Assessment and management of obesity in childhood and adolescence

Scoping literature review and focus groups with healthcare professionals on psychosocial and lifestyle assessments for childhood obesity care

BACKGROUND

Childhood obesity is a complex disease resulting from the interaction of multiple factors. The effective management of childhood obesity requires assessing the psychosocial and lifestyle factors that may play a role in the development and maintenance of obesity. This study centers on available scientific literature on psychosocial and lifestyle assessments for childhood obesity, and experiences and views of healthcare professionals with regard to assessing psychosocial and lifestyle factors within Dutch integrated care.

METHODS

Two methods were used. First, a scoping review (in PubMed, Embase, PsycInfo, IBSS, Scopus and Web of Science) was performed by systematically searching for scientific literature on psychosocial and lifestyle assessments for childhood obesity. Data were analysed by extracting data in Microsoft Excel. Second, focus group discussions were held with healthcare professionals from a variety of disciplines and domains to explore their experiences and views about assessing psychosocial and lifestyle factors within Dutch integrated care. Data were analysed using template analysis, complemented with open coding in MAXQDA.

RESULTS

The results provide an overview of relevant psychosocial and lifestyle factors that should be assessed and were classified as child, family, parental and lifestyle (e.g. nutrition, physical activity and sleep factors) and structured into psychological and social aspects. Insights into how to assess psychosocial and lifestyle factors were identified as well, including talking about psychosocial factors, lifestyle and weight; the professional-patient relationship; and attitudes of healthcare professionals.

CONCLUSIONS

This study provides an overview of psychosocial and lifestyle factors that should be identified within the context of childhood obesity care, as they may contribute to the development and maintenance of obesity. The results highlight the importance of both what is assessed and how it is assessed. The results of this study can be used to develop practical tools for facilitating healthcare professionals in conducting a psychosocial and lifestyle assessment.

The association between metabolic equivalent and visceral adiposity index among children and adolescents: Ten-cycle cross-sectional study on NHANES (1999-2018)

Metabolic disorder is globally prevalent in children and adolescents, and physical activity may have a protective role against metabolic disorder. However, the association between metabolic equivalent (MET) and visceral adiposity index (VAI) among children and adolescents remains unclear. This study aimed to address this concern. Data were retrieved from the National Health and Nutrition Examination Survey (NHANES), which used the Global Physical Activity Questionnaire to assess the physical activity levels. VAI was calculated according to body mass index (BMI), waist circumference (WC), triglyceride (TG), and high-density lipoprotein (HDL). Linear regression was adopted to assess the association between MET and VAI. Restricted cubic spline regression was used to further explore the nonlinear relationship, Interaction effect analysis was conducted to identify whether the sample characteristic could modify the effect of MET on VAI. After data cleansing, a total of 3402 participants aged <18 years were enrolled. In the fully adjusted linear regression model, the β for VAI was 0.01 (95% confidence interval [CI]: -0.08, 0.09) for the second tertile and -0.11 (95% CI: -0.20, -0.03) for the third tertile. A linear downward trend was found in the restricted cubic spline regression (overall P < .05). Interaction effect analysis revealed no significant effects of age, gender, race, income poverty ratio, and insurance (all P for interaction >0.05). High physical activity intensity is associated with decreased VAI scores in children and adolescents.

Benefits of Physical Activity on Cardiometabolic Diseases in Obese Children and Adolescents

In the past few decades, obesity in the pediatric population has dramatically increased and is common in many countries. Childhood obesity often causes health problems and increases the risk of cardiometabolic diseases such as type 2 diabetes, nonalcohol fatty liver, and cardiovascular diseases. Obesity in young people has been closely associated with environmental, behavioral, and genetic defects, including the availability of high-energy and sugary food and beverages, sedentary behavior, and hereditary factors. Few drugs are currently available to treat obesity in children and adolescents because it is difficult to demonstrate the safety of these drugs on the growth and development of the youth. Lifestyle modifications, such as diet control and physical exercise, are the primary approaches for preventing and treating childhood obesity. Among them, physical activity is a crucial component. This review summarizes the epidemiology, cardiometabolic risk of obesity, therapeutic strategies, and the benefits of exercise on obesity-related chronic diseases in children and adolescents.

Obesity in children and adolescents: epidemiology, causes, assessment, and management

This Review describes current knowledge on the epidemiology and causes of child and adolescent obesity, considerations for assessment, and current management approaches. Before the COVID-19 pandemic, obesity prevalence in children and adolescents had plateaued in many high-income countries despite levels of severe obesity having increased. However, in low-income and middle-income countries, obesity prevalence had risen. During the pandemic, weight gain among children and adolescents has increased in several jurisdictions. Obesity is associated with cardiometabolic and psychosocial comorbidity as well as premature adult mortality. The development and perpetuation of obesity is largely explained by a bio-socioecological framework, whereby biological predisposition, socioeconomic, and environmental factors interact together to promote deposition and proliferation of adipose tissue. First-line treatment approaches include family-based behavioural obesity interventions addressing diet, physical activity, sedentary behaviours, and sleep quality, underpinned by behaviour change strategies. Evidence for intensive dietary approaches, pharmacotherapy, and metabolic and bariatric surgery as supplemental therapies are emerging; however, access to these therapies is scarce in most jurisdictions. Research is still needed to inform the personalisation of treatment approaches of obesity in children and adolescents and their translation to clinical practice.

Novel dietary interventions for adolescents with obesity: A narrative review

Adolescent obesity is increasing and a range of treatment approaches are needed. Provision of tailored treatment options accounting for individual and family needs, preferences, and capacity may encourage adolescents with obesity to seek treatment, and/or improve treatment outcomes. Delivered by trained health care professionals, novel dietary interventions may have utility for adolescents not responding to conventional diets, adolescents with comorbidities or severe obesity, and/or when rapid or substantial weight loss is required. This review describes current evidence and clinical considerations relating to the use of very low energy diets, low carbohydrate diets, and intermittent energy restriction in the treatment of adolescent obesity. Emerging evidence on the use of these novel dietary interventions demonstrates short-term weight-related and cardiometabolic improvements. While the evidence is encouraging, and no serious adverse effects have been reported, monitoring of intervention safety is essential. Considerations for health care professionals providing care to adolescents include nutritional adequacy, psychosocial health and social relationships during the intervention. Furthermore, long-term weight-related, cardiometabolic and psychological health outcomes of these dietary interventions are not well understood. Large randomised controlled trials are warranted to inform clinical practice and future guidelines for the use of novel dietary interventions in adolescents with obesity.

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

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

Acceptability of Hospital-Based Pediatric Weight Management Services among Patients and Families: A Narrative Synthesis

High rates of attrition from pediatric weight management services are well documented in the literature; however, studies reporting on acceptability of "real-world" services have not previously been reviewed. This narrative synthesis aimed to summarize quantitative and qualitative research reporting on satisfaction of families who attended a secondary or tertiary pediatric weight management service. Electronic databases were searched for studies of family and/or patient satisfaction with hospital-based pediatric weight management services. Included articles were scored on their methodological quality. Searches returned 4509 articles of which 17 were eligible. Education, practical strategies to assist behavior change and the approach of staff were reported as the most valued service aspects. Practical, organizational, and service content issues were reported as the primary reasons for poor engagement or discontinuation of treatment. The majority of recommendations for service improvement related to service content, with the following subthemes: program content, delivery of the weight management intervention, individualized treatment, and treatment expectations. Potential strategies for reducing attrition and improving consumer satisfaction include assessment of families' readiness to change at the outset of treatment and implementation of treatment non-negotiables. Development of a standardized measure of patient satisfaction for use in pediatric weight management service development, evaluation, and comparison is recommended.

Contemporary approaches to the prevention and management of paediatric obesity: an Australian focus

Of the 34 member countries of the Organisation for Economic Co-operation and Development, obesity prevalence is highest in the United States, with Australia ranking fifth for girls and eighth for boys. Curbing the problem is achievable and can be realised through a combination of smart governance across many sectors, community initiatives, the support of individual efforts, and clinical leadership. At 5 years of age, one in five Australian children are already affected by overweight or obesity; obesity prevention strategies must therefore start before this age. There is strong evidence that reducing screen time and promoting breastfeeding in 0-2-year-olds are effective interventions in the early years. The main behavioural risk factors for obesity are overconsumption of energy-dense, nutrient-poor foods and a lack of physical activity. Emerging evidence suggests poor sleep quality and duration and high amounts of sedentary time also play a role. Systems-based policy actions may change long term obesity prevalence in children by targeting the food environment through nutrition labelling, healthy foods in schools, restricted unhealthy food marketing to children, and fiscal policies to reduce consumption of harmful foods and sugar-sweetened beverages. Macro-environmental factors influence obesity risk. Public transport policy and the built environment (proximity to parks, bike paths, green space, schools and shops) influence play time spent outdoors, walking and cycling. Greater access to parks and playgrounds and active commuting are associated with lower body mass index. Australian interventions have largely employed individual level approaches. These are important, but of limited effectiveness unless priority is also given to policies that reduce obesity-conducive environments. Clinicians can provide anticipatory guidance to support healthy weight and weight-related behaviours, including weight monitoring, early feeding and children's diets, physical activity opportunities, and limited sedentary and screen time. Investigations in children with obesity usually include liver function tests and measuring fasting glucose, lipid and possibly insulin levels. As obesity can be associated with micronutrient deficiencies, it may be prudent to check full blood count and iron, vitamin B12 and vitamin D levels. Endocrinological assessment is usually not needed. Second line investigations may include liver ultrasound, oral glucose tolerance testing and sleep study. Traditional treatment of child and adolescent obesity has focused on family-based, multicomponent (diet, physical activity and behaviour change) interventions, although these lead to small and often short term weight reductions (mean, - 1.45 kg; 95% CI, 1.88 to - 1.02). Nevertheless, these principles remain core interventions in children and adolescents with obesity. A very low energy diet should be considered in adolescents with severe obesity or obesity-related comorbidities, and for adolescents who have not achieved weight loss following a more conventional dietary approach. Pharmacotherapy confers only small reductions in weight; for example, effect size for metformin is - 3.90 kg (95% CI, - 5.86 to - 1.94). Bariatric surgery should be considered in adolescents over 15 years of age with severe obesity (body mass index > 40 kg/m², or > 35 kg/m² in the presence of severe complications).

Patients' autonomy as a negotiated order: an ethnographic perspective on the clinical management of childhood obesity

The principle of patients' autonomy has assumed a central place in healthcare. Patients are encouraged to play an active role in the management of their health, especially when they are affected by chronic illnesses that require long-term follow-up. In this article, we analyse patients' and professionals' conceptions of patients' autonomy in the context of childhood obesity management. Based on the results of an ethnographic study that we conducted within a paediatric hospital in French-speaking Switzerland, we put into perspective the discourses that professionals, parents and children construct around their experiences of the therapy. Our study reveals that the conceptions that these three different actors have of patients' autonomy converge on several points, but they also diverge on many others. While the rise of autonomy in healthcare has mostly been analysed as a form of empowerment of patients, our results show that this principle also introduces new forms of social control over patients' lives, and it creates new tensions for patients who are unable to match with the normative expectations of professionals in terms of self-management and self-care.

Metformin for Weight Gain Associated with Second-Generation Antipsychotics in Children and Adolescents: A Systematic Review and Meta-Analysis

BACKGROUND

Weight gain is a potentially concerning side effect of second-generation antipsychotics (SGAs). Metformin, a biguanide with antihyperglycemic effects, is used to manage weight gain in adults treated with SGAs.

OBJECTIVE

The objective of this study was to perform the first systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the effects of metformin on weight gain in children and adolescents treated with SGAs.

METHODS

Based on a pre-registered protocol (PROSPERO-CRD42017074839), we searched the PubMed, EMBASE, PsychoINFO, BIOSIS, Science Direct, Cochrane Central, and ClinicalTrials.gov electronic databases through March 2018 (with no restrictions on language, date, or type of publication) for RCTs that assessed the effect of metformin or placebo on body weight in children or adolescents (< 18 years of age) treated with selected SGAs (risperidone, aripiprazole, olanzapine, and clozapine) for any psychiatric disorder. We also contacted relevant drug manufacturers for possible additional pertinent studies/data. A random effects model was used and the quality of the included RCTs was assessed using the Cochrane Risk of Bias tool.

RESULTS

Five RCTs (205 participants in total) were included in the meta-analysis. We found a significant weight decrease in the metformin group compared with placebo after 4, 12, and 16 weeks of treatment {mean difference - 0.98 kg (95% confidence interval [CI] - 1.26, - 0.69); - 1.83 kg (95% CI - 2.47, - 1.18); and - 3.23 kg (95% CI - 5.59, - 0.86), respectively}. A weight decrease at weeks 2 and 8 did not reach statistical significance. The decrease in body mass index (BMI) paralleled that of weight, with a significant effect at weeks 4, 12, and 16. Overall, four studies were rated as unclear, and one study was rated as high, risk of bias.

CONCLUSION

Meta-analytical evidence shows that metformin might decrease weight in children/adolescents treated with SGAs but additional high-quality evidence is needed. Clinicians need to be aware that this use of metformin is currently off-label.

The acceptability, effectiveness, and impact of different models of care for pediatric weight management services: protocol for a concurrent mixed-methods study

Background

Pediatric obesity is a serious, but clinically neglected, chronic health problem. Despite the high prevalence, excess weight problems are rarely managed when children attend clinical services. It is recommended that obesity treatment uses a “chronic-care” approach to management, with different types and intensity of treatment dependent upon severity of obesity. There are several new secondary and tertiary weight management services being implemented within New South Wales (NSW), Australia in 2017/2018 with differing models of care. This study will ascertain what factors affect acceptability, reach, and participation, as well as measure the clinical effectiveness of these services.

Methods

This is a acceptability and effectiveness study building upon existing and planned secondary and tertiary level service delivery in several health districts. This study will recruit participants from seven different pediatric weight management services (PWMS) across five Local Health Districts in NSW, Australia. Using a mixed-methods approach we will document a range of process, impact and clinical outcome measures in order to better understand the context and the effectiveness of each PWMS model. The project development and implementation is guided by the Theoretical Domains Framework. Participants will include parents of children less than 18 years of age attending PWMS, clinicians working as part of PWMS and health service managers. Data will be captured using a combination of anthropometric measures, questionnaires, one-on-one semi-structured interviews and focus groups.

Discussion

Results from this study will assess the acceptability and effectiveness of different models of care for pediatric weight management. Such information is required to inform long-term sustainability and scalability of secondary and tertiary care services to the large number of families with children above a healthy weight.

Treatment of adolescent obesity

The increased prevalence of adolescent obesity and associated short-term and long-term complications emphasize the need for effective treatment. In this Review, we aim to describe the evidence for, and elements of, behaviour management and adjunctive therapies and highlight the opportunities and challenges presented by obesity management in adolescence. The broad principles of treatment include management of obesity-associated complications; a developmentally appropriate approach; long-term behaviour modification (dietary change, increased physical activity, decreased sedentary behaviours and improved sleep patterns); long-term weight maintenance strategies; and consideration of the use of pharmacotherapy, more intensive dietary therapies and bariatric surgery. Bariatric surgery should be considered in those with severe obesity and be undertaken by skilled bariatric surgeons affiliated with teams experienced in the medical and psychosocial management of adolescents. Adolescent obesity management strategies are more reliant on active participation than those for childhood obesity and should recognize the emerging autonomy of the patient. The challenges in adolescent obesity relate primarily to the often competing demands of developing autonomy and not yet having attained neurocognitive maturity.

Tip60-mediated lipin 1 acetylation and ER translocation determine triacylglycerol synthesis rate

Obesity is characterized by excessive fatty acid conversion to triacylglycerols (TAGs) in adipose tissues. However, how signaling networks sense fatty acids and connect to the stimulation of lipid synthesis remains elusive. Here, we show that homozygous knock-in mice carrying a point mutation at the Ser⁸⁶ phosphorylation site of acetyltransferase Tip60 (Tip60^SA/SA) display remarkably reduced body fat mass, and Tip60^SA/SA females fail to nurture pups to adulthood due to severely reduced milk TAGs. Mechanistically, fatty acids stimulate Tip60-dependent acetylation and endoplasmic reticulum translocation of phosphatidic acid phosphatase lipin 1 to generate diacylglycerol for TAG synthesis, which is repressed by deacetylase Sirt1. Inhibition of Tip60 activity strongly blocks fatty acid-induced TAG synthesis while Sirt1 suppression leads to increased adiposity. Genetic analysis of loss-of-function mutants in Saccharomyces cerevisiae reveals a requirement of ESA1, yeast ortholog of Tip60, in TAG accumulation. These findings uncover a conserved mechanism linking fatty acid sensing to fat synthesis.

The acetyltransferase Tip60 mediates signaling pathways by acetylating non-histone proteins. Here the authors show that fatty acids induce Tip60–dependent acetylation of phosphatidic acid phosphatase lipin1 which, then, translocates to the ER and generates diacylglycerols for triglyceride synthesis.

The effect of a multi-disciplinary obesity intervention compared to usual practice in those ready to make lifestyle changes: design and rationale of Whanau Pakari

BACKGROUND

Child obesity internationally has been identified as one of the major threats to future population health. Indigenous people and those from lower socio-economic backgrounds are over-represented in obesity statistics. There is a need for evidence of effect of interventions for child obesity with long-term follow-up. Whether engaging with those that are more motivated to make lifestyle changes is a useful strategy has not been fully explored. We hypothesise that in obese/overweight children, assessed as psychologically "ready for change", delivery of a 12-month multi-disciplinary intervention programme results in a significant reduction in body mass index standard deviation score.

METHODS/DESIGN

Whanau Pakari is an unblinded randomised controlled clinical trial comparing a 12 month intervention programme with standard practice, with 6 monthly assessments for 2 years, conducted in Taranaki, New Zealand (a region where 15.8 % of the population are indigenous). It specifically targets indigenous people and those in more deprived households. Obese/overweight children and adolescents aged 5-16 years are eligible. Exclusion criteria are medical/psychological conditions leading to inability to undertake physical activity/participate in group sessions; those not "ready" to make lifestyle changes; and those without a committed family member. Assessments of health parameters, dietary history, physical activity and overall health-related quality of life/psychological functioning are completed in the participant's home. Fasting blood tests are obtained at baseline, 12 and 24 months. The primary outcome is body mass index standard deviation score. Secondary outcomes include quality of life, dietary behaviour and physical activity, cardiovascular and metabolic profile (blood pressure, resting heart rate, waist circumference), glycaemic control (fasting glucose and glycated Haemoglobin), fasting insulin, and lipids. A general linear mixed model will be used to assess change from baseline using the 6, 12, 18 and 24 month measures, adjusting for age, gender, socioeconomic status and ethnicity, and whether at the contemplative or preparation/action stages of readiness for change.

DISCUSSION

This trial will inform the development of management programmes for obese children and adolescents that are appropriate for indigenous populations. It will investigate whether those at the preparation/action stage of "readiness" to make lifestyle changes are more successful in making changes than those who are contemplative.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR):12611000862943. (Date registered 15/08/2011).

Surgery for the treatment of obesity in children and adolescents

BACKGROUND

Child and adolescent overweight and obesity have increased globally, and are associated with significant short and long term health consequences.

OBJECTIVES

To assess the effects of surgical interventions for treating obesity in childhood and adolescence.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, PubMed, EMBASE as well as LILACS, ICTRP Search Portal and ClinicalTrials.gov (all from database inception to March 2015). References of identified studies and systematic reviews were checked. No language restrictions were applied.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of surgical interventions for treating obesity in children and adolescents (age < 18 years) with a minimum of six months follow-up. Interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity were excluded. Pregnant females were also excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. Where necessary authors were contacted for additional information.

MAIN RESULTS

We included one RCT (a total of 50 participants, 25 in both the intervention and comparator group). The intervention focused on laparoscopic adjustable gastric banding surgery, which was compared to a control group receiving a multi component lifestyle programme. The participating population consisted of Australian adolescents (a higher proportion of girls than boys) aged 14 to 18 years, with a mean age of 16.5 and 16.6 years in the gastric banding and lifestyle group, respectively which was conducted in a private hospital, receiving funding from the gastric banding manufacturer. The study authors were unable to blind participants, personnel and outcome assessors which may have resulted in a high risk of performance and detection bias. Attrition bias was noted as well. The study authors reported a mean reduction in weight of 34.6 kg (95% confidence interval (CI) 30.2 to 39.0) at two years, representing a change in body mass index (BMI) of 12.7 (95% CI 11.3 to 14.2) for the surgery intervention; and a mean reduction in weight of 3.0 kg (95% CI 2.1 to 8.1) representing a change in BMI of 1.3 (95% CI 0.4 to 2.9) for the lifestyle intervention. The differences between groups were statistically significant for all weight measures at 24 months (P < 0.001). The overall quality of the evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was low. Adverse events were reported in 12/25 (48%) participants in the intervention group compared to 11/25 (44%) in the control group (low quality evidence). A total of 28% of the adolescents undergoing gastric banding required revisional surgery. No data were reported for all-cause mortality, behaviour change, participants views of the intervention and socioeconomic effects. At two years, the gastric banding group performed better than the lifestyle group in two of eight health-related quality of life concepts (very low quality evidence) as measured by the Child Health Questionnaire (physical functioning score (94 versus 78, community norm 95) and change in health score (4.4 versus 3.6, community norm 3.5)).

AUTHORS' CONCLUSIONS

Laparoscopic gastric banding led to greater body weight loss compared to a multi component lifestyle program in one small study with 50 patients. These results do not provide enough data to assess efficacy across populations from different countries, socioeconomic and ethnic backgrounds, who may respond differently. This systematic review highlights the lack of RCTs in this field. Future studies should assess the impact of the surgical procedure and post operative care to minimise adverse events, including the need for post operative adjustments and revisional surgery. Long-term follow-up is also critical to comprehensively assess the impact of surgery as participants enter adulthood.

Kaledo, a board game for nutrition education of children and adolescents at school: cluster randomized controlled trial of healthy lifestyle promotion

During childhood and adolescence, a game could be an effective educational tool to learn healthy eating habits. We developed Kaledo, a new board game, to promote nutrition education and to improve dietary behavior. A two-group design with one pre-treatment assessment and two post-treatment assessments was employed. A total of 3,110 subjects (9-19 years old) from 20 schools in Campania, Italy, were included in the trial. In the treated group, the game was introduced each week over 20 consecutive weeks. Control group did not receive any intervention. The primary outcomes were (i) score on the "Adolescent Food Habits Checklist" (AFHC), (ii) scores on a dietary questionnaire, and (iii) BMI z-score. At the first post-assessment (6 months), the treated group obtained significantly higher scores than the control group on the AFHC (14.4 (95 % confidence interval (CI) 14.0 to 14.8) vs 10.9 (95 % CI 10.6 to -11.2); F(1,20) = 72.677; p < 0.001) and on four sections of the dietary questionnaire: "nutrition knowledge" (6.5 (6.4 to 6.6) vs 4.6 (4.5 to 4.7); F(1,16) = 78.763; p < 0.001), "healthy and unhealthy diet and food" (11.2 (11.0 to 11.4) vs 10.4 (10.3 to 10.6); F(1,32) = 21.324; p < 0.001), "food habits" (32.4 (32.0 to 32.8) vs 27.64 (27.3 to 28.0); F(1,26) = 195.039; p < 0.001), and "physical activity" (13.4 (13.2 to 13.7) vs 12.0 (11.8 to 12.6); F(1,20) = 20.765; p < 0.001). Moreover, the treated group had significantly lower BMI z-score with respect to the controls at the first (0.44 (0.42 to 0.46) vs 0.58 (0.56 to 0.59), F(1,18) = 16.584, p = 0.001) and at the second (18 months) (0.34 (0.30 to 0.38) vs 0.58 (0.54 to 0.62), F(1,13) = 7.577; p = 0.017) post-assessments.

CONCLUSION

Kaledo improved nutrition knowledge and dietary behavior over 6 months and had a sustained effect on the BMI z-score. Therefore, it may be used as an effective tool in childhood and adolescence obesity prevention programs.

Insulin and BMI as predictors of adult type 2 diabetes mellitus

BACKGROUND AND OBJECTIVES

Fasting insulin concentrations are increasingly being used as a surrogate for insulin resistance and risk for type 2 diabetes (T2DM), although associations with adult outcomes are unclear. Our objective was to determine whether fasting insulin concentrations in childhood associate with later T2DM.

METHODS

Fasting insulin values were available from 2478 participants in the longitudinal Cardiovascular Risk in Young Finns Study at baseline age 3 to 18 years, along with data on adult T2DM (N = 84, mean age = 39.6 years).

RESULTS

Among 3- to 6-year-olds, a 1-SD increase in fasting insulin was associated with a relative risk (RR) of 2.04 (95% confidence interval [CI], 1.54-2.70) for later T2DM, which remained significant after we adjusted for BMI and parental history of T2DM. For those aged 9 to 18 years, a 1-SD increase in insulin was associated with an RR of 1.32 (95% CI, 1.06-1.65) for T2DM, but this became nonsignificant after we adjusted for BMI and parental history of T2DM. In the latter age group, a 1-SD increase in BMI was associated with an RR of 1.45 (95% CI, 1.21-1.73) for T2DM, with adjustment for insulin and parental history of T2DM not improving this association. BMI in younger children was not associated with later T2DM. In life course analyses, those with T2DM had higher fasting insulin levels in early childhood and later adulthood but not in peripubertal years.

CONCLUSIONS

Elevated fasting insulin concentrations in early childhood, but not adolescence, are independently associated with an elevated risk of T2DM in adulthood.

Childhood obesity and insulin resistance: how should it be managed?

OPINION STATEMENT

Concomitant with the rise in global pediatric obesity in the past decades, there has been a significant increase in the number of children and adolescents with clinical signs of insulin resistance. Given insulin resistance is the important link between obesity and the associated metabolic abnormalities and cardiovascular risk, clinicians should be aware of high risk groups and treatment options. As there is no universally accepted biochemical definition of insulin resistance in children and adolescents, identification and diagnosis of insulin resistance usually relies on clinical features such as acanthosis nigricans, polycystic ovary syndrome, hypertension, dyslipidemia, and nonalcoholic fatty liver disease. Treatment for reducing insulin resistance and other obesity-associated comorbidities should focus on changes in health behaviors to achieve effective weight management. Lifestyle interventions incorporating dietary change, increased physical activity, and decreased sedentary behaviors, with the involvement of family and adoption of a developmentally appropriate approach, should be used as the first line treatment. Current evidence suggests that the primary objective of dietary interventions should be to reduce total energy intake and a combination of aerobic and resistance training should be encouraged. Metformin can be used in conjunction with a lifestyle intervention program in obese adolescents with clinical insulin resistance to achieve weight loss and to improve insulin sensitivity. Ongoing evaluation and research are required to explore optimal protocol and long-term effectiveness of lifestyle interventions, as well as to determine whether the improvements in insulin sensitivity induced by lifestyle interventions and weight loss will lead to a clinical benefit including reduced cardiovascular morbidity and mortality.

Initial steps for quality improvement of obesity care across divisions at a tertiary care pediatric hospital

Background: Pediatric subspecialists can participate in the care of obese children. Objective: To describe steps to help subspecialty providers initiate quality improvement efforts in obesity care. Methods: An anonymous patient data download, provider surveys and interviews assessed subspecialty providers’ identification and perspectives of childhood obesity and gathered information on perceived roles and care strategies. Participating divisions received summary analyses of quantitative and qualitative data and met with study leaders to develop visions for division/service-specific care improvement. Results: Among 13 divisions/services, subspecialists’ perceived role varied by specialty; many expressed the need for cross-collaboration. All survey informants agreed that identification was the first step, and expressed interest in obtaining additional resources to improve care. Conclusions: Subspecialists were interested in improving the quality and coordination of obesity care for patients across our tertiary care setting. Developing quality improvement projects to achieve greater pediatric obesity care goals starts with engagement of providers toward better identifying and managing childhood obesity.

Where should we measure waist circumference in clinically overweight and obese youth?

AIMS

Waist circumference (WC) measurement is a useful tool in the assessment of overweight/obese individuals, but standard measures may miss an apron of 'overhanging' fat (termed 'panniculus'). The objective of this study was to assess whether, in clinically overweight/obese youth, 'pannicular' WC better correlates with fat mass than a standard WC measurement.

METHODS

Standard and pannicular WC, alongside body composition (BC) measures, were collected from 181 consultations on 127 overweight and obese children/adolescents (52% male; mean (standard deviation) age 12.5 (3.4) years). Correlation coefficients describe associations between WC and measures of BC, and between ΔWC and ΔBC, while linear regression models assessed which of the WC measures explained more of the variability in BC and ΔBC over time.

RESULTS

Standard and pannicular WC were highly correlated (r = 0.95). Correlation coefficients with measures of BC were generally greater for pannicular than standard WC, with greatest correlations seen for whole body (r = 0.94 vs. 0.85, respectively) and truncal (r = 0.86 vs. 0.77) fat mass. Furthermore, pannicular and Δpannicular WC explained more variability in truncal fat and Δtruncal fat than the standard measure of WC.

CONCLUSIONS

These data show that pannicular, rather than standard, WC measurements better correlate with absolute measures of fat mass, and their change over time, in clinically overweight/obese youth.

Principles and pitfalls in the differential diagnosis and management of childhood obesities

Obesity is currently the most prevalent chronic childhood disease in Western countries. It is one of the most frequent consultations in general pediatrics and is even more common in pediatric endocrinology. As might be predicted, the prevalence of obesity-associated comorbidities is also increasing in children and adolescents. It is widely accepted that this increase in obesity results from an imbalance between energy intake and expenditure, with an increase in positive energy balance being closely associated with the current lifestyle in Western countries. However, there is increasing evidence indicating that an individual's genetic background is important in determining obesity risk. The physiologic mechanisms controlling appetite and energy expenditure are being revealed in part because of the identification of new causes of human monogenic, syndromic, and endocrine-related obesity. Thus, it is no longer appropriate to talk about obesity, but rather about "obesities" or "different diseases causing obesity," because their pathophysiologic bases differ. Moreover, these obesities require different diagnostic and management approaches. The pediatrician must be aware of this issue and focus the clinical history and physical examination toward specific clinical signs and symptoms to better exploit the available diagnostic and therapeutic resources when facing a child with obesity. Genetic, genomic, and metabolomic studies are often necessary to obtain a more appropriate diagnosis. Cognitive behavioral therapy is fundamental in obese children. The identification of potential targets will hopefully result in new pharmacologic approaches for translational and personalized medicine for obesity in the near future.

Stepping up to the challenge: the development, implementation, and assessment of a statewide, regional, leadership program for school nutrition directors

A statewide professional development program was developed and implemented throughout California for school nutrition directors with the goal of creating healthy school environments and regional networks for collaboration and healthy school environment sustainability. Needs of school nutrition directors were identified through a needs assessment questionnaire. Results of the needs assessment questionnaire (n = 256) identified (a) planning cost-effective menus; (b) reducing calories, sodium, saturated fat, and trans fat in menus; and (c) using U.S. Department of Agriculture foods cost-effectively as the most useful topics. Highest rated topics informed the content of the professional development program. A post-professional development questionnaire identified key "insights, inspirations, and strategies" as (a) marketing of school foods program, (b) expansion of salad bars, and (c) collaboration with community partners. A 6-month follow-up questionnaire identified that 86% of participants made progress toward implementing at least one of their five insights, inspirations, and strategies in their school districts. Most common areas that were implemented were marketing and branding (32%), revamping salad bars (18%), and motivating staff (16%). School and Community Actions for Nutrition survey analysis showed a significant increase in the use of marketing methods in school nutrition programs from baseline to 6-month post-program implementation (p = .024).