Web-based family intervention for overweight children: a pilot study

Parent Website Engagement and Health Equity Implications in a Child Care-Based Wellness Intervention

OBJECTIVE

To evaluate demographic differences in parent website engagement in a child care-based wellness intervention.

DESIGN

Parent-reported demographic characteristics and observed website engagement were averaged by child care centers participating in the web-based intervention arm of a cluster randomized controlled trial of wellness interventions.

SETTING AND PARTICIPANTS

Parents of preschoolers in 17 Maryland child care centers.

MAIN OUTCOME MEASURES

Website engagement: (1) webpage views, (2) average time on webpage, and (3) intervention activity completion.

INTERVENTION

Parents received access to a website containing content on wellness-promoting topics (eg, parenting, nutrition, physical activity) and their child care center's activities.

ANALYSIS

Cross-sectional differences in website engagement by demographic characteristics were assessed using ANOVA.

RESULTS

Centers with a high proportion of parents who identified as other than non-Hispanic White and had less than a bachelor's degree had significantly fewer webpage views, and completed significantly fewer intervention activities compared with centers with parents who were predominantly non-Hispanic White and had more than a bachelor's degree.

CONCLUSIONS AND IMPLICATIONS

Demographic differences in parents' child care center website engagement represent disparities that could contribute to health inequities in parents' access to wellness-promoting material. Future efforts could identify factors that eliminate demographic disparities in parent engagement in web-based interventions.

Development, implementation and early results of a 12-week web-based intervention targeting 51 children age 5-13 years and their families

Background

Internet-based treatments have proven effective for various health issues. There is a need to scale up interventions targeting children with obesity, also in less densely populated areas where the prevalence in many countries is higher than in urban areas. The aim of this study was to design and implement an internet-based program as an add-on to standard treatment for childhood obesity.

Methods

Web-Childhood Obesity Prevention (Web-COP) was a prospective feasibility study with a pre- post- design. The intervention consisted of four group-based education sessions at the clinic, physical activity on prescription, and a new 12-week internet-based program. Web-COP was offered to children with obesity (International Obesity Task Force Body Mass Index (IOTF-BMI) ≥ 30 kg/m2) and their parents in two counties in Northern Sweden from August 2018 to June 2019. The primary outcome was change in BMI standard deviation score (BMI-SDS).

Results

The study included 55 children 5-13 years of age. The internet-based component was well received, and retention rate was 51/55 (92.7%). Data was analysed for 51 children. Mean BMI-SDS was 3.3 at start and decreased by 0.2, 0.3, and 0.4 at two, four, and six months from baseline. Using a continuous algorithm, 42/51 (81%), children lowered their BMI-SDS and 33/51 (65%) lowered their BMI.

Conclusion

Adding group sessions and an internet-based program to standard care was feasible and two thirds of included children with obesity reduced their BMI.

Effectiveness of Family-Based Behavior Change Interventions on Obesity-Related Behavior Change in Children: A Realist Synthesis

Effective treatment interventions for childhood obesity involve parents, are multicomponent and use behavior change strategies, but more information is needed on the mechanisms influencing behavioral outcomes and the type of parental involvement that is efficacious in behavioral treatment interventions with school-age children. This review aimed to understand key characteristics of programs that contribute to dietary and physical activity behavioral outcomes, and through which key mechanisms. This was a systematic review with narrative synthesis following PRISMA guidelines and realist analysis using RAMESES guidelines to explain outcome patterns and influence of parental involvement. Overall, the findings contribute to understanding the complex relationship between family barriers to behavior change, strategies employed in treatment interventions and behavioral outcomes. Implications for enhancing future policy and practice include involving parents in goal setting, motivational counselling, role modeling, and restructuring the physical environment to promote mutual empowerment of both parents and children, shared value and whole-family ownership in which intrinsic motivation and self-efficacy are implicit. These characteristics were associated with positive dietary and physical activity behavior change in children and may be useful considerations for the design and implementation of future theory-based treatment interventions to encourage habitual healthy diet and physical activity to reduce childhood obesity.

A systematic evaluation of digital nutrition promotion websites and apps for supporting parents to influence children's nutrition

Background

Globally children’s diet quality is poor. Parents are primary gatekeepers to children’s food intake; however, reaching and engaging parents in nutrition promotion can be challenging. With growth in internet and smartphone use, digital platforms provide potential to disseminate information rapidly to many people. The objectives of this review were to conduct a comprehensive and systematic evaluation of nutrition promotion via websites and apps supporting parents to influence children’s nutrition, from three different perspectives: 1) current evidence base, 2) end user (parent) experience and 3) current commercial offerings.

Methods

Three systematic reviews were undertaken of (1) studies evaluating the effectiveness for digital platforms for improving nutrition in children and parents, (2) studies conducting user-testing of digital tools with parents, (3) websites and apps providing lunch-provision information to parents. Searches were conducted in five databases for reviews one and two, and systematic search of Google and App Store for review three. Randomised controlled trials, cohort and cross-sectional and qualitative studies (study two only) were included if published in English, from 2013, with the intervention targeted at parents and at least 50% of intervention content focused on nutrition. Search results were double screened, with data extracted into standardised spreadsheets and quality appraisal of included search results.

Results

Studies evaluating digital nutrition interventions targeting parents (n = 11) demonstrated effectiveness for improving nutrition outcomes, self-efficacy and knowledge. Six of the included randomised controlled trials reported digital interventions to be equal to, or better than comparison groups. User-testing studies (n = 9) identified that digital platforms should include both informative content and interactive features. Parents wanted evidence-based information from credible sources, practical tools, engaging content and connection with other users and health professionals. Websites targeting lunch provision (n = 15) were developed primarily by credible sources and included information-based content consistent with dietary guidelines and limited interactive features. Lunchbox apps (n = 6), developed mostly by commercial organisations, were more interactive but provided less credible information.

Conclusions

Digital nutrition promotion interventions targeting parents can be effective for improving nutrition-related outcomes in children and parents. As demonstrated from the lunchbox context and user-testing with parents, they need to go beyond just providing information about positive dietary changes, to include the user-desired features supporting interactivity and personalisation.

Web-based intervention to promote physical activity in Taiwanese children

PURPOSE

This study investigated the effectiveness of a theory-based, technology-integrated website in promoting the physical activity of schoolchildren.

DESIGN AND METHODS

A website designed using a self-management strategy and supplemented with a geographical information system (GIS) mapping function was used to increase children's physical activity levels. A total of 524 students from six elementary schools in Taipei City completed surveys at three times during 2010 and were assigned to one of three groups: (1) a self-management group, using a website employing a goal-setting strategy and a storytelling schema based on a classical Chinese novel; (2) a knowledge-only group that was given only access to the website; or (3) a control group that was only given lectures and not allowed to access the website.

RESULTS

After adjustment for the effects of the pretest, the self-management and knowledge-only groups were found to be more physically active and have higher self-efficacy than the control group. Moreover, the self-management group had higher scores for these two variables than the knowledge-only group. Furthermore, the intervention was more effectives for male students than female students.

CONCLUSION

Overall, the self-management website proved to be effective in promoting schoolchildren's physical activity. The positive correlation of self-efficacy with the ability to handle the difficulties inherent in physical activity continued for 3 months after the intervention was completed.

Technology Components as Adjuncts to Family-Based Pediatric Obesity Treatment in Low-Income Minority Youth

BACKGROUND

Strategies to treat pediatric obesity are needed, especially among high-need populations. Technology is an innovative approach; however, data on technology as adjuncts to in-person treatment programs are limited.

METHODS

A total of 64 children [body mass index (BMI) ≥85th percentile, mean age = 9.6 ± 3.1 years, 32.8% female, 84.4% Hispanic] were recruited to participate in one of three cohorts of a family-based behavioral group (FBBG) treatment program: FBBG only, TECH1, and TECH2. Rolling, nonrandomized recruitment was used to enroll participants into three cohorts from May 2014 to February 2015. FBBG began in May 2014 and received the standard, in-person 12-week treatment only (n = 21); TECH1 began in September 2014 and received FBBG plus a digital tablet equipped with a fitness app (FITNET) (n = 20); TECH2 began in February 2015 and received FBBG and FITNET, plus five individually tailored TeleMed health-coaching sessions delivered via Skype (n = 23). Child BMI z-score (BMI-z) was assessed at baseline and postintervention. Secondary aims examined weekly FBBG attendance, feasibility/acceptability of FITNET and Skype, and the effect of technology engagement on BMI-z.

RESULTS

FBBG and TECH1 participants did not show significant reductions in BMI-z postintervention [FBBG: β = -0.05(0.04), p = 0.25; TECH1: β = -0.006(0.06), p = 0.92], but TECH2 participants did [β = -0.09(0.02), p < 0.001] and TeleMed session participation was significantly associated with BMI-z reduction [β = -0.04(0.01), p = 0.01]. FITNET use and FBBG attendance were not associated with BMI-z in any cohort. Overall, participants rated the technology as highly acceptable.

CONCLUSIONS

Technology adjuncts are feasible, used by hard-to-reach participants, and show promise for improving child weight status in obesity treatment programs.

Supporting health-related parenting: A scoping review of programs assisted by the Internet and related technologies

Abstract eHealth interventions have been proposed as a possible solution to overcome major obstacles associated with low adherence rates, low accessibility, and high costs of parenting programs. Due to the number and variety of interventions found in the literature, this study aimed to conduct a scoping review of parenting interventions directed at supporting parents in promoting their child’s health and carrying out disease-related tasks. The scoping review identified 119 technology-based programs directed both at universal, preventive objectives and at the management and adaptation to chronic or severe acute health conditions. Several different web-based applications have been creatively used in healthrelated parenting interventions. Most programs use evidence-based psychological methodologies to promote parental self-management, build specific parenting skills, and provide customized feedback and social support. Further studies are needed to assess the contribution of the Internet and mobile applications to enhance the effectiveness of health-related parenting interventions and the dissemination of empirically validated programs.

Outcome Evaluation of Family Eats

This article presents the results of a randomized clinical trial evaluating the eight-session Family Eats web-based intervention promoting healthy home food environments for African American families. African American families ( n = 126) with 8- to 12-year-old children completed online baseline questionnaires and were randomized into intervention or control groups. Data collection occurred at baseline, immediately postintervention (Post 1), and 4 months later (Post 2), for parents and children, separately. There were two group by time intervention effects: Control group parents reported a significantly greater frequency of drinking 100% fruit juice at Post 1 compared with intervention group parents. Parent menu planning skills were significantly higher at Post 2 for the intervention group compared with the control group. Significant positive changes overtime were noted for both groups for home fruit/vegetable availability, food preparation practices, and healthy restaurant selection. Intervention group children reported a significant increase in home juice availability at Post 1 compared with the control group; home fruit availability improved for both groups. There was no difference in log on rates by group: 84% and 86% for those who completed Post 1 and Post 2 measurements, respectively. Sixty-four participants completed the evaluation survey: 17 control (50%) and 47 intervention (51%) participants. All participants reported liking the program components; all but one gave it an A or B grade. An Internet-delivered nutrition intervention for families was successful in achieving change in some mediating variables, with good log on rates. Future research with Family Eats should include larger sample sizes, with longer follow-up and a more objective measure of diet.

Decreased Body Mass Index in Schoolchildren After Yearlong Information Sessions With Parents Reinforced With Web and Mobile Phone Resources: Community Trial

BACKGROUND

The obesity pandemic has now reached children, and households should change their lifestyles to prevent it.

OBJECTIVE

The objective was to assess the effect of a comprehensive intervention on body mass index z-score (BMIZ) in schoolchildren.

METHODS

A yearlong study was conducted at 4 elementary schools in Mexico City. Intervention group (IG) and control group (CG) were split equally between governmental and private schools. Three educational in-person parents and children sessions were held at 2-month intervals to promote healthy eating habits and exercise. To reinforce the information, a website provided extensive discussion on a new topic every 2 weeks, including school snack menus and tools to calculate body mass index in children and adults. Text messages were sent to parents' mobile phones reinforcing the information provided. The IG contained 226 children and CG 181 children. We measured their weight and height and calculated BMIZ at 0, 6, and 12 months.

RESULTS

The CG children showed a change of +0.06 (95% CI 0.01, 0.11) and +0.05 (95% CI 0.01, 0.10) in their BMIZ at 6 and 12 months, respectively. The BMIZ of IG children decreased by -0.13 (95% CI -0.19 to -0.06) and -0.10 (95% CI -0.16 to -0.03), respectively, and the effect was greater in children with obesity.

CONCLUSIONS

The comprehensive intervention tested had beneficial effects, preserved the BMIZ of normal weight children, and reduced the BMIZ of children with obesity.

Family-based interventions to increase physical activity in children: a systematic review, meta-analysis and realist synthesis

OBJECTIVE

Family-based interventions represent a potentially valuable route to increasing child physical activity (PA) in children. A dual meta-analysis and realist synthesis approach examined existing interventions to assist those developing programmes to encourage uptake and maintenance of PA in children.

DESIGN

Studies were screened for inclusion based on including participants aged 5-12 years, having a substantive aim of increasing PA by engaging the family and reporting on PA outcome. Duplicate data extraction and quality assessment were conducted. Meta-analysis was conducted in STATA. Realist synthesis included theory development and evidence mapping.

RESULTS

Forty-seven studies were included, of which three received a 'strong' quality rating, 21 'moderate' and 23 'weak'. The meta-analysis (19 studies) demonstrated a significant small effect in favour of the experimental group (standardized mean difference: 0.41; 95%CI 0.15-0.67). Sensitivity analysis, removing one outlier, reduced this to 0.29 (95%CI 0.14-0.45). Realist synthesis (28 studies) provided insight into intervention context (particularly, family constraints, ethnicity and parental motivation), and strategies to change PA (notably, goal-setting and reinforcement combined).

CONCLUSION

This review provides key recommendations to inform policy makers and other practitioners in developing evidence-based interventions aimed at engaging the family to increase PA in children, and identifies avenues for future research.

Nutrition Interventions for Prevention and Management of Childhood Obesity: What Do Parents Want from an eHealth Program?

With the growth of Internet technologies, offering interventions for child and family weight management in an online format may address barriers to accessing services. This study aimed to investigate (i) whether an eHealth family healthy lifestyle program would be of interest to parents; and (ii) preferences and/or expectations for program components and features. Parents of children aged four to18 years were recruited through social media and completed an online survey (54 items) including closed and open-ended questions. Responses were collated using descriptive statistics and thematic analysis. Seventy-five participants were included (92% mothers, mean age 39.1 ± 8.6 years, mean BMI 27.6 ± 6.3 kg/m²). The index child had a mean age of 11 ± 6.2 years with 24% overweight/obese. The majority of parents (90.3%) reported interest in an online program, with preference expressed for a non-structured program to allow flexibility users to log-on and off as desired. Parents wanted a program that was easy to use, practical, engaging, endorsed by a reputable source, and able to provide individual tailoring and for their children to be directly involved. The current study supports the need for online delivery of a healthy lifestyle program that targets greater parental concerns of diet rather than child weight.

A formative evaluation of the SWITCH® obesity prevention program: print versus online programming

Background

SWITCH® is an evidence-based childhood obesity prevention program that works through schools to impact parenting practices. The present study was designed as a formative evaluation to test whether an online version of SWITCH® would work equivalently as the established print version.

Methods

Ten elementary schools were matched by socio-economic status and randomly assigned to receive either the print (n = 5) or online (n = 5) version. A total of 211 children from 22, 3^rd grade classrooms were guided through the 4 month program by a team of program leaders working in cooperation with the classroom teachers. Children were tasked with completing weekly SWITCH® Trackers with their parents to monitor goal setting efforts in showing positive Do (≥60 minutes of moderate-to-vigorous physical activity), View (≤2 hours of screen time), and Chew (≥5 servings of fruits and vegetables) behaviors on each day. A total of 91 parents completed a brief survey to assess project-specific interactions with their child and the impact on their behaviors.

Results

The majority of parents (93.2%) reported satisfactory experiences with either the online or print SWITCH® program. The return rate for the SWITCH® Trackers was higher (42.5% ± 11%) from the print schools compared to the online schools (27.4% ± 10.9%). District program managers rated the level of teacher engagement in regards to program facilitation and the results showed a higher Trackers return rate in the highly engaged schools (38.5% ± 13.3%) than the lowly engaged schools (28.6 ± 11.9%). No significant differences were observed in parent/child interactions or reported behavior change (ps > .05) suggesting the equivalence in intervention effect for print and online versions of the SWITCH® program.

Conclusions

The findings support the utility of the online SWITCH® platform but school-based modules are needed to facilitate broader school engagement by classroom teachers and PE teachers.

Working With Parents to Prevent Childhood Obesity: Protocol for a Primary Care-Based eHealth Study

Background

Parents play a central role in preventing childhood obesity. There is a need for innovative, scalable, and evidence-based interventions designed to enhance parents’ motivation to support and sustain healthy lifestyle behaviors in their children, which can facilitate obesity prevention.

Objective

(1) Develop an online screening, brief intervention, and referral to treatment (SBIRT) eHealth tool to enhance parents’ concern for, and motivation to, support children’s healthy lifestyle behaviors, (2) refine the SBIRT eHealth tool by assessing end-user acceptability, satisfaction, and usability through focus groups, and (3) determine feasibility and preliminary effectiveness of the refined SBIRT eHealth tool through a randomized controlled trial.

Methods

This is a three-phase, multi-method study that includes SBIRT eHealth tool development (Phase I), refinement (Phase II), and testing (Phase III). Phase I: Theoretical underpinnings of the SBIRT tool, entitled the Resource Information Program for Parents on Lifestyle and Education (RIPPLE), will be informed by concepts applied within existing interventions, and content will be based on literature regarding healthy lifestyle behaviors in children. The SBIRT platform will be developed in partnership between our research team and a third-party intervention development company. Phase II: Focus groups with parents, as well as health care professionals, researchers, and trainees in pediatrics (n=30), will explore intervention-related perceptions and preferences. Qualitative data from the focus groups will inform refinements to the aesthetics, content, structure, and function of the SBIRT. Phase III: Parents (n=200) of children—boys and girls, 5 to 17 years old—will be recruited from a primary care pediatric clinic while they await their children’s clinical appointment. Parents will be randomly assigned to one of five groups—four intervention groups and one control group—as they complete the SBIRT. The randomization function is built into the tool. Parents will complete the eHealth SBIRT using a tablet that will be connected to the Internet. Subsequently, parents will be contacted via email at 1-month follow-up to assess (1) change in concern for, and motivation to, support children’s dietary and physical activity behaviors (primary outcome), and (2) use of online resources and referrals to health services for obesity prevention (secondary outcome).

Results

This research was successfully funded and received ethics approval. Development of the SBIRT started in summer 2012, and we expect all study-related activities to be completed by fall 2016.

Conclusions

The proposed research is timely and applies a novel, technology-based application designed to enhance parents concern for, and motivation to, support children’s healthy lifestyle behaviors and encourage use of online resources and community services for childhood obesity prevention. Overall, this research builds on a foundation of evidence supporting the application of SBIRTs to encourage or “nudge” individuals to make healthy lifestyle choices. Findings from Phase III of this project will directly inform a cluster randomized controlled trial to study the effectiveness of our intervention across multiple primary care-based settings.

Trial Registration

ClinicalTrials.gov NCT02330588; http://clinicaltrials.gov/ct2/show/NCT02330588 (Archived by WebCite at http://www.webcitation.org/6WyUOeRlr).

The impact of a Web-based app (eBalance) in promoting healthy lifestyles: randomized controlled trial

Background

The use of Web-based apps to promote a healthy lifestyle is increasing, although most of these programs were not assessed using suitable epidemiological methods. We evaluated the effectiveness of a newly developed Web-based app in promoting a healthy lifestyle and educating adults on such lifestyles. We also analyzed predictors for success in acquiring and maintaining a healthy lifestyle.

Objective

Our aim was to compare people receiving a new Web-based app with people who got an introductory lecture alone on healthy lifestyle, weight change, nutritional knowledge, and physical activity, and to identify predictors of success for maintaining a healthy lifestyle.

Methods

Subjects were recruited from the community and were randomized into intervention and control groups. The intervention subjects received access to the app without any face-to-face support; the control subjects continued their standard lifestyle. Measurements were taken by the researcher at baseline and after 14 weeks and included weight and waist circumference. Nutritional knowledge, diet quality, and physical activity duration were obtained using online questionnaires. The new Web-based app was developed based on current US Department of Agriculture and Israel Ministry of Health recommendations for healthy lifestyle. The app provides tools for monitoring diet and physical activity while instructing and encouraging healthy diet and physical activity.

Results

Out of 99 subjects who were randomized into app and control groups, 85 participants (86%) completed the study, 56 in the intervention and 29 in the control group. The mean age was 47.9 (SD 12.3) years, and mean Body Mass Index was 26.2 (SD 3.9). Among the intervention group only, frequency of app use was 2.7 (SD 1.9) days/week. The mean change in physical activity was 63 (SD 20.8) minutes in the app group and -30 (SD 27.5) minutes in the control group (P=.02). The mean weight change was -1.44 (SD 0.4) kg in the app group and -0.128 (SD 0.36) kg in the control group (P=.03). Knowledge score increased significantly in the app group, 76 (SD 7.5) to 79 (SD 8.7) at the end of the study (P=.04) compared with the control group. Diet quality score also increased significantly at the end of the study, from 67 (SD 9.8) to 71 (SD 7.6; P<.001) in contrast to the control group. Success score (represents the success in maintaining healthy lifestyle) was higher among the app group (68%) compared with 36% in the control group (P<.001). The app frequency of use was significantly related to a higher success score (P<.001).

Conclusions

We showed a positive impact of a newly developed Web-based app on lifestyle indicators during an intervention of 14 weeks. These results are promising in the app’s potential to promote a healthy lifestyle, although larger and longer duration studies are needed to achieve more definitive conclusions.

Trial Registration

Clinicaltrial.gov number: NCT01913496; http://www.clinicaltrials.gov/ct2/show/NCT01913496 (Archived by WebCite at http://www.webcitation.org/6WSTUEPuJ).

Evidence update on the treatment of overweight and obesity in children and adolescents

Childhood obesity is associated with increased medical and psychosocial consequences and mortality and effective interventions are urgently needed. Effective interventions are urgently needed. This article reviews the evidence for psychological treatments of overweight and obesity in child and adolescent populations. Studies were identified through searches of online databases and reference sections of relevant review articles and meta-analyses. Treatment efficacy was assessed using established criteria, and treatments were categorized as well-established, probably efficacious, possibly efficacious, experimental, or of questionable efficacy. Well-established treatments included family-based behavioral treatment (FBT) and Parent-Only Behavioral Treatment for children. Possibly efficacious treatments include Parent-Only Behavioral Treatment for adolescents, FBT-Guided Self-Help for children, and Behavioral Weight Loss treatment with family involvement for toddlers, children, and adolescents. Appetite awareness training and regulation of cues treatments are considered experimental. No treatments are considered probably efficacious, or of questionable efficacy. All treatments considered efficacious are multicomponent interventions that include dietary and physical activity modifications and utilize behavioral strategies. Treatment is optimized if family members are specifically targeted in treatment. Research supports the use of multicomponent lifestyle interventions, with FBT and Parent-Only Behavioral Treatment being the most widely supported treatment types. Additional research is needed to test a stepped care model for treatment and to establish the ideal dosage (i.e., number and length of sessions), duration, and intensity of treatments for long-term sustainability of healthy weight management. To improve access to care, the optimal methods to enhance the scalability and implementability of treatments into community and clinical settings need to be established.

The development and effectiveness of a health information website designed to improve parents' self-efficacy in managing risk for obesity in preschoolers

PURPOSE

To evaluate the effects of web-based information on parental self-efficacy in managing obesity risk in preschoolers.

DESIGN AND METHODS

The project included a literature review and the development and field testing of an information website that presented information on how to manage nine obesity risk factors for childhood obesity.

RESULTS

Parents stated that they had no problems using the website, and 69% reported improved self-efficacy on at least two risk factors.

PRACTICE IMPLICATIONS

Many parents access the Internet to obtain health information. A website that offers practical information on managing childhood obesity risk factors is a valuable resource for obesity prevention efforts.

Obesity and type 2 diabetes in children: epidemiology and treatment

The incidence of overweight and obesity among children has increased dramatically in recent decades, with about one-third of children in the U.S. currently being either overweight or obese. Being overweight in early childhood increases risk for later obesity. There is evidence for the efficacy of family-based behavioral treatment to control weight and improve health outcomes. Obesity-related health risks have been documented, including metabolic syndrome. There is also increasing incidence of type 2 diabetes (T2D) among youth in recent years, with obesity and family history of T2D generally present. Lower income and ethnic minority status are associated with both obesity and T2D in youth. Most youth with T2D do not achieve optimal glycemic control, and are at high risk for later health complications. Obesity and T2D represent significant public health issues with potentially great personal and societal cost. Research addressing the prevention of obesity and T2D among youth is urgently needed.