Position of the Academy of Nutrition and Dietetics: interventions for the prevention and treatment of pediatric overweight and obesity

School-based gardening, cooking and nutrition intervention increased vegetable intake but did not reduce BMI: Texas sprouts - a cluster randomized controlled trial

BACKGROUND

Although school garden programs have been shown to improve dietary behaviors, there has not been a cluster-randomized controlled trial (RCT) conducted to examine the effects of school garden programs on obesity or other health outcomes. The goal of this study was to evaluate the effects of a one-year school-based gardening, nutrition, and cooking intervention (called Texas Sprouts) on dietary intake, obesity outcomes, and blood pressure in elementary school children.

METHODS

This study was a school-based cluster RCT with 16 elementary schools that were randomly assigned to either the Texas Sprouts intervention (n = 8 schools) or to control (delayed intervention, n = 8 schools). The intervention was one school year long (9 months) and consisted of: a) Garden Leadership Committee formation; b) a 0.25-acre outdoor teaching garden; c) 18 student gardening, nutrition, and cooking lessons taught by trained educators throughout the school-year; and d) nine monthly parent lessons. The delayed intervention was implemented the following academic year and received the same protocol as the intervention arm. Child outcomes measured were anthropometrics (i.e., BMI parameters, waist circumference, and body fat percentage via bioelectrical impedance), blood pressure, and dietary intake (i.e., vegetable, fruit, and sugar sweetened beverages) via survey. Data were analyzed with complete cases and with imputations at random. Generalized weighted linear mixed models were used to test the intervention effects and to account for clustering effect of sampling by school.

RESULTS

A total of 3135 children were enrolled in the study (intervention n = 1412, 45%). Average age was 9.2 years, 64% Hispanic, 47% male, and 69% eligible for free and reduced lunch. The intervention compared to control resulted in increased vegetable intake (+ 0.48 vs. + 0.04 frequency/day, p = 0.02). There were no effects of the intervention compared to control on fruit intake, sugar sweetened beverages, any of the obesity measures or blood pressure.

CONCLUSION

While this school-based gardening, nutrition, and cooking program did not reduce obesity markers or blood pressure, it did result in increased vegetable intake. It is possible that a longer and more sustained effect of increased vegetable intake is needed to lead to reductions in obesity markers and blood pressure.

CLINICAL TRIALS NUMBER

NCT02668744 .

Current Systems-Level Evidence on Nutrition Interventions to Prevent and Treat Cardiometabolic Risk in the Pediatric Population: An Evidence Analysis Center Scoping Review

Improving and maintaining cardiometabolic health remains a major focus of health efforts for the pediatric population. Recent research contributes understanding of the systems-level nutrition factors influencing cardiometabolic health in pediatric individuals. This scoping review examines current evidence on interventions and exposures influencing pediatric cardiometabolic health to inform registered dietitian nutritionists working at each systems level, ranging from individual counseling to public policy. A literature search of MEDLINE, CINAHL, Cochrane Databases of Systematic Reviews, and other databases was conducted to identify evidence-based practice guidelines, systematic reviews, and position statements published in English from January 2017 until April 2020. Included studies addressed nutrition interventions or longitudinal exposures for participants 2 to 17 years of age who were healthy or had cardiometabolic risk factors. Studies were categorized according level of the social-ecological framework addressed. The databases and hand searches identified 2614 individual articles, and 169 articles were included in this scoping review, including 6 evidence-based practice guidelines, 141 systematic reviews, and 22 organization position statements. The highest density of systematic reviews focused on the effects of dietary intake (n = 58) and interventions with an individual child or family through counseling or education (n = 54). The least frequently examined levels of interventions or exposures were at the policy level (n = 12). Registered dietitian nutritionists can leverage this considerable body of recent systematic reviews to inform a systems-level, collaborative approach to prevention and treatment of pediatric cardiometabolic risk factors.

Program for Healthier School Cafeterias in Rio Grande do Sul, Brazil: Protocol for a Community-Based Randomized Trial

Background

School cafeterias can promote poor eating habits, as these retail outlets have a variety of foods considered to be nonnutritive and unhealthy. However, despite the need for effective preventive strategies, there is still disagreement on the best approach due to the lack of evidence on interventions to prevent and treat obesity in the school settings.

Objective

We aim to verify the efficacy of an educational intervention program to improve the hygienic conditions and the composition of the menu offered in school cafeterias in the state of Rio Grande do Sul, Brazil.

Methods

We will conduct a randomized, parallel, two-arm, community-based controlled study. Elementary and high schools, both public and private, in the State of Rio Grande do Sul, Brazil, that have a cafeteria will be eligible. Schools will be recruited and randomly assigned to the intervention (n=27) or control (n=27) group. The intervention group will receive an educational intervention program based on the guidelines issued by the Ministry of Health of Brazil, consisting of a 160-hour distance-learning qualification course, for 10 weeks, and using the Moodle platform and WhatsApp app. The intervention targets the owners and people in charge of the cafeterias, food handlers, principals, vice principals, teachers, pedagogical coordinators, dietitians, representatives of students' parents, and students over 16 years old. Meanwhile, the control group will receive only a printed copy of the book containing the guidelines used. The efficacy of the intervention will be determined by the hygienic conditions of the cafeteria and the composition of the menu offered, also considering the levels of processing of food sold. All outcomes will be analyzed as intention-to-treat and per-protocol. We will use covariance analysis or a generalized linear model for continuous data and ordinal logistic regression for ordinal categorical data. The level of statistical significance considered will be P<.05 for a 95% CI.

Results

This project was funded in early 2018. We administered the intervention program in 2019. All data have already been collected, and we are analyzing the data. The results are expected in 2021.

Conclusions

To our knowledge, this may be the first randomized controlled study in school cafeterias held in Brazil. The results will provide evidence for the formulation of public food and nutritional security policies and for the development of effective strategies to provide safe and healthy school meals.

Trial Registration

Brazilian Clinical Trials Registry RBR-9rrqhk; https://ensaiosclinicos.gov.br/rg/RBR-9rrqhk

International Registered Report Identifier (IRRID)

DERR1-10.2196/22680

Guidelines for designing age-appropriate cooking interventions for children: The development of evidence-based cooking skill recommendations for children, using a multidisciplinary approach

Cooking interventions have been criticised for their weak designs and 'kitchen sink' approach to content development. Currently, there is no scientific guidance for the inclusion of specific skills in children's cooking interventions. Therefore, a four step method was used to develop age-appropriate cooking skill recommendations based on relevant developmental motor skills. The steps include: 1) a critical review of academic and publicly available sources of children's cooking skills recommendations; 2) cooking skill selection, deconstruction and mapping to relevant motor skills; 3) grouping the cooking skills by underlying motor skills for age appropriateness to generate evidence based recommendations; 4) establish face validity using a two-stage expert review, critique and refinement with a multidisciplinary international team. Seventeen available sources of cooking skills recommendations were identified, critiqued and deconstructed and cooking skills mapped to developmental motor skills. These new recommendations consist of 32 skills, across five age categories: 2-3 years, 3-5 years, 5-7 years, 7-9 years, and 9+ years. The proposed recommendations will strengthen programme design by providing guidance for content development targeted at the correct age groups and can act as a guide to parents when including their children in cooking activities at home.

Online Behavioral Screener with Tailored Obesity Prevention Messages: Application to a Pediatric Clinical Setting

Obesity prevention involves promoting healthy eating and physical activity across all children. Can we leverage technology to feasibly survey children's health behaviors and deliver theory-based and user-tailored messages for brief clinical encounters? We assessed the acceptability and utility of an online pediatric-adapted liking survey (PALS) and tailored messages among children receiving non-urgent care in a pediatric emergency department (PED). Two hundred and forty-five children (average age = 10 years, racially/ethnically diverse, 34% overweight/obese from measured indices, 25% of families reporting food insecurity) and their parents/caregivers participated. Each reported the child's activity and behaviors using the online PALS and received two to three messages tailored to the responses (aligned with elaboration likelihood and transtheoretical models) to motivate behavioral improvements or reinforce healthy behaviors. Most children and parents (>90%) agreed the PALS was easy to complete, encouraging thought about their own/child's behaviors. The child's PALS responses appeared reasonable (fair-to-good child-parent intraclass correlations). Most children and parents (≥75%) reported the tailored messages to be helpful and favorable for improving or maintaining the targeted behavior. Neither message type (motivating/reinforcing) nor favorability responses varied significantly by the child's weight or family's food security status. In summary, children and parents found the PALS with tailored messages acceptable and useful. The message types and responses could help focus brief clinical encounters.

Magnitude of Overweight and Obesity and Associated Factors Among Public and Private Secondary School Adolescent Students in Mekelle City, Tigray Region, Ethiopia, 2019: Comparative Cross-Sectional Study

BACKGROUND

Overweight and obesity emerged as one of the most serious public health concerns in adolescents. Overweight and obesity are problems of not only high income but also low-middle income countries. Therefore, this study aimed to assess the magnitude and associated factors of overweight and obesity among public and private secondary school adolescents in Mekelle city, Tigray, Ethiopia, 2019.

MATERIALS AND METHODS

A school-based comparative cross-sectional study was conducted in Mekelle city, from April to May 2019. A multi-stage sampling technique was used to select 858 participants. Chi-square test was checked before bivariate logistic regression analyses. All variables at a p-value <0.25 in bivariate logistic regression were entered into a multivariable logistic regression to determine the association between a set of independent variables with the dependent variable. Finally, statistical significance was declared at a p-value <0.05.

RESULTS

The magnitude of overweight and obesity in private and public schools were 11.8% and 3.9%, respectively. Consuming dinner not daily [AOR=5.3:95% CI=1.93-14.6] and working moderate-intensity sports at least 10 minutes/day continuously [AOR=0.19:95% CI=0.04-0.9] were associated factors of overweight and obesity in public school adolescent students. Being female [AOR=2.03:95% CI=1.08-3.8], time taken from home to public physical activities ≤15 minutes [AOR=3.6:95% CI=1.13-11.51], using transport from school to home [AOR=2.2:95% CI=1.06-4.18] and good knowledgeable adolescents [AOR=0.5:95% CI=0.27-0.9] were associated factors of overweight and obesity in private schools.

CONCLUSION

The magnitude of overweight and obesity was higher among private schools. Consuming dinner not daily and working moderate-intensity sports at least 10 minutes/day continuously were the associated factors for the occurrence of overweight and obesity in public school adolescent students. Being female, time taken from home to public physical activity facilities ≤15 minutes, using transport from school to home, and nutritional knowledge status of adolescents were associated factors for overweight and obesity in private school adolescent students.

Dietetic management of obesity and severe obesity in children and adolescents: A scoping review of guidelines

This scoping review describes current guidelines for the dietary management of pediatric obesity and severe obesity. Guidelines were identified via electronic searches of six databases, grey literature, and reference lists and included international clinical practice guidelines (n = 21), position papers (n = 5), and scientific/consensus statements (n = 2) produced by professional bodies and/or expert panels. All recommend multicomponent lifestyle interventions including diet, physical activity, and behavior modification as first-line treatment. Most guidelines (n = 21) recommend weight loss as a treatment goal for children and adolescents with obesity and associated comorbidities or severe obesity; 15 recommend using dietary approaches. Fourteen of 28 guidelines refer to the management of severe obesity, 10 refer to dietary approaches, and seven recommend using intensive dietary approaches. Dietary approaches to weight loss focus on caloric restriction (n = 14) with some guidelines recommending very low-energy diet (n = 4), protein-sparing modified fast (n = 2), and very low-carbohydrate/ketogenic diets (n = 2). A stronger evidence base is required for dietary management of pediatric obesity and severe obesity to improve consistency in future guidelines. Guidance on the use of dietary approaches, beyond caloric restriction, and in line with the growing evidence base on novel dietary approaches is required to facilitate personalized care and optimal patient outcomes.

Assessing Walking and Cycling around Schools

To encourage students to walk and cycle to school and ensure their health and safety, it is essential to provide safe and operationally efficient infrastructure around schools. This study used an audit tool to assess the infrastructure and environment around schools in the city of Doha, Qatar, with a particular emphasis on active transport (walking and cycling). The aim was to identify strengths, weaknesses, and areas for improvement. Twenty-two schools with varied education levels were assessed. Among all assessed categories, active transport items scored the lowest, requiring the most improvements. A detailed analysis was conducted based on school type (elementary, primary, high, and mixed-schools) and revealed similar results except for elementary schools (scored acceptable for active transport). The study revealed that adding bike lanes, installing bicycle parking, and providing good separation of travel modes are the most needed improvements at school sites. In summary, improving active transport could significantly improve the overall quality of the infrastructure around schools in Qatar. Such improvements could greatly encourage more school children to walk and cycle to school instead of being primarily dropped-off and picked up by their parents’ vehicles or school buses.

Supporting food literacy among children and adolescents: Undergraduate students apply public health nursing principles in clinical practice

Effective public health nurses excel in partnership building and program planning to address priority health concerns, such as childhood obesity and disordered eating. Worldwide, children are at risk for low food and nutrition literacy with associated patterns of low fruit and vegetable consumption. This report focuses on the application of public health nursing principles by undergraduate nursing student teams in the design and delivery of food literacy interventions among a population of children and adolescents. Over a four-year time period, the cumulative intervention reach was 640 children/adolescents. Over 75 nursing students implemented the public health nursing process in support of food literacy, gaining skills across multiple practice domains. Lessons learned from academic-community partnerships to promote food literacy among children and adolescents have direct implications for undergraduate nursing education. Chief among these implications include the growing significance of integrating nutrition in the nursing curriculum and the need for scaffolding to support clinical application of interventions beyond health teaching to address broad determinants of health.

An Update on Physical Activity Research among Children in Hong Kong: A Scoping Review

Similar to their Western counterparts, children in Hong Kong generally fail to reach the recommended levels of physical activity (PA). As an ultra-dense metropolis, Hong Kong is different from most Western cities. It is therefore important to update and appraise previous PA research in order to inform future PA promotion for Hong Kong children. Using a scoping review, the current study aimed to evaluate PA research among preschool and school-aged children in Hong Kong aged 3-12 years old who are at a critical development stage. Literature was searched from four English databases: Medline via EBSCOhost, SPORTDiscus, ERIC and PsycINFO via ProQuest; and three Chinese databases: CNKI, CQVIP and WAN-FANG. PA research among Hong Kong children published from 1 January 1997 to the searching date, 31 March 2020 was included. A total of 63 studies were identified, with the majority of studies focused on school-aged children as compared to preschoolers, adopted a cross-sectional design, using self-reported PA measures, and with small to medium sample sizes. We classified eligible studies into five main categories: (a) Health benefits of PA (k = 12). Consistent evidence on the health benefits of skeletal and cardiovascular capacity, quality of life, cognitive function, and sleep quality was revealed. However, inconsistent evidence was found on the benefits of weight-related indicators and academic performance. (b) Patterns of PA (k = 12). There is a general pattern of low levels of PA among Hong Kong children, in particular girls and children with special educational needs. (c) Measures of PA and related constructs (k = 11). The Chinese versions of self-reported measures of PA, PA-related social environment, and PA-related psychological constructs showed acceptable reliabilities and validities. (d) Correlates of PA (k = 18). The correlates of PA include physical environment, social environment, physical factors, psychological factors, and multiple correlates, which is in line with the social-ecological model. (e) Interventions for promoting PA (k = 10). PA interventions among Hong Kong children were conducted for healthy children, children with special educational needs, and children with cancer. Overall, there is a growing volume of PA research among children in Hong Kong in the recent decade. Yet, there is a lack of high-quality research for measuring, understanding, and promoting PA among Hong Kong children. It is highly recommended that future PA research among children should pay more attention on the preschoolers, adopting robust research design (e.g., randomized controlled trials), recruiting large and representative sample, and collecting device-assessed data.

Multicomponent Exercise Training Combined with Nutritional Counselling Improves Physical Function, Biochemical and Anthropometric Profiles in Obese Children: A Pilot Study

Aerobics or strength exercise plus diet interventions have been shown to counteract childhood obesity. However, little is known with regard to periodized multicomponent exercise interventions combined with nutritional counselling, which might be less demanding but more enjoyable and respectful of children and adolescents’ nature. In order to analyze the impact of such a multimodal approach, 18 obese children (10.8 ± 1.6 years; 63% females; z Body Mass Index 3 ± 0.4) trained for 60 min, twice weekly and were measured for body composition, biochemical parameters and physical function. We found that 16 weeks of multimodal intervention (14 of training), based on fun-type skill-learning physical activities and physical conditioning with challenging circuits and games, together with nutritional counselling, led to an attendance > 80%, with significant overall health improvement. Body composition was enhanced (p < 0.01 for z BMI, mid-upper-arm-circumference, waist-to-height ratio, tricipital and subscapular skinfolds, body-fat % by Slaughter equation and Dual energy X-ray absorptiometry body fat% and trunk fat%), as well as metabolic profile (LDL cholesterol, gamma-glutamyl transferase , alanine aminotransferase ; p < 0.05), homeostatic model assessment of insulin resistance (HOMA-IR; p < 0.05) and inflammatory response (C-Reactive Protein; p < 0.05). Physical fitness was also improved (p < 0.01) through better cardiovascular test scores and fundamental movement patterns (Functional Movement Screen-7, FMS-4). Tailoring multimodal supervised strategies ensured attendance, active participation and enjoyment, compensating for the lack of strict caloric restrictions and the low volume and training frequency compared to the exercise prescription guidelines for obesity. Nutritional counselling reinforced exercise benefits and turned the intervention into a powerful educational strategy. Teamwork and professionals’ specificity may also be key factors.

Strengthening national nutrition research: rationale and options for a new coordinated federal research effort and authority

BACKGROUND

The US faces remarkable food and nutrition challenges. A new federal effort to strengthen and coordinate nutrition research could rapidly generate the evidence base needed to address these multiple national challenges. However, the relevant characteristics of such an effort have been uncertain.

OBJECTIVES

Our aim was to provide an objective, informative summary of 1) the mounting diet-related health burdens facing our nation and corresponding economic, health equity, national security, and sustainability implications; 2) the current federal nutrition research landscape and existing mechanisms for its coordination; 3) the opportunities for and potential impact of new fundamental, clinical, public health, food and agricultural, and translational scientific discoveries; and 4) the various options for further strengthening and coordinating federal nutrition research, including corresponding advantages, disadvantages, and potential executive and legislative considerations.

METHODS

We reviewed government and other published documents on federal nutrition research; held various discussions with expert groups, advocacy organizations, and scientific societies; and held in-person or phone meetings with >50 federal staff in executive and legislative roles, as well as with a variety of other stakeholders in academic, industry, and nongovernment organizations.

RESULTS

Stark national nutrition challenges were identified. More Americans are sick than are healthy, largely from rising diet-related illnesses. These conditions create tremendous strains on productivity, health care costs, health disparities, government budgets, US economic competitiveness, and military readiness. The coronavirus disease 2019 (COVID-19) outbreak has further laid bare these strains, including food insecurity, major diet-related comorbidities for poor outcomes from COVID-19 such as diabetes, hypertension, and obesity, and insufficient surveillance on and coordination of our food system. More than 10 federal departments and agencies currently invest in critical nutrition research, yet with relatively flat investments over several decades. Coordination also remains suboptimal, documented by multiple governmental reports over 50 years. Greater harmonization and expansion of federal investment in nutrition science, not a silo-ing or rearrangement of existing investments, has tremendous potential to generate new discoveries to improve and sustain the health of all Americans. Two identified key strategies to achieve this were as follows: 1) a new authority for robust cross-governmental coordination of nutrition research and other nutrition-related policy and 2) strengthened authority, investment, and coordination for nutrition research within the NIH. These strategies were found to be complementary, together catalyzing important new science, partnerships, coordination, and returns on investment. Additional complementary actions to accelerate federal nutrition research were identified at the USDA.

CONCLUSIONS

The need and opportunities for strengthened federal nutrition research are clear, with specific identified options to help create the new leadership, strategic planning, coordination, and investment the nation requires to address the multiple nutrition-related challenges and grasp the opportunities before us.

Dietary Knowledge, Dietary Adherence, and BMI of Lebanese Adolescents and Their Parents

Paediatric obesity is a severe public health problem accompanied by several physical and mental complications, mainly due to an imbalance between energy input and output. Dietary behaviours are influenced by many demographic factors and determinants, such as the place of residence and the level of dietary knowledge of the children and their parents. The aim of the current paper is to assess the levels of dietary knowledge, dietary adherence (in relation to recommendations), and the body mass index (BMI) of Lebanese adolescents in association with demographic variables, their parents’ dietary knowledge and adherence levels, and with other lifestyle behaviours. This cross-sectional study included 1535 Lebanese adolescents aged 15 to 18 years, from 16 public and private high schools located in urban and rural regions, and 317 of their parents. Our results showed that 30.2% of the adolescents were overweight or obese. Participants enrolled in private schools and those living in urban regions had a significantly higher BMI z-score compared to those enrolled in public schools and living in rural regions, respectively. In addition, Lebanese adolescents generally had low levels of dietary knowledge and 32.4% had low levels of dietary adherence. Their dietary adherence was significantly associated with their parents’ dietary adherence. The findings underline the significant role of the parents in shaping their children’s eating behaviours, in addition to the other determinants and factors affecting the diet of Lebanese adolescents. As the prevalence of paediatric overweight and obesity has reached alarming rates, the results of the current study have important implications for both public health policies and obesity prevention interventions in the Middle East and worldwide.

Obesity: Assessment and prevention: Module 23.2 from Topic 23 "Nutrition in obesity"

Obesity is one the major health problems of today showing an increasing prevalence among most countries. It is associated with increased risk of several diseases. The importance of early life strategies in the prevention of obesity is well established, whereas, in general, breastfed infants tend to have a lower body mass index (BMI) than formula-fed infants. There seem to be a series of behavioral and hormonal mechanisms that explain this difference. Lifestyle plays a crucial role in the development of overweight and/or obesity and targeted lifestyle modifications have an important impact on preventing obesity. In particular, sedentary behavior (viewing television, playing video games, doing cognitive work, and listening to music) and reduced overall physical activity along with shorter sleep duration promote the overconsumption of dietary macronutrients leading to obesity; at the same time physical activity or exercise in a sufficient dose seems to better facilitate long-term maintenance of new lower body weight. There is enough discussion about a potential effect of nutrients on obesity. Nevertheless, the most the crucial parameter regarding weight loss and prevention of obesity is to achieve a negative energy balance. In regard to specific diet regimes, again energy balance rather that any specific macronutrients composition and/or favoring of low glycemic index products, seems to be have a stronger effect on maintenance of lower weight after 12 months. It has to be noted, that for specific sup groups, obesity or overweight might be showing some favorable trends in survival. In particular, "obesity paradox" (OP) refers to an overall prognosis that is no worse and may even be better in some groups than non-obese patients. The OP could be explained by the fact that current classifications of obesity based on BMI may place together, in the same category, subjects with very different clinical and biochemical characteristics.

Healthy Body, Healthy Mind: A Mindset Intervention for Obese Youth

As growth mindset intervention research continues to develop, more work is needed to understand how to most effectively implement these interventions to encourage healthy cognitions and behaviors. The present study details the initial testing of a single-session, online mindset intervention (Healthy Body, Healthy Mind) for obese children and adolescents enrolled in obesity treatment clinics. Using a pre to post-test design, results indicated that growth mindsets of health and cognitions related to health behavior (nutrition and exercise self-efficacy and perceived control) increased significantly. However, despite efforts to mitigate feelings of culpability, blame also increased from pretest to post-test. Yet, body dissatisfaction decreased significantly. Intrinsic value for health behaviors remained unchanged from pretest to post-test. Analysis of narratives suggests that youth were engaged with the intervention content. Additionally, when youth's narratives incorporated themes related to the changeable nature of the attribute, they also self-reported stronger growth mindsets. In the discussion, we note implications of findings for the development of large-scale health-based growth mindset interventions that are developmentally-appropriate for children and adolescents.

The Effects of Parental Emotion Regulation Ability on Parenting Self-Efficacy and Child Diet

Child weight issues can be emotionally challenging for parents. The purpose of this study was to examine how parents' ability to manage negative emotions may facilitate parenting self-efficacy and healthy parenting behaviors (e.g., providing healthy food for a child). In this study, parents (N = 159) of a 6-12-year-old child completed a health-specific parenting self-efficacy questionnaire and retrospectively reported their child's daily servings of fruits and vegetables and sweets and soda. They also completed a parental emotion regulation task where they viewed film clips of families struggling with child weight challenges. During this task, parents managed their emotions by either positively reframing the situation to feel less negative (down-regulate negative emotions) or negatively reframing the situation to feel more negative (up-regulate negative emotions). We tested a mediation model examining the relations among parent emotion regulation, parenting self-efficacy, and child dietary habits. Results revealed that parents' ability to down-regulate negative emotions was associated with lower parenting self-efficacy, which in turn was associated with greater sweets and soda consumption among children. In contrast, parents' ability to up-regulate negative emotions was directly associated with lower sweets and soda consumption, regardless of parenting self-efficacy. Our findings have implications for healthcare practice and child weight interventions as they underscore the importance of helping parents consider the consequences of childhood obesity to encourage healthy eating behavior in families.

Changes in association between school foods and child and adolescent dietary quality during implementation of the Healthy, Hunger-Free Kids Act of 2010

PURPOSE

The purposes of the study were to estimate the effect of Healthy, Hunger-Free Kids Act of 2010 (HHFKA) implementation on dietary quality of all U.S. school-aged children and adolescents and examine whether those effects differed by the demographic group.

METHODS

We used survey regression on 2007-2016 National Health and Nutrition Examination Survey data to estimate the proportion of energy intake from school foods and the association between school food intake and dietary quality, before and after HHFKA passage/implementation. To account for demographic changes in the U.S. population over time, inverse probability weighting was used. The product of the proportion of energy from school foods and the association between school food intake and dietary quality estimated the effect of HHFKA implementation on dietary quality.

RESULTS

School food intake quantity remained stable during the study period. HHFKA implementation improved students' dietary quality by 4.3 Healthy Eating Index-2010 points (95% confidence interval: 2.5, 6.1) on days when school foods were eaten and by 1.3 Healthy Eating Index-2010 points (95% confidence interval: 0.73, 1.8) averaged over all days annually.

CONCLUSIONS

HHFKA implementation improved the total dietary quality of U.S. school students. U.S. students would benefit from eating school meals in the post-HHFKA era, and HHFKA regulations should not be relaxed.

Changes in Lifestyle Habits among Adolescent Girls after FitSpirit Participation

Adolescence is a crucial time in the development and maintenance of lifestyle habits. Interventions to improve health-related behaviors are important, including those that can contribute to an increase in physical activity (PA). During adolescence, PA typically decreases with age, particularly in girls. The FitSpirit program offers services that help Canadian schools from Quebec and Ontario implement PA interventions for adolescent girls. This study aimed to evaluate changes in participants' PA levels and lifestyle habits (sedentary time, sleep duration and eating habits) and to assess whether these changes depended on adherence to the Canadian 24-Hour Movement Guidelines and Canada's Food Guide recommendations at enrollment. At the time of FitSpirit registration (between December 2018 and March 2019) and in May/June 2019, 73 participants answered online questionnaires. The participants reported improvements, with an increase in the number of days with PA and a decrease in daily consumption of sweets. The greatest changes were observed in those who did not adhere to the Canadian recommendations before enrollment and who significantly increased their number of days with PA and their consumption of fruits and vegetables, and decreased their screen time. In conclusion, participation in FitSpirit improved several health behaviors among adolescent girls, particularly those who did not comply with the Canadian recommendations at enrollment.

Clinical audit in the pediatric primary care office and overweight prevention in toddlers

BACKGROUND

Clinical audit is a process by which physicians or other health care professionals perform a regular and systematic review of their clinical practice and amend it, when necessary. An internal audit allows to review the activities carried out by professionals, in order to assess the appropriateness, effectiveness, efficiency and safety of the services provided. Aim of this study was to apply the process of clinical audit to the obesity/overweight care in toddlers. After the correction of the nutritional errors that were considered potentially responsible for the excess weight gain, the effect of the changes of dietary advice on the frequency of overweight/obesity was assessed in a cohort of children aged 24-36 months.

METHODS

Three Italian primary care pediatricians set up the audit strategy by recognizing the high prevalence of overweight and obesity in the entire cohort of toddlers born in 2005, 2006 and 2007 (Pre-Audit group, age 24-36 months old) under their care. By reviewing their clinical practice, they changed the protocol of weaning and feeding up to 36 months, mainly reducing protein and sugar excess. The change involved the cohorts of toddlers born in the years 2010, 2011 and 2012 (Post-Audit group).

RESULTS

Change in the approach of pediatricians to children's diet yielded a reduction of the frequency of overweight/obesity in children between 24 and 36 months of life from 26.3% in the Pre-Audit group to 13.9% in the Post-Audit group (p < 0.0001).

CONCLUSION

Clinical audit revealed high rates of obesity/overweight among toddlers. The practice developed a new strategy for nutritional counseling, which was effective in reducing the frequency of overweight/obesity in young children.

Associations between appetitive traits, dietary patterns and weight status of children attending the School Kids Intervention Program

BACKGROUND

The nexus between appetitive traits, dietary patterns and weight status has predominantly been studied in a mixed sample (healthy weight, overweight and obese sample).

AIM

This cross-sectional study examined associations between overweight/obese children's appetitive traits, dietary patterns and weight status.

METHODS

We studied children (N = 58, body mass index z-score: 2.25±0.46), 4-12 years attending the School Kids Intervention Program. Children's appetitive traits and dietary patterns were measured with the Child Eating Behaviour Questionnaire and Children's Dietary Questionnaire, respectively. Children's height and weight were used to compute body mass index z-score; waist circumference was also measured and waist-to-height ratio was calculated.

RESULTS

After controlling for children's age and gender, hierarchical linear regression analyses showed that lower scores for slowness in eating were associated with higher body mass index z-scores in children (β = -0.31, p = 0.01). Higher scores for emotional overeating were associated with higher waist-to-height ratio in children (β = 0.48, p = 0.01). Higher scores for fussiness were correlated with lower scores for fruits and vegetables (β = -0.59, p < 0.001) and higher scores for non-core foods (β = 0.26, p = 0.04).

CONCLUSION

Results observed in the current sample of overweight and obese children are consistent with previous studies examining healthy-weight children. Slowness in eating may foster an obesity 'protective' effect, whereas emotional overeating may promote susceptibility to weight gain. Fussy eating may impair diet quality by lower consumption of vegetables and fruits and higher intake of non-core foods. This evidence will support dietitians to consider children's appetitive traits when providing dietary consultation to support obesity management among overweight/obese children.

Designing a mobile app to promote healthy behaviors and prevent obesity: analysis of adolescents' preferences

To ensure that adolescents adhere to programmes promoting healthy behaviors, these programmes must be appealing and interesting. This study aims to characterize and assess the devices, operating system and type of mobile apps frequently used by adolescents; understand the features that mHealth apps should have to be appealing; comprehend the facilitators and barriers for adolescents to use mHealth apps. The sample comprised 165 adolescents (12-18 years) from the main population, recruited in 2018. Most participants used smartphones and the Android system. Food and physical activity suggestions were considered the most important features for an mHealth app. 62.6% had never tried an mHealth app. For those who had tried one, 26.0% stated it was to improve health status/lifestyle. Their favorite feature was physical exercise tips/plans (41.8%). Adolescents pointed out that the reasons that made them keep using the app were utility and interest (35.7%). Regarding possible barriers, 48.4% reported a lack of a senseof need/practical utility, and 18.8% considered notifications as their least favorite feature. Lack of interest was pointed out for 38.2% as the main reason for stopping use. Results provide practical information for the planning, design, and implementation of future mHealth apps for the promotion of healthy behaviors - an important implication for future research in this area.

Community-level obesity prevention is not associated with dieting behaviours and weight dissatisfaction in children: The Healthy Communities Study

BACKGROUND

Within the context of high childhood obesity prevalence, there is a concern that community efforts intended to reduce childhood obesity may lead to unintended adverse outcomes.

OBJECTIVE

This analysis examined relationships between community programs, policies, and environmental changes (CPPs) for obesity prevention with unhealthy dieting behaviours and body weight satisfaction in children.

METHODS

Using the Healthy Communities Study 2013 to 2015 survey sample of 5138 US children aged 4 to 15 years old, multilevel models examined associations between standardized CPP intensity scores and child dieting behaviours and weight satisfaction, adjusting for community and child-level covariates and clustered study design.

RESULTS

In fully adjusted models, higher total, physical activity, and nutrition CPP intensity scores were associated with lower odds of dissatisfaction with weight (1 year total CPP odds ratio [OR]: 0.41, 95% confidence interval [CI], 0.22-0.73; 6 year total CPP OR: 0.48, 0.29-0.80). Higher physical activity CPP intensity over the past year was associated with greater odds of weight satisfaction (OR: 1.77, 95% CI, 1.10-2.84). No associations were observed with dieting behaviours.

CONCLUSIONS

Results suggest that community efforts focusing on nutrition and physical activity to prevent childhood obesity may be associated with weight satisfaction and not with unhealthy dieting behaviours.

School-based nutrition interventions for Indigenous children in Canada: a scoping review

Background

Indigenous children in Canada (First Nations, Inuit, and Métis) are disproportionately affected by nutrition-related chronic diseases such as obesity and diabetes. Comprehensive school-based nutrition interventions offer a promising strategy for improving children’s access to healthy foods and sustaining positive eating behaviors. However, little is known about school-based nutrition interventions for Indigenous children. The objectives of this scoping review were to identify school-based nutrition interventions for Indigenous children in Canada and describe their components.

Methods

The scoping review consisted of searches in seven peer-reviewed databases and a general web search for grey literature. Eligibility criteria were applied by two reviewers, and data were extracted and charted by one reviewer using components of the comprehensive school health approach (social and physical environment, teaching and learning, policy, partnerships and services) and additional components with relevance to Indigenous interventions (cultural content, Indigenous control and ownership, funding source, evaluation). Numerical and descriptive summaries were used to present findings.

Results

Thirty-four unique interventions met the inclusion criteria. The majority (97%) of interventions targeted the social and physical environment, most often by offering food programs. Over half of interventions also incorporated teaching and learning (56%) and partnerships and services (59%), but fewer included a policy component (38%). Many interventions included a cultural component (56%) and most (62%) were owned and controlled by Indigenous communities (62%). Finally, over half of interventions disclosed their source(s) of funding (59%), but less than half (41%) included an evaluation component.

Conclusions

The review suggests that school-based interventions for Indigenous children can be more comprehensive by incorporating culturally relevant nutrition education and professional development opportunities for teachers, written school nutrition policies, and activities that actively engage families and community members. The continued focus on Indigenous control and ownership and incorporation of content specific to individual communities may enhance cultural relevancy and sustainability of interventions. Furthermore, there is a need to increase intervention evaluation and the sharing of resources related to funding. These recommendations may be used by communities, as well as by researchers and professionals working with communities, in developing comprehensive school-based nutrition interventions to improve the eating behaviors of Indigenous children.

[Adherence to the Mediterranean diet, and importance in the physical activity and screen time in High School adolescents from Extremadura (Spain)]

Introduction

Introduction: in Spain, one third of young people from 7 to 14 years of age are overweight or obese. Health-related behaviors such as a high level of physical activity, low screen time, and good eating habits can prevent overweight and obesity in young people. Objectives: to assess adherence to the Mediterranean diet and quality of food pattern in an adolescent sample from Extremadura (Spain). Method: the present research is a cross-sectional, descriptive study in 1566 adolescents aged 12-14 years, 857 boys (13.12 ± 0.89) and 709 girls (13.05 ± 0.82). Physical activity was measured through the physical activity questionnaire for adolescents (PAQ-A). Screen time was analyzed through the youth leisure-time sedentary behaviour questionnaire (YLSBQ). Adherence to the Mediterranean diet was calculated using the KIDMED questionnaire. Results: 24.5 % of adolescents reported having good adherence to the Mediterranean diet. The youngest schoolchildren (p < 0.001) had a better eating pattern, with no difference between genders or body mass indices. Students who met recommendations for physical activity and screen time had greater adherence to the Mediterranean diet (p < 0.01). Conclusions: results showed that most children and adolescents needed to improve their eating pattern. Participants who met the recommendations for physical activity and screen time showed greater adherence to the Mediterranean diet.

Nutrition Assessment and Intervention in a Pediatric Patient with Angelman Syndrome: A Case Presentation Highlighting Clinical Challenges and Evidence-Based Solutions

BACKGROUND

Angelman syndrome (AS) is a rare disorder of genetic imprinting which results in intellectual and developmental disability. It meets criteria of a disorder of neurologic impairment. A deletion in the long arm of chromosome 15 (del 15q11.2-q13) is responsible for about 70% of cases of AS (deletion genotype).

SUMMARY

There is a paucity of evidence to allow algorithmic nutrition assessment and intervention in pediatric patients with AS. Therefore, our objective is to use a case presentation to provide an example of nutrition assessment and intervention in a pediatric patient with the deletion genotype of AS and then highlight common challenges to providing evidenced-based nutrition care. For the highlighted challenges, we suggest evidence-based solutions to provide a resource for clinicians who may encounter similar challenges in clinical practice. Key Messages: There are genotype-phenotype correlations in AS that can help guide clinicians regarding nutritionally relevant clinical characteristics and corresponding interventions that are patient specific. The deletion genotype in AS is associated with multiple characteristics that are relevant to nutrition care and may also be different and/or more severe than characteristics seen in other AS genetic mechanisms. There is also overlap in certain nutritionally relevant clinical characteristics between AS and other conditions, including Prader-Willi syndrome, autism spectrum disorders, and disorders of neurological impairment like cerebral palsy. Clinicians can utilize nutrition resources related to these conditions to expand the scope of relevant resources available.

Nutritional Management in Childhood Obesity

The increasing prevalence of overweight and obese children and adolescents poses a major concern worldwide. Dietary practice in these critical periods affects physical and cognitive development and has consequences in later life. Therefore, acquiring healthy eating behaviors that will endure is important for children and adolescents. Nutrition management has been applied to numerous childhood obesity intervention studies. Diverse forms of nutrition education and counseling, key messages, a Mediterranean-style hypocaloric diet, and nutritional food selection have been implemented as dietary interventions. The modification of dietary risk in terms of nutrients, foods, dietary patterns, and dietary behaviors has been applied to changing problematic dietary factors. However, it is not easy to identify the effectiveness of nutritional management because of the complex and interacting components of any multicomponent approach to intervention in childhood obesity. In this review, we describe the modifiable dietary risk factors and nutritional components of previous nutrition intervention studies for nutritional management in childhood obesity. Furthermore, we suggest evidence-based practice in nutrition care for obese children and adolescents by considering obesity-related individual and environmental dietary risk factors.

Using Physiologic, Genetic, and Epigenetic Information to Provide Care to Clients Who Are Obese

The pathology of obesity is a complex process involving interactions among behavioral, environmental, immunologic, genetic, and epigenetic factors. This article gives a broad overview of obesity. The physiology of fat storage, influence of eating behaviors on obesity, and the genetic relationship between eating and food sources are discussed. Specific genes that have been associated with obesity are introduced, with information on leptin and genes such as FTO, GLUT4, and others. This synopsis of obesity expands into environmental influences and epigenetic factors. These include food selection, gut microbiota, pregnancy, and exercise. The nurse will gain specific knowledge to assist in tailoring therapies specific to clients who are working to overcome the long-term effects of this disorder.

Partnering Support Interventions with Bariatric Surgery to Maximize Health Outcomes in Adolescents with Severe Obesity

OBJECTIVE

Rates of adolescents with severe obesity continue to rise worldwide, with concurrent increases in metabolic and bariatric surgery (MBS) uptake. The gap between support (lifestyle, pharmacotherapy) interventions and MBS as treatment options for adolescents has been understudied. This review, couched in a socio-ecological framework, investigates how support interventions for adolescents with severe obesity could be combined or sequenced with MBS to optimize health outcomes.

METHODS

A comprehensive search revealed 36 published articles between 1995 and 2019 that included the combination of support interventions and MBS among adolescents.

RESULTS

There were no studies that specifically reported outcomes or effect sizes for the combination of lifestyle intervention with MBS. Previous studies have reported individual results for either lifestyle intervention or MBS but not for their compound effect.

CONCLUSIONS

As rates of adolescents with severe obesity are on the rise globally, future research should focus on how partnering support interventions with MBS can amplify positive short- and long-term health outcomes and within a socio-ecological framework. Understanding the sequence of these approaches will be of particular importance. High-risk and vulnerable populations such as ethnic minorities who have suffered a disproportionate burden of the obesity epidemic must be included in rigorously tested future trials of combination interventions to maximize health outcomes worldwide.

Uso temprano de antibióticos en la infancia y obesidad pediátrica: revisión sistemática de la literatura

Introducción: la prevalencia de obesidad en el mundo es creciente y específicamente la obesidad en niños se ha convertido en un problema de salud pública que preocupa a varios países. La evidencia ha señalado al uso de antibióticos en la infancia como un factor relacionado con la presencia de obesidad infantil.Objetivo: Analizar sistemáticamente la evidencia reciente acerca de la relación entre el uso temprano de antibióticos en la infancia y la presencia de obesidad infantil.Métodos: Se realizó una búsqueda bibliográfica en las bases de Pubmed, Ovid, EBSCO, Lilacs, JAMA pediatrics de estudios observacionales en los últimos diez años que abordaran la relación entre el uso de antibióticos antes de los 24 meses de edad y la obesidad infantil.Resultados: Luego de realizar el tamizaje de los artículos, se seleccionaron 9 para la síntesis cualitativa. Con dos excepciones, los estudios analizados muestran una relación estadísticamente significativa entre el uso temprano de antibióticos y la obesidad o sobrepeso infantil, medido como peso para la edad o mediante el índice de masa corporal y aún con el ajuste por las potenciales variables de confusión, esta asociación permanece siendo estadísticamente significativa, debido a algunos de los diseños epidemiológicos, no se puede verificar la relación de antecedencia temporal de la exposición. 

Estimated Physical Activity in Adolescents by Wrist-Worn GENEActiv Accelerometers

BACKGROUND

Reports of physical activity (PA) measured via wrist-worn accelerometers in adolescents are limited. This study describes PA levels in adolescents at baseline of an obesity prevention and weight management trial.

METHODS

Adolescents (n = 930) at 8 high schools wore an accelerometer for 7 days, with average acceleration values of <50 mg, >150 mg, and >500 mg categorized as sedentary, moderate, and vigorous PA, respectively. In a 3-level mixed-effects generalized linear model, PA was regressed on sex, weight status, and day of week. Daily PA was nested within students, and students within schools, with random effects included for both.

RESULTS

Adolescents accumulated a median of 40 minutes daily of moderate to vigorous PA (MVPA). MVPA was significantly different for teens with obesity versus teens with normal weight (-5.4 min/d, P = .03); boys versus girls (16.3 min/d, P < .001); and Sundays versus midweek (-16.6 min/d, P < .001). Average sedentary time increased on weekends (Saturday: 19.1 min/d, P < .001; Sunday: 44.8 min, P < .001) relative to midweek but did not differ by sex or weight status.

CONCLUSIONS

Interventions to increase PA in adolescents may benefit from focusing on increasing weekend PA and increasing MVPA in girls.

Do Schools That Screen for Body Mass Index Have Recommended Safeguards in Place?

The Centers for Disease Control and Prevention recommends that schools adopt 10 safeguards before launching a body mass index (BMI) screening program; however, little is known about schools' safeguard adoption. Authors identified questions from the 2014 School Health Policies and Practices Study that aligned with 4 of the 10 safeguards to estimate safeguard prevalence among schools that screened students for BMI (40.7%, N = 223). Among these schools, 3.1% had all four safeguards and 56.5% had none or one. The most prevalent safeguard was having reliable and accurate equipment (54.1%, 95% confidence interval [CI] = [46.1, 62.1]). Providing staff with appropriate expertise and training was the least prevalent; respondents in 26.4% (95% CI [17.1, 35.6]) of schools received recent training on weight status assessment, weight management, and eating disorder identification. School-based BMI screening is common, but adopting multiple recommended safeguards is not. Absent these safeguards, BMI screening programs may fall short of intended outcomes and potentially incur unintended consequences.

Evidence-based Nutritional Intervention Protocol for Korean Moderate-Severe Obese Children and Adolescents

Diet-related behavioral modification for healthy eating and lifestyle is required to improve childhood obesity. The present study aimed to develop customized nutritional intervention protocol and education program to find barriers to adhere healthy diet and lifestyle for moderate to severe obese children and adolescents and their families. Theoretical framework approaches can be used to change behavior and achieve goals. Previous studies that described the relationship between behavioral modification and nutrition education theory were reviewed. The social cognitive theory and transtheoretical model were employed with behavioral changes to target a healthful diet and lifestyle. The nutrition care process (NCP) model was adopted to customize nutrition care for the participants. Customized nutritional intervention protocol was developed following as the four steps of the NCP. Firstly, nutrition status of the participants was assessed by the nutrition expert. Nutrition problems were described as "inadequate energy intake," "overweight/obesity," or "food and nutrition-related knowledge deficit." All nutrition sessions were designed for nutrition intervention to give nutritional knowledge and a practical mission in real life for individual goal setting and self-control. Meal planning, portion control, healthy snack selection and cooking with fruits and vegetables were consisted of five components of the nutrition education session. During each session, the participants and their families were interviewed by a nutrition expert for monitoring and evaluating diet-related goal setting and achievement. A theoretical and evidence-based nutritional intervention was developed for the secondary to tertiary prevention of childhood obesity. This nutrition intervention protocol and program might be helpful for the further research on childhood obesity.

Trial Registration

Clinical Research Information Service Identifier: KCT0002111.

Costs of Preparing to Implement a Family-Based Intervention to Prevent Pediatric Obesity in Primary Care: a Budget Impact Analysis

The costs associated with implementing evidence-based programs for pediatric obesity contribute to a lack of widespread adoption. This study examined the costs of preparing to implement the Family Check-Up 4 Health (FCU4Health), a family-centered behavioral program for the prevention of pediatric obesity and excess weight gain in primary care. Budget impact analysis was used to estimate the cost of preparing to implement FCU4Health (i.e., the activities to prepare for, but prior to, offering the service to families). Electronic cost capture methods were used to prospectively track personnel time associated with implementation preparation activities. We also estimated the cost of replicating these preparatory activities to inform future decisions to adopt the program and associated budgetary planning. The total cost of FCU4Health implementation preparation in three clinics and developing delivery materials and infrastructure was $181,768, for an average of $60,589 per clinic. Over two thirds of the total cost were personnel related, the largest of which was associated with the time spent developing automated fidelity coding for monitoring (20%), developing and tailoring clinical materials (16%), and training FCU4Health coordinators (15%). Due to these development costs associated with an initial implementation, that we anticipate would not be repeated in full, we estimated the cost to prepare FCU4Health for implementation in a future initiative will range from $15,195 to $17,912 per clinic. This study is a critical step towards equipping decision-makers with comprehensive short-term information about expected costs that are incurred immediately after choosing to adopt an evidence-based program.

Long-term effect of feeding snacks at age 6 years on body mass index at ages 12 and 22 years

We investigated the effect of snacking habits in childhood on changes in body mass index (BMI) and high BMI in adolescence and adulthood. In total, 2141 Japanese children from the Ibaraki Children's Cohort Study were evaluated at age 6 years (baseline), then at ages 12 and 22 years. We examined associations between snacking (scheduled times, when children wanted, and freely) at age 6 years and changes in BMI over time and the proportion of high BMI at ages 12 and 22 years, using time-dependent mixed-effects and logistic regression models. Compared with children who snacked at scheduled times, those provided snacks when they wanted experienced larger increases in BMI over time between ages 6 and 22 years (multivariable time-dependent effect: 0.03 kg/m² for boys, p = 0.047; 0.04 kg/m² for girls, p = 0.019). No differences were observed in children who snacked freely. A higher proportion of high BMI was found in boys who were provided snacks when they wanted compared with those who snacked at scheduled times. The multivariable odds ratio (95% confidence interval) was 1.52 (1.04-2.23) at age 12 years and 2.23 (1.12-4.45) at age 22 years. No differences were observed for girls at either age. Children who were provided snacks when they wanted showed larger increases in BMI over time compared with those who snacked at scheduled times. Boys who were provided snacks when they wanted showed the higher proportion of high BMI at follow-up.

Efficacy of very low-energy diet programs for weight loss: A systematic review with meta-analysis of intervention studies in children and adolescents with obesity

The objective of this review was to evaluate the efficacy and safety of very low-energy diet (VLED) programs for weight loss in children and adolescents with obesity. Six electronic databases were searched identifying 24 eligible studies (16 pre-post studies, four nonrandomized trials, two randomized controlled trials [RCTs], and two chart reviews) published up to October 2018. Studies were in English, implemented a VLED (≤3360 kJF/day [≤800 kcal/day] or <50% estimated energy requirements) in 5- to 18-year-olds with obesity, and reported at least one weight-related outcome. Weight-related outcomes significantly improved postintervention in all studies. Meta-analysis of 20 studies indicated a mean 10.1 kg (95% confidence interval [CI], 8.7-11.4 kg, P < 0.001; I²  = 92.3%) weight loss following interventions lasting 3 to 20 weeks. Moderator analysis indicated greater weight loss in adolescent-only studies (10-18 years) and formulated meal replacement interventions and inpatient settings. Meta-analysis of seven studies reporting weight at follow-up (5-14.5 months from baseline) indicated 5.3 kg mean weight loss (CI, 2.5-8.0 kg, P < 0.001; I²  = 50.6%). Details of adverse events were limited. VLED programs are effective for treating children and adolescents with obesity. However, conclusions on their safety cannot be drawn from the existing literature at this time. Future studies should include long-term follow-up with ongoing support and comprehensive monitoring of all adverse events.

The development of child and adult care food program best-practice menu and training for Native American head start programs: The FRESH study

New Child and Adult Care Food Program (CACFP) meal patterns and best practices were implemented nationally in 2017 to address the shift in dietary need from ensuring essential nutrient consumption to chronic disease prevention. Young American Indian (AI) children have disproportionately higher risk of chronic disease. Some AI tribes operate early care and education (ECE) programs and have the opportunity to participate in the CACFP. The purpose of this paper is to describe a CACFP best-practice menu and training developed and implemented as part of the Food Resource Equity and Sustainability for Health (FRESH) study, a community-based participatory research (CBPR) intervention implemented within ECE programs in the Osage Nation of Oklahoma. Site managers and cooks from each of the nine ECE programs attended meetings and provided investigators with feedback that shaped the best-practice menu and training. Each site participated in a three-hour training in January 2018 to discuss the best-practice menu and ways to overcome implementation barriers. Goals of the menu aimed to increase intake of fruit and vegetables and whole grains and reduce pre-fried and processed foods without increasing cook burden. Training included application activities individually and in small and large groups. Though the project is still underway, lessons learned, including the need for technical assistance, improved communication between ECE program staff and food supply vendors, and infrastructure barriers (e.g., limited space, lack of supplies) that challenge workflow, have emerged. Efforts to improve menus in rural and low-income ECE programs must consider these issues in developing feasible intervention strategies.

[Emotional therapies for overweight or obesity]

Obesity has become a public health problem. But care, mainly diets, is often ineffective over the long term. Emotional therapies seem to be an interesting track especially for emotional eating. After defining two key concepts of emotional eating and acceptance, the theoretical frameworks of the different emotional therapies used in the treatment of overweight or obesity will be presented: Mindfulness-Based for Eating Disorder (MB-EAT), Acceptance and Commitment Therapy, and Acceptance-Based Behavioral Treatment for Weight Loss (ABT). The goal is to understand their usefulness in the treatment of overweight or obesity and perhaps avoid using contradictory techniques such as dieting with mindfulness. If current results are promising, the effectiveness of these therapies needs to be confirmed by new studies. Finally, the article points to the emergence of new "integrative" therapies that resemble the others presented and are related but are in fact the exact opposite. Control and acceptance are indeed antithetical.

Delivering in-school interventions to improve dietary behaviours amongst 11- to 16-year-olds: A systematic review

Childhood obesity is a global health concern, which has both short- and long-term health consequences for the individual, and is a potential burden on health care services and the wider economy. The school environment is a setting where changes can be applied to dietary behaviours, as schools have direct and intensive contact with children. This systematic review evaluated school-based interventions designed to improve dietary behaviours among adolescents (11- to 16-year-olds). The aims were to review types of interventions delivered, dietary behaviours targeted, and interventions' effectiveness in improving dietary behaviour and associated intervention components. Twenty-nine school-based interventional studies with this population were identified for review. The data were synthesized by identifying and comparing individual studies' results, intervention components, and characteristics. Interventions appeared more effective when they involved peers, used educational media to deliver health messages, increased availability of healthy foods in school, and incorporated computer-based individualized feedback with normative information on eating behaviours. A limitation of the review was the lack of description in certain reviewed studies and the nonfeasibility of conducting a meta-analysis owing to study heterogeneity. Future interventions with this population could consider including the aforementioned components, gender-specific feedback, and both short- and long-term follow-ups as change may not be apparent immediately and to determine if changes are sustained.

Nutrition Intervention to Hispanic Groups: Pilot Studies with Children and Caregivers

Childhood obesity is a pressing public health issue, especially in the Hispanic community. Two pilot studies were performed; Study 1 was performed to assess the effect of a nutrition education intervention on the nutrition-related knowledge, attitudes, and behaviors of Hispanic children in an after-school program. Nutrition educational lessons were administered 1 h per week. Evaluation was conducted as a baseline Pre-test, a Post-test (following the last session) and a 4-month follow-up. Children showed a significant decrease in the consumption of less-healthy foods from the time of the Pre-test to the Post-test measure (P < .05) and could identify healthy foods. Study 2 was performed to assess the effect of a nutrition education intervention on Hispanic children's caregivers' willingness to engage in healthy behaviors. Caregivers increased their willingness to engage in healthy behaviors (P < .05). This indicates that knowledge and attitudes about foods can be altered, and that caregiver education is needed so to ensure that healthy foods are available in a child's diet and to reinforce positive attitudes about foods.

A qualitative study examining medical provider advice, barriers, and perceived effectiveness in addressing childhood obesity to patients and families from a low-income community health clinic

Objective:

To examine medical provider (n = 16) perceptions in addressing and managing pediatric obesity with a diverse, low-income patient population.

Methods:

Semi-structured audio-recorded interviews were performed at three pediatric clinics. Transcripts were reviewed using content analysis and consensus was reached among authors for themes. Themes were grouped into categories including: (1) initiation of weight discussions, (2) advice and perceived effectiveness, and (3) barriers.

Results:

Most providers reported being comfortable addressing weight and use a variety of methods to initiate conversations; however, many challenges were reported, which include limited time and parent misperceptions of child’s weight. A broad range of lifestyle advice was utilized, but preference to discuss physical activity over nutrition was reported.

Conclusion:

Results suggest that successful management of children’s weight involves addressing issues at both the parent and the provider levels. Improved nutrition resources or training for providers is suggested; however, time must also be available for individualized counseling. Incorporation of registered dietitians may also reduce the burden.

Current Recommendations for Nutritional Management of Overweight and Obesity in Children and Adolescents: A Structured Framework

Nutritional management is an important component of the treatment of pediatric overweight and obesity, but clinicians struggle to keep abreast with the abundant literature. Therefore, our aim is to provide a tool that integrates the current recommendations and clinical expertise to assist dietitians and other practitioners in their decision making about the nutritional management of pediatric overweight and obesity. To construct this practice-based evidence-informed framework, we conducted a systematic review of the guidelines on nutritional management of pediatric overweight or obesity in 2 databases and in the grey literature. We analyzed and synthesized recommendations of 17 guidelines. We selected the recommendations that were common to at least 30% of the guidelines and added by consensus the recommendations relevant to clinical expertise. Finally, we structured the framework according to the Nutritional Care Process in collaboration with a specialized team of dietitians who assessed its validity in clinical practice. The framework contributes to facilitate the integration of evidence-based practice for dietitians by synthesizing the current evidence, supporting clinical expertise, and promoting structured care following Nutrition Care Process model for children and adolescents with obesity.

Clinical Considerations Regarding the Use of Obesity Pharmacotherapy in Adolescents with Obesity

A growing number of youth suffer from obesity and in particular severe obesity for which intensive lifestyle intervention does not adequately reduce excess adiposity. A treatment gap exists wherein effective treatment options for an adolescent with severe obesity include intensive lifestyle modification or metabolic and bariatric surgery while the application of obesity pharmacotherapy remains largely underutilized. These youth often present with numerous obesity-related comorbid diseases, including hypertension, dyslipidemia, prediabetes/type 2 diabetes, obstructive sleep apnea, nonalcoholic fatty liver disease, musculoskeletal problems, and psychosocial issues such as depression, anxiety, and social stigmatization. Current pediatric obesity treatment algorithms for pediatric primary care providers focus primarily on intensive lifestyle intervention with escalation of treatment intensity through four stages of intervention. Although a recent surge in the number of Food and Drug Administration-approved medications for obesity treatment has emerged in adults, pharmacotherapy options for youth remain limited. Recognizing treatment and knowledge gaps related to pharmacological agents and the urgent need for more effective treatment strategies in this population, discussed here are the efficacy, safety, and clinical application of obesity pharmacotherapy in youth with obesity based on current literature. Legal ramifications, informed consent regulations, and appropriate off-label use of these medications in pediatrics are included, focusing on prescribing practices and prescriber limits.

Prevalence and Types of School-Based Out-of-School Time Programs at Elementary Schools and Implications for Student Nutrition and Physical Activity

BACKGROUND

Out-of-school time (OST) programs are an important setting for supporting student health and academic achievement. This study describes the prevalence and characteristics of school-based OST programs, which can inform efforts to promote healthy behaviors in this setting.

METHODS

A nationally representative sample of public elementary schools (N = 640) completed surveys in 2013-2014. Administrators reported on OST programs and policies at their school. Multivariable logistic regression models estimated the prevalence of school-based OST programs, adjusting for school characteristics. Among schools with OST programs (N = 475), chi-square tests identified school characteristics associated with having an OST policy about physical activity or nutrition.

RESULTS

Three fourths of elementary schools (75.6%) had a full- or partial-year school-based OST program, with 30.8% having both. Full- and partial-year programs were significantly less prevalent in rural and township areas versus urban settings. Only 27.5% of schools with OST programs reported having physical activity and/or nutrition policies.

CONCLUSIONS

Most US elementary schools have an on-site OST program, but disparities in access exist, and most lack policies or awareness of existing policies regarding physical activity and nutrition. To maximize OST programs' potential benefits, strategies are needed to increase access to programs and physical activity and/or nutrition policy adoption.

Developing a patient-centered outcome for targeting early childhood obesity across multiple stakeholders

Background

Patient-centered outcome measures for childhood obesity are limited. Identifying outcomes that patients and families consider important could be a viable avenue for better engagement of patients and interventions that are efficacious and acceptable to patients. Latino children experience high rates of obesity, and under-recognition of obesity in preschool aged children is common.

Methods

We used growth chart data to identify low-income, Latino children 2-5 years of age with obesity who decreased their adiposity (positive deviants) and a set of controls. We used qualitative interview data to identify themes around goals parents used in addressing weight. Then, we applied a modified Delphi approach across groups of caregivers and providers to identify common goals. We conducted focus groups to explore conflicts and congruency between caregivers and providers related to goals. Using the focus group data, we developed a decision tool for use between patients and providers relevant for early childhood obesity.

Results

We identified 257 children who successfully reduced adiposity (positive deviants) from 1621 eligible growth charts. From interviews with 44 parents (21 positive deviants and 23 controls), we coded and categorized outcomes such as increased happiness, clothing size and improved activity. We recruited 81 parents, grandparents and health care providers to participate in the modified Delphi process of ranking outcomes by importance and feasibility. Focus groups (2, total n = 24) suggested potential methods for a common framework to discuss goals, including a modified growth chart. We created a decision-tool that incorporated a growth chart and a section for discussion of patient-centered goals. A final focus group (1, n = 10) provided feedback on the tool as acceptable and potentially useful.

Conclusions

The development of a patient-centered tool around achieving a healthy weight in early childhood identified common goals between providers and parents. While the tool has been developed, prospective testing of this patient-centered tool and its effects on engagement, parent motivation, and behavior change would be a useful next step.

A systematic review of strategies to reduce sugar-sweetened beverage consumption among 0-year to 5-year olds

OBJECTIVE

The objective of this study is to summarize evidence for strategies designed to reduce sugar-sweetened beverage (SSB) consumption among children aged 0 to 5 years.

DATA SOURCES

PubMed, Web of Science, EMBASE, CINAHL, ERIC, Cab Abstracts and the Cochrane Central Register of Controlled Trials are the electronic databases searched in this systematic review.

STUDY SELECTION

Each included study evaluated an intervention to reduce SSB consumption in children aged 0 to 5 years, was conducted in a high-income country and was published between 1 January 2000 and 15 December 2017.

DATA SYNTHESIS

Twenty-seven studies met the inclusion criteria. The primary intervention settings were healthcare (n = 11), preschool/daycare (n = 4), home (n = 3), community venues (n = 3) and other settings (n = 6). Overarching strategies which successfully reduced SSB consumption included (i) in-person individual education, (ii) in-person group education, (iii) passive education (e.g. pamphlets), (iv) use of technology, (v) training for childcare/healthcare providers and (vi) changes to the physical access of beverages. Studies were of moderate methodological quality (average score of 20.7/29.0 for randomized studies; 3.1/9.0 for non-randomized studies).

CONCLUSIONS

Evidence suggests that interventions successful at reducing SSB consumption among 0-year to 5-year olds often focused on vulnerable populations, were conducted in preschool/daycare settings, specifically targeted only SSBs or only oral hygiene, included multiple intervention strategies and had higher intervention intensity/contact time.

Childhood obesity prevention cluster randomized trial for Hispanic families: outcomes of the healthy families study

BACKGROUND

Obesity prevalence is disproportionately high among Hispanic children.

OBJECTIVES

The Healthy Families Study assessed the efficacy of a culturally targeted, family-based weight gain prevention intervention for Hispanic immigrant families with children ages 5-7 years.

METHODS

The study used a two-group, cluster randomized trial design, assigning 136 families (clusters) to the active intervention (weight gain prevention) and 136 families to attention control (oral health). The active intervention included a 4-month intensive phase (eight classes) and an 8-month reinforcement phase (monthly mail/telephone contact). Children's body mass index z-score (BMI-Z) was the primary outcome.

RESULTS

The BMI-Z growth rate of the active intervention group did not differ from the attention control group at short-term follow-up (median 6 months; 168 families, 206 children) or long-term follow-up (median 16 months; 142 families, 169 children). Dose response analyses indicated a slower increase in BMI-Z at short term among overweight/obese children who attended more intervention classes. Moderate physical activity on weekends increased at short term. Weekend screen time decreased at short term among those attending at least one class session.

CONCLUSION

Low class attendance likely impacted intention-to-treat results. Future interventions targeting this population should test innovative strategies to maximize intervention engagement to produce and sustain effects on weight gain prevention.