The association of eating styles with weight change after an intensive combined lifestyle intervention for children and adolescents with severe obesity

Inpatient medical management of severe pediatric obesity: Literature review and case reports

Pediatric obesity rates continue to rise steeply with significant adverse effects on health outcomes across the lifespan. Significant obesity can affect the efficacy, side effects, and ability to use certain treatment, medication, or imaging modalities needed in the evaluation and management of acute pediatric conditions. Inpatient settings are rarely used as an opportunity for weight counseling and thus there is a paucity of clinical guidelines on how to manage severe obesity in the inpatient setting. We present a literature review and three patient cases with single-center protocol for non-surgical management of severe obesity in children admitted for other acute medical reasons. We performed a PubMed review from January 2002 to February 2022 utilizing keywords: "inpatient," "obesity," and "intervention." For our cases, we identified three patients with severe obesity acutely impacting their health while admitted for medical treatment who concurrently underwent acute, inpatient, weight loss regimens at a single children's hospital. The literature search yielded 33 articles describing inpatient weight loss treatments. Three patients met case criteria, all three of which demonstrated a decrease in their weight in excess percent of the 95th percentile after inpatient weight-management protocol implementation (% reduction BMI_p95: 16%-30%). This highlights obesity acutely limits or impacts specific medical care required during inpatient admissions in pediatric patients. It also suggests that implementation of an inpatient weight-management protocol during admission may provide an opportune setting to support acute weight loss and overall improved health outcomes in this high-risk cohort.

A brief emotion regulation training in children and adolescents with obesity: A feasibility study

BACKGROUND

Recent studies emphasize the role of emotion dysregulation as an underlying mechanism initiating and maintaining emotional eating in obesity. Since multidisciplinary obesity treatment (MOT) does not directly address emotion regulation (ER), the current study aimed to investigate the feasibility of an ER training in children and adolescents with obesity on top of MOT. Feasibility was evaluated multi-informant on relevant parameters e.g. practicability, satisfaction, change in affect and homework compliance.

METHODS

Participants (N = 50, M_age = 12.26, 60.7 % girls) with obesity received a brief ER training and were assigned to one out of three conditions to learn one specific ER strategy (i.e., Cognitive reappraisal, Distraction or Acceptance). Afterwards the ER strategy was further trained by a homework assignment during 5 consecutive days. Children and adolescents, trainers and as well as the educators of the treatment center completed a feasibility questionnaire.

RESULTS

The training was positively evaluated by different informants for 11 out of 19 feasibility criteria. Only one implementation barrier was reported regarding homework compliance. Furthermore, some important considerations could be taken into account e.g. session length and motivation.

CONCLUSIONS

Reports suggest that, with some modifications, it is feasible to implement an ER training on top of MOT. In addition, future training protocols should focus on other essential components of ER (e.g., emotional awareness, emotional flexibility).

Family-based treatment of children with severe obesity in a public healthcare setting: Results from a randomized controlled trial

To compare the effectiveness of family-based behavioural social facilitation treatment (FBSFT) versus treatment as usual (TAU) in children with severe obesity. Parallel-design, nonblinded, randomized controlled trial conducted at a Norwegian obesity outpatient clinic. Children aged 6-18 years referred to the clinic between 2014 and 2018 were invited to participate. Participants were randomly allocated using sequentially numbered, opaqued, sealed envelopes. FBSFT (n = 59) entailed 17 sessions of structured cognitive behavioural treatment, TAU (n = 55) entailed standard lifestyle counselling sessions every third month for 1 year. Primary outcomes included changes in body mass index standard deviation score (BMI SDS) and percentage above the International Obesity Task Force cut-off for overweight (%IOTF-25). Secondary outcomes included changes in sleep, physical activity, and eating behaviour. From pre- to posttreatment there was a statistically significant difference in change in both BMI SDS (0.19 units, 95% confidence interval [CI]: 0.10-0.28, p < .001) and %IOTF-25 (5.48%, 95%CI: 2.74-8.22, p < .001) between FBSFT and TAU groups. FBSFT participants achieved significant reductions in mean BMI SDS (0.16 units, (95%CI: -0.22 to -0.10, p < .001) and %IOTF-25 (6.53%, 95% CI: -8.45 to -4.60, p < .001), whereas in TAU nonsignificant changes were observed in BMI SDS (0.03 units, 95% CI: -0.03 to 0.09, p = .30) and %IOTF-25 (-1.04%, 95% CI: -2.99 to -0.90, p = .29). More FBSFT participants (31.5%) had clinically meaningful BMI SDS reductions of ≥0.25 from pre- to posttreatment than in TAU (13.0%, p = .021). Regarding secondary outcomes, only changes in sleep timing differed significantly between groups. FBSFT improved weight-related outcomes compared to TAU.

Pediatric weight management, dietary restraint, dieting, and eating disorder risk: a systematic review

CONTEXT

Whether dietary restraint and dieting are risk factors associated with eating disorders has not been explored in the context of pediatric weight management.

OBJECTIVE

To review associations between dietary pediatric weight management, dietary restraint, dieting, and eating disorder risk.

DATA SOURCES, SELECTION, AND EXTRACTION

Four databases - MEDLINE, EMBASE, Cochrane Library, and PsycINFO - were searched to May 2020 to identify pediatric weight management interventions with a dietary component for children and adolescents with overweight or obesity. The review was limited to studies reporting dietary restraint and/or dieting at preintervention, postintervention, and/or follow-up. Screening and quality assessment were conducted in duplicate, and data extraction was completed by 1 reviewer and cross-checked for accuracy. Data extracted included study characteristics, dietary restraint/dieting, and eating disorder-related outcomes (including disordered eating, body image, self-esteem, depression, and anxiety).

RESULTS

A total of 26 papers, representing 23 studies, were included. Of these, 20 studies reported on dietary restraint, which increased (10 postintervention, 6 follow-up) or remained unchanged (7 postintervention, 5 follow-up), and 5 studies reported on dieting, which increased (1 study), remained unchanged (2 studies) or decreased (2 studies) postintervention. All studies that reported on other eating disorder risk factors (eg, binge eating, body dissatisfaction, and depression) and weight-related outcomes found improvement or no change postintervention or at follow-up.

CONCLUSION

The results of this review suggest that current measures of dietary restraint and dieting are not associated with eating disorder risk within the context of pediatric weight management; however, long-term data is limited. In addition, those current measures may not be suitable risk markers. Concerns about dietary restraint and dieting leading to eating disorders should not prevent access to quality care for young people with obesity.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. 2017 CRD42017069488.

Beyond sleep duration: Sleep timing as a risk factor for childhood obesity

BACKGROUND

Ample evidence attests to the relationship between short sleep duration, sleep problems and childhood obesity. However, few studies have examined the association between sleep timing and obesity in children.

OBJECTIVES

To investigate how sleep duration, problems and timing relate to obesity and obesogenic behaviours in children.

METHODS

Eighty-five children (58.8% girls) with severe obesity and mean (SD) age of 12.1 (2.9) years, were matched by age and sex with peers with normal weight (n = 85,12.0 [2.8] years). Sleep and moderate-to-vigorous physical activity (MVPA) were measured via accelerometer for seven consecutive days. Children self-reported emotional eating on the Dutch eating behavior questionnaire. Parents reported children's screen time and sleep problems.

RESULTS

Children with severe obesity had significantly later mean mid-sleep time, overall (36 minutes later, P < .001), on school nights (36 minutes later, P < .001) and weekend nights (39 minutes later, P = .002) compared to children with normal weight. Children with obesity had more sleep problems (P = .030), but no differences emerged in sleep duration or social jetlag. After adjusting for demographic factors, mid-sleep time was positively related to screen time (P = .030). Mid-sleep time and sleep duration were inversely related to time in MVPA (Ps ≤ .041). There were no other significant associations between the sleep variables and the obesogenic behaviours.

CONCLUSIONS

Later sleep timing was related to obesogenic behaviours in children and may represent an obesity risk factor.

The interactive effects of parental self-efficacy and child eating styles in relation to naturalistically-assessed craving, overeating, and loss of control eating

OBJECTIVE

Parental factors have been linked to weight-related outcomes in children, though less is known regarding the role of parental self-efficacy (PSE) for promoting healthy dietary behaviors (HDBs). This study examined associations between PSE for promoting HDBs and child reports of craving, overeating, and loss of control eating in daily life. The interactive effects of PSE and child eating style (emotional eating, external eating, and restraint) were also explored.

METHOD

Thirty-eight youth (ages 8-14; 55.3% female) with overweight/obesity and their parents completed the Dutch Eating Behavior Questionnaire for Children (DEBQ-C) and Parental Self-Efficacy for Healthy Dietary and Physical Activity Behaviors Scale, respectively. Youth completed ecological momentary assessment (EMA) to report craving, overeating, and loss of control eating.

RESULTS

Generalized estimating equations indicated no consistent main effects of PSE on EMA outcomes, but PSE interacted with DEBQ-C child eating styles to predict each EMA outcome. Among children of parents with lower PSE, (a) higher emotional eating was associated with greater overeating and loss of control eating; (b) higher external eating was associated with greater craving; and (c) higher restraint was associated with greater loss of control eating and craving. Conversely, these associations were attenuated among children of parents with higher PSE.

DISCUSSION

Together findings suggest the interplay of child characteristics and PSE regarding children's eating behaviors warrants future investigation in the context of eating and weight disorders. In particular, further research is needed to examine the directionality of effects and mechanisms underlying these associations.

Disturbed eating behaviours do not impact treatment response in a paediatric obesity chronic care treatment programme

AIM

This study investigates the prevalence of disturbed eating behaviours in children and adolescents initiating obesity treatment, and how the prevalence varies with age, sex and body mass index (BMI) standard deviation score (SDS). Secondly, it examines whether the presence of disturbed eating behaviours at enrolment is associated with the degree of weight loss after 12 months of treatment.

METHODS

A total of 3621 patients aged 3-18 years enrolled in a multidisciplinary obesity treatment programme were studied. Follow-up data after a median of 12.4 months were available for 2055 patients. Upon entry, patients were assessed for the following disturbed eating behaviours: meal skipping, emotional eating, overeating and rapid eating. Height and weight were measured at baseline and follow-up.

RESULTS

At enrolment, median age was 11.4 years, median BMI SDS was 2.87, and 82.2% of patients exhibited one or more disturbed eating behaviours. The prevalence of meal skipping, emotional eating and rapid eating increased with age (P < 0.01). Patients who reported overeating or rapid eating exhibited a 0.06-0.11 higher BMI SDS at enrolment than patients without these disturbed eating behaviours (P < 0.02). After 1 year of treatment, BMI SDS was reduced in 75.7% of patients, and the median reduction was 0.24 (95% confidence interval: 0.22-0.27). Overeating was associated with a higher degree of weight loss, while meal skipping, emotional eating and rapid eating did not associate with the degree of weight loss at follow-up.

CONCLUSIONS

Disturbed eating behaviours were highly prevalent in children and adolescents with overweight or obesity, and varied with age and sex. After 1 year of treatment, the degree of obesity improved, regardless of the presence of disturbed eating behaviours at treatment initiation.

Role of Motor Competence and Executive Functioning in Weight Loss: A Study in Children with Obesity

OBJECTIVE

This study aimed to compare motor competence and executive functioning (EF) between children with obesity and peers with healthy weight. Additionally, the predictive value of motor competence and EF in weight loss after a 5-month multidisciplinary residential treatment program was examined.

METHODS

Thirty-two children with obesity (7-11 years, 14 boys) and 32 age-matched controls (18 boys) performed 8 motor skill tasks and 4 tasks of EF (only at baseline). In the group of children with obesity, anthropometric measurements were performed at baseline and 5 months after the start of their treatment program. Also in control children, there was a time span of 5 months in between anthropometric measurements.

RESULTS

Lower levels of motor competence and reduced updating abilities, inhibition control, and planning skills were observed in children with obesity compared with healthy-weight controls. Within the total group, better general motor competence and balance skills were significantly associated with better updating, inhibition control, and planning. Finally, hierarchical regression analyses revealed that ball skills, balance skills, and inhibition/updating at baseline predicted 14% to 17% of the variance in weight loss after a 5-month treatment program in children with obesity.

CONCLUSION

These results suggest that motor competence and EF are both relevant factors associated with childhood obesity. Moreover, these factors seem to be significant predictors of weight loss. Future (intervention) studies are needed to understand the impact of the difficulties in motor and EF on obesity-related behaviors as well as on short-term and, especially, long-term weight loss and maintenance.

Treatment of obesity, with a dietary component, and eating disorder risk in children and adolescents: A systematic review with meta-analysis

This review aimed to investigate the impact of obesity treatment, with a dietary component, on eating disorder (ED) prevalence, ED risk, and related symptoms in children and adolescents with overweight or obesity. Four databases were searched to identify pediatric obesity treatment interventions, with a dietary component, and validated pre-post intervention assessment of related outcomes. Of 3078 articles screened, 36 met inclusion criteria, with a combined sample of 2589 participants aged 7.8 to 16.9 years. Intervention duration ranged from 1 week to 13 months, with follow-up of 6 months to 6 years from baseline. Prevalence of ED was reported in five studies and was reduced post-intervention. Meta-analyses showed a reduction in bulimic symptoms (eight studies, standardized mean difference [SE], -0.326 [0.09], P < 0.001), emotional eating (six studies, -0.149 [0.06], P = 0.008), binge eating (three studies, -0.588 [0.10], P < 0.001), and drive for thinness (three studies, -0.167 [0.06], P = 0.005) post-intervention. At follow-up, a reduction in ED risk (six studies, -0.313 [0.13], P = 0.012), emotional eating (five studies, -0.259 [0.05], P < 0.001), eating concern (three studies, -0.501 [0.06], P < 0.001), and drive for thinness (two studies, -0.375 [0.07], P < 0.001) was found. Structured and professionally run obesity treatment was associated with reduced ED prevalence, ED risk, and symptoms.

Pediatric Obesity and Eating Disorders Symptoms: The Role of the Multidisciplinary Treatment. A Systematic Review

The prevalence of obesity in children/adolescents has increased worldwide during the past 30 years, becoming a significant public health concern; prevention, and management of pediatric obesity onset is one of the most critical public health goals for both industrialized and developing countries. Pediatric obesity has been identified as a risk factor for various psychopathologies, including eating disorders (ED). Although it has been demonstrated that a comprehensive multidisciplinary treatment (MT), with small steps and practical approaches to lifestyle change, can be an effective treatment for children and adolescents with obesity, to the best of our knowledge, this is the first systematic review investigating the effect of MT on the development, progression or decrease of ED symptoms (EDS) in this target population. PubMed and Web of Science databases were searched (last search on 18 February 2019) according to a predetermined search strategy, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines and Statement. Original studies published in English examining the effect of MT on pediatric overweight/obesity, paying particularly attention at the development of EDS, were eligible for inclusion. Seven hundred and forty-four records have been identified; nine articles with study quality ranging from weak to moderate have been included. MTs were heterogeneous in nature including length, number, frequency and type of sessions, parent-involvement and use of technology, besides several psychometric questionnaires were used to screen for EDS, since there are no standardized criteria. In 3 studies there was a significant decrease in external and emotional eating and in four studies a significant increase in restraint eating post MT. Two studies found a significant decrease of binge eating symptoms and other two studies showed an improvement of self-perception, weight, and shape concern. A statistical significant decrease in BMI, BMIz, BMISDS, and adjusted BMI was observed after all MTs, except one. A narrative summary of the evidences reported highlighted the positive impact of MT on the EDS. Moreover, since weight loss post MTs was not necessarily related to EDS, clinicians should also look for the presence of EDS and treat them accordingly.

Validation of a child version of the Three-Factor Eating Questionnaire in a Canadian sample: a psychometric tool for the evaluation of eating behaviour

OBJECTIVE

To examine score validity and reliability of a child version of the twenty-one-item Three-Factor Eating Questionnaire (CTFEQ-R21) in a sample of Canadian children and adolescents and its relationship with BMI Z-score and food/taste preferences.

DESIGN

Cross-sectional study.

SETTING

School-based.

PARTICIPANTS

Children (n 158), sixty-three boys (mean age 11·5 (sd 1·6) years) and ninety-five girls (11·9 (sd 1·9) years).

RESULTS

Exploratory factor analysis revealed that the CTFEQ-R21 was best represented by four factors with item 17 removed (CFFEQ-R20), representing Cognitive Restraint (CR), Cognitive Uncontrolled Eating (UE 1), External Uncontrolled Eating (UE 2) and Emotional Eating (EE), accounting for 41·2 % of the total common variance with good scale reliability. ANOVA revealed that younger children reported higher UE 1 and CR scores than older children, and boys who reported high UE 1 scores had significantly higher BMI Z-scores. Children with high UE 1 scores reported a greater preference for high-protein and -fat foods, and high-fat savoury (HFSA) and high-fat sweet (HFSW) foods. Higher preference for high-protein, -fat and -carbohydrate foods, and HFSA, HFSW and low-fat savoury foods was found in children with high UE 2 scores.

CONCLUSIONS

The study suggests that the CFFEQ-R20 can be used to measure eating behaviour traits and associations with BMI Z-score and food/taste preferences in Canadian children and adolescents. Future research is needed to examine the validity of the questionnaire in larger samples and other geographical locations, as well as the inclusion of extraneous variables such as parental eating or socio-economic status.

Parental Rejection as a Predictor of Emotional Eating After Inpatient Weight Loss Treatment for Youngsters

Objective

The main objective of the study was to examine the relationships between parental rejection, maladaptive emotion regulation strategies, and the emotional eating style of youngsters who finished an inpatient multidisciplinary weight loss treatment program and were back in their home environment.

Method

Participants were 52 youngsters (age 11–17 years) with an average percent over ideal BMI of 186.11% (SD= 27.54) before treatment and 136.37% (SD= 19.65) at a mean follow-up of 4 months. Participants completed questionnaires assessing maternal and paternal rejection, maladaptive emotion regulation strategies, and emotional eating. Data were analysed using bootstrapping procedure.

Results

Mediation analyses showed that maladaptive emotion regulation partially mediated the association between maternal rejection and the youngsters’ emotional eating style. Paternal rejection was directly related to emotional eating.

Conclusion

The results suggest that the family climate may have an impact on the eating style of the youngsters after weight loss treatment.

Development and validation of the Child Three-Factor Eating Questionnaire (CTFEQr17)

OBJECTIVE

To develop and validate a child and adolescent version of the Three-Factor Eating Questionnaire (CTFEQr17) and to assess its psychometric properties and factor structure. We also examined associations between the CTFEQr17 and BMI and food preferences.

DESIGN

A two-phase approach was utilized, employing both qualitative and quantitative methodologies.

SETTING

Primary and secondary schools, UK.

SUBJECTS

In phase 1, seventy-six children (thirty-nine boys; mean age 12·3 (sd 1·4) years) were interviewed to ascertain their understanding of the original TFEQr21 and to develop accessible and understandable items to create the CTFEQr17. In phase 2, 433 children (230 boys; mean age 12·0 (sd 1·7) years) completed the CTFEQr17 and a food preference questionnaire, a sub-sample (n 253; 131 boys) had their height and weight measured, and forty-five children (twenty-three boys) were interviewed to determine their understanding of the CTFEQr17.

RESULTS

The CTFEQr17 showed good internal consistency (Cronbach's α=0·85) and the three-factor structure was retained: cognitive restraint (CR), uncontrolled eating (UE) and emotional eating (EE). Qualitative data demonstrated a high level of understanding of the questionnaire (95 %). High CR was found to be significantly associated with a higher body weight, BMI and BMI percentile. High UE and EE scores were related to a preference for high-fat savoury and high-fat sweet foods. The relationships between CTFEQr17, anthropometry and food preferences were stronger for girls than boys.

CONCLUSIONS

The CTFEQr17 is a psychometrically sound questionnaire for use in children and adolescents, and associated with anthropometric and food preference measures.