Predicting success: factors associated with weight change in obese youth undertaking a weight management program

Evaluating an acceptance-based lifestyle modification program to address cardiovascular disease risk among adolescent girls with overweight and obesity: Protocol for a randomized controlled trial

BACKGROUND

Behavioral weight loss interventions achieve only limited weight loss in adolescent samples and weight regain is common. This limited intervention success may be attributed, in part, to adolescents' lack of self-regulation skills essential for lifestyle modification and use of a one-size fits-all approach to produce weight loss in boys and girls. Interventions which teach self-regulation skills, such as Acceptance-Based Therapy (ABT), and are tailored to meet gender-specific concerns, are critical to help adolescents adapt to pervasive biological and environmental influences toward weight gain.

OBJECTIVE

This trial tests the effect of an ABT intervention on cardiometabolic health, health-related behaviors, and psychological factors among adolescent girls with overweight or obesity (OW/OB).

METHODS

Girls 14-19 years (N = 148; ≥ 40% racial/ethnic minorities) with OW/OB (BMI: ≥ 85th percentile) will be enrolled in the study. Participants will be randomized to one of two 6-month interventions, consisting of either 18 sessions of ABT or 9 sessions of a health education control, an augmented version of standard care for adolescent OW/OB, both led by bachelor's level interventionists.

RESULTS

Recruitment is taking place in Philadelphia, USA, from January 2024 to January 2028. Cardiometabolic health markers (adiposity; blood pressure; blood lipids), health-related behaviors (dietary intake; physical activity; sleep), and psychological factors (quality of life; depression; disordered eating; psychological flexibility) will be measured at baseline, mid-treatment, post-treatment, 6-month follow-up, and 12-month follow-up.

CONCLUSIONS

This study will provide valuable information on a novel intervention tailored to the needs of adolescent girls with OW/OB to address self-regulation and cardiometabolic health.

Review of paediatric obesity and non-alcoholic fatty liver disease-A focus on emerging non-pharmacologic treatment strategies

Obesity in paediatrics has become one of the most serious public health concerns worldwide. Paediatric obesity leads to increased adult obesity and is associated with several comorbidities, both physical and psychological. Within gastroenterology, non-alcoholic fatty liver disease (NAFLD) is now the most common cause of paediatric liver disease and the most common cause of liver transplantation in young adults. Treatment for NAFLD largely focuses on treatment of obesity with weight loss strategies. Unfortunately, the traditional method of weight loss using multicomponent lifestyle modification (dietary changes, increased exercise and behavioural modification) has often led to disappointing results. In adult patients with obesity, treatment strategies have evolved to include bariatric surgery and, more recently, bariatric endoscopy. In paediatrics, the obesity and NAFLD epidemics will likely require this variety of treatment to address children in a personalized manner. Here, we present a review of paediatric obesity, paediatric NAFLD and the various treatment strategies to date. We focus on non-pharmacologic and emerging therapies, including bariatric surgery and bariatric endoscopy-based treatments. With such a large population of children and adolescents with obesity, further development of these treatments, including paediatric-focused clinical trials, is essential for these emerging modalities.

Real-world effectiveness of the Bright Bodies healthy lifestyle intervention for childhood obesity

OBJECTIVE

This study aimed to examine the extent to which Bright Bodies, a high-intensity, family-based pediatric weight management intervention, improved BMI for participants since publication of the randomized controlled trial establishing efficacy in 2007 and to describe adaptations to the program.

METHODS

For participants enrolled from 2008 to 2018, linear mixed-effects models were used to estimate monthly change in BMI expressed as percentage of the 95th percentile (%BMIp95) during participants' first beginner-level program.

RESULTS

The sample included 396 youth individuals (mean age: 11.7  [SD 2.8] years, 61.6% female, 37.1% non-Hispanic Black, 26.3% Hispanic or Latino, 53.8% with public insurance, 80.1% with severe obesity). Across the 11 years, participants' %BMIp95 reduced on average by 1.63% (95% CI: 1.44%-1.82%) per month during their first program (mean duration: 10 weeks) after adjusting for age, sex, season and year, starting %BMIp95, race and ethnicity, and insurance category. Greater reduction in %BMIp95 was associated with male versus female sex, spring/fall versus winter seasons, enrollment in 2008 to 2018 versus 2015 to 2018, and higher starting %BMIp95 (p value for all <0.001). Adaptations since 2007 included pragmatic changes to increase engagement and address funding shortages.

CONCLUSIONS

These results suggest sustained clinical effectiveness of Bright Bodies in the context of real-world adaptations.

Predictors of successful weight loss in children treated at a community hospital-based tertiary care pediatric weight management program

Childhood obesity is a major public health concern. However, predictors of successful outcomes for patients treated at multidisciplinary community hospital-based pediatric weight management programs remain poorly understood. We conducted a retrospective analysis to evaluate 633 pediatric patients from ages 2 to 18 at a tertiary pediatric weight management program in 2018. Predictors were evaluated in univariate comparisons, and significant variables were included in a linear regression analysis to identify factors associated with improvements in body mass index relative to the age- and sex-specific 95th percentile body mass index (%BMIp95). We found that male sex and increased number of clinical visits were independently and significantly associated with reductions in %BMIp95. Baseline %BMIp95, age, preferred language, and insurance status were not significant predictors of outcomes. A total of 398 (63%) patients experienced a decrease in %BMIp95 from baseline to follow-up. One quarter (24.8%) of patients experienced a decrease in %BMIp95 of at least 5%, a threshold associated with cardiometabolic improvements. Further, we observed significant improvements in cholesterol, triglycerides, alanine aminotransferase, aspartate aminotransferase, HbA1c, and waist circumference. These findings support a potential need for sex- and gender-tailored care as well as the benefits of increased access to pediatric weight management programs.

Exploratory Decision Trees to Predict Obesity Intervention Response among Hispanic American Youth

Introduction: Individual variability in weight-related outcomes from obesity intervention is widely acknowledged, yet infrequently addressed. This study takes a first step to address individual variation by determining characteristics that distinguish responsive (improvements in BMI) from unresponsive individuals. Methods: Classification regression tree (CRT) analysis grouped 185 low-income, Hispanic American middle school students who received a school-based obesity intervention. Predictors included baseline age, gender, standardized BMI, health-related quality of life (PedsQL), minutes of moderate-vigorous physical activity (MVPA; accelerometry), energy consumption, and dietary quality (Block Kids 2004 Food Frequency Questionnaire). Response regarding weight-related outcomes to the intervention was defined according to the American Academy of Pediatrics (AAP) guidelines. Six trees were produced, one for 3- and one for 6-month outcomes among all participants, participants with healthy weight status, and participants with overweight/obesity at baseline. Results: The AAP criteria for response were met by 57.3% and 35.1% of participants at 3 and 6 months, respectively. CRT produced six unique trees. Notably, minutes of MVPA appeared twice (the first time at the top of the tree) in most 3-month models. In addition, response at 3 months consistently appeared as the first variable in all the 6-month models. Conclusions: Overall, the number of distinct pathways and the repeated appearance of the same variable within a pathway illustrate the complex, interactive nature of factors predicting an intervention response. Initially unresponsive individuals were unlikely to respond later in the intervention. More complex modeling is needed to better understand how to best predict who will be responsive to interventions.

Physician-related predictors of referral for multidisciplinary paediatric obesity management: a population-based study

BACKGROUND

It is recommended that primary care-based physicians refer children with overweight and obesity to multidisciplinary paediatric obesity management, which can help to improve weight and health.

OBJECTIVE

To determine predictors of referral to multidisciplinary paediatric obesity management.

METHODS

This retrospective, population-level study included physicians who could refer 2-17 years old with a body mass index ≥85th percentile to one of three multidisciplinary paediatric obesity management clinics in Alberta, Canada. Physician demographic and procedural data were obtained from Practitioner Claims and Provider Registry maintained by Alberta Health from January 2014 to December 2017. Physician characteristics were compared based on whether they did or did not refer children for obesity management. Univariable and multivariable logistic regression models analysed associations between physician characteristics and referral making.

RESULTS

Of the 3863 physicians (3468 family physicians, 395 paediatricians; 56% male; 49.3 ± 12.2 years old; 22.3 ± 12.6 years since graduation) practicing during the study period, 1358 (35.2%) referred at least one child for multidisciplinary paediatric obesity management. Multivariable regression revealed that female physicians (versus males) [odds ratio (OR): 1.68, 95% confidence interval (CI): 1.46-1.93; P < 0.0001], paediatricians (versus family physicians) (OR: 4.89, 95% CI: 3.85-6.21; P < 0.0001) and urban-based physicians (versus non-urban-based physicians) (OR: 2.17, 95% CI: 1.79-2.65; P < 0.0001) were more likely to refer children for multidisciplinary paediatric obesity management.

CONCLUSIONS

Approximately one-third of family physicians and paediatricians referred children for multidisciplinary paediatric obesity management. Strategies are needed to improve referral practices for managing paediatric obesity, especially among male physicians, family physicians and non-urban-based physicians as they were less likely to refer children.

Characteristics of achieving clinically important weight loss in two paediatric weight management interventions

OBJECTIVE

To examine characteristics and lifestyle behaviours associated with achieving clinically important weight loss (CIWL) in two paediatric weight management interventions (PWMIs).

METHODS

We examined 1010 children enrolled in the STAR and Connect for Health trials. We defined achieving CIWL as any participant who had decreased their BMI z-score by ≥0.2 units over 1 year. Using log-binomial regression we examined associations of child and household characteristics and lifestyle behaviours with achieving CIWL.

RESULTS

In multivariable analyses, children with severe obesity had a lower likelihood of achieving CIWL compared to children without severe obesity (RR: 0.68 [95% CI: 0.49, 0.95]). Children who were ≥10 years were less likely to achieve CIWL (RR: 0.56 [95% CI: 0.42, 0.74]) vs those 2-6 years of age. Children who consumed <1 sugary beverage per day at the end of the intervention were more likely to achieve CIWL vs those who did not meet the goal (RR: 1.36 [95% CI 1.09-1.70]).

CONCLUSION

In this analysis of children enrolled in PWMIs, achieving CIWL was associated with younger age, not having severe obesity and consuming fewer sugary beverages at the end of the intervention. Focusing on intervening earlier in life, when a child is at a lower BMI, and reducing sugary beverages could allow for more effective PWMI's.

Cross-National Outcomes of a Digital Weight Loss Intervention in the United States, Canada, United Kingdom and Ireland, and Australia and New Zealand: A Retrospective Analysis

Mobile health (mHealth) interventions are ubiquitous and effective treatment options for obesity. There is a widespread assumption that the mHealth interventions will be equally effective in other locations. In an initial test of this assumption, this retrospective study assesses weight loss and engagement with an mHealth behavior change weight loss intervention developed in the United States (US) in four English-speaking regions: the US, Australia and New Zealand (AU/NZ), Canada (CA), and the United Kingdom and Ireland (UK/IE). Data for 18,459 participants were extracted from the database of Noom's Healthy Weight Program. Self-reported weight was collected every week until program end (week 16). Engagement was measured using user-logged and automatically recorded actions. Linear mixed models were used to evaluate change in weight over time, and ANOVAs evaluated differences in engagement. In all regions, 27.2–33.2% of participants achieved at least 5% weight loss by week 16, with an average of 3–3.7% weight loss. Linear mixed models revealed similar weight outcomes in each region compared to the US, with a few differences. Engagement, however, significantly differed across regions (P < 0.001 on 5 of 6 factors). Depending on the level of engagement, the rate of weight loss over time differed for AU/NZ and UK/IE compared to the US. Our findings have important implications for the use and understanding of digital weight loss interventions worldwide. Future research should investigate the determinants of cross-country engagement differences and their long-term effects on intervention outcomes.

Feasibility/acceptability of an acceptance-based therapy intervention for diverse adolescent girls with overweight/obesity

BACKGROUND

Behavioral obesity interventions using an acceptance-based therapy (ABT) approach have demonstrated efficacy for adults, yet feasibility and acceptability of tailoring an ABT intervention for adolescents remains unknown.

OBJECTIVE

This study assessed the feasibility and acceptability of an ABT healthy lifestyle intervention among diverse adolescent cisgender girls with overweight/obesity (OW/OB).

METHODS

Adolescent cisgender girls aged 14-19 with a BMI of ≥85th percentile-for-sex-and-age were recruited for participation in a single-arm feasibility study. The primary outcomes were recruitment and retention while the secondary outcome was change in BMI Z-score over the 6-month intervention. Exploratory outcomes included obesity-related factors, health-related behaviors, and psychological factors.

RESULTS

Recruitment goals were achieved; 13 adolescents (>60% racial/ethnic minorities) participated in the intervention, and 11 completed the intervention (85% retention). In completers (n = 11), a mean decrease in BMI Z-score of -0.15 (SD = 0.34, Cohen's d = -0.44) was observed. Improvements were also noted for change in percentage of 95th percentile (d = -0.35), percent body fat (d = -0.35), quality of life (d = 0.71), psychological flexibility (d = -0.86), and depression (d = -0.86).

CONCLUSIONS

These preliminary findings suggest an ABT healthy lifestyle intervention tailored for adolescent cisgender girls with OW/OB may be an acceptable treatment that could lead to improvements in BMI Z-score, obesity-related measures, and psychological outcomes.

Determinants of attrition in a pediatric healthy lifestyle intervention: The CIRCUIT program experience

INTRODUCTION

Attrition in pediatric weight management programs is notoriously high. Greater understanding of its determinants is needed to inform retention strategies. We identified determinants of attrition in CIRCUIT, a healthy lifestyle intervention program for youth at risk of cardiovascular disease.

METHODS

A one-arm intervention study of children aged 4-18 years who initiated the CIRCUIT program in the first five years of its existence (N = 403). We defined attrition as attending the baseline visit but ceasing attendance prior to the 1-year follow-up. Potential determinants of dropout included the child's age, sex, ethnicity, body mass index (BMI) z-score, family socio-demographic characteristics, and estimated driving time to the program, all measured at baseline. Associations were estimated bivariately, using chi-squared- and t-tests, and simultaneously in a multivariable logistic regression model.

RESULTS

Of the 403 participants who started the program, 198 (49%) dropped out within 12 months of enrollment. Youth who dropped out were older (mean age 12.8y vs. 11.3y; p < 0.01), were less likely to live with both parents (62% vs. 71%; p = 0.05), and to have mothers who had completed high school (79% vs. 88%; p = 0.01). No group differences were observed for sex, ethnicity, baseline BMI z-score, fathers' education, or driving time to the program. In multivariate models, only older age at initiation of the intervention (OR: 1.2; CI: 1.1,1.3) and lower maternal education (OR: 2.0; CI: 1.0,3.8) were associated with dropout.

CONCLUSION

Improved tailoring of interventions to older pediatric participants and to families of lower maternal education may help reduce attrition in CIRCUIT and similar lifestyle intervention programs.

Effect of a high protein/low glycaemic index diet on insulin resistance in adolescents with overweight/obesity-A PREVIEW randomized clinical trial

BACKGROUND

Pubertal insulin resistance (IR) is associated with increased risk of type 2 diabetes mellitus development in adolescents with overweight/obesity.

OBJECTIVES

The PREVIEW study was a randomized parallel trial assessing the change in IR, analyzed by Homeostatic Model Assessment of IR (HOMA-IR), at 2 years after randomization to a high protein vs a moderate protein diet in adolescents with overweight/obesity. It was hypothesized that a high protein/low glycaemic index diet would be superior in reducing IR compared to a medium protein/medium GI diet, in insulin resistant adolescents with overweight or obesity.

METHODS

Adolescents with overweight/obesity and IR from the Netherlands, United Kingdom and Spain were randomized into a moderate protein/moderate GI (15/55/30En% protein/carbohydrate/fat, GI ≥ 56) or high protein/low GI (25/45/30En% protein/carbohydrate/fat, GI < 50) diet. Anthropometric and cardiometabolic parameters, puberty, dietary intake and physical activity (PA) were measured and effects on HOMA-IR were analyzed.

RESULTS

126 adolescents were included in this study (13.6 ± 2.2 years, BMI z-score 3.04 ± 0.66, HOMA-IR 3.48 ± 2.28, HP n = 68, MP n = 58). At 2 years, changes in protein intake were not significantly different between timepoints or intervention groups and no effects of the intervention on IR were observed. The retention rate was 39%, while no compliance to the diets was observed.

CONCLUSIONS

The PREVIEW study observed no effect of a high protein/low GI diet on IR in adolescents with overweight/obesity and IR because of lack of feasibility, due to insufficient retention and dietary compliance after 2 years.

Higher Body Mass Index, Uric Acid Levels, and Lower Cholesterol Levels are Associated with Greater Weight Loss

Background:

Identifying predictive factors that contribute to changes in body weight may well be an interesting approach to the management of obesity.

Objective:

This study was firstly aimed at examining the effect of a one-year lifestyle program based on improvements in the habitual diet and increased levels of physical activity on weight loss. Secondly, it was focused on identifying anthropometric, and serum hormonal, metabolic and haematochemical factors which can be associated with the degree of weight loss in Kg.

Methods:

488 overweight or obese subjects, 383 women and 105 men, aged 18-67 years, were enrolled in the study. Body mass index, waist circumference, serum blood glucose, lipids, uric acid, creatinine, insulin, TSH, FT3, FT4, and 24-h urine catecholamines were measured.

Results:

Weight loss was positively associated with BMI (P < 0.01), waist circumference (P < 0.01), uric acid (P < 0.01), creatinine (P < 0.05), smoking (P < 0.01), and negatively correlated with age (P < 0.01), total cholesterol (P < 0.05), LDL-cholesterol (P < 0.01), HDL cholesterol (P < 0.05). In a multiple regression model considering weight loss as a dependent variable, and smoking, age, BMI, uric acid, creatinine, total cholesterol, LDL-cholesterol and HDL cholesterol as independent variables, weight loss maintained a direct independent relationship with BMI (P < 0.001), uric acid (P < 0.05), LDL-cholesterol (P < 0.05), and HDL-cholesterol (P < 0.05), and an inverse independent association with cholesterol (P < 0.01).

Conclusions:

This study suggests that higher BMI and uric acid levels, and lower total cholesterol concentrations are associated with a greater potential to lose weight.

A review of the short- and long-term impact of weight loss on appetite in youth: what do we know and where to from here?

This review seeks to synthesise our knowledge about changes in hunger and satiety that occur during diet-induced weight loss and during weight loss maintenance, with a particular focus on youth with obesity. Mechanisms of appetite responses to weight loss rely heavily on the adult literature. Physiological mechanisms that control appetite and satiety via the gut-brain axis have been elucidated but we have an incomplete picture of changes in gut hormones and peptides in youth with obesity. In adolescents, the role of the brain in long-term sensing of body composition and modifying appetite and satiety changes is easily over-ridden by hedonic influences for the reward of highly palatable sweet foods and encourages over-consumption. Accordingly, reward cues and hyper-responsiveness to palatable foods lead to a pattern of food choices. Different reward systems are necessary that are substantial enough to reward the continued individual effort required to sustain new behaviours, that need to be adopted to support a reduced body weight. Periods of growth and development during childhood provide windows of opportunity for interventions to influence body weight trajectory but long-term studies are lacking. More emphasis needs to be placed on anticipatory guidance on how to manage powerful hedonic influences of food choice, essential to cope with living in our obesogenic environment and managing hunger which comes with the stronger desire to eat after weight has been lost.

Obesity Treatment Among Adolescents: A Review of Current Evidence and Future Directions

Importance

Obesity in adolescence has reached epidemic proportions around the world, with the prevalence of severe obesity increasing at least 4-fold over the last 35 years. Most youths with obesity carry their excess adiposity into adulthood, which places them at increased risk for developing obesity-driven complications, such as type 2 diabetes and cardiovascular disease, and negatively affects social and emotional health. Given that adolescence is a unique transition period marked by significant physiologic and developmental changes, obesity-related complications can also negatively affect adolescent growth and developmental trajectories.

Observations

Provision of evidence-based treatment options that are tailored and appropriate for the adolescent population is paramount, yet complex. The multifactorial etiology of obesity along with the significant changes that occur during the adolescent period increasingly complicate the treatment approach for adolescent obesity. Treatment practices discussed in this review include an overview of evidence supporting currently available behavioral, pharmacologic, surgical, and device interventions for obesity. However, it is important to note that these practices have not been effective at reducing adolescent obesity at the population level.

Conclusions and Relevance

Because adolescent obesity requires lifelong treatment, effectively addressing this disease will require significant resources, scientific rigor, and the provision of access to quality care similar to other chronic health conditions. Effective and less invasive therapies, effective adjuncts, and comprehensive centers that offer specialized treatment are critical. This considerable need for increased attention to obesity care calls for dedicated resources in both education and research for treatment of obesity in youths.

Weight-related quality of life and temperament as predictors and moderators of outcomes among treatment-seeking, low-income, ethnically diverse children with obesity

Within any childhood obesity treatment program, some children have better outcomes than others. Little is known about predictors or moderators of more positive outcomes. We aimed to identify whether child temperament and weight-related quality of life predict or moderate childhood obesity treatment outcomes at 6 months. From 2015 to 2016, children (n = 97) ages 5-11 years old with obesity were randomized to a clinic-community (Bull City Fit) or a clinic-only treatment program. Linear regression was used to explore whether dimensions of child temperament and weight-related quality of life predicted or moderated 6-month anthropometric and physical activity outcomes. Children who had more social avoidance due to their weight at baseline had significantly better improvements in body fat percent in the clinic-community model compared with the clinic-only model at 6 months. Across programs, better baseline social quality of life predicted greater increases in waist circumference; conversely, better physical quality of life predicted a decrease in percent of the 95th percentile. Also, children with longer attention spans had greater increases in physical activity. Our findings suggest that children who have social avoidance due to their weight may benefit most from comprehensive clinic-community treatment. Weight-related quality of life may influence outcomes across all treatments, and practitioners need to carefully counsel children experiencing weight negatively.

Body Mass Index Change Between Referral to and Enrollment in Pediatric Weight Management

This study describes changes in body mass index z score (BMIz) and percent of 95th percentile (P95) between referral to pediatric weight management (PWM) and initial PWM visit. We conducted a prospective cohort analysis among subjects (n = 77) aged 5 to 11 years referred to PWM and compared height and weight at time of referral versus initial PWM visit. Mean BMIz decreased by 0.05, and P95 decreased by 1.48 across all age groups (both P < .01) from time of referral to initial visit. Children 5 to 8 years old experienced a greater BMIz change than older children (-0.07 vs -0.02; P < .05). Interval BMIz change was greater for non-Hispanic White and Hispanic children compared with non-Hispanic Blacks (-0.10 vs -0.01; P < .001). There were no subgroup differences in P95. Interval BMI changes between referral and treatment approach half the effect reported by some PWM programs. Referral to PWM may motivate pretreatment lifestyle changes in some patients.

Characteristics Associated with Successful Weight Management in Youth with Obesity

OBJECTIVE

To identify the medical, demographic, and behavioral factors associated with a reduction of body mass index percent of the 95th percentile (BMIp95) after 1 year for patients receiving care at a tertiary care obesity management clinic.

STUDY DESIGN

A retrospective review of data from first and 12 ± 3-month follow-up visits of subjects aged 8-17 years with obesity. Data included anthropometrics, demographics, medical/psychological history, reported diet patterns, and participation in moderate/vigorous physical activity. After analyzing factors associated with 1-year follow-up, we used a forward conditional logistic regression model, controlling for subject's sex, to examine associations with a BMIp95 ≥5-point decrease at 1 year.

RESULTS

Of 769 subjects, 184 (23.9%) had 1-year follow-up. Boys more often had follow-up (28.4% vs girls, 19.1%; P = .003). The follow-up sample was 62.0% male, 65.8% Hispanic, and 77.7% with public insurance; 33.2% achieved a ≥5-point decrease in BMIp95. In regression results, the ≥5-point decrease group was more likely to have completed an initial visit in April-September (OR 2.0, 95% CI 1.1-3.9); have increased physical activity by 1-2 d/wk (OR 3.4, 95% CI 1.4-7.8) or increased physical activity by ≥ 3 d/wk at 1 year (OR 2.7, 95% CI 1.1-6.3); and less likely to have been depressed at presentation (OR 0.4, 95% CI 0.2-0.9). Demographic and dietary factors were not significantly associated with BMIp95 group status.

CONCLUSIONS

Strategies improving follow-up rates, addressing mental health concerns, and promoting year-round physical activity are needed to increase the effectiveness of obesity management clinics.

Health Outcomes of Youth in Clinical Pediatric Weight Management Programs in POWER

OBJECTIVE

To describe treatment outcomes of children and adolescents enrolled in the Pediatric Obesity Weight Evaluation Registry, a consortium of multicomponent pediatric weight management programs in the US.

STUDY DESIGN

This multicenter prospective observational cohort study, established in 2013, includes youth (2-18 years of age) with obesity enrolled from 31 Pediatric Obesity Weight Evaluation Registry (POWER) sites over a 2-year period and followed up to 12 months. Weight status was evaluated by the percentage of the 95th percentile for body mass index (%BMIp95). Associations of weight status outcomes with patient characteristics and program exposure were analyzed with multivariable mixed effects modeling.

RESULTS

We included 6454 children and adolescents (median age, 11 years; IQR, 9-14 years; 53% white, 32% Hispanic; 73% with severe obesity) who were enrolled in POWER. Median changes in %BMIp95 for this cohort were -1.88 (IQR, -5.8 to 1.4), -2.50 (IQR, -7.4 to 1.8), -2.86 (IQR, -8.7 to 1.9), at 4-6, 7-9, and 10-12 of months follow-up, respectively (all P < .05). Older age (≥12 years), greater severity of obesity, and Hispanic race/ethnicity were associated with better improvement in %BMIp95. A 5-percentage point decrease in %BMIp95 was associated with improvement in cardiometabolic risk factors.

CONCLUSIONS

Overall, treatment in pediatric weight management programs is associated with a modest median decrease in BMI as measured by change in %BMIp95. Further studies are needed to confirm these findings, as well as to identify additional strategies to enhance the effectiveness of these multicomponent interventions for youth with severe obesity.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02121132.

Short-Term Predictors for Weight Correction Success of the First Paediatric Weight Correction Programme in Children's Clinical University Hospital in Riga

Background and objectives: The efficacy of a weight correction programme can be affected by such predictors as the number of contact hours, gender, age, baseline weight, parental weight status, psycho-emotional status, insulin resistance, and socioeconomic status. The aim of this current study was to evaluate the overall efficacy of the Weight Correction Programme at Children's Clinical University Hospital, and explore the impact of the probable predictors. We evaluated the efficacy depending on gender, age, parental weight status, signs of depression, baseline body mass index z-score (z-BMI), and baseline waist circumference. Materials and Methods: The data were gathered from medical records. The inclusion criteria were as follows: Entered the programme by 13 June 2017, at least five years old, follow-up data available. All the respondents were divided into two age groups: <10 years old and ≥10 years old. Results: The study included 181 respondents. They were 5 to 17 years old on the first day of participation in the Weight Correction Programme. Results indicated that 117 (65%) patients managed to reduce z-BMI and 69 (38%) patients achieved clinically significant reduction of z-BMI. Boys had four times higher odds (odds ratio (OR) = 4,22; CI 1.37⁻13.05; p = 0.012) to reduce their z-BMI by at least 0.20 units than girls. The respondents of the older age group (≥10 years) had a better chance to reduce z-BMI than the younger ones (OR = 11,51; CI 2.04⁻64.83; p = 0.006). The odds to reduce z-BMI were lower by 7% for every extra cm of waist circumference (OR = 0.93; CI 0.88⁻0.99; p = 0.014) for reducing z-BMI. The follow-up time was also a positive predictor, and with every month the odds for clinically significant z-BMI reduction increased by 7% (OR = 1.07; CI 1.00⁻1.15; p = 0.047). The parental weight status, signs of depression, and baseline z-BMI were not significant predictors. Conclusions: More than half of the patients of the respondents managed to reduce their z-BMI. Female gender, younger age, and larger waist circumference were negative predictors.

Does Love Really Make Mothers Blind? A Large Transcontinental Study on Mothers' Awareness About Their Children's Weight

OBJECTIVE

The aim of this study was to assess maternal misperception rates (perception as normal or underweight of a child with overweight or obesity) and their role in affecting the chance of implementing actions to change children's weight.

METHODS

Obesogeneicity of Gadgets Marketed with Snacks (OBEY-AD) is an international study investigating factors promoting childhood overweight and obesity in 10 countries, in which 2,720 child-mother dyads have been enrolled. Mothers' perception of their children's weight was assessed using a projective test. Children's weight status was measured according to the anthropometric standards established by the World Health Organization.

RESULTS

Mothers classified 89% of children with overweight and 52% of children with obesity as normal weight. The odds ratio of mothers' misperception was significantly higher for higher parental BMI, higher children's International Brand Awareness Inventory score, and high family socioeconomic status. Children with overweight and/or obesity who were perceived as normal weight by their mothers were less likely to be referred to specific health care services.

CONCLUSIONS

Most children with overweight and/or obesity were perceived as normal weight by their mothers. Such lack of concern regarding a severe disease might interfere with the effectiveness of prevention programs. Considering the contextual factors that frame the etiological causes of a disease may help in finding effective and enduring solutions to target childhood obesity.

Paediatric obesity treatment had better outcomes when children were younger, well motivated and did not have acanthosis nigricans

AIM

This study evaluated the efficacy of a paediatric obesity treatment programme and explored the factors that contributed to the outcome.

METHODS

We recorded the body mass index standard deviation scores (BMI SDS) of 654 children aged 2-18 years who were treated for obesity in 2005-2012 in three Finnish hospitals, one year before treatment and up to three years after treatment. The family-based multidisciplinary treatment included nutritional advice, exercise and behavioural counselling. The BMI SDS changes, and their contributors, were explored with mixed-model and logistic regression analyses.

RESULTS

BMI SDS increased before baseline and decreased at six, 12 and 24 months (all p < 0.001) and 36 months (p = 0.005). Younger age (p < 0.001), higher BMI SDS at baseline (p = 0.001), motivation (p = 0.013), adherence to the protocol (p = 0.033) and lack of acanthosis nigricans (p < 0.001) improved the outcome. The BMI SDS of children aged 2-6 decreased best from baseline to 12 (-0.35), 24 (-0.58) and 36 months (-0.64) (all p < 0.001).

CONCLUSION

Paediatric obesity treatment was most effective at a younger age. Good motivation and adherence contributed to favourable outcomes, while acanthosis nigricans was associated with a poor outcome.

Systematic Review: Nutrition and Physical Activity in the Management of Paediatric Nonalcoholic Fatty Liver Disease

OBJECTIVES

The aim of the study was to evaluate efficacy of nutrition and physical activity interventions in the clinical management of paediatric nonalcoholic fatty liver disease. The prevalence of paediatric nonalcoholic fatty liver disease continues to rise alongside childhood obesity. Weight loss through lifestyle modification is currently first-line treatment, although supplementation of specific dietary components may be beneficial.

METHODS

Medline, CINAHL, EMBASE, Scopus, and Cochrane Libraries were systematically searched to identify randomized controlled trials assessing nutritional and physical activity interventions. Primary outcome measures were changes to liver biomarkers assessed by imaging, histology, or serum liver function tests. Study quality was evaluated using the American Dietetic Association Quality Criteria Checklist.

RESULTS

Fifteen articles met eligibility criteria investigating nutritional supplementation (vitamin E [n = 6], probiotics [n = 2], omega-3 fatty acids [n = 5]), dietary modification (low glycaemic load [n = 1] and reducing fructose intake [n = 1]). No randomized controlled trials examining physical activity interventions were identified. Vitamin E was ineffective at improving alanine transaminase levels, whereas omega-3 fatty acids decreased hepatic fat content. Probiotics gave mixed results, whereas reduced fructose consumption did not improve primary outcome measures. A low glycaemic load diet and a low-fat diet appeared equally effective in decreasing hepatic fat content and transaminases. Most studies were deemed neutral as assessed by the American Dietetic Association Quality Criteria Checklist.

CONCLUSIONS

The limited evidence base inhibits the prescription of specific dietary and/or lifestyle strategies for clinical practice. General healthy eating and physical activity guidelines, promoting weight loss, should remain first-line treatment until high-quality evidence emerges that support specific interventions that offer additional clinical benefit.

Evaluation of a Commercially Delivered Weight Management Program for Adolescents

OBJECTIVE

To evaluate a commercially available, structured short-term weight management program designed for adolescents with obesity delivered by nonhealth professionals.

STUDY DESIGN

A multisite parallel-group randomized controlled trial was conducted to evaluate a commercial 12-week lifestyle behavioral program in commercial weight management centers in Australia. Eligible participants (13-17 years, body mass index (BMI) z score ?1.282 with no presenting morbidities) were randomized (n?=?88) to intervention or wait-list, and the program was delivered by consultants at participating weight management centers. The primary outcome was change in BMI z score. Secondary outcomes included the psychometric variables quality of life, body-esteem, and self-esteem. Data was analyzed according to intention-to-treat principles.

RESULTS

Of 74 participants who consented to enter the study, 66 provided baseline anthropometric data and 12-week data were available for 55 individuals (74%). A significantly greater decrease in BMI z score in the intervention group (n?=?32) was observed when compared with the wait-list control group, mean difference (MD)?=??0.27?kg/m²; 95% CI, ?0.37,?0.17; P?<?.001). Participants allocated to receive the lifestyle intervention reported a greater improvement in body esteem (MD = 1.7, 95% CI, 0.3, 3.1; P?=?.02) and quality of life (MD?=?5.9, 95% CI, 0.9, 10.9; P?=?.02) compared with the wait-list control group.

CONCLUSIONS

A structured lifestyle intervention delivered by a commercial provider in an adolescent population can result in clinically relevant weight loss and improvements in psychosocial outcomes in the short term. Further research is required to evaluate long-term outcomes.

TRIAL REGISTRATION

International Clinical Trials Registry: ISRCTN13602313.

The effectiveness and promising strategies of obesity prevention and treatment programmes among adolescents from disadvantaged backgrounds: a systematic review

This review aimed to summarize the evidence on the effectiveness of obesity prevention and treatment programmes for adolescents from socioeconomically disadvantaged backgrounds. A secondary aim was to identify potential successful intervention strategies for this target group. PubMed, EMBASE, PsycINFO and Cochrane Library were searched from January 2000 up to February 2016. Intervention studies targeting adolescents from disadvantaged backgrounds were included, with body mass index as outcome. Secondary outcomes were other adiposity measures, physical activity, diet, sedentary behaviour and screen time. Two independent reviewers extracted data, coded intervention strategies and conducted quality assessments. Fourteen studies were included: nine obesity prevention and five obesity treatment studies. Two preventive and four treatment studies showed significant beneficial effects on body mass index. Five of six studies (four preventive, one treatment studies) measuring dietary behaviour reported significant intervention effects. Evidence on other secondary outcomes was inconclusive. We found no conclusive evidence for which specific intervention strategies were particularly successful in preventing or treating obesity among disadvantaged adolescents. However, the current evidence suggests that involving adolescents in the development and delivering of interventions, the use of experiential activities and involvement of parents seem to be promising strategies. More high quality studies are needed. PROSPERO registration number: CRD42016041612.

Acanthosis nigricans in obese adolescents: prevalence, impact, and management challenges

Obesity in adolescence is a public health priority because it usually tracks into adulthood, resulting in enormous medical and social costs. This underscores the importance of early identification and intervention. Acanthosis nigricans (AN) was once considered a rare paraneoplastic dermatosis, but is now frequently observed in obese adolescents. Current understanding suggests that it is associated with insulin resistance and has a unique role in secondary prevention. The purpose of this narrative review is to provide a comprehensive overview of AN in obese adolescents, covering its history, current knowledge on the condition, its clinical significance, management challenges, and the direction of future research.

From Bench to Bedside: Understanding Stress-Obesity Research Within the Context of Translation to Improve Pediatric Behavioral Weight Management

A growing body of literature suggests that stress, including chronic stress and acute physiologic stress reactivity, is one contributor to the development and maintenance of obesity in youth. Little has been done to apply the literature on stress and obesity risk to inform the development of pediatric behavioral weight control (BWC) interventions. The aims of this review are to (1) discuss research linking stress and pediatric obesity, (2) provide examples of the implications of the stress-obesity research for pediatric BWC development, and (3) propose that a mindfulness-based approach may be useful in targeting stress reduction within pediatric BWC.

Can early weight loss, eating behaviors and socioeconomic factors predict successful weight loss at 12- and 24-months in adolescents with obesity and insulin resistance participating in a randomised controlled trial?

BACKGROUND

Lifestyle interventions in adolescents with obesity can result in weight loss following active intervention but individual responses vary widely. This study aimed to identify predictors of weight loss at 12- and 24-months in adolescents with obesity and clinical features of insulin resistance.

METHODS

Adolescents (n = 111, 66 girls, aged 10-17 years) were participants in a randomised controlled trial, the RESIST study, examining the effects of two diets differing in macronutrient content on insulin sensitivity. Eighty-five completed the 12-month program and 24-month follow-up data were available for 42 adolescents. Change in weight was determined by BMI expressed as a percentage of the 95th percentile (BMI95). The study physician collected socioeconomic data at baseline. Physical activity and screen time, and psychological dimensions of eating behavior were self-reported using the validated CLASS and EPI-C questionnaires, respectively. Stepwise multiple regressions were conducted to identify models that best predicted change in BMI95 at 12- and 24-months.

RESULTS

Mean BMI95 was reduced at 12-months compared with baseline (mean difference [MD] ± SE: -6.9 ± 1.0, P < 0.001) but adolescents had significant re-gain from 12- to 24-months (MD ± SE: 3.7 ± 1.5, P = 0.017). Participants who achieved greater 12-month weight loss had: greater 3-month weight loss, a father with a higher education, lower baseline external eating and parental pressure to eat scores and two parents living at home. Participants who achieved greater 24-month weight loss had: greater 12-month weight loss and a lower baseline emotional eating score.

CONCLUSIONS

Early weight loss is consistently identified as a strong predictor of long-term weight loss. This could be because early weight loss identifies those more motivated and engaged individuals. Patients who have baseline factors predictive of long-term weight loss failure may benefit from additional support during the intervention. Additionally, if a patient does not achieve early weight loss, further support or transition to an alternate intervention where they may have increased success may be considered.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registration Number (ACTRN) 12608000416392 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=83071.

A Randomized Controlled Trial of Two Different Macronutrient Profiles on Weight, Body Composition and Metabolic Parameters in Obese Adolescents Seeking Weight Loss

Objective

Adolescent obesity is difficult to treat and the optimal dietary pattern, particularly in relation to macronutrient composition, remains controversial. This study tested the effect of two structured diets with differing macronutrient composition versus control, on weight, body composition and metabolic parameters in obese adolescents.

Design

A randomized controlled trial conducted in a children’s hospital.

Methods

Eighty seven obese youth (means: age 13.6 years, BMI z-score 2.2, waist: height ratio 0.65, 69% female) completed a psychological preparedness program and were then randomized to a short term ‘structured modified carbohydrate’ (SMC, 35% carbohydrate; 30% protein; 35% fat, n = 37) or a ‘structured low fat’ (SLF, 55% carbohydrate; 20% protein; 25% fat, n = 36) or a wait listed control group (n = 14). Anthropometric, body composition and biochemical parameters were measured at randomization and after 12 weeks, and analyzed under the intention to treat principle using analysis of variance models.

Results

After 12 weeks, data was collected from 79 (91%) participants. BMI z-scores were significantly lower in both intervention groups compared to control after adjusting for baseline values, SLF vs. control, mean difference = -0.13 (95%CI = -0.18, -0.07), P<0.001; SMC vs. control, -0.14 (-0.19, -0.09), P<0.001, but there was no difference between the two intervention diet groups: SLF vs. SMC, 0.00 (-0.05, 0.04), P = 0.83.

Conclusions

Both dietary patterns resulted in similar changes in weight, body composition and metabolic improvements compared to control. The use of a structured eating system which allows flexibility but limited choices can assist in weight change and the rigid application of a low fat eating pattern is not exclusive in its efficacy.

Trial Registration

International Clinical Trials Registry ISRCTN49438757

Study protocol: evaluation of 'JenMe', a commercially-delivered weight management program for adolescents: a randomised controlled trial

BACKGROUND

Early lifestyle intervention with overweight and obese adolescents could help to avoid serious health events in early adulthood, ultimately alleviating some of the strain on the public health system due to obesity-related morbidity. Commercial weight loss programs have wide reach into the community setting, and have demonstrated success in long term weight management in adults, beyond that of current public health care. Commercial weight-management programs have not been evaluated as a method of delivery for overweight and obese adolescents. This study aims to evaluate the efficacy of a new adolescent weight management program in a commercial environment.

METHODS

One hundred and forty adolescents, 13 to 17 years old, will be randomised to either a weight management program intervention or a wait-listed group for 12 weeks. The commercial program will consist of a combined dietary and lifestyle approach targeting improved health behaviours for weight-loss or weight-stability. Participants will be overweight or obese (above the 85(th) percentile for BMI) and without existing co-morbidities. Outcome measures will be assessed at baseline and after 12 weeks. Primary outcome measures will be changes in BMI Z-score and waist-height ratio. Secondary outcome measures will include changes in behaviour, physical activity and psychosocial wellbeing. Intervention participants will be followed up at 6 months following completion of the initial program. Ethics approval has been granted from the Monash University Human Research Ethics Committee (CF11/3687-2011001940).

DISCUSSION

This independent evaluation of a weight management program for adolescents, delivered in a commercial setting, will provide initial evidence for the effectiveness of such programs; which may offer adolescents an avenue of weight-management with ongoing support prior to the development of obesity related co-morbidities.

TRIAL REGISTRATION

The protocol for this study is registered with the International Clinical Trials Registry ISRCTN13602313.

How effective are interventions at reducing socioeconomic inequalities in obesity among children and adults? Two systematic reviews

Background

Tackling obesity is one of the major contemporary public health policy challenges and is vital in terms of addressing health inequalities.

Objectives

To systematically review the effectiveness of interventions (individual, community and societal) in reducing socioeconomic inequalities in obesity among (1) children aged 0–18 years (including prenatal) and (2) adults aged ≥18 years, in any setting, in any country, and (3) to establish how such interventions are organised, implemented and delivered.

Data sources

Nine electronic databases including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and NHS Economic Evaluation Database were searched from database start date to 10 October 2011 (child review) and to 11 October 2012 (adult review). We did not exclude papers on the basis of language, country or publication date. We supplemented these searches with website and grey literature searches.

Review methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Experimental studies and observational studies with a duration of at least 12 weeks were included. The reviews considered strategies that might reduce existing inequalities in the prevalence of obesity [i.e. effective targeted interventions or universal interventions that work more effectively in low socioeconomic status (SES) groups] as well as those interventions that might prevent the development of inequalities in obesity (i.e. universal interventions that work equally along the SES gradient). Interventions that involved drugs or surgery and laboratory-based studies were excluded from the reviews. The initial screening of titles and abstracts was conducted by one reviewer with a random 10% of the sample checked by a second reviewer. Data extraction was conducted by one reviewer and independently checked by a second reviewer. The methodological quality of the included studies was appraised independently by two reviewers. Meta-analysis and narrative synthesis were conducted focusing on the ‘best-available’ evidence for each intervention type (defined in terms of study design and quality).

Results

Of 56,967 papers of inequalities in obesity in children, 76 studies (85 papers) were included, and of 70,730 papers of inequalities in obesity in adults, 103 studies (103 papers) were included. These studies suggested that interventions that aim to prevent, reduce or manage obesity do not increase inequalities. For children, there was most evidence of effectiveness for targeted school-delivered, environmental and empowerment interventions. For adults, there was most evidence of effectiveness for primary care-delivered tailored weight loss and community-based weight loss interventions, at least in the short term among low-income women. There were few studies of appropriate design that could be included on societal-level interventions, a clear limitation of the evidence base found.

Limitations

The reviews located few evaluations of societal-level interventions and this was probably because they included only experimental study designs. The quality assessment tool, although described as a tool for public health interventions, seemed to favour those that followed a more clinical model. The implementation tool was practical but enabled only a brief summary of implementation factors to be made. Most of the studies synthesised in the reviews were from outside the UK and related to women.

Conclusions

The reviews have found some evidence of interventions with the potential to reduce SES inequalities in obesity and that obesity management interventions do not increase health inequalities. More experimental studies of the effectiveness and cost-effectiveness of interventions (particularly at the societal level) to reduce inequalities in obesity, particularly among adolescents and adult men in the UK, are needed.

Study registration

The studies are registered as PROSPERO CRD42011001740 and CRD42013003612.

Funding

The National Institute for Health Research Public Health Research programme.

Impact of dietary macronutrient distribution on BMI and cardiometabolic outcomes in overweight and obese children and adolescents: a systematic review

The present systematic review examined the effectiveness of weight management interventions comparing diets with varying macronutrient distributions on BMI and cardiometabolic risk factors in overweight or obese children and adolescents. A systematic search of seven databases for the period 1975-2013 identified 14 eligible randomized or quasi-randomized controlled trials conducted with 6-18-year-old subjects. Seven trials compared a low-fat (≤ 33% energy or < 40 g/day) to an isocaloric (n = 2) or ad libitum (n = 5) low-carbohydrate diet (< 20% energy or < 60 g/day). Meta-analysis indicated a greater reduction in BMI in the low-carbohydrate group immediately after dietary intervention; however, the quality of the studies was limited and cardiometabolic benefits were inconsistent. Six trials compared increased-protein diets (19-30% energy) to isocaloric standard-protein diets (15-20% energy) and one compared an increased-fat diet (40% energy) to an isocaloric standard-fat diet (27% energy); there were no differences in outcomes in these studies. Current evidence suggests that improved weight status can be achieved in overweight or obese children and adolescents irrespective of the macronutrient distribution of a reduced-energy diet. Tailoring the macronutrient content to target specific cardiometabolic risk factors, such as a low-carbohydrate diet to treat insulin resistance, may be possible, but further research is needed before specific recommendations can be made.