Childhood obesity is associated with multiple cardio-metabolic abnormalities. A sensitive hypothesis underlying these alterations is oxidative stress, shown to be present in obesity, often accompanied by a diminished antioxidant defense. Specifically, plasma vitamin concentrations have been observed to be associated with obesity in adults and children. However, their association with cardio-metabolic alterations in children is less clear.

985 children (49.2% males, 71.7% prepubertal, 71.9% excess weight) were recruited in a case-control study of obesity in three Spanish hospitals. Pubertal status was assessed and anthropometry (weight, height), systolic and diastolic blood pressure (SBP, DBP) and serum glucose, insulin, triacylglycerols (TAG) and high-density lipoprotein cholesterol (HDL-C) were measured. Plasma concentrations of tocopherols and carotenes were determined with HPLC-MS and referred to TAG. Children were classified as MU if showing one or more of these criteria: SBP or DBP ≥ 90th percentile (age, sex, height), serum TAG > 90th percentile (age, sex), HDL-C < 10th percentile (age, sex), glucose ≥ 100 mg/dL or elevated HOMA-IR (≥ 2.5 prepubertal, ≥ 3.38 pubertal males, ≥ 3.905 pubertal females). Non-fulfillment was indicative of MH status. General linear models adjusted for sex, age, recruitment center and BMI were used to evaluate differences in vitamins between MH and MU children.

Prepubertal and pubertal children with excess weight showed lower tocopherols (Pre: 0.133 ± 0.061 vs 0.165 ± 0.065, P < 0.001; Pub: 0.120 ± 0.057 vs 0.163 ± 0.066, P < 0.001) and carotenes (Pre: 15.63 ± 13.72 vs 30.31 ± 26.04, P < 0.001; Pub: 12.34 ± 9.86 vs 22.98 ± 19.25, P < 0.001) plasma concentrations than normal-weight children. MU prepubertal and pubertal children showed lower tocopherols (Pre: 0.120 ± 0.056 vs 0.165 ± 0.064, P < 0.001; Pub: 0.111 ± 0.051 vs 0.154 ± 0.066, P < 0.001) and carotenes (Pre: 14.07 ± 12.61 vs 25.97 ± 21.94, P < 0.001; Pub: 10.90 ± 8.54 vs 19.03 ± 14.58, P < 0.001) plasma concentrations than MH children, independently of BMI. Individual MU components analyses showed similar associations between tocopherols and carotenes and insulin resistance, low HDL-C values and hypertriglyceridemia in prepubertal children; and between tocopherols and carotenes and elevated SBP, hyperglycemia and hypertriglyceridemia in pubertal children.

Our findings agree with previous studies that showed decreased plasma concentrations of tocopherols and carotenes in children with obesity. However, we observe further implications of low circulating concentrations of non-enzymatic antioxidants in terms of their negative association with cardio-metabolic alterations such as insulin resistance and dyslipidemia in prepubertal and pubertal children, independently of BMI. These results must be considered when designing prevention and treatment strategies of obesity and its complications.

Hypertension is a public health problem and its prevalence in children is on the rise, often continuing into adulthood and increasing the risk related cardiovascular complications. Sleep plays an essential role in children's growth and several studies suggest that insufficient sleep duration is associated with hypertension in adults. However, few studies have evaluated this association in children. Thus, the aim of the study is to ascertain whether the sleep duration is a risk factor for elevated blood pressure (BP) in children.

We studied 776 children (5–18 years old), (46.7% male, 78.8% 5–13 years, 73.6% overweight/obesity). Weight and height were measured and body mass index (BMI) was calculated. BP was measured with an electronic manometer to find a 25.3% of children with an elevated systolic BP (SBP, > P90th) and 14% with an elevated diastolic BP (DBP, > P90th) (Task Force 2017). Sleep duration was assessed by asking the parents “¿How many hours does your child sleep in a typical weekday?”. Weekday sleep hours were considered since they are more representative of children's routines than weekend hours. Hours were converted into a dichotomous variable based on the fulfillment or not of the “Canadian 24-Hour Movement Guidelines for Children and Youth recommendations”: 9–11 hours for 5- to 13-year-olds; 8–10 hours for 14- to 17-year-olds.

A spearman correlation analysis was performed between sleep duration, SBP and DBP. Then, a general linear model analysis adjusted for BMI Z-score was done to evaluate differences in SBP and DBP between children following the sleep recommendations. Analyses were stratified by sex and age range (5–13 and 14–17).

In girls 5–13 years, we found a significant negative correlation between sleep duration and body mass index (BMI) (r = -0.226, p = 0.000) and between sleep and systolic BP (r = -0.188, p = 0.001). Girls 5–13 years not following sleep recommendations showed significantly higher SBP values than those who followed the recommendations (112 ± 11 mmHg vs. 106 ± 12 mmHg, p = 0.007), independently of BMI. No significant differences were observed in girls 14–17 years nor in males.

In the present study, we show that girls 5–13 years with shorter sleep duration show increased SBP values independently of BMI, in contrast to previous studies which showed similar associations that disappeared when adjusting for BMI. Our results support the need for wider strategies in population education so that sleep recommendations are followed by children in the general population.

Obesity is known to be associated with a low-grade inflammatory state. Most studies reporting inflammation in obesity have been done in pubertal children or adults or have focused only on the relation between body mass index (BMI) and the classical inflammatory markers. Nerve growth factor (NGF), monocyte chemoattractant protein–1 (MCP-1) and hepatocyte growth factor (HGF) are adipokines previously shown to be involved in the inflammatory context of obesity and metabolic syndrome but few studies have been conducted in children.

To evaluate the association between NGF, MCP-1, HGF with total and abdominal adiposity and in prepubertal and pubertal children.

889 children participated in a prospective obesity case-control study (50.2% males, 72% prepubertals, 27% overweight and 43% obesity), paired by age and sex. The relationship between total fat (assessed using the BMI, the sum of skinfolds thickness (SF) and fat mass index (FMI) from bioelectrical impedance analysis and waist circumference as a surrogate marker of abdominal obesity) and plasma concentrations of MCP-1, HGF, and NGF was studied in prepubertal and pubertal children.

Linear regression analysis for prepubertal and pubertal children, adjusting for age, sex and center was used.

NGF was associated with WC, with a stronger association in prepubertal than in pubertal children. MCP-1 was positively associated with WC, SF, FMI and BMI in pubertal children whereas HGF was positively associated with WC and BMI only in prepubertal children. The strongest associations were between WC and NGF (β 0.123 95%CI 0.133, 0.709; p < 0.001) in prepubertal children and WC and MCP-1 (β 0.123 95%CI 0.438, 2.035; p < 0.001) in pubertal children.

Total and abdominal adiposity are related to plasma concentrations of adipokines in prepubertal and pubertal children with obesity. Adipokines such as NGF, HGF and MCP-1 have not been so well studied so far in obese children. Particularly, NGF was associated with WC and BMI in prepubertal children and with WC in pubertal children. The association between this neurotrophin, secreted by adipose tissue and involved in the development and survival of sympathetic neurons, with adiposity, especially in prepubertal children, could suggest an anti-inflammatory mechanism and thus be a potential therapeutic target.

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Conclusions and recommendations of health technology assessment (HTA) reports have an impact on all relevant actors involved in the health system (health authorities, administrators, health professionals, patients, citizens and industry). The involvement of all those relevant stakeholders in the HTA process facilitates making valid and informed decisions and an efficient allocation of resources. Improving communication, participation and transparency among all agents will lead to more efficient evaluation and decision-making processes.

To review key aspects of the relations between HTA agencies and health industries, two process were carried out: a narrative review of literature searched in Medline, PubMed, Embase, CINAHL and WOS (2007-2017) and a review of websites of international HTA agencies. References and webs with information on the framework, objectives, methodologies, impact or results of the relationships were included.

A total of 1961 references were located and forty-five were selected. From the synthesis of the selected references the following key aspects of the relationships between HTA and industry were identified: (i) the importance of early dialogues with industry to align HTA objectives with the generation of evidence; (ii) challenges of the bias in the evidence produced by industry; (iii) difficulties in industry engagement in HTA processes; and (iv) industry interest in HTA. The review of six agency websites provided information on industry involvement in strategic activities, early dialogues, provision of documentation, management of industry clarifications, review of the report/allegations and other forms of relationship.

Both the review of the literature and the contents of the web pages of international agencies with experience in relations with industry show that the interest is in the creation of collaborative frameworks between regulatory authorities that decide on authorization and price and reimbursement and HTA agencies, while both try to maintain an early, transparent and systematic interaction with the healthcare industry.

The Spanish Network of Agencies for Health Technology Assessment (REDETS) is a group of eight agencies, units and services, depending on National and Regional Governments that coordinate their work within a common methodological framework, guided by the principles of mutual recognition and cooperation. In this work, guided by the necessity of implementing a Quality Management System, we present the process to achieve this objective.

As an initial step, a review was carried out based on a structured search strategy in the main electronic databases Medline and EMBASE, and a manual search in websites of national and international agencies (March 2016) in order to collate previous knowledge and experiences. Through the information included in this review, a proposal to create a quality, self-evaluating tool is necessary.

In total, 800 references were found and finally 6 studies were included in the review (1-3). All had a similar structure. Some lists of good practices, classified in dimensions related to different quality aspects in Health Technology Assessment (HTA) organizations, were found. Also some information about questions for evaluating quality standards was indicated. Taking all this information, a proposal of sixty-six standard titles was put forward. These standards were then grouped into twelve quality criteria structured in four dimensions: I Responsibility, II Clients and Stakeholders, III Production Process and IV Resources.

Based on the systematic review, we developed a proposal for a self-evaluating tool and this is the baseline for a common Quality Management System for the Spanish Network of HTA Agencies. The quality management process will require the development of a handbook by each member of REDETS that will be based on agreed quality standards.

The Spanish National Network (REDETS) is a group of eight agencies, units and services, depending on National and Regional Governments that coordinate their work within a common methodological framework, guided by the principles of mutual recognition and cooperation. The necessity of considering a Quality Management System has been detected and, consequently, a common tool for all the members needs to be developed. We describe in this study the process to achieve that goal.

Based on both a review of previous literature and the proposal for a self-evaluating tool, a group of experts from each agency through consensus have developed a tool for self-evaluation in Health Technology Assessment (HTA) agencies. Through the structure described in the handbook of the Andalusian Agency for Healthcare Quality (ACSA), each standard should have a statement or proposal that needs to also include evidence or good practices, and the corresponding evaluation questions. In separate workgroups, the definition of these proposals, evidence and evaluation questions were developed. One face-to-face meeting and two meetings via teleconference were necessary to achieve a final document with all the quality standards.

From a proposed structure of sixty-six standards, the titles, definitions, statements and evidence as well as good practices and evaluation questions were established in workgroups with consensus among all of the members (1 - 3). The final version of the self-assessment tool was composed of sixty-eight standards, grouped in twelve quality criteria structured in four dimensions: I Responsibility, II Clients and Stakeholders, III Production Process, and IV Resources.

Quality management requires an evaluation tool and this version, based on a systematic review and consensus, is a useful and practical instrument for developing a handbook by each member of REDETS. An online version of the tool is in process of development.