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

Effectiveness of a Parent-Based eHealth Intervention for Physical Activity, Dietary Behavior, and Sleep Among Preschoolers: Protocol for a Randomized Controlled Trial

BACKGROUND

Preschoolers' lifestyles have become physically inactive and sedentary, their eating habits have become unhealthy, and their sleep routines have become increasingly disturbed. Parent-based interventions have shown promise to improve physical activity (PA), improve dietary behavior (DB), and reduce sleep problems among preschoolers. However, because of the recognized obstacles of face-to-face approaches (eg, travel costs and time commitment), easy access and lower costs make eHealth interventions appealing. Previous studies that examined the effectiveness of parent-based eHealth for preschoolers' PA, DB, and sleep have either emphasized 1 variable or failed to balance PA, DB, and sleep modules and consider the intervention sequence during the intervention period. There is an acknowledged gap in parent-based eHealth interventions that target preschoolers raised in Chinese cultural contexts.

OBJECTIVE

This study aims to investigate the effectiveness of a parent-based eHealth intervention for PA, DB, and sleep problems among Chinese preschoolers.

METHODS

This 2-arm, parallel, randomized controlled trial comprises a 12-week intervention with a 12-week follow-up. A total of 206 parent-child dyads will be randomized to either an eHealth intervention group or a control group. Participants allocated to the eHealth intervention group will receive 12 interactive modules on PA, DB, and sleep, with each module delivered on a weekly basis to reduce the sequence effect on variable outcomes. The intervention is grounded in social cognitive theory. It will be delivered through social media, where parents can obtain valid and updated educational information, have a social rapport, and interact with other group members and facilitators. Participants in the control group will receive weekly brochures on PA, DB, and sleep recommendations from kindergarten teachers, but they will not receive any interactive components. Data will be collected at baseline, 3 months, and 6 months. The primary outcome will be preschoolers' PA. The secondary outcomes will be preschoolers' DB, preschoolers' sleep duration, preschoolers' sleep problems, parents' PA, parenting style, and parental feeding style.

RESULTS

Parent-child dyads were recruited in September 2023. Baseline and posttest data collection occurred from October 2023 to March 2024. The follow-up data will be obtained in June 2024. The results of the study are expected to be published in 2025.

CONCLUSIONS

The parent-based eHealth intervention has the potential to overcome the barriers of face-to-face interventions and will offer a novel approach for promoting a healthy lifestyle among preschoolers. If this intervention is found to be efficacious, the prevalence of unhealthy lifestyles among preschoolers may be alleviated at a low cost, which not only has a positive influence on the health of individuals and the well-being of the family but also reduces the financial pressure on society to treat diseases caused by poor lifestyle habits.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06025019; https://clinicaltrials.gov/study/NCT06025019.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/58344.

Trends in Nutrition-Related Risk Factors Identified Post-Operatively in Patients Treated for a Lower-Extremity Injury

This study investigated trends within a custom Sports Nutrition Assessment for Consultation (SNAC) survey designed to identify nutrition-related risk factors among post-operative lower-extremity youth athletes. Athletes aged 8-18 years who completed the SNAC at a sports medicine institution after lower-extremity surgery were reviewed for associations between SNAC questions and age/sex differences. Of 477 patients (15.0 ± 2.0 years; 47.8% female), 319 (66.9%) answered 'yes' to at least one question and were identified for a consult, though 216 (64.3%) declined. The most frequent questions to prompt a consult were a desire to better understand nutrition for recovery (41.5%) and regularly skipping at least one meal a day (29.8%). Inter-question responses were often significantly related, especially regarding appetite changes, weight changes, and/or meal-skipping. While consult acceptance was not significantly different between sex/age, males were more likely to report a desire to better understand nutrition (p = 0.004) and a weight change (p = 0.019), and females were more likely to report struggling with dizziness/fatigue (p < 0.001). Additionally, older athletes reported an appetite change (p = 0.022), meal-skipping (p = 0.002), a desire to better understand nutrition (p < 0.001), a weight change (p < 0.001), and an effort/recommendation to change their body composition/weight (p = 0.005). These findings demonstrate a link between risky nutrition behaviors and physical detriments.

The neighborhood food environment modifies the association between infant feeding and childhood obesity

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) issues infant formula to infants who are not fully breastfed, and prior research found elevated obesity risk among children receiving lactose-reduced infant formula with corn syrup solids (CSSF) issued by WIC. This study was conducted to evaluate associations between a broader set of specialty infant formulas issued by WIC and child obesity risk, whether neighborhood context (e.g. neighborhood food environment) modifies associations, and whether racial/ethnic disparities in obesity are partly explained by infant formula exposure and neighborhood context.

METHODS

WIC administrative data, collected from 2013-2020 on issued amount (categorical: fully formula fed, mostly formula fed, mostly breastfed, fully breastfed) and type of infant formula (standard cow's milk formula, and three specialty formulas: any CSSF, any soy-based formula, and any cow's milk-based formula with added rice starch) and obesity at ages 2-4 years (defined as a Body Mass Index z-score ≥ 95th percentile according to World Health Organization growth standard) were used to construct a cohort (n = 59,132). Associations of infant formula exposures and race/ethnicity with obesity risk were assessed in Poisson regression models, and modification of infant feeding associations with obesity by neighborhood context was assessed with interaction terms.

RESULTS

Any infant formula exposure was associated with significantly higher obesity risk relative to fully breastfeeding. Receipt of a CSSF was associated with 5% higher obesity risk relative to the standard and other specialty infant formulas (risk ratio 1.05, 95% confidence interval 1.02, 1.08) independent of breastfeeding duration and receipt of other specialty infant formulas. The association between CSSF and obesity risk was stronger in neighborhoods with healthier food environments (10% higher risk) compared to less healthy food environments (null). Racial/ethnic disparities in obesity risk were robust to adjustment for infant formula exposure and neighborhood environment.

CONCLUSIONS

Among specialty infant formulas issued by WIC, only CSSFs were associated with elevated obesity risk, and this association was stronger in healthier food environments. Future research is needed to isolate the mechanism underlying this association.

Associations of Body Mass Index with Self-Rated Health and Weight Perceptions Among Rural Appalachian Adolescent Students

BACKGROUND

Adolescents with overweight or obesity are at greater risk of having physical and psychosocial consequences. With increased disparities and inadequate literature on prevalence of adolescent weight status in rural Appalachia, there is potential for further complications. Unfortunately, adolescent obesity treatment options are often limited, especially in medically underserved regions.

METHODS

This cross-sectional study of adolescents at eight rural Appalachian schools examined weight status among and associations between body mass index percentile (BMIp) categories and health-related perceptions and weight-control intentions. Previously validated instruments were utilized. Analyses included independent samples t-tests, ANOVA tests, and chi-squared tests.

RESULTS

Of 814 adolescents (ages 11-13; 55.0% girls), BMIp revealed 20.8% overweight, 22.7% obese, and 10.6% severely obese. Adolescents with higher BMIp categories reported poorer self-rated health, inaccurate weight perceptions, and greater weight loss intentions (all p < .05).

CONCLUSIONS

Findings, including high prevalence of adolescents with overweight and obesity, emphasize the need for more obesity prevention and treatment options. Schools may be an ideal setting to reach at-risk adolescents and provide obesity prevention and treatment options, especially in medically underserved regions such as rural Appalachia. Opportunities and challenges to apply findings, including school-based obesity programs, are discussed.

Any Infant Formula Amount, but Not Infant Formula Type, Is Associated with Less Healthful Subsequent Beverage Intake among Special Supplemental Nutrition Program for Women, Infants, and Children-Participating Children

Background

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition assistance to low-income households, including infant formula for infants not fully breastfeeding. Issuance of lactose-reduced infant formula made with corn syrup solids (CSSF) is associated with elevated risk of obesity in early life, but associations between formula type and dietary intake have not been examined.

Objectives

To evaluate associations between infant formula (amount and type) issued by WIC with subsequent child diet at ages 12-59 mo.

Methods

Dietary data from 2014, 2017, and 2020 Los Angeles County WIC Survey respondents (n = 1339 children, 12-59 mo of age) were merged with WIC administrative data on infant feeding (amount and type of infant formula at ages 0-12 mo). Intake frequencies were available for sweetened beverages, sweets, juice, fast food, water, fruit, vegetables, and milk. Infant feeding was categorized by amount of WIC-issued formula (descending: fully formula fed, mostly formula fed, mostly breastfed, fully breastfed) and issuance of a CSSF (any, none). Associations between infant feeding (infant formula amount and type) and child diet were evaluated in multivariable generalized estimating equation negative binomial regression models, stratified by child age (12 to <24 mo, 24 to <60 mo).

Results

Any infant formula issuance in the first year of life was adversely associated with subsequent dietary intake. This included 21%-23% higher 100% juice intake at 24 to <60 mo and 11%-13% (at 24 to <60 mo) or 20%-22% (at 12 to <24 mo) lower water intake. CSSF receipt compared with only other infant formula was not consistently associated with subsequent child diet.

Conclusions

Any infant formula amount, but not CSSF receipt compared with other formula types, was associated with less healthful beverage intake patterns among WIC-participating children. WIC nutrition education may have a stronger impact if tailored based on infant feeding practices.

Assessment of an intervention for preventing pediatric overweight and obesity through the World Café technique: A qualitative study

PURPOSE

To evaluate the self-reported perspectives of participants involved in the Previene Cádiz intervention for preventing pediatric overweight and obesity.

DESIGN AND METHODS

This qualitative study collected information through the World Café technique. A purposive sample of 40 participants was used, of which 14 were schoolchildren, 12 were teachers, and 14 were parent volunteers. The data were segmented, and concepts were created and grouped into dimensions and categories.

RESULTS

The participants confirmed they had learned new information and behaviors about healthy habits. Parental awareness was considered a crucial and necessary element in changing family habits; therefore, increasing the motivation of family members was deemed a critical task in public health interventions conducted in school settings.

DISCUSSION

Despite the suitability of qualitative methodology to evaluate the perceptions of the main players in an educational intervention, scientific literature is scarce. Obtaining information from the educational community about an intervention is not always easy, so the perspectives of teachers, students, and families about the Previene Cádiz intervention through the World Café approach is considered a relevant contribution.

CONCLUSIONS

The participants considered the intervention positive in terms of learning and fostering increased knowledge, awareness, and healthy behaviors.

PRACTICE IMPLICATIONS

Future interventions should encourage the active participation of all social groups involved, integrating dynamic and collaborative training activities that are acceptable to all participants.

State-level working memory and dysregulated eating in children and adolescents: An exploratory ecological momentary assessment study

BACKGROUND

Children with loss of control (LOC) eating and overweight/obesity have relative deficiencies in trait-level working memory (WM), which may limit adaptive responding to intra- and extra-personal cues related to eating. Understanding of how WM performance relates to eating behavior in real-time is currently limited.

METHODS

We studied 32 youth (ages 10-17 years) with LOC eating and overweight/obesity (LOC-OW; n = 9), overweight/obesity only (OW; n = 16), and non-overweight status (NW; n = 7). Youth completed spatial and numerical WM tasks requiring varying degrees of cognitive effort and reported on their eating behavior daily for 14 days via smartphone-based ecological momentary assessment. Linear mixed effects models estimated group-level differences in WM performance, as well as associations between contemporaneously completed measures of WM and dysregulated eating.

RESULTS

LOC-OW were less accurate on numerical WM tasks compared to OW and NW (ps < .01); groups did not differ on spatial task accuracy (p = .41). Adjusting for between-subject effects (reflecting differences between individuals in their mean WM performance and its association with eating behavior), within-subject effects (reflecting variations in moment-to-moment associations) revealed that more accurate responding on the less demanding numerical WM task, compared to one's own average, was associated with greater overeating severity across the full sample (p = .013). There were no associations between WM performance and LOC eating severity (ps > .05).

CONCLUSIONS

Youth with LOC eating and overweight/obesity demonstrated difficulties mentally retaining and manipulating numerical information in daily life, replicating prior laboratory-based research. Overeating may be related to improved WM, regardless of LOC status, but temporality and causality should be further explored.

PUBLIC SIGNIFICANCE STATEMENT

Our findings suggest that youth with loss of control eating and overweight/obesity may experience difficulties mentally retaining and manipulating numerical information in daily life relative to their peers with overweight/obesity and normal-weight status, which may contribute to the maintenance of dysregulated eating and/or elevated body weight. However, it is unclear whether these individual differences are related to eating behavior on a moment-to-moment basis.

Applying the Integrated Sustainability Framework to explore the long-term sustainability of nutrition education programmes in schools: a systematic review

OBJECTIVE

This review aimed to identify and synthesise the enablers and barriers that influence the long-term (≥ 2 years) sustainment of school-based nutrition programmes.

DESIGN

Four databases (PubMed, Cochrane Library, Embase and Scopus) were searched to identify studies reporting on the international literature relating to food and nutrition programmes aimed at school-age (5-14 years) children that had been running for ≥ 2 years (combined intervention and follow-up period). Eligible studies were analysed using the Integrated Sustainability Framework (ISF), which involved deductive coding of programme enablers and barriers. A quality assessment was completed, using the Mixed-Methods Appraisal Tool and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

SETTING

International school-based nutrition programmes.

SUBJECTS

Individuals involved with the implementation of school-based nutrition programmes.

RESULTS

From the 7366 articles identified, thirteen studies (seven qualitative, five mixed methods and one quantitative descriptive) were included, from which the enablers and barriers of eleven different nutrition-related programmes were analysed. Thirty-four factors across the five domains of the ISF were identified that influenced the sustained implementation of programmes. The most common barrier was a lack of organisational readiness and resources, whereas the most common enabler was having adequate external partnerships and a supportive environment.

CONCLUSIONS

These findings have application during the initiation and implementation phases of school-based nutrition programmes. Paying attention to the 'outer contextual factors' of the ISF including the establishment and maintenance of robust relationships across whole of government systems, local institutions and funding bodies are crucial for programme sustainment.

Elective musculoskeletal surgery is associated with postoperative weight changes in pediatric and adolescent patients

Purpose

Patients of elective orthopedic surgeries often reduce activity levels during postoperative recovery. It is unclear whether these extended periods of modified activities lead to weight changes. The purpose of this study was to evaluate changes in body mass index percentile in pediatric patients over 2.5 years following primary musculoskeletal surgeries.

Methods

Institutional records for utilized current procedural terminology codes were used to identify patients aged 21 years or younger who underwent elective surgery at a single pediatric orthopedic institution between October 2016 and December 2018. Non-primary surgeries and patients without preoperative body mass index measurements were excluded. Demographic characteristics, height, weight, and body mass index within 30 months of surgery were collected. Body mass index relative to age was calculated. Analysis of body mass index changes at follow-up intervals of 3-7, 9-18, and 24-30 months after surgery was performed for the overall sample, within surgical categories, and within preoperative weight classifications.

Results

A total of 1566 patients (53.1% female, average age 12.4 years) were included. Over one-third of patients were overweight or obese at presentation. The average change in body mass index percentile relative to baseline was increased at all follow-up intervals. Values reached significance at 9-18 months (p = .002) and 24-30 months (p = .001). While underweight and normal-weight patients had increased body mass index at all three timepoints, overweight or obese patients decreased.

Conclusions

Patients undergoing elective orthopedic procedures may experience significant changes in body mass index percentile postoperatively. At extremes of weight, patients experience improvement toward the mean, but most patients may undergo body mass index increases beyond what would be expected during normal growth.

Level of evidence

Retrospective level III.

A randomised controlled school-based nutritional intervention in five Middle Eastern countries: Ajyal Salima improved students' dietary and physical activity habits

OBJECTIVE

The purpose of this study was to measure the impact of the Ajyal Salima school intervention on nutrition and physical activity outcomes in children aged 9–11 years.

DESIGN

The study was a 1-year cluster-randomised controlled trial. Ajyal Salima used a multi-component approach including classroom activities, family programme and food service adaptation. Outcomes included daily intake of breakfast, frequency of healthy and unhealthy food consumption, frequency of physical activity, knowledge score and self-efficacy score. Intervention and control groups were compared for all main outcomes and a post-intervention qualitative evaluation assessed strengths and limitations of the intervention components.

SETTING

Schools in five countries – Lebanon, Jordan, Palestine, Saudi Arabia and Bahrain.

PARTICIPANTS

Schools were selected by Ministries of Health and Education within their jurisdictions. Forty-five intervention schools (6052 students) and forty-six control schools (6200 students) were included in the analysis.

RESULTS

The intervention group had a significantly higher odds of consuming breakfast daily (OR 95 % CI = 1·60, 1·35, 1·90), consuming healthy foods (OR 95 % CI = 1·60, 1·39, 1·84) and a decreased odds of consuming unhealthy foods and sweetened beverages (OR, 95 % CI = 0·70, 0·60, 0·81). Additionally, school children in the intervention group, as compared with the control group, were 47 % more likely to exercise outside school hours (OR 95 % CI = 1·47, 1·23, 1·76). Lastly, children in the intervention group had a significantly improved nutritional knowledge score and improved self-efficacy by 1·3 score unit and 1·1 score unit, respectively.

CONCLUSIONS

The Ajyal Salima intervention led to significant improvements in dietary and physical activity habits among school children and increased nutritional knowledge scores.

Bringing down barriers to children's healthy eating: a critical review of opportunities, within a complex food system

This narrative review revises the scientific evidence of recent years on healthy eating in children and adolescents, making sense of promising avenues of action, from a food system perspective. A conceptual framework is provided to better understand how eating habits of children and adolescents are shaped to identify key multisectoral approaches that should be implemented to promote healthier diets. The following influencing factors are discussed: individual factors (physiological and psychological factors, food preferences and food literacy competencies), factors within the personal and socio-cultural food environments, external food environments, and the supply chain. In each section, the main barriers to healthy eating are briefly discussed focussing on how to overcome them. Finally, a discussion with recommendations of actions is provided, anchored in scientific knowledge, and transferable to the general public, industry, and policymakers. We highlight that multidisciplinary approaches are not enough, a systems approach, with a truly holistic view, is needed. Apart from introducing systemic changes, a variety of interventions can be implemented at different levels to foster healthier diets in children through fostering healthier and more sustainable food environments, facilitating pleasurable sensory experiences, increasing their food literacy, and enhancing their agency by empowering them to make better food related decisions. Acknowledging children as unique individuals is required, through interpersonal interactions, as well as their role in their environments. Actions should aim to enable children and adolescents as active participants within sustainable food systems, to support healthier dietary behaviours that can be sustained throughout life, impacting health at a societal level.

Effectiveness of school-based nutrition interventions promoted in the League of Arab States: a systematic review

Arab countries are doubly burdened with undernutrition as well as overweight and obesity. To provide guidance to those looking to address concerns of obesity and overweight among children in this region, the current review bridges an existing knowledge gap and systematically characterizes and evaluates the available scientific evidence pertaining to school-based nutrition interventions completed to date across the Arab world. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and relevant keywords, terms and phrases, a search of the literature across 14 databases for school-based nutrition interventions implemented in this region was conducted. Out of 1568 articles from 14 databases, 38 full-text articles meeting the inclusion criteria were retrieved. Further assessment for eligibility excluded 23 articles and included one article from hand-searching references, leaving 16 articles in the final analysis. Most articles (n = 7) with the implementation of 5 months or longer found strong positive and significant impacts on limiting sweets consumption, increased dietary knowledge, self-efficacy, breakfast and fruit and vegetable consumption, among others. We also found evidence (n = 5) that teachers trained by experts such as dietitians and pediatricians can effectively implement nutrition interventions that achieve the intended outcomes. Training teachers to implement theory-based nutrition and health promotion curricula serves as a potential solution to improving nutrition knowledge, health behaviors and dietary practices among children living in Arab countries. Appropriately designed and implemented nutrition interventions can positively impact nutrition knowledge, health and diet-related behaviors in children and adolescents in this region.

Child and adolescent obesity

The prevalence of child and adolescent obesity has plateaued at high levels in most high-income countries and is increasing in many low-income and middle-income countries. Obesity arises when a mix of genetic and epigenetic factors, behavioural risk patterns and broader environmental and sociocultural influences affect the two body weight regulation systems: energy homeostasis, including leptin and gastrointestinal tract signals, operating predominantly at an unconscious level, and cognitive-emotional control that is regulated by higher brain centres, operating at a conscious level. Health-related quality of life is reduced in those with obesity. Comorbidities of obesity, including type 2 diabetes mellitus, fatty liver disease and depression, are more likely in adolescents and in those with severe obesity. Treatment incorporates a respectful, stigma-free and family-based approach involving multiple components, and addresses dietary, physical activity, sedentary and sleep behaviours. In adolescents in particular, adjunctive therapies can be valuable, such as more intensive dietary therapies, pharmacotherapy and bariatric surgery. Prevention of obesity requires a whole-system approach and joined-up policy initiatives across government departments. Development and implementation of interventions to prevent paediatric obesity in children should focus on interventions that are feasible, effective and likely to reduce gaps in health inequalities.

Targeted dietary approaches for the management of obesity and severe obesity in children and adolescents: A systematic review and meta-analysis

There is a need for a detailed understanding of effective dietary interventions for children with obesity. This systematic review examined the effectiveness of diets of varying energy content as a component of weight treatment in children and adolescents with obesity, severe obesity and obesity-related comorbidity. A systematic search of six databases, from 2000 to 2021, for intervention studies of targeted dietary treatment for obesity in children aged 2-18 years identified 125 studies. Dietary interventions were grouped according to diet type and energy target. Risk of bias was assessed using the Effective Public Healthcare Panacea Project assessment tool. Meta-analysis examined change in body mass index (BMI) at intervention end. A broad array of diet types were effective at reducing BMI in children with obesity. When dietary types were considered by energy target, a gradient effect was observed. Very-low energy diets were most effective with a - 4.40 kg/m² (n = 3; 95% CI -7.01 to -1.79). While dietary interventions with no specified energy target were ineffective, resulting in a BMI gain of +0.17 kg/m² (n = 22; 95% CI 0.05 to 0.40). Practical definitions of dietary energy target in the management of obesity and severe obesity are urgently required to ensure treatment seeking children have timely access to efficacious interventions.

The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position on the Role of the Registered Dietitian Nutritionist in the Care of the Pediatric Patient With Chronic Gastrointestinal Diseases

The optimization of nutrition is essential for the growth and development of all children, including those with gastrointestinal (GI) conditions that can variably affect nutrient intake, absorption, or metabolism. Registered Dietitian Nutritionists (RDNs) are essential partners in delivering high quality care for pediatric GI disorders, but limited evidence is available to support the role of the RDN in the care of these patients. This position paper outlines the evidence supporting the role of the RDN in the management of chronic pediatric GI issues in both inpatient and outpatient settings. Gaps in the literature, opportunities for future research, and barriers to RDN access are discussed.

Thyroid axis hormones and anthropometric recovery of children/adolescents with overweight/obesity: A scoping review

Introduction

Thyroid hormones exert multiple physiological effects essential to the maintenance of basal metabolic rate (BMR), adaptive thermogenesis, fat metabolism, growth, and appetite. The links between obesity and the hormones of the thyroid axis, i.e., triiodothyronine (T3), thyroxine (T4), and thyrotropin (TSH), are still controversial, especially when considering children and adolescents. This population has high rates of overweight and obesity and several treatment approaches, including nutritional, psychological, and physical exercise interventions have been used. Understanding the importance of the hormones of the thyroid axis in the recovery from overweight and obesity may help directing measures to the maintenance of a healthy body composition. The present scoping review was carried out to analyze studies evaluating these hormonal levels throughout interventions directed at treating overweight and obesity in children and adolescents. The main purpose was to ascertain whether the hormones levels vary during weight loss.

Methods

We selected for analysis 19 studies published between 1999 and 2022.

Results

Most of the studies showed that changes in different anthropometric indicators, in response to the multidisciplinary interventions, correlated positively with free T3 (fT3), total T3 (TT3), and TSH. With respect to free T4 (fT4) and total T4 (TT4).

Discussion

The most common finding was of unchanged levels and, hence, no significant association with weight loss. Moreover, thyroxine supplementation has failed to affect the response to the interventions. Further studies are necessary to elucidate the relevance of the variations in hormone levels to the establishment of overweight/obesity and to the recovery from these conditions in children/adolescents.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42020203359.

Fuel for Fun Process Evaluation Reveals Strong Implementation and Approval with Varied Parent Engagement

OBJECTIVE

To describe the implementation and process characteristics of Fuel for Fun: Cooking with Kids Plus Parents and Play (FFF).

DESIGN

Mixed methods.

SETTING

Elementary schools in 2 Northern Colorado school districts.

PARTICIPANTS

Fourth graders (aged 9-11 years), parents, school staff, and implementation researchers; measured over 2 consecutive years in 8 schools (851 students, 45 classrooms).

INTERVENTION(S)

Social Cognitive and active learning theory-based classroom cooking with tasting lessons, active recess games, cooking with tasting food promotion during school lunch, family nights, and take-home intervention reinforcements. A 7-month program delivered by a trained intervention team.

MAIN OUTCOME MEASURE(S)

Implementation measures (observations and debriefings) assessed context, reach, dose delivered, fidelity, and dose received; process measures (surveys) assessed student and parent perceptions and intervention participation.

ANALYSIS

Descriptive statistics for quantitative and themes for qualitative data.

RESULTS

Minor adjustments in program delivery plans were required to accommodate changes in school schedules and policies. Process measures demonstrated > 90% achievement of goals for nearly all child-centered activities. One-quarter of eligible families participated in evening events, with strong parent and student approval. Fifty out of 116 parents (43%) completing an online survey reported preparing ≥ 1 of 5 recipes with their child. Fifty-nine percent of eligible students completed >1 of 10 take-home activity sheets with their parents.

CONCLUSIONS AND IMPLICATIONS

Engagement and commitment of the intervention team and school staff supported strong implementation. Participant responses were positive, but improvement in parent engagement requires investigation.

Improving Obesogenic Dietary Behaviors among Adolescents: A Systematic Review of Randomized Controlled Trials

The overweight and obesity epidemic persists, and over 340 million children and adolescents aged 5–19 were classified as overweight or obese worldwide in 2020. Obesity intervention becomes crucial during the adolescent years due to the increased autonomy and adolescent motivation to oversee one’s own behaviors and lifestyle-related decisions. The objective of the current study was to conduct a systematic review of randomized controlled trials aimed at improving dietary intake and behaviors among adolescents. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized. The key terms used in the searches referred to the study population and the topic of interest and included words and phrases such as “obesity or overweight and adolescents”, “dietary behaviors and adolescents”, “dietary intake and adolescents”, and “dietary habits and adolescents.” A tertiary screening process was employed, and the National Heart, Lung, and Blood Institute Quality Assessment of Controlled Intervention Studies quality scoring tool was utilized to assess the quality of research articles independently by n = 2 researchers. A total of 7441 articles were identified through the database search, and 36 were included in the current systematic review. The most common outcomes explored included dietary behaviors, anthropometric or biometric outcomes, and physical activity. Approximately half of the studies demonstrated significant improvements in the primary outcomes investigated. The majority of the high-impact studies where significant improvements in primary outcomes were demonstrated were conducted in school settings or were multicomponent or multilevel in nature. Thus, interventions targeting dietary behaviors in adolescents that are delivered in the school setting and are multicomponent or multilevel in nature are the most effective in terms of impact on dietary intake, anthropometric or biometric outcomes, and physical activity.

Teachers’ Resources to Support School Lunch: Professional Development Is Warranted

In the United States, many children who come from low-income backgrounds and experience food insecurity do not take and eat school lunch, despite it being a nutritious meal. Teachers could play a role in encouraging students’ consumption of school lunch; however, teachers in America are traditionally uninvolved in the lunch period. The purpose of this research was to understand the resources kindergarten through twelfth grade (K-12) teachers need to encourage students to take and eat school lunch. Two data collection workshops and semi-structured follow-up interviews were conducted with K-12 teachers. The workshops and interviews were recorded, transcribed, and analyzed for salient themes. Ten teachers participated in the workshops and six teachers participated in the follow-up interviews. In general, teachers believe school meals are essential for students’ focus and behavior in the classroom. However, to encourage students to take and eat school lunch, teachers need support and resources. From the workshops and interviews, three themes emerged: (1) improvements in the food quality; (2) school community support; and (3) professional development. The data suggests professional development is the greatest resource teachers need, as professional development can enhance teachers’ motivation to advocate for better food quality and engage school community support. Greater teacher involvement in school lunch could lay the groundwork for future healthier generations.

Birth weight and nutritional status of children under five in sub-Saharan Africa

Introduction

Over the past three decades, undernutrition has become a major cause of morbidity and mortality among children under five years globally. Low birth weight has been identified as a risk factor for child morbidity and mortality, especially among children under five years in sub-Saharan Africa. There is, however, a paucity of empirical literature establishing the association between low birth weight and undernutrition in sub-Saharan Africa. We examined the association between birth weight and nutritional status of children under five in sub-Saharan Africa.

Methods

Our analyses were performed on a weighted sample of 110,497 children under five years from 32 countries in sub-Saharan Africa. Data were obtained from the Demographic and Health Surveys conducted from 2010 to 2019. We reported the prevalence of low birth weight and nutritional status (stunting, wasting, and underweight) for all the 32 countries using percentages. We used multilevel binary logistic regression to examine the association between birth weight and nutritional status (stunting, wasting, and underweight) of the children, controlling for covariates. The results of the regression analyses were presented using adjusted odds ratios (aOR) with 95% confidence intervals. Statistical significance was set at p<0.05.

Results

The prevalence of low birth weight was 5.4%, with the highest (13.1%) and lowest (0.9%) reportedin South Africa and Chad, respectively. The pooled prevalence of wasting, underweight, and stunting were 8.1%, 17.0%, and 31.3%, respectively. Niger had the highest prevalence of wasting (21.5%) and underweight (37.1%), whereas Burundi had the highest prevalence of stunting (51.7%). We found that children with low birth weight were more likely to be stunted [aOR = 1.68, 95% CI = 1.58–1.78], underweight [aOR = 1.82, 95% CI = 1.70–1.94], and wasted [aOR = 1.35, 95% CI = 1.20–1.38] after controlling for covariates.

Conclusion

Our study has demonstrated that low birth weight is a key determinant of undernutrition among children under five in sub-Saharan Africa. Policymakers need to give special attention to improving the nutritional status of children under-five years in sub-Saharan Africa by implementing measures aimed at enhancing the weight of children. To accelerate progress towards the achievement of the Sustainable Development Goal 3.2 target of ending preventable deaths of newborns and under-five by 2030, it is imperative for countries in sub-Saharan Africa to intensify interventions aimed at improving maternal and child nutrition. Specific nutrition interventions such as dietary modification counselling should prioritized.

Central American Parents' Preferences for Content and Modality for a Family-Centered Intervention to Promote Healthful Energy Balance-Related Behaviors of Their Preschool-Age Children

This formative research used a cross-sectional survey to assess interest in informational content and intervention modalities for the design of an early childhood obesity prevention intervention for Central American families from the Northern Triangle countries (El Salvador, Guatemala, and Honduras) living in the United States. A total of 74 parents (36 mothers, 38 fathers) with a mean age of 31.6 years (SD = 5.6) completed the survey; 59.5% of whom were born outside of the United States. Although most parents reported being very interested in receiving information related to the seven assessed energy balance-related behaviors, there were significant differences by parents' gender and nativity. Most parents endorsed remote modalities for content delivery via text/SMS, WhatsApp, and e-mail. However, respondents were also receptive to in-person delivery provided by community health workers. There were also significant differences in parents' preferences for intervention modalities by parents' gender and nativity. Future steps should include investigating different intervention modalities and their integration into a linguistic and culturally sensitive family-based intervention to promote healthful energy balance-related behaviors of preschool-age children in Central American families originating from the Northern Triangle countries.

Physical activity and obesity spectrum disorders in post-bariatric surgery patients: A systematic review and Meta-analysis

OBJECTIVES

This systematic review and meta-analysis is based on randomized controlled trials evaluating the effect of physical activity on weight loss in adults undergoing bariatric surgery. The study compared certain biomarkers for individuals with and without physical activity after bariatric surgery. Secondary, the study identified potential successful interventions for the target population.

METHOD

PubMed, Embase, OVID, CINAHL, and Cochrane Library were searched from January 2000 to December 2020. Intervention studies on the effect of physical activity in adults after bariatric surgery were selected, included, and analyzed following the PRISMA guidelines. The primary outcome was weight loss followed by selected biomarkers.

RESULTS

Two independent reviewers extracted data and conducted quality assessments. Of the 11 studies included, six reported BMI, two reported fat-free mass, three reported fat mass, two reported waist-hip ratio, and two reported waist circumference. Six studies measuring change from baseline BMI reported a significant intervention effect: SMD = -0.93 (-1.65;-0.20) with high heterogeneity of included trials (I2 = 72%). There was no significant difference between control and intervention groups for other outcomes.

CONCLUSION

BMI as a measure of physical activity positively impacts the target population. Large-scale studies with better criteria and a longer evaluation follow-up may finalize pronounced outcomes.

Individual differences in the effects of the ACTION-PAC intervention: an application of personalized medicine in the prevention and treatment of obesity

There is an increased interest in the use of personalized medicine approaches in the prevention or treatment of obesity, however, few studies have used these approaches to identify individual differences in treatment effects. The current study demonstrates the use of the predicted individual treatment effects framework to test for individual differences in the effects of the ACTION-PAC intervention, which targeted the treatment and prevention of obesity in a high school setting. We show how methods for personalized medicine can be used to test for significant individual differences in responses to an intervention and we discuss the potential and limitations of these methods. In our example, 25% of students in the preventive intervention, were predicted to have their BMI z-score reduced by 0.39 or greater, while at other end of the spectrum, 25% were predicted to have their BMI z-score increased by 0.09 or more. In this paper, we demonstrate and discuss the process of using methods for personalized medicine with interventions targeting adiposity and discuss the lessons learned from this application. Ultimately, these methods have the potential to be useful for clinicians and clients in choosing between treatment options, however they are limited in their ability to help researchers understand the mechanisms underlying these predictions.

Effect Evaluation of Sahtak bi Sahnak, a Lebanese Secondary School-Based Nutrition Intervention: A Cluster Randomised Trial

Objective

To evaluate the effectiveness of Sahtak bi Sahnak on dietary knowledge and adherence to dietary guidelines in Lebanese adolescents.

Design/setting

A cluster randomised controlled trial was conducted in public and private secondary schools located in urban and rural regions in Lebanon.

Participants

Sixteen secondary schools including 1,572 adolescents were randomly assigned to the intervention (n = 739) or control group (n = 833).

Intervention

Sahtak bi Sahnak is an educational school-based intervention dedicated to improving dietary adherence to nutritional guidelines, increasing the level of dietary knowledge, and preventing the development of obesity during adolescence. It was systematically designed based on the Intervention Mapping framework. The total length of the intervention was around seven educational sessions, until all of the 11 lessons were covered. Each education session lasted 20-40 min.

Main Outcome Measures

Dietary knowledge and adherence levels were measured at baseline and post-intervention using validated questionnaires.

Statistical Analysis

Multivariate multilevel regression models were used to examine intervention effects on outcomes, controlled for background characteristics (i.e., age, gender, location, type of school, grade, BMI z-score).

Results

The intervention group showed significant improvements in total dietary knowledge (B = 12.74, p < 0.001) and intake of healthy items (B = 1.89, p < 0.001), compared to the control group. Intake of unhealthy items decreased significantly (B = -1.43, p < 0.001), compared to the control group. These results were adjusted for age, gender, type of school, location, BMI z-score, study group, and score at baseline.

Conclusion and Implications

Sahtak bi Sahnak is an effective and culturally appropriate school-based intervention for targeting diet among a variety of Lebanese adolescents.

Comprehensive Nutrition Interventions in First Nation-Operated Schools in Canada

Comprehensive school-based nutrition interventions offer a promising strategy to support healthy eating for First Nations children. A targeted strategic review was performed to identify nutrition interventions in 514 First Nation-operated schools across Canada through their websites. Directed content analysis was used to describe if interventions used 1 or more of the 4 components of the Comprehensive School Health (CSH) framework. Sixty schools had interventions. Nearly all (n = 56, 93%) schools offered breakfast, snack, and (or) lunch programs (social and physical environment). About one-third provided opportunities for students to learn about traditional healthy Indigenous foods and food procurement methods (n = 18, 30%) (teaching and learning) or facilitated connections between the school and students' families or the community (n = 16, 27%) (partnerships and services). Few schools (n = 10, 17%) had a nutrition policy outlining permitted foods (school policy). Less than 1% (n = 3) of interventions included all 4 CSH components. Results suggest that most First Nation-operated schools provide children with food, but few have nutrition interventions that include multiple CSH components. First Nation-operated schools may require additional financial and (or) logistical support to implement comprehensive school-based nutrition interventions, which have greater potential to support long-term health outcomes for children than single approaches.

Typology of eating episodes in children and adolescents with overweight/obesity

BACKGROUND

Research suggests that youth with overweight/obesity can be subtyped according to disinhibited eating tendencies. No research has attempted to subtype classes of eating episodes along sensational, psychological, and hedonic dimensions.

METHODS

Youth (N = 39; 55% female) aged 8-14 y with overweight/obesity completed a 2-week ecological momentary assessment protocol in which they reported on all eating episodes and their sensational, environmental, affective, and interpersonal contexts. Latent profile analysis (LPA) was used to classify episodes based on loss of control (LOC) while eating, self-reported overeating, food palatability, hunger, and cravings. Classes were compared on affective, interpersonal, appearance-related, and environmental correlates using Wald chi-square tests.

RESULTS

LPA identified three classes of eating episodes involving high levels of LOC/self-reported overeating ("binge-like" class), low levels of hunger ("eating-in-the-absence-of-hunger" class), and high hunger and cravings ("appetitive eating" class). Binge-like eating was associated with the highest levels of body dissatisfaction, interpersonal distress, and positive affect, and was most likely to occur in the after-school hours.

CONCLUSIONS

Binge-like eating tends to occur in a psychological context relative to other types of eating episodes in youth with overweight/obesity. Future research should explore whether certain classes of eating episodes are associated with distinct weight trajectories over time.

'Read for Nutrition' programme improves preschool children's liking and consumption of target vegetable

OBJECTIVE

To determine whether the 'Read for Nutrition' programme would increase liking and consumption of broccoli (a target vegetable) in preschool children and test acceptability and practicality of the programme.

DESIGN

Pilot pre-post intervention study, where childcare teachers received training and coaching followed by reading the book 'Monsters Don't Eat Broccoli' multiple times with the children during a three-week intervention.

SETTING

Five classrooms of Educare, Lincoln, Nebraska in 2018.

PARTICIPANTS

Sixty-nine (11 to 16 children per classroom) preschool-aged children and sixteen teachers (minimum, three per classroom).

RESULTS

Average total consumption of broccoli increased 35 % (0·14 ounces or 0·05th cup) after the 'Read for Nutrition' programme (t = 2·66; P = 0·01; 95 % CIs (0·035, 0·246)) for all children. Proportional consumption increased for children who received ≥ five exposures to the book (t46 = 2·77; P = 0·008). Exposures to the book predicted proportional consumption (β = 0·365; P = 0·002). Liking of broccoli increased (W69 = 2·2, P = 0·03) as well. Teachers rated the programme as acceptable, practical and enjoyable to children and to themselves.

CONCLUSIONS

Programmes such as 'Read for Nutrition' have the potential to improve children's vegetable liking and consumption in early care and education settings with only book readings and no exposure to a real vegetable.

Adolescent Self-Efficacy for Diet and Exercise Following a School-Based Multicomponent Lifestyle Intervention

Self-efficacy is perhaps the most important parameter associated with behavioral changes. The main aim of this study was to provide insight into the diet and exercise self-efficacy of Greek adolescents and how they could be modified via a multilevel multicomponent school-based lifestyle intervention. Secondary aims were to study the associations of students’ dietary and exercise self-efficacy indices with their anthropometric and sociodemographic parameters. A representative sample of the adolescent population in Attica, consisting of 1610 adolescents aged 12–17 years, recruited from 23 public high schools in three municipalities of the Attica area in Greece, received a three-component lifestyle educational intervention for health promotion and underwent screening for characteristics of metabolic syndrome with the use of portable telemedicine. All assessments and anthropometric measurements were performed at baseline and after the 6-month intervention. Anthropometric measurements included body mass index, waist circumference (WC), waist-to-height ratio (WHtR) and waist-to-hip ratio (WHR). Assessment tools included the Self-efficacy for Diet and the Self-efficacy for Exercise questionnaires, as well as the Mediterranean Diet Quality Index in Children and Adolescents (KIDMED). Analysis included 1020 adolescent students (421 males and 599 females), who completed the self-efficacy questionnaires pre- and post-intervention. Overall, the dietary (p < 0.001) and exercise (p < 0.001) self-efficacy increased significantly post-intervention. Post-intervention, all adolescents decreased their abdominal obesity indices (WC, WHtR, WHR), and this improvement was even more pronounced and significant (p = 0.019, p = 0.019, p = 0.023 respectively) in the adolescents with overweight/obesity. Post-intervention, the proportion of adolescents with normal weight increased from 73.9% to 78.6%, whereas the proportion of adolescents with overweight and obesity decreased from 20.4% to 15.9% and from 5.7% to 5.5%, respectively. Abdominal obesity also decreased from 10.4% to 9.0%. Female adolescents achieved significantly (p = 0.010) higher changes in diet self-efficacy than males. Other sociodemographic characteristics such as family structure, parental age, parental educational level and family income showed non-significant differences. Adolescents with higher KIDMED scores manifested significantly higher dietary and exercise self-efficacy than those with lower KIDMED scores. Both adolescents with normal weight and overweight/obesity manifested a reciprocal relation between diet and exercise self-efficacy. Multicomponent lifestyle interventions in the school environment may provide a first step in students’ behavior changes and provide grounds for future prevention programs in youth.

Can the School Fruit and Vegetable Scheme Be an Effective Strategy Leading to Positive Changes in Children's Eating Behaviours? Polish Evaluation Results

Background: The School Fruit and Vegetable Scheme (SFVS) was developed to form the habit of eating fruit and vegetables (F&V) among children. The survey aimed to identify both the strengths of the scheme and areas that required support and strengthening in the further implementation of school schemes. Methods: The study was conducted from 2012 to 2015 among students of randomly selected 85 primary schools that participated in the programme (intervention group) or did not participate therein (control group). The F&V consumption among the students was evaluated based on the 3 day food record method. Other behaviours were evaluated via frequency and preference questionnaires. Results: Over the three years of implementing SFVS, fruit consumption significantly increased by approximately 30 g/day, i.e., by 18%. In the control group, it increased only by approximately 4%. At the same time, no increase in vegetable consumption was observed. A number of other positive effects of SFVS were also found. These concerned students’ nutritional attitudes and behaviours, such as a further increase in the children’s knowledge on the health aspects of F&V consumption, the levels of their consumption and an increased preference for fruit in general. Conclusions: The results indicate that providing F&V in schools free of charge can be an effective strategy for enhancing F&V consumption among children, in particular by raising the awareness of the health importance of F&V consumption and gradually influencing children’s eating habits, especially when it comes to the habit of fruit consumption. The issue of vegetable consumption is an area for intervention enhancement. There is also a need for further, in-depth analyses, taking into account the impact of potential confounding factors.

School-based obesity interventions in the metropolitan area of Rio De Janeiro, Brazil: pooled analysis from five randomised studies

School-based studies, despite the large number of studies conducted, have reported inconclusive results on obesity prevention. The sample size is a major constraint in such studies by requiring large samples. This pooled analysis overcomes this problem by analysing 5926 students (mean age 11·5 years) from five randomised school-based interventions. These studies focused on encouraging students to change their drinking and eating habits, and physical activities over the one school year, with monthly 1-h sessions in the classroom; culinary class aimed at developing cooking skills to increase healthy eating and attempts to family engagement. Pooled intention-to-treat analysis using linear mixed models accounted for school clusters. Control and intervention groups were balanced at baseline. The overall result was a non-significant change in BMI after one school year of positive changes in behaviours associated with obesity. Estimated mean BMI changed from 19·02 to 19·22 kg/m2 in the control group and from 19·08 to 19·32 kg/m2 in the intervention group (P value of change over time = 0·09). Subgroup analyses among those overweight or with obesity at baseline also did not show differences between intervention and control groups. The percentage of fat measured by bioimpedance indicated a small reduction in the control compared with intervention (P = 0·05). This large pooled analysis showed no effect on obesity measures, although promising results were observed about modifying behaviours associated with obesity.

A parsimonious model to validate cost-effectiveness analyses on preventive health care

Background

The effect of preventive health care on health expenditures is ambiguous. On the one hand, prevention reduces the costs of future morbidity. On the other hand, prevention leads to costs of life extension. The purpose of this paper is to develop a parsimonious model that determines for a preventive measure of interest whether savings from preventing morbidity are more than offset by the costs of living longer, resulting in a net expenditure increase.

Methods

A theoretical model was built based on a Weibull survival function. It includes savings and life extension costs over the remaining lifetime. The model was applied to the example of obesity prevention.

Results

The model shows that the cost consequences of prevention are essentially driven by two factors: i) the relative reduction of morbidity-related costs, which determines the amount of savings from avoiding morbidity; and ii) the hazard ratio of death, which determines the amount of life extension costs. In the application example, the model is able to validate the results of a more complex cost-effectiveness model on obesity prevention.

Conclusions

This work provides new insight into the lifetime cost consequences of prevention. The model can be used both to check plausibility of the results of other models and to conduct an independent analysis.

Time-Limited Eating and Continuous Glucose Monitoring in Adolescents with Obesity: A Pilot Study

Due to its simplicity, time-limited eating (TLE) may represent a more feasible approach for treating adolescents with obesity compared to other caloric restriction regimens. This pilot study examines the feasibility and safety of TLE combined with continuous glucose monitoring (CGM) in adolescents. Fifty adolescents with BMI ≥95th percentile were recruited to complete a 12-week study. All received standard nutritional counseling, wore a CGM daily, and were randomized to: (1) Prolonged eating window: 12 h eating/12 h fasting + blinded CGM; (2) TLE (8 h eating/16 h fasting, 5 days per week) + blinded CGM; (3) TLE + real-time CGM feedback. Recruitment, retention, and adherence were recorded as indicators of feasibility. Weight loss, dietary intake, physical activity, eating behaviors, and quality of life over the course of the intervention were explored as secondary outcomes. Forty-five participants completed the study (16.4 ± 1.3 years, 64% female, 49% Hispanic, 75% public insurance). There was high adherence to prescribed eating windows (TLE 5.2 d/wk [SD 1.1]; control 6.1 d/wk [SD 1.4]) and daily CGM wear (5.85 d/wk [SD 4.8]). Most of the adolescents (90%) assigned to TLE reported that limiting their eating window and wearing a CGM was feasible without negative impact on daily functioning or adverse events. There were no between-group difference in terms of weight loss, energy intake, quality of life, physical activity, or eating behaviors. TLE combined with CGM appears feasible and safe among adolescents with obesity. Further investigation in larger samples, with a longer intervention duration and follow-up assessments are needed.

Factors related to dietary habits, energy drink consumption, and physical activity in marginalized Palestinian schools: A cross-sectional study

Background: The current study assessed different dietary habits, energy drinks intake, body mass index (BMI) and physical activity and associated factors among Palestinian adolescents attending marginalized schools.

Methods: A cross-sectional study targeted a random sample of 1480 students in the sixth andninth grades attending 20 marginalized public schools in the West Bank area of the occupied Palestinian Territories (oPt). Students were interviewed in-person by trained senior dental students about their dietary habits, physical activity, fathers’ employment and mothers’ level of education. Weight and height were measured, and BMI percentile was calculated. Descriptive statistics were generated for the study’s main variables and the dependent variables were compared by grade, gender, mothers’ level of education and father’s employment.

Results: A total of 1282 students (98% response) completed the questionnaire. Of them, 6% were ‘underweight’ (fifth percentile or under) and 34% were ‘overweight’ or ‘obese’ (85thpercentile or over). Ninth graders had more added sugar than 6th graders (P=0.002), less frequent milk consumption (P<0.001), more frequent energy drink consumption (P=0.001),and less physical activity (P<0.0001). Frequency of carbonated and sweetened drink consumption was associated with being overweight or obese (P=0.016, P=0.001). Frequency of carbonated drinks consumption was higher among children of mothers with a high school level of education or less (P<0.001). In addition, children of mothers educated to high school level or below were associated with being underweight (P=0.05).

Conclusion: Dietary habits and physical activity get worse between the ages of 12 and 15. Mothers’ level of education is an important factor in being overweight or underweight. Energy drink consumption among boys and milk consumption among girls are two challenges that need to be addressed urgently and adequately.

Precision Food Parenting: A Proposed Conceptual Model and Research Agenda

Precision medicine, nutrition and behavioral interventions are attempting to move beyond the specification of therapies applied to groups, since some people benefit, some do not and some are harmed by the same therapy. Instead, precision therapies are attempting to employ diverse sets of data to individualize or tailor interventions to optimize the benefits for the receiving individuals. The benefits to be achieved are mostly in the distant future, but the research needs to start now. While precision pediatric nutrition will combine diverse demographic, behavioral and biological variables to specify the optimal foods a child should eat to optimize health, precision food parenting will combine diverse parent and child psychosocial and related variables to identify the optimal parenting practices to help a specific child accept and consume the precision nutrition specified foods. This paper presents a conceptual overview and hypothetical model of factors we believe are needed to operationalize precision food parenting and a proposed research agenda to better understand the many specified relationships, how they change over the age of the child, and how to operationalize them to encourage food parenting practices most likely to be effective at promoting healthy child food choices.

Systematic Review of Setting-Based Interventions for Preventing Childhood Obesity

Introduction

Child obesity is recognized as one of the major public health problems globally, which demands multicomponent and comprehensive interventions. The objective of this systematic review is to evaluate, synthesize, and combine the existing evidence of various setting-based interventions across developed and developing countries that aim to prevent childhood obesity.

Methods

An electronic and systematic search was conducted on setting-based interventions related to childhood obesity both in developed and developing countries. A study was considered eligible if it was a randomized controlled trial that focused on home-based, school-based, or community-based intervention for childhood obesity and published in English from 2010 to 2020. A wide range of electronic bibliographic databases, such as PubMed, Medline, Embase, and ERIC were searched. The various studies were carried out among children aged 4-18 years old. A total of 32 studies were identified; out of which 24 were school-based interventions, and the remaining were nonschool-based.

Results

The studies in this review highlighted important school and nonschool-based interventions to avoid obesity among children and adolescents. School-based interventions that had considered both physical activity (PA) and diet along with home elements showed great effectiveness. These findings reveal that the specific intervention components such as nutrition education curriculum, prolonged time for PA, and upgrading self-efficacy of study participants should be considered to prevent obesity across developed and developing countries. However, the findings from nonschool-based interventions were restricted by the scarcity of the studies.

Conclusion

Multisetting and multipronged strategies are required to avoid or reduce childhood obesity across the globe. However, additional studies are needed with a large sample size. Further study designs based on theory should be conducted in nonschool settings for the creation of meaningful and detailed guidelines that can support the prevention of obesity in children.

Dishing up Science: Integrated Content Links History, Microbiology, and Nutrition

Although public health recommendations encourage educators to include nutrition into the school day to prevent obesity, teachers cite lack of time as a common barrier. Thus, they are often told to integrate nutrition across the curriculum. The purpose of this project was to create an educational program integrating easy-to-demonstrate experiments with lessons illustrating key concepts in microbiology, nutrition, and food history for elementary school groups visiting a museum. Programs were created by researching and developing short lessons with visual aids, hands-on science experiments, handouts, and teacher's guides that could be used by museum staff. These lessons were aligned with New Jersey elementary school curricula and learning standards. This project illustrated a creative approach to integrating microbiology, nutrition, and history content into the curriculum so that teachers could more easily fit nutrition into the school day.

Cow's milk fat and child adiposity: a prospective cohort study

BACKGROUND

International guidelines recommend children aged 9 months to 2 years consume whole (3.25%) fat cow's milk, and children older than age 2 years consume reduced (0.1-2%) fat cow's milk to prevent obesity. The objective of this study was to evaluate the longitudinal relationship between cow's milk fat (0.1-3.25%) intake and body mass index z-score (zBMI) in childhood. We hypothesized that higher cow's milk fat intake was associated with lower zBMI.

METHODS

A prospective cohort study of children aged 9 months to 8 years was conducted through the TARGet Kids! primary care research network. The exposure was cow's milk fat consumption (skim (0.1%), 1%, 2%, whole (3.25%)), measured by parental report. The outcome was zBMI. Height and weight were measured by trained research assistants and zBMI was determined according to WHO growth standards. A linear mixed effects model and logistic generalized estimating equations were used to determine the longitudinal association between cow's milk fat intake and child zBMI.

RESULTS

Among children aged 9 months to 8 years (N = 7467; 4699 of whom had repeated measures), each 1% increase in cow's milk fat consumed was associated with a 0.05 lower zBMI score (95% CI -0.07 to -0.03, p < 0.0001) after adjustment for covariates including volume of milk consumed. Compared to children who consumed reduced fat (0.1-2%) milk, there was evidence that children who consumed whole milk had 16% lower odds of overweight (OR = 0.84, 95% CI 0.77 to 0.91, p < 0.0001) and 18% lower odds of obesity (OR = 0.82, 95% CI 0.68 to 1.00, p = 0.047).

CONCLUSIONS

Guidelines for reduced fat instead of whole cow's milk during childhood may not be effective in preventing overweight or obesity.

The Families Improving Health Together (FIT) Program: Initial evaluation of retention and research in a multispecialty clinic for children with obesity

BACKGROUND

Obesity affects ∼17% of US children, with parallel increases in multiple comorbidities, especially among African-, Asian-, Hispanic-, and Native-Americans. Barriers to patient retention in pediatric obesity programs include lack of centralized care, and frequent subspecialty MD visits which conflict with patient school attendance and parental work attendance as well as with support service utilization. Lack of integration of multispecialty clinical care with interdisciplinary research is a major barrier to fuller exploration of the treatment, prevention, and understanding of obesity in childhood.

OBJECTIVE

To test the hypothesis, a novel multispecialty/interdisciplinary clinical and research infrastructure with strong emphasis on a primary obesity care physician for children with early-onset (<9 years) obesity (Families Improving health Together [FIT]) could promote lower patient attrition (primary goal) and foster productive research in pediatric obesity (secondary goal).

RESULTS

Data support the hypotheses. Over 15 months, FIT reported a >90% participant retention (p < 0.001 vs. expected rate based on other studies of similar programs). Though 90% of children had at least one adiposity-related comorbidity and 70% had at least two, there was no need for additional subspecialist visits with cardiologists, endocrinologists, gastroenterologists, or molecular geneticists. Three abstracts were presented at national meetings, and two manuscripts were published all with junior faculty as primary authors.

CONCLUSION

This pilot study suggests that an integrated multispecialty/interdisciplinary approach to children with obesity improves patient retention and can be integrated successfully with research.

Dietary and behavior changes following RDN-led corporate wellness counseling: A secondary analysis

BACKGROUND

Worksite wellness programs have the ability to activate health promotion and stimulate behavior change.

OBJECTIVE

To measure longitudinal associations between visits with a Registered Dietitian Nutritionist (RDN), as part of worksite wellness programs, on dietary and lifestyle behavior changes.

METHODS

The study sample included 1,123 employees with 77 different worksite wellness programs across the United States from March to December 2017. Hierarchical linear modeling was used to evaluate the associations of RDN visits with behavior changes.

RESULTS

The mean BMI at baseline was 33.48, indicating over half of all employees are considered obese. Employees who attended more than one visit showed an increase in whole grain consumption and corresponding weight loss (t-ratio = 2.41, p = 0.02). Age played a significant factor in the rise of systolic blood pressure; employees who attended more visits showed an increase in whole grain consumption and corresponding blood pressure (t-ratio = -2.11, p = 0.04).

CONCLUSIONS

RDNs as part of worksite wellness programs, can contribute to improvements in lifestyle behavior changes. These data highlight the need for nutrition intervention at the workplace. Research on nutrition-focused worksite wellness programs is needed to assess the long-term health outcomes related to dietary and lifestyle behavior changes.

Healthy eating strategies for socioeconomically disadvantaged populations: a meta-ethnography

Purpose: In developed countries, diet-related health inequalities between people with different levels of socioeconomic advantage persist. However, there is limited qualitative evidence to inform the design of effective healthy eating (HE) strategies in socioeconomically disadvantaged populations (SDPs). The purpose of this review was to explore the characteristics influencing HE strategies for SDPs and develop a new understanding of how and why they influence their success.

Methods: A qualitative evidence synthesis using a systematic meta-ethnographic approach. The twelve studies included were conducted in the USA, Canada, Australia, and UK.

Results: The studies described a range of HE strategies, including nutrition education programs, food vouchers, and community gardens. Personal values and sense of pride and autonomy were found to have an influence on participants’ attitudes towards HE strategies. Similarly, social characteristics such as level of social support and opportunities for shared benefits influenced participants’ engagement. Structural characteristics such as the affordability and accessibility of healthy foods determined strategy acceptability and success. Finally, organizational characteristics such as flexibility influenced how well strategies supported the circumstances of participants.

Conclusions: These overlapping characteristics may be used to inform the development, implementation, and evaluation of strategies to improve healthy eating in SDPs.

Clinical management and treatment of obesity in China

China has one of the largest populations with obesity in the world, and obesity has become a major challenge for the country's health-care system. Current guidelines for obesity management are not adequately supported by evidence from clinical studies in Chinese populations. Effective lifestyle interventions suitable for Chinese populations are scarce, insufficient weight-loss medications have been approved by regulatory bodies, and there is low acceptance of non-lifestyle interventions (ie, medications and surgery) among both health-care providers and the general public. Large, well designed, and well implemented clinical trials are needed to strengthen the evidence base for the clinical management of obesity in China. Obesity management can be improved through use of a tiered system involving health management centres, integrated lifestyle interventions and medical treatments, strengthened obesity education and training, and use of advanced electronic health technologies. Resource mobilisation, support from major stakeholders for people with overweight or obesity, and education and changes to social norms among the wider public are also needed. National health policies should prioritise both obesity prevention and improvement of the treatment and management of obesity.

Anthropometric Outcomes of Children and Adolescents Using Telehealth with Weight Management Interventions Compared to Usual Care: A Systematic Review and Meta-analysis

Objective:This systematic review and meta-analysis evaluated the effect of telehealth (TH) weight management interventions compared to usual care on anthropometric outcomes in children and adolescents with overweight and obesity.Methods: Comprehensive searches were conducted identifying randomized controlled trials (RCTs) published between January 1, 2005 and June 1, 2019. Studies using a web-based, smartphone or email TH intervention in children between 2-18 years of age were included. Outcome measures of interest included body mass index (BMI) z-score, BMI percentile, waist circumference (WC) and waist-to-hip-ratio (WHR). The Grade Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to rate strength of evidence (SOE) and a random-effects meta-analysis was performed when five or more RCTs reported the same outcome.Results: Thirteen RCTs met the inclusion criteria for the systematic review. Random effects meta-analysis of 10 RCTs detected a small effect for TH interventions compared to usual care in reducing BMI z-score (pooled net change in BMI z-score = -0.04; 95% CI -0.07, 0.00: I2 = 12%). No significant differences were found between groups for other outcomes. Strength of evidence ratings were low or very low in part due to concerns with heterogeneity in study designs, intervention durations, ages of participants, the type of TH used and risk of bias (ROB) of included studies.Conclusions: There is a low strength of evidence that TH had a small effect on anthropometric outcomes compared to usual care. Future RCTs should be well designed to minimize clinical heterogeneity and ROB. Studies of longer intervention duration with adequate, statistically powered analyses should be conducted. Key teaching pointsStudies using TH with pediatric weight management interventions may be effective to improve health of children with overweight and obesity.Future RCTs should consider clinical heterogeneity of study design for setting, age-group of children, preferences for type of TH and ROB.Studies that include children with severe obesity (<95th%) may need more sensitive outcome measures.Studies of longer duration are needed to better understand long-term weight management success.

Diagnosis, treatment and prevention of type 2 diabetes mellitus in children and adolescents

During the last two decades, there have been several reports of an increasing incidence of type 2 diabetes mellitus (T2DM) in children and adolescents, especially among those belonging to minority ethnic groups. This trend, which parallels the increases in prevalence and degree of pediatric obesity, has caused great concern, even though T2DM remains a relatively rare disease in children. Youth T2DM differs not only from type 1 diabetes in children, from which it is sometimes difficult to differentiate, but also from T2DM in adults, since it appears to be an aggressive disease with rapidly progressive β-cell decline, high treatment failure rate, and accelerated development of complications. Despite the recent research, many aspects of youth T2DM still remain unknown, regarding both its pathophysiology and risk factor contribution, and its optimal management and prevention. Current management approaches include lifestyle changes, such as improved diet and increased physical activity, together with pharmacological interventions, including metformin, insulin, and the recently approved glucagon-like peptide-1 analog liraglutide. What is more important for everyone to realize though, from patients, families and physicians to schools, health services and policy-makers alike, is that T2DM is a largely preventable disease that will be addressed effectively only if its major contributor (i.e., pediatric obesity) is confronted and prevented at every possible stage of life, from conception until adulthood. Therefore, relevant comprehensive, coordinated, and innovative strategies are urgently needed.

Momentary and personal characteristics predicting maternal fruit and vegetable preparation for children using ecological momentary assessment

A large body of literature on child-focused research regarding healthy eating within the family context has focused on behavioral management strategies, such as reinforcement, or parental modeling through personal intake or encouragement. However, food preparation behaviors among mothers have been understudied. Also unknown is how maternal food preparation behaviors vary across population subgroups and contexts. The study objective was to elucidate momentary characteristics (i.e., time of day, weekday, and family meals) and personal characteristics (i.e., ethnicity, working status, household characteristics, body mass index, income, and child's age) associated with maternal fruit and vegetable (F/V) preparation through ecological momentary assessment (EMA). 186 mothers (M_age = 40.81) of children (M_age = 9.61, 49.5% female) completed six semi-annual waves, each lasting seven days. Mothers completed up to eight EMA surveys a day, which assessed family meals and F/V preparation, and reported personal characteristics through paper questionnaires. Multilevel generalized estimating equations examined the likelihood of F/V preparation. Momentary, within-day characteristics (i.e., occurrence of family meals, weekdays, afternoons) were associated with greater likelihood of mothers' fresh F/V preparation (ps < 0.05). Additionally, personal characteristics such as non-Hispanic ethnicity, not working full-time, having a child aged six months to five years in the household, and lower child BMI-z were associated with greater fresh F/V preparation among mothers (ps < 0.05). Findings may inform family-based obesity and nutrition intervention programs by understanding which families and in what contexts mothers are more likely to prepare F/Vs.

Impact of Nutrition Care Process Documentation in Obese Children and Adolescents with Metabolic Syndrome and/or Non-Alcoholic Fatty Liver Disease

This study evaluated the Nutrition Care Process documentation used by dietitians for obese pediatric patients diagnosed with metabolic syndrome (MetS) and/or non-alcoholic fatty liver disease (NAFLD) and its impact on the achievement of nutritional goals. This retrospective cohort study utilized data retrieved from three tertiary care hospitals in Riyadh. A total of 142 obese pediatric patients aged 8–18 years diagnosed with NAFLD and/or MetS were evaluated. Data on weight, height, blood pressure (BP), lipid profile, and liver enzymes were collected. A validated audit was used to assess the documentation quality. Twenty-seven (46.6%) dietitian notes received a high score, 21 (36.2%) received a medium score, and 10 (17.2%) received a low score. There was no significant effect of dietitian audit scores on nutritional outcomes, however, the change in body mass index from 6 to 12 months follow-up period was inversely correlated with the audit score (r = −0.761, p = 0.007), and alkaline phosphatase was inversely correlated with the audit score (r = −0.819, p = 0.013). In conclusion, there was a clear variation in the quality of dietitians’ documentation and the impact of documentation scores on nutritional outcomes.

Three-Year Follow-Up of the POIBA Intervention on Childhood Obesity: A Quasi-Experimental Study

Childhood obesity has increased worldwide over the past four decades. This quasi-experimental study aimed to assess the effectiveness of a multicomponent and multilevel school-based intervention (POIBA) at 3 years of follow-up. The nutrition intervention focused on food groups, food pyramid, nutrients, portions, and balanced menus. In total, 3624 children participated in the study. Anthropometric measurements and information on food frequency and behavior, physical activity, and daily screen use were collected in the intervention (IG) and comparison group (CG). Positive unadjusted changes toward adherence to recommendations were found for water, meat, sweets, and fried potato consumption, proper breakfast, not having dinner in front of the TV, out-of-school physical activity, and daily screen use. Three scores were used to calculate the proportion of children making more than one change to improve healthy habits regarding physical activity (global Activity score), nutrition (global Nutrition score), and both (global score). Students exposed to the intervention had a significantly better global Activity score (16.2% IG vs. 11.9% CG; p = 0.012) and Global score (63.9% IG vs. 58.5% CG; p = 0.025). Intervention effects on obesity incidence at 3-year follow-up lost significance but maintained the positive trend. In conclusion, school-based interventions including a family component could be useful to address the childhood obesity problem.