rome III classification differentiates between functional constipation (with or without FI) and non-retentive FI (without constipation) from the age of 4 years onwards after excluding organic causes [2]. Prevalence rates of 9.1e18.2% for NE, 4.4e16.9% for DUI, and 1.4e5.4% for FI for 6e7.5-year-old children have been reported [3]. Overweight (>85th body mass index [BMI] percentile) and obesity (>95th BMI percentile) are also common in children and adolescents with prevalence rates between 15% for obesity and 34% for overweight (þobesity) among 2e19-year-old US-American children and adolescents. Similar rates were reported for other countries [4]. Classic eating disorders (ED) according to DSM-5, such as anorexia nervosa, bulimia nervosa, and binge eating disorder have their typical onset during adolescence and do not play a major role in early childhood [5]. In contrast, atypical eating disorders (e.g. selective eating, food avoidance or restrictive eating) affect 1e2% and atypical eating symptoms up to 25% of all typically developing children. In a population-based study, 23% of 6-year-old children showed symptoms of selective eating and 26% of aversion to new foods [5]. NE, DUI, overactive bladder (OAB), as well as FI and constipation are common in obese children [6e9]. Treatment efficacy among obese children with NE or dysfunctional voiding compared with normal-weighted incontinent children is lower [10]. In contrast, the prevalence of obesity among children with functional constipation is increased too [11]. High BMI was also associated with NE, DUI, and constipation [12,13]. Further, food refusal (FR) was reported more often among children with FI [14]. The aim of the present study was to assess associations between eating problems, BMI, and incontinence. Compared to continent controls, it was hypothesized that BMI is higher in children with incontinence and that children with incontinence show an increased rate of eating problems. Further, the aim was to analyze subgroups of incontinence (NE, DUI, and FI) regarding BMI, psychological comorbidity, and eating problems.
Subjects and methods The sample consisted of 43 children with different forms of functional incontinence (NE, DUI, FI, or any combination) (58.1% boys; mean age Z 8.2 years, SD Z 2.1, range 5.0e12.4 years) who presented consecutively at a specialized outpatient department for incontinence and 44 continent controls recruited from local schools (54.5% boys; mean age Z 8.3 years, SD Z 1.9, range 5.1e12.8 years),
C. Wagner et al. matched by age and gender. Exclusion criteria were an IQ < 70 or an organic disorder. The study was approved by the local ethics committee. Diagnoses of NE, DUI, and FI were made according to ICCS- [1] and Rome-III-criteria [2]. All children received a physical examination and sonography of the bladder and rectum. Additionally, weight and height were measured and BMI percentiles were calculated. According to the US Centers for Disease Control and Prevention, BMI percentiles were combined into four groups: underweight (
