Attrition and the management of pediatric obesity: an integrative review

A Scoping Review of Tailoring in Pediatric Obesity Interventions

Background: Families with children who have or are at risk for obesity have differing needs and a one-size-fits-all approach can negatively impact program retention, engagement, and outcomes. Individually tailored interventions could engage families and children through identifying and prioritizing desired areas of focus. Despite literature defining tailoring as individualized treatment informed by assessment of behaviors, intervention application varies. This review aims to exhibit the use of the term "tailor" in pediatric obesity interventions and propose a uniform definition. Methods: We conducted a scoping review following PRISMA-ScR guidelines among peer-reviewed pediatric obesity prevention and management interventions published between 1995 and 2021. We categorized 69 studies into 6 groups: (1) individually tailored interventions, (2) computer-tailored interventions/tailored health messaging, (3) a protocolized group intervention with a tailored component, (4) only using the term tailor in the title, abstract, introduction, or discussion, e) using the term tailor to describe another term, and (5) interventions described as culturally tailored. Results: The scoping review exhibited a range of uses and lack of explicit definitions of tailoring in pediatric obesity interventions including some that deviate from individualized designs. Effective tailored interventions incorporated validated assessments for behaviors and multilevel determinants, and recipient-informed choice of target behavior(s) and programming. Conclusions: We urge interventionists to use tailoring to describe individualized, assessment-driven interventions and to clearly define how an intervention is tailored. This can elucidate the role of tailoring and its potential for addressing the heterogeneity of behavioral and social determinants for the prevention and management of pediatric obesity.

Intermittent Fasting in Youth: A Scoping Review

Intermittent fasting (IF) focuses on the timing of eating rather than diet quality or energy intake, with evidence supporting its effects on weight loss and cardiometabolic outcomes in adults. However, there is limited evidence for its efficacy in adolescents and emerging adults. To address this, a scoping review examined IF regimens in individuals aged 10 to 25, focusing on methodology, intervention parameters, outcomes, adherence, feasibility, and efficacy. The review included 39 studies with 731 participants aged 15 to 25. Methodologies varied, with 18 studies on time-restricted eating and others requiring caloric restriction. Primary outcomes included cardiometabolic risk factors (11/29), body composition (9/29), anthropometric measurements (8/29), and feasibility (2/29). Most studies reported significant weight loss. This review underscores IF's potential in treating obesity in this age group but highlights the need for rigorous studies with standardized frameworks for feasibility to ensure comparability and determine IF's practicality in this age group.

Mental health and BMI in children and adolescents during one year in obesity treatment

BACKGROUND

Mental health plays a major role in children and adolescents with obesity. The aim of this study was (1) to compare mental health in children with obesity with the background population and (2) to investigate if mental health changed during one year in an obesity treatment program.

METHODS

Data on self-reported mental health was collected in 107 children and adolescents (mean age 13.2 years) with obesity at first visit in an obesity treatment program and at one year follow-up (n = 47). Mental health was assessed by eight questions from the Danish Health Behaviour in School-aged Children (HBSC) questionnaire: (1) self-rated health (2) life satisfaction (3) feeling low (4) body-image (5) loneliness (6) self-esteem (7) self-efficacy and (8) social competence. Data was compared to a reference population based on HBSC data. BMI-SDS was based on Danish reference values.

RESULTS

Children and adolescents with obesity had significantly higher odds of reporting negative body image and feeling low and lower odds of reporting high self-rated health and high self-esteem compared to a reference population. There was no difference between the groups regarding life-satisfaction, social competence, self-efficacy or feeling lonely. There were no significant changes in mental health from first visit to one-year follow-up.

CONCLUSION

Our findings highlight the mental health difficulties in children and adolescents with obesity, and the importance of addressing these issues in obesity treatment. The results also indicate that children with obesity have psychosocial resources that should be exploited in treatment protocols.

Which adolescents are more likely to complete home-based sleep manipulation trials?

OBJECTIVES

Attrition and nonadherence are common concerns that can distort findings in clinical trials. This study examines the potential for systematic attrition in the largest sample to date of adolescents undergoing sleep manipulation.

METHODS

Using pooled data across two trials involving 242 adolescents, a cumulative logistic regression tested whether demographics and baseline sleep predicted study completion/adherence.

RESULTS

Race, a composite measure of socioeconomic status, and its elements (e.g., income, education) individually predicted completion/adherence. When entered concurrently into a multivariate predictive model, only socioeconomic status and study (trial A vs. B) were significant. Adolescents from households with higher socioeconomic status were more likely to complete or adhere to the protocol than those from households with lower socioeconomic status, p < .001.

CONCLUSIONS

Systematic attrition in sleep manipulation research could distort conclusions about under-resourced groups. Future sleep trials should intentionally measure systemic/structural factors and adopt strategies to recruit and retain participants from various backgrounds.

Impact of the motivational interviewing for childhood obesity treatment: The Obemat2.0 randomized clinical trial

BACKGROUND AND OBJECTIVE

The aim was assessing a short training for healthcare providers on patient-focused counselling to treat childhood obesity in primary care, along with dietitian-led workshops and educational materials.

METHODS

Randomized clustered trial conducted with paediatrician-nurse pairs (Basic Care Units [BCU]) in primary care centres from Tarragona (Spain). BCUs were randomized to intervention (MI) (motivational interview, dietitian-led education, and educational materials) or control group (SC, standard care). Participants were 8-14-year-old children with obesity, undergoing 1-11 monthly treatment visits during 1 year at primary care centres. The primary outcome was BMI z-score reduction.

RESULTS

The study included 44 clusters (23 MI). Out of 303 allocated children, 201 (n = 106 MI) completed baseline, final visits, and at least one treatment visit and were included in the analysis. BMI z-score reduction was -0.27 (±0.31) in SC, versus -0.36 (±0.35) in MI (p = 0.036). Mixed models with centres as random effects showed greater reductions in BMI in MI than SC; differences were B = -0.11 (95% CI: -0.20, -0.01, p = 0.025) for BMI z-score, and B = -2.06 (95% CI: -3.89, -0.23, p = 0.028) for BMI %. No severe adverse events related to the study were notified.

CONCLUSION

Training primary care professionals on motivational interviewing supported by dietitians and educational materials, enhanced the efficacy of childhood obesity therapy.

Parental Factors Associated With Intentions to Initiate a Family-Based Pediatric Weight Management Program

Background: Childhood obesity can be addressed through family-based pediatric weight management; however, treatment enrollment in the United States is low. This study aimed to identify parental factors associated with intentions to initiate a family-based pediatric weight management program. Methods: Cross-sectional survey data were collected from an online panel of US parents with at least one 5- to 11-year-old child identified as likely to have overweight or obesity. Participants viewed a video about a hypothetical family-based pediatric weight management program, rated their 30-day initiation intentions for that program, and answered additional related questionnaires. Results: Participants (n = 158) identified as White/Caucasian (53%) or Black/African American (47%), were primarily female (61.4%) and married/cohabitating (81.6%) with children who were predominantly girls (53.2%) and, on average, 9-year-olds. Higher parents' perception of program effectiveness predicted initiation intentions (p < 0.001), while concern for their child's weight and parent depression and anxiety levels did not. Higher initiation intentions and perceived program effectiveness were reported by Black/African American participants (p < 0.01) and those with at least a bachelor's degree (p < 0.01) compared to White/Caucasian participants and those without a bachelor's degree, respectively. Initiation intentions were higher for those with greater financial security (p = 0.020) and fewer than three children in the home (p = 0.026). Participants endorsed initiation barriers of time constraints (25%), possible lack of enjoyment for the child (16.9%), and lack of family support (15%). Conclusions: Future program enrollment efforts may need to focus on strategies to increase perceived program effectiveness, although further research is needed that measures actual enrollment in real-world contexts.

Effectiveness of a Scalable mHealth Intervention for Children With Overweight and Obesity

Background: Multicomponent interventions are the first line of treatment for pediatric obesity, but are challenging to access. Mobile health (mHealth) interventions hold promise as they address commonly cited barriers for attending in person programs and have potential for wide scale dissemination. Methods: This retrospective cohort study examined data from youth who enrolled in the Kurbo program, which includes personal health coaching and a mobile app. Hierarchical linear regression was used to examine the impact of baseline percentage of the 95th% percentile for body mass index (%BMIp95), number of coaching sessions, and length of time enrolled in the program on change in %BMIp95, controlling for baseline age and sex. Results: A total of 3500 youth (mean age of 12.79 years, 71.3% female) were included. Youth experienced a 0.70 U decrease in BMI [standard deviation (SD) = 2.19] and a 4.45% decrease (SD = 8.5) in %BMIp95 over a mean of 31.5 weeks. The overall regression model was significant, R2 = 0.066, F(3,3494) = 77.18, and p < 0.001. Predictors of decrease in weight status included being female (b = -1.11, p < 0.001), higher baseline %BMIp95, (b = -0.58, p < 0.001), and greater number of coaching sessions (b = -0.12, p < 0.001), while greater time enrolled in the program (b = 0.02, p < 0.001) was associated with less change. Conclusion: Findings suggest a scalable coaching program with integrated digital tools for monitoring diet and activity can lead to significant reductions in weight status. Findings need to be replicated with more rigorous study designs, including a comparison condition and verified assessment of height and weight.

Attrition rate and predictors of a monitoring mHealth application in adolescents with obesity

BACKGROUND

Integrating mobile health (mHealth) into paediatric obesity treatment can provide opportunities for more personalized and lifetime treatment. However, high attrition rates pose a significant challenge. The current study attempts to better understand attrition by exploring (1) attrition rates of a monitoring mHealth application for usage over 14 days and (2) testing predictors of attrition in adolescents with obesity.

METHODS

Participants were 69 adolescents between 12 and 16 years old who engaged in a multidisciplinary obesity treatment centre (either outpatient or inpatient) in two countries (Belgium and France). To assess the attrition rates, frequency distributions were used. To test the predictors of attrition, zero-inflated negative binomial regression was performed.

RESULTS

Attrition rates were high, in the outpatient group, more than half of the participants (53.3%) used the app for only 0-7 days. In the inpatient group, this percentage was 24.1%. Only deficits in initiating (a component of executive functions) were a negative predictor of attrition, indicating that deficits in initiating lead to lower attrition rates.

CONCLUSIONS

This study provides evidence for high attrition rates in mHealth interventions for adolescents with obesity and was the first to investigate psychological predictors of attrition to an mHealth monitoring tool in adolescents with obesity in treatment. Findings regarding predictors of attrition should be approached with caution due to the small sample size.

Adolescent and Caregiver Perspectives on Family Navigation to Improve Healthcare Access and Use for Managing Pediatric Obesity

We interviewed families to explore their views on the role of family navigation (FN) to improve access to and use of health services for managing pediatric obesity. From March to December, 2020, we conducted individual, structured telephone interviews with adolescents with obesity (13-17 years old) and their caregivers from Edmonton and Calgary, Canada. Among our 37 participants (14 adolescents, 23 caregivers), most (n = 27; 73.0%) reported FN could improve their access to obesity management. Participants recommended several activities to support healthcare access and use, including appointment reminders, evening/weekend appointments, parking/transportation support, and in-clinic childcare, all of which help families to attend appointments over an extended period to support obesity management. Most participants preferred FN be offered by healthcare professional 'navigators' who were approachable, empathic, and compassionate since issues regarding health and obesity can be sensitive, emotional topics to discuss. Overall, families supported integrating FN into multidisciplinary pediatric obesity management to improve healthcare access and use by navigators who apply a range of practical strategies and relational skills to enhance long-term access and adherence to care.

Measuring severe obesity in pediatrics using body mass index-derived metrics from the Centers for Disease Control and Prevention and World Health Organization: a secondary analysis of CANadian Pediatric Weight management Registry (CANPWR) data

To examine the (i) relationships between various body mass index (BMI)-derived metrics for measuring severe obesity (SO) over time based the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) references and (ii) ability of these metrics to discriminate children and adolescents based on the presence of cardiometabolic risk factors. In this cohort study completed from 2013 to 2021, we examined data from 3- to 18-year-olds enrolled in the CANadian Pediatric Weight management Registry. Anthropometric data were used to create nine BMI-derived metrics based on the CDC and WHO references. Cardiometabolic risk factors were examined, including dysglycemia, dyslipidemia, and elevated blood pressure. Analyses included Pearson correlations, intraclass correlation coefficients (ICC), and receiver operator characteristic area-under-the-curve (ROC AUC). Our sample included 1,288 participants (n = 666 [52%] girls; n = 874 [68%] white). The prevalence of SO varied from 60-67%, depending on the definition. Most BMI-derived metrics were positively and significantly related to one another (r = 0.45-1.00); ICCs revealed high tracking (0.90-0.94). ROC AUC analyses showed CDC and WHO metrics had a modest ability to discriminate the presence of cardiometabolic risk factors, which improved slightly with increasing numbers of risk factors. Overall, most BMI-derived metrics rated poorly in identifying presence of cardiometabolic risk factors.    Conclusion: CDC BMI percent of the 95th percentile and WHO BMIz performed similarly as measures of SO, although neither showed particularly impressive discrimination. They appear to be interchangeable in clinical care and research in pediatrics, but there is a need for a universal standard. WHO BMIz may be useful for clinicians and researchers from countries that recommend using the WHO growth reference. What is Known: • Severe obesity in pediatrics is a global health issue. • Few reports have evaluated body mass index (BMI)-derived metrics based on the World Health Organization growth reference. What is New: • Our analyses showed that the Centers for Disease Control and Prevention BMI percent of the 95th percentile and World Health Organization (WHO) BMI z-score (BMIz) performed similarly as measures of severe obesity in pediatrics. • WHO BMIz should be a useful metric to measure severe obesity for clinicians and researchers from countries that recommend using the WHO growth reference.

A multicomponent family intervention, combined with salt reduction for children with obesity: a factorial randomized study protocol

BACKGROUND

Clinical trials to treat childhood obesity show modest results, weight regain and high dropout rates. Children with obesity often live in families with habits that contribute to unhealthy weight gain. This study will test whether a family intervention with a Brazilian-adapted Planetary Healthy Diet (PHD) and reduced portion sizes, along with increased physical activity and reduced sedentary behavior, can reduce excessive weight gain. The protocol promotes the intake of in natura products and water and reduces ultra-processed foods, sugar, and sodium. It encourages family lifestyle changes and physical activities, with randomized allocation to experimental and control groups. The responsible family member will be evaluated during follow-up. The control group will receive a print of the Brazilian dietary guideline.

METHODS

A factorial crossover design will also allocate families to receive reduced sodium salt plus anti-inflammatory herbs and a placebo salt. Both the control and intervention groups will be randomly assigned to the sequence of both salts. The approach aims to reduce body weight expectations and evaluate salt's impact on blood pressure. It includes a 1-month intervention, 1-month washout, and 1-month intervention with monthly clinic visits and teleservice by health professionals. The primary outcomes will be the variation in the Body Mass Index (BMI) of the children. BMI and the variation in the blood pressure of the pair (child/mother or father) as well as waist circumference (WC) and waist-to-height ratio (WHtR) will also be measured.

DISCUSSION

The project will test the effectiveness of the use of the recommendations of the PHD, physical activity and a salt-reduced sodium. The results of the present study will allow the refinement of interventions aimed at the treatment of childhood obesity and may help develop guidelines for the treatment of obesity in Brazilian children.

TRIAL REGISTRATION

The study is registered in the Brazilian Registry of Clinical Trials (RBR-10 mm62vs). Registered 10 February 2023.

Randomized control trial of a childhood obesity prevention family-based program: "Abriendo Caminos" and effects on BMI

Background

Hispanic individuals are at increased risk for obesity and other chronic health conditions. This article evaluates the effect of a family-based, childhood obesity primary prevention intervention in a community setting.

Methods

A multi-site, randomized controlled trial community program with assessments at pre (T0), post-program (T1), and 6-months post-program (T2). Participating families were recruited from five sites. Only families of Mexican or Puerto Rican heritage with a least one child between 6 and 18 years were included in the study, without weight restrictions. Families were randomized to the intervention and control arms. Intervention families received six-2 h weekly workshops. Control families received printed generic nutrition and wellness information. Heights and weights were measured at the 3-time points to calculate BMI z-scores, BMI-percentiles, and weight status using age- and sex-specific growth charts, according to the CDC guidelines.

Results

There were no differences in BMI-z scores between children in the intervention (n = 239) and control groups (n = 187) at T0. BMI z-scores decreased in the intervention group (-0.03, 95% CI, -0.066, -0.003, p = 0.032) at T1, but not in the control group at T1. Changes in BMI z-scores were not statistically significant at T2.

Conclusion

The Abriendo Caminos intervention effectively prevented unhealthy weight gain in Hispanic children in the short-term, but not at 6-months post-intervention. Younger children and girls benefited more from the program at 6-months post-intervention. Additional efforts are needed to sustain long-term changes. Culturally-tailored programs can provide families with the knowledge to produce short-term changes and a potential pathway for sustainable changes in implementing healthy behaviors.

Household food insecurity and changes in BMI z-score in a pediatric obesity management clinic

BACKGROUND

Multicomponent lifestyle interventions are fundamental in pediatric obesity management. However, whether household food insecurity influences the efficacy of such interventions remains undocumented.

OBJECTIVE

The objective was to compare changes in body mass index z-score (BMIz) among children whose family received lifestyle counseling at a pediatric obesity management clinic in Montreal (Canada) according to their household food security status.

METHODS

This is a retrospective, longitudinal analysis of medical records of children (2-17 years) with overweight or obesity who received lifestyle counseling at a pediatric obesity management clinic. The number of visits at the clinic and the duration of the follow-up were individualized. Household food security status was assessed using Health Canada's Household Food Security Survey Module at the first visit at the clinic. BMIz was calculated and updated at each visit. A reduction of ≥0.25 in BMIz between the last and the first visit at the clinic was considered clinically meaningful. Statistical significance was considered at P<0.05.

RESULTS

Among the 214 children included in the study, 83 (38.8%) lived in a food insecure household. In multivariable-adjusted analyses, differences in BMIz between the last and the first appointment tended to be smaller among children who lived in a food insecure household compared with those in a food secure household [ΔBMIz_{food insecurity}=-0.432 (95% confidence interval (CI): -0.672, -0.193) vs ΔBMIz_{food security}=-0.556 (95% CI: -0.792, -0.319; P=0.14)]. Differences were most notable in the first 6 months of follow-up. The odds ratio of achieving a clinically significant reduction in BMIz over follow-up associated with household food insecurity, compared with household food security, was 0.57 (95% CI: 0.31, 1.05; P=0.07).

CONCLUSIONS

In this sample of children followed at a pediatric obesity clinic, those who lived in a food insecure household experienced smaller BMIz reductions compared with those who lived in a food secure household.

Factors predicting parent engagement in a family-based childhood obesity prevention and control program

BACKGROUND

Family-based interventions are efficacious at preventing and controlling childhood overweight and obesity; however, implementation is often hindered by low parent engagement. The purpose of this study was to evaluate predictors of parent engagement in a family-based childhood obesity prevention and control intervention.

METHODS

Predictors were assessed in a clinic-based community health worker (CHW)-led Family Wellness Program consisting of in-person educational workshops attended by parents and children. This program was part of a larger effort known as the Childhood Obesity Research Demonstration projects. Participants included 128 adult caretakers of children ages 2-11 (98% female). Predictors of parent engagement (e.g., anthropometric, sociodemographic, psychosocial variables) were assessed prior to the intervention. Attendance at intervention activities was recorded by the CHW. Zero-inflated Poisson regression was used to determine predictors of non-attendance and degree of attendance.

RESULTS

Parents' lower readiness to make behavioral and parenting changes related to their child's health was the sole predictor of non-attendance at planned intervention activities in adjusted models (OR = 0.41, p < .05). Higher levels of family functioning predicted degree of attendance (RR = 1.25, p < .01).

CONCLUSIONS

To improve engagement in family-based childhood obesity prevention interventions, researchers should consider assessing and tailoring intervention strategies to align with the family's readiness to change and promote family functioning.

TRIAL REGISTRATION

NCT02197390, 22/07/2014.

Clinician and healthcare managers' perspectives on the delivery of secondary and tertiary pediatric weight management services

Clinician and healthcare managers' (HCMs) views on weight management service delivery are imperative for informing the nature of future services to treat children with obesity. This qualitative study used semi-structured focus groups and one-on-one semi-structured interviews. Participants were 27 clinicians (medical, nursing, or allied health) and nine HCMs (senior executives in the hospital) who worked in six secondary or tertiary pediatric weight management clinics across five public hospitals in New South Wales, Australia. Clinicians reported that using a combination of group and individual sessions improved engagement with families and reduced attrition rates. Clinicians and HCMs recommended integrating clinics into community centers and providing specific programs for sub-groups, such as children from culturally and linguistically diverse communities or children with developmental delay. Many clinicians and HCMs stressed the importance of pediatric weight clinics using a holistic approach to treatment. To improve the likelihood of future funding for pediatric weight management clinics and to optimize models of care, centers must embed research into their practice. Addressing common barriers to current pediatric weight management services and designing future models of care based on key stakeholders' preferences is critical to achieving optimal care provision for this high-risk population.

Parents as Agents of Change in Managing Pediatric Obesity: A Randomized Controlled Trial Comparing Cognitive Behavioral Therapy versus Psychoeducation Interventions

Background: Obesity interventions for parents of children with obesity can improve children's weight and health. This randomized controlled trial (RCT) evaluated whether a parent-based intervention based on cognitive behavioral therapy (CBT) principles was superior to a parent-based intervention based on a psychoeducation program (PEP) in improving children's obesity. Methods: This study was a pragmatic, two-armed, parallel, superiority RCT. Conducted at a Canadian outpatient pediatric obesity management clinic (September 2010-January 2014), this trial included families with children 8-12 years with an age- and sex-specific BMI ≥85th percentile. The 16-week manualized interventions were similar in content and delivered to parents exclusively, with different theoretical underpinnings. The primary outcome was children's BMI z-score at postintervention (4 months). Secondary outcomes included anthropometric, lifestyle, psychosocial, and cardiometabolic variables. Data were collected at preintervention (0 months), postintervention (4 months), 10, and 16 months. Intention-to-treat analysis using linear mixed models was used to assess outcomes. Results: Among 52 randomly assigned children, the mean age (standard deviation) was 9.8 (1.7) years and BMI z-score was 2.2 (0.3). Mean differences in BMI z-score were not significantly different between the CBT (n = 27) and PEP (n = 25) groups from 0 to 4-, 10-, and 16-month follow-up. At 4 months, the mean difference in BMI z-score from preintervention between the CBT (-0.05, 95% CI = -0.09 to 0.00) and PEP (-0.04, 95% CI = -0.09 to 0.01) groups was -0.01 (95% CI = -0.08 to 0.06, p = 0.80). Similar results were found across all secondary outcomes. Conclusions: Our CBT-based intervention for parents of children with obesity was not superior in reducing BMI z-score vs. our PEP-based intervention.

Perceived barriers in family-based behavioural treatment of paediatric obesity - Results from the FABO study

BACKGROUND

To date, few studies have investigated perceived barriers among those who participate in and drop out of family-based behavioural treatment (FBT) for paediatric obesity. Examining experienced barriers during treatment, and their role in participation and completion of treatment has important implications for clinical practice.

OBJECTIVES

To compare perceived barriers to participating in a family-based behavioural social facilitation treatment (FBSFT) for obesity among families who completed and did not complete treatment.

METHODS

Data were analysed from 90 families of children and adolescents (mean (M) age = 12.8 years, standard deviation (SD) = 3.05) with severe obesity enrolled in a 17-session FBSFT program. After completing 12 sessions or at the time of dropout, parents and therapists completed the Barriers to Treatment Participation Scale (BTPS), a 5-point Likert scale (1 = never a problem, 5 = very often a problem) which includes four subscales: 1. Stressors and obstacles that compete with treatment, 2. Treatment demands and issues, 3. Perceived relevance of treatment, 4. Relationship with the therapist.

RESULTS

Families who did not complete treatment scored significantly higher on the BTPS subscales stressors and obstacles that compete with treatment (M = 2.03, SD = 0.53 vs. M = 1.70, SD = 0.42), p = 0.010 and perceived relevance of treatment (M = 2.27, SD = 0.48 vs. M = 1.80, SD = 0.50), p < 0.001 than families who completed treatment. No other significant differences between groups were observed.

CONCLUSION

Families are more likely to drop out of FBSFT when experiencing a high burden from life stressors or when treatment is not meeting the expectations and perceived needs of the family.

Influence of Executive Function Training on BMI, Food Choice, and Cognition in Children with Obesity: Results from the TOuCH Study

BACKGROUND

Children with obesity have a higher risk of future health and psychological problems. Executive functions (EFs) play a key role in successful dietetic and exercise planning; therefore, new treatments aimed at improving EFs may optimize outcomes.

OBJECTIVES

This study evaluates the impact of EF training on body mass index (BMI), food choice, and cognition in children with obesity. We also examine their real-life executive functioning, emotional state, and quality of life.

METHODS

Randomized controlled double-blind trial. Forty-six children with obesity were randomly allocated into an executive functions training or a control task training group and attended 30-45 min of daily training (5/week over 6 weeks), with both groups receiving counseling on diet and wearing an activity/sleep tracker. Participants were evaluated at baseline and after treatment.

RESULTS

BMI decreased over time in the whole sample, although there were no differences between groups at post-training in BMI, food choice, and cognition. Both groups showed significant improvements in attention, speed, cognitive flexibility, and inhibitory control. Additionally, there were some benefits in real-life executive functioning and self-esteem. Over the 6 weeks, participants showed worse food choices in both groups.

CONCLUSIONS

EFs training showed a lack of significant effects. The executive function enhancement alone did not explain these changes, as there were no significant differences between the experimental groups. It might be that the control task training could also produce some benefits, and multi-component interventions might be useful for weight loss.

Weight-neutral interventions in young people with high body mass index: A systematic review

AIM

This systematic review explored the feasibility, acceptability and effect on health outcomes of weight-neutral interventions in health improvement-seeking young people with overweight/obesity.

METHODS

Six databases were searched to March 2021 for health, but not weight, focused interventions (PROSPERO, CRD42020152671). Eligible studies recruited young people (10-24 years) with overweight/obesity. The studies were described using narrative synthesis, with numerical results summarised. The quality of included studies was assessed using the Joanna Briggs Institute critical appraisal tools.

RESULTS

Six articles were included, representing three pilot studies. Study 1 (n = 37, 14-17 years) compared a 6-week mindful eating program with single-session lifestyle education; Study 2 (n = 35, 14-17 years) compared 12-week weight-neutral lifestyle education focused on intuitive eating and carbohydrate quality, with/without guided imagery; and Study 3 (n = 33, 12-17 years) compared a 6-week mindfulness intervention with cognitive behavioural therapy in adolescents with depressive symptoms at risk of type 2 diabetes. All interventions explored feasibility (intervention group retention 57%-88%, attendance >80%) and reported interventions were acceptable. Studies 1 and 3 reported no change in mindfulness. Study 2 reported an increase (p < 0.05) in intuitive eating following weight-neutral plus guided imagery (0.32 ± 0.36, Hawks' Scale, score 1-4), compared with weight-neutral alone (0.15 ± 0.29). Study 1 reported decreased body mass index (p < 0.001) following mindful eating (-1.1 kg/m² ), compared with single-session lifestyle education (+0.7 kg/m² ); Studies 2 and 3 found no change in body mass index or body mass index z-score.

CONCLUSIONS

Weight-neutral interventions may be feasible and acceptable in adolescents with overweight/obesity in the short term (≤12 weeks), but data are limited.

A multi-center, randomized, 12-month, parallel-group, feasibility study to assess the acceptability and preliminary impact of family navigation plus usual care versus usual care on attrition in managing pediatric obesity: a study protocol

BACKGROUND

Pediatric obesity management can be successful, but some families discontinue care prematurely (i.e., attrition), limiting treatment impact. Attrition is often a consequence of barriers and constraints that limit families' access to obesity management. Family Navigation (FN) can improve access, satisfaction with care, and treatment outcomes in diverse areas of healthcare. To help our team prepare for a future effectiveness trial, the objectives of our randomized feasibility study are to (i) explore children's and caregivers' acceptability of FN and (ii) examine attrition, measures of study rigor and conduct, and responses to FN + Usual Care vs Usual Care by collecting clinical, health services, and health economic data.

METHODS

In our 2.5-year study, 108 6-17-year-olds with obesity and their caregivers will be randomized (1:1) to FN + Usual Care or Usual Care after they enroll in obesity management clinics in Calgary and Mississauga, Canada. Our Stakeholder Steering Committee and research team will use Experience-Based Co-Design to design and refine our FN intervention to reduce families' barriers to care, maximizing the intervention dose families receive. FN will be delivered by a navigator at each site who will use logistical and relational strategies to enhance access to care, supplementing obesity management. Usual Care will be offered similarly at both clinics, adhering to expert guidelines. At enrollment, families will complete a multidisciplinary assessment, then meet regularly with a multidisciplinary team of clinicians for obesity management. Over 12 months, both FN and Usual Care will be delivered virtually and/or in-person, pandemic permitting. Data will be collected at 0, 3, 6, and 12 months post-baseline. We will explore child and caregiver perceptions of FN acceptability as well as evaluate attrition, recruitment, enrolment, randomization, and protocol integrity against pre-set success thresholds. Data on clinical, health services, and health economic outcomes will be collected using established protocols. Qualitative data analysis will apply thematic analysis; quantitative data analysis will be descriptive.

DISCUSSION

Our trial will assess the feasibility of FN to address attrition in managing pediatric obesity. Study data will inform a future effectiveness trial, which will be designed to test whether FN reduces attrition.

TRIAL REGISTRATION

This trial was registered prospectively at ClinicalTrials.gov (# NCT05403658 ; first posted: June 3, 2022).

Predictors of Effectiveness and Adherence in a Multimodal Obesity Treatment Program for Children and Adolescents in Routine Care

Multimodal obesity treatments for children and adolescents generally showed only small to modest treatment effects and high dropout rates. Potential variations by patients' clinical and sociodemographic factors remain, however, largely unclear. For this reason, our study analyzed psychological, physical, and sociodemographic predictors of treatment success and adherence in a multimodal obesity treatment over 12 months. The intent-to-treat sample included n = 361 children and adolescents (ages 3-17 years), of which n = 214 or 59.28% of patients completed treatment. A younger age and, in the sensitivity analysis, additionally a greater eating disorder psychopathology and treatment initiation before COVID-19 pandemic predicted greater BMI-SDS reductions (Body Mass Index-Standard Deviation Score). In contrast, predictors of treatment adherence were not found. The results underline the importance of early treatment of juvenile obesity. Additionally, eating disorder psychopathology includes restrained eating, which implies the ability to self-regulate eating behavior and therefore may have a positive effect on the treatment goal of controlled food intake. Challenges from altered treatment procedures due to the COVID-19 pandemic nonetheless remain.

Parents' Experiences Using Digital Health Technologies in Paediatric Overweight and Obesity Support: An Integrative Review

This study aimed to explore parents' perspectives regarding the use of digital health technologies in paediatric overweight and obesity weight support. A systematic search in 'Academic Search Premier', 'British Nursing Index', 'Cumulative Index to Nursing and Allied Health', and 'Health Research Premium Collection' was conducted in November 2021. Inclusion criteria were English or Nordic peer-reviewed articles published after 2010, overweight and obese children aged 2-10, weight support using digital health technologies, and parental experiences examined. An integrative review was conducted using Joanna Briggs Institute quality appraisal checklists and a constant comparison analysis method. In total, 14 articles were analysed that included SMS, telephone, apps, websites, and social media as the main technology groups. A limitation of this review was the heterogenicity of the studies. The results indicate that parents, mostly mothers, had a positive experience, finding technologies helpful and easy to use, and expressed optimism toward future use. An option for interacting with others and the possibility of personalising support were enjoyed or requested. In conclusion, digital health technologies can be a suitable tool to empower the parents of children with overweight and obesity concerns, whose perspective should be considered during the design and support phases.

Recreational Physical Activity Improves Adherence and Dropout in a Non-Intensive Behavioral Intervention for Adolescents With Obesity

Purpose: The aim of this study was to compare adherence and dropout rates in adolescents with obesity participating in a behavioral-counseling intervention with or without recreational physical activity (PA). Material and methods: Seventy-four adolescents (13 to 18y, 40 girls and 34 boys) with obesity (body mass index [BMI] z-score ≥ 2.0) were randomized into a counseling group (CG; n = 37) and a counseling + recreational physical activity group (CPAG; n = 37). Adolescents from both groups received behavioral counseling once a week for 12 weeks and monthly for an additional 12 weeks. CPAG adolescents participated in supervised recreational physical activity sessions twice a week for 12 weeks. Body composition, body image dissatisfaction, symptoms of depression, binge eating, bulimia, anorexia and quality of life were assessed at baseline and after 24-weeks. Result: The dropout rate was 2.73 times higher in adolescents from CG compared to CPAG (χ² = 4.48; p = .034; R²_McF = 0.044). Girls were 2.56 times more likely to withdraw when compared to boys (χ² = 3.86; p = .049; R²_McF = 0.038). Binomial logistic regression which incorporated sex, intervention group, BMI z-score and BSQ score at baseline (R²_McF = 0.177) explained 75% of the dropout rate. Both interventions were effective in reducing waist circumference (p < .01) and improving quality of life, symptoms of depression, bulimia and binge eating (p < .01). Conclusion: Incorporating a recreational physical activity component to a non-intensive behavioral intervention may be a feasible strategy to reduce dropout rates in adolescents with obesity seeking treatment.

Family-reported barriers and predictors of short-term attendance in a multidisciplinary intervention for managing childhood obesity: A psycho-family-system based randomised controlled trial (ENTREN-F)

OBJECTIVE

This study was aimed to examine patient enrolment in the pre-intervention stage, family-reported barriers, attendance rates and underlying predictors of short-term attendance in a family-system-based randomised controlled trial for managing childhood obesity in children aged 8-12-years-old (ENTREN-F).

METHOD

Psychosocial and anthropometric measures were collected through primary health referral. The data were used for descriptive analyses of sample characteristics and linear regression analyses.

RESULTS

Low enrolment rates and several family-reported barriers were observed in the pre-intervention stage. Logistical barriers were the most frequent family-reported reason for attrition in the different stages of the study. Having a first face-to-face orientation session with the families and the use of motivational interviewing helped to improve adherence in the initial phases of the study. After 6 months of intervention, family based treatments (FBTs) under consideration achieve greater adherence compared with the standard intervention. Moreover, family involvement was a predictor of success for better treatment adherence rates. By contrast, participants who attended a brief standard intervention, mothers with primary education, greater body mass index, higher levels of depressive symptomatology and more critical comments towards their children, children with higher weight status and lower levels of self-reported depressive symptoms at baseline attended interventions less frequently.

CONCLUSIONS

In future programmes a comprehensive screening of modifiable factors related to family and their setting characteristics is paramount prior to intervention, identifying key barriers related to drop-out, especially in the case of less-advantaged families.

Determinants of dropout and compliance of children participating in a multidisciplinary intervention programme for overweight and obesity in socially deprived areas

BACKGROUND

Children with overweight and obesity in socially deprived areas (SDAs) are less likely to complete and be compliant to a weight-loss programme.

OBJECTIVES

To identify factors associated with dropout and compliance of a multidisciplinary weight-loss programme in SDA.

METHODS

This prospective longitudinal cohort study included children (6-12 years) with overweight and obesity in a 12-week multidisciplinary intervention living in SDA in Rotterdam, the Netherlands. Potential predictive variables for dropout and compliance included were age, sex, the weight of the child and parents, quality of life, and referral status (self-registration or referral). A Cox proportional hazards model was performed to study the association between dropout and its potential predictive variables, whereas logistic regression analyses were used for the potential predictors for compliance.

RESULTS

A total of 121 children started the intervention programme. Forty-one (33.9%) children dropped out and 68 (56.2%) were compliant with the intervention. The risk of dropping out of the intervention was significantly lower for a child with overweight parents than for those with parents with normal weight (adjusted hazard ratio [HR] 0.22 [95% confidence interval, CI 0.063-0.75]), and for those with parents with obesity (adjusted HR 0.18 [95% CI 0.060-0.52]). No other potential predictive variables were associated with dropout or compliance.

CONCLUSION

Children from SDA participating in a weight-loss programme have a relatively high dropout and a low compliance rate. Parental weight seems to be an important predictor for dropout of children from SDA, where children with normal weight or obese parents have the highest risk of dropout compared with children of overweight parents.

Insight Into the Adolescent Patient Experience With Nonalcoholic Fatty Liver Disease

OBJECTIVES

Nonalcoholic fatty liver disease (NAFLD) is the leading chronic liver disease in youth, yet little is known about the adolescent patient's experience with NAFLD, which is key for treatment engagement. We examined adolescents' experiences with NAFLD diagnosis, thoughts on how NAFLD affects their daily life, understanding and perceptions of diagnosis and treatment, and impressions of how to improve care.

METHODS

Utilizing a mixed-method design, adolescents with NAFLD (N = 16; Mean age = 15.8 years; Mean BMI = 37 kg/m 2 ) participated in focus groups. To supplement qualitative data, adolescents and their caregiver completed measures assessing illness perceptions, adolescent quality of life, and eating/activity behaviors.

RESULTS

Focus group themes suggested reactions to diagnosis varied from unconcerned to anxious. NAFLD diagnosis occurred within the context of other psychological/medical concerns and was not perceived to affect most adolescents' daily lives. Although adolescents understood general contributors to NAFLD, comprehension of their diagnosis varied. Adolescents were more likely to make lifestyle changes when families were supportive, and they preferred tailored recommendations for health behavior change from the healthcare team. Notably, 62.5% of adolescents were more concerned about their weight than NAFLD. Almost half (43.8%) identified as food insecure.

CONCLUSIONS

Adolescents with NAFLD may benefit from personalized treatment. Care could be enhanced by ensuring comprehension of diagnosis, problem-solving personal, and family barriers and increasing family support. Harnessing adolescents' desire for weight loss may be a more salient driver for change in disease status. Interventions should also address systemic barriers such as food insecurity to ensure equitable care.

Multidisciplinary Treatment for Childhood Obesity: A Two-Year Experience in the Province of Naples, Italy

Childhood obesity must be faced through an integrated multi-level preventive approach. This study was aimed at assessing the adherence and the outcomes of an outpatient service for childhood obesity treatment activated in the province of Naples, Italy, throughout a 2-year follow-up period. At first visit (T0), weight, height, waist circumference, and body composition of children were assessed, together with sociodemographic features and physical activity levels of children and parents. Anthropometric and body composition parameters of children were measured at 6 ± 3 months (T1) and 12 ± 3 months (T2). A total of 451 non-related children who accessed the service were analyzed: 220 (48.7%) of them returned at least once (attrition rate 51.3%). Returner outpatients showed higher age (p = 0.046) and father’s educational level (p = 0.041) than non-returner ones. Adherence to the treatment was found to be related to father’s (Rho = 0.140, p = 0.005) and mother’s (Rho = 0.109, p = 0.026) educational level. All the outcomes improved between T0 and T1 (p < 0.001), while only body mass index (BMI) decreased significantly at T2. Changes in BMI-SDS were associated with baseline value (OR 0.158, 95%CI 0.017−0.298, p = 0.029). The multidisciplinary approach seems to be promising to treat childhood obesity in this geographic context. Lower parents’ educational level should be considered as an attrition determinant.

Effect of an interactive mobile health support system and daily weight measurements for pediatric obesity treatment, a 1-year pragmatical clinical trial

Background

Pediatric obesity lifestyle treatment is not always successful. Frequent clinical visits are of major importance to certify sufficient effect but are difficult due to the associated costs and the great demands on families. We hypothesized that an interactive digital support may reduce the need for frequent physical visits. The aim of the study was to assess 1-year weight outcome for patients using a digital support system compared with standard care.

Methods

An obesity lifestyle treatment with a digital support system was implemented in one clinic in Stockholm, Sweden. Measurements from a custom-made body scale without digits for daily home measurement of weights were transferred via Bluetooth to a mobile application, where BMI Z-score was calculated and presented graphically with an individualized weight loss target curve. An automatic transfer of data to the web-based clinic interface enables a close monitoring of treatment progress, and frequent written communication between the clinical staff and families via the application. One-year outcome was compared with a randomly retrieved, age and sex matched control group from the Swedish childhood obesity treatment register (BORIS), which received standard treatment at other clinics. Main outcome was change in BMI Z-score and missing data was imputed.

Results

107 children were consecutively included to digi-physical treatment and 321 children to standard care. Age range 4.1–17.4 years (67% males). The attrition rate was 36% and 46% respectively, p = 0.08. After 1 year, the mean ± SD change in BMI Z-score in the treatment group was −0.30 ± 0.39 BMI Z-score units and in the standard care group −0.15 ± 0.28, p = 0.0002. The outcome was better for both sexes and all age groups in the digi-physical treated group.

Conclusion

A digital support system with a personalized weight-loss target curve and daily weight measurements shared by the family and the clinic is more effective than a standard care childhood obesity treatment.

Clinicaltrial.gov ID

NCT04323215

Screening for hypertension in young people with obesity: Feasibility in the real life

BACKGROUND AND AIM

Screening for pediatric hypertension (HTN) is based on several measurements of blood pressure (BP) in different visits. We aimed to assess its feasibility in outpatient youths with overweight/obesity (OW/OB) in terms of adherence to two-repeated measurements of BP and to show the features of youths who missed the follow-up and the predictive role of clinical and/or anamnestic features on confirmed HTN.

METHODS AND RESULTS

Six hundred, eighty-eight youths (9-17 years) with OW/OB, consecutively recruited, underwent a first measurement of BP. Those exhibiting BP levels within the hypertensive range were invited to repeat a second measurement within 1-2 weeks. Confirmed HTN was diagnosed when BP in the hypertensive range was confirmed at the second measurement. At entry, 174 youths (25.1%) were classified as hypertensive. At the second visit, 66 youths (37.9%) were lost to follow-up. In the remaining 108 participants, HTN was confirmed in 59, so that the prevalence of confirmed HTN was 9.5% in the overall sample; it was higher in adolescents than children (15.9% vs 6.8%, P = 0.001). HTN at first visit showed the best sensitivity (100%) and a good specificity (91%) for confirmed HTN. The association of HTN at first visit plus familial HTN showed high specificity (98%) and positive predictive value of 70%.

CONCLUSION

The high drop-out rate confirms the real difficulty to obtain a complete diagnostic follow up in the obese population. Information about family history of HTN may assist pediatricians in identifying those children who are at higher risk of confirmed HTN.

George SM, Prinz R, Resnicow K. The Results of the Families Improving Together (FIT) for Weight Loss Randomized Trial in Overweight African American Adolescents

BACKGROUND

Few intervention studies have integrated cultural tailoring, parenting, behavioral, and motivational strategies to address African American adolescent weight loss.

PURPOSE

The Families Improving Together (FIT) for Weight Loss trial was a randomized group cohort study testing the efficacy of a cultural tailoring, positive parenting, and motivational intervention for weight loss in overweight African American adolescents (N = 241 adolescent/caregiver dyads).

METHODS

The trial tested an 8-week face-to-face group motivational plus family weight loss program (M + FWL) compared with a comprehensive health education control program. Participants were then rerandomized to an 8-week tailored or control online program to test the added effects of the online intervention on reducing body mass index and improving physical activity (moderate-to-vigorous physical activity [MVPA], light physical activity [LPA]), and diet.

RESULTS

There were no significant intervention effects for body mass index or diet. There was a significant effect of the group M + FWL intervention on parent LPA at 16 weeks (B = 33.017, SE = 13.115, p = .012). Parents in the group M + FWL intervention showed an increase in LPA, whereas parents in the comprehensive health education group showed a decrease in LPA. Secondary analyses using complier average causal effects showed a significant intervention effect at 16 weeks for parents on MVPA and a similar trend for adolescents.

CONCLUSIONS

While the intervention showed some impact on physical activity, additional strategies are needed to impact weight loss among overweight African American adolescents.

Characteristics of paediatric weight management in the United States: Associations with program retention and BMI outcomes in the paediatric obesity weight evaluation registry (POWER)

OBJECTIVE

To describe characteristics of paediatric weight management (PWM) programs across the United States and evaluate associations with program-specific retention rates and body mass index (BMI) outcomes at 6 months.

METHODS

A program profile survey was administered to 33 programs within the Paediatric Obesity Weight Evaluation Registry (POWER) to assess program staffing, services, and treatment format. Patient retention and percent of the 95th BMI percentile (%BMIp95) changes were assessed for each program.

RESULTS

At 6 months program retention rates ranged from 15% to 74% (median: 41%), and program %BMIp95 changes ranged from -9.0 to +0.5 percentage points (median: -1.7). Percent of patients with ≥5 percentage-point decrease in %BMIp95 ranged from 17% to 71% across programs (median: 29%). No associations were detected between program characteristics and retention or %BMIp95 changes.

CONCLUSIONS

Six-month patient retention and BMI outcomes vary substantially in PWM programs across the United States. Yet, no associations were found between PWM treatment factors and these program-level patient outcomes.

Patient Retention in Pediatric Weight Management Programs in the United States: Analyses of Data from the Pediatrics Obesity Weight Evaluation Registry

Objective: Meeting recommended provider contact hours in multicomponent pediatric weight management (PWM) programs is difficult when patient retention is low. Our objective was to examine associations between individual patient characteristics, program characteristics, and patient retention. Methods: Using the Pediatric Obesity Weight Evaluation Registry, a prospective longitudinal study of 32 PWM programs, we included children (≤18 years; n = 6502) enrolled for a full year. We examined associations between retention (any follow-up visit) and patient and program characteristics using multivariable models with site-clustering random effects. Results: Sixty-seven percent of children had at least one follow-up visit, whereas 12% had four or more visits. Compared with non-Hispanic white children, non-Hispanic black children were less likely to have a follow-up visit [adjusted odds ratio (aOR) = 0.79], whereas Hispanic children (any race) were more likely (aOR = 1.22). Children with Medicaid had similar retention to those with private insurance. Retention did not differ by age, gender, weight status, or comorbidities, nor by program characteristics. Conclusions: Few characteristics of PWM programs are clearly associated with retention, indicating that a variety of formats can support continued treatment and likely reflect the influence of unmeasured characteristics. Clearer ways to identify and overcome barriers for individual patients will be needed to improve retention in PWM.

Comparing two different family-based childhood obesity treatment programmes in a medically underserved region: Effectiveness, engagement and implementation outcomes from a randomized controlled trial

BACKGROUND

Access to evidence- and family-based childhood obesity (FBCO) treatment interventions is a challenge, especially in underserved regions where childhood obesity disparities persist.

OBJECTIVE

Compare two 6-month FBCO treatment interventions, iChoose (high intensity, parent-child dyads) and Family Connections (low intensity, parents only), in one underserved US region.

METHODS

This unblinded, RCT reports on effectiveness and implementation outcomes. Eligibility included children ages 5-12 with BMI ≥85th percentile. Analyses included descriptive statistics and intention-to-treat Heckman treatment effect models.

RESULTS

Enrolled children (n = 139, mean age 10.1 ± 1.7 years, 30% with overweight, 70% with obesity, 45% black, 63% Medicaid) were randomly assigned to iChoose (n = 70) or Family Connections (n = 69). Retention rates were 63% for iChoose and 84% for Family Connection. Among children, 6-month BMI z-score changes were not statistically significant within iChoose [BMI z-score 0.03 (95% CI = -0.13, 0.19)] or Family Connections [BMI z-score 0.00 (95% CI = -0.16, 0.16)]. Likewise, parents' BMI changes were not statistically significant. No adverse events were reported. Both programmes were delivered with high fidelity (77%-100%). Engagement in core components was 25%-36% for iChoose and 52%-61% for Family Connections. Implementation costs per child with improved BMI z-score were $2841 for iChoose and $955 for Family Connections.

CONCLUSIONS

Neither intervention yielded significant improvements in child BMI z-score or parent BMI, yet both were delivered with high fidelity. Relative to iChoose, descriptive data indicated higher retention, better engagement, and lower costs for Family Connections-suggesting that a lower intensity and parent-focused programme may better fit the intended audience's context.

Promoting healthy lifestyle behaviours in youth: Findings from a novel intervention for children at risk of cardiovascular disease

Objectives

Obesity is the most prevalent risk factor for cardiovascular disease (CVD) in children. We developed a 2-year lifestyle intervention for youth at risk of CVD. We assessed changes in body mass index z-scores (zBMI) and key cardiometabolic risk factors, physical fitness, and capacity among those who completed the program.

Methods

The CIRCUIT program is a multidisciplinary lifestyle intervention for children aged 4 to 18 years at risk of CVD, based on a personalized plan to improve cardiometabolic outcomes by increasing physical activity and reducing sedentary behaviours. Both at baseline and 2-year follow-up, we measured zBMI, blood pressure z-scores (zBP), adiposity (%body and %trunk fat), fasting blood glucose and lipid profile, aerobic (VO2max) and anaerobic (5×5 m shuttle run test) fitness, and physical capacity indicators. Differences between baseline and follow-up were examined using paired t-tests (for age-sex standardized outcomes) and multivariable mixed effect models, adjusted for age and sex (for other outcomes).

Results

Among the 106 participants (53 males) who completed the 2-year program, mean age at baseline was 10.9 years (SD=3.2). After 2 years, zBMI and diastolic zBP decreased by 0.30SD (95% CI: −0.44; −0.16) and 0.43SD (95% CI: −0.65; −0.23), respectively. Participants improved %body and %trunk fat, lipid profile, aerobic and anaerobic fitness levels, and physical capacity (p&lt;0.02). No changes in systolic zBP nor in fasting plasma glucose were observed.

Conclusion

Our findings showed improved zBMI, cardiometabolic outcomes, physical fitness, and capacity among children at risk of CVD, suggesting that CIRCUIT is a promising intervention.

A telehealth intervention for ensuring continuity of care of pediatric obesity during the CoVid-19 lockdown in Italy

BACKGROUND AND AIMS

Restriction measures adopted during the Coronavirus Disease-19 pandemic favored unhealthy behaviors. Tele-health offered the opportunity to pursue alternative ways of chronic diseases management. This retrospective study sought to determine the effects of a telehealth counselling intervention during the lockdown to children and adolescents with obesity previously engaged in a family-based secondary care program in an outpatient clinic of South Italy.

METHODS AND RESULTS

117 out of 156 patients participated to the tele-health intervention. Participants underwent videocalls with each component of the multidisciplinary team to receive support in adopting adequate dietary habits and to practice exercise at home. They were included in a closed social group to watch age-adapted tutorials on healthy habits. 75 patients returned to the Center after the end of the lockdown, while only 7 patients who did not participate to the videocalls, took part to the follow-up. Body Mass Index and body composition were assessed in all these patients. BMI z score did not increase in both groups. However, a significant increase of fat mass was observed in the non-participating group (0.046), while the intervention group showed an increase of fat free mass (p < 0.000).

CONCLUSION

Notwithstanding the limited sample size, the telehealth intervention allowed the maintenance of baseline weight status in participants, with an increase of fat-free mass. As the CoViD-19 pandemic moves forward, the increasing adoption of the new technologies may help the continuity of care, even in pediatric obesity treatment.

Conservative Treatment for Childhood and Adolescent Obesity: Real World Follow-Up Profiling and Clinical Evolution in 1300 Patients

Background: Limited therapeutic tools and an overwhelming clinical demand are the major limiting factors in pediatric obesity management. The optimal protocol, environment, body mass index (BMI) change targets and duration of obesity-oriented interventions remain to be elucidated. Aims: We aimed to characterize the singularities of follow-up, anthropometric and metabolic evolution of a large cohort of pediatric patients with obesity in a specialized university hospital outpatient obesity unit. Patients and methods: Follow-up duration (up to seven years), attrition rate and anthropometric and metabolic evolution of 1300 children and adolescents with obesity were studied. An individualized analysis was conducted in patients attaining a high level of weight loss (over 1.5 BMI-SDS (standard deviation score) and/or 10% of initial weight; n = 252; 19.4%) as well as in "metabolically healthy" patients (n = 505; 38.8%). Results: Attrition rate was high during the early stages (11.2% prior to and 32.5% right after their initial metabolic evaluation). Mean follow-up time was 1.59 ± 1.60 years (7% of patients fulfilled 7 years). The highest BMI reduction occurred in the first year (-1.11 ± 0.89 SDS, p < 0.001 in 72.5% of patients). At the end of the follow-up, improvements in glucose and lipid metabolism parameters were observed (both p < 0.05), that were highest in patients with the greatest weight reduction (all p < 0.01), independent of the time spent to achieve weight loss. The pubertal growth spurt negatively correlated with obesity severity (r = -0.38; p < 0.01) but patients attaining adult height exceeded their predicted adult height (n = 308, +1.6 ± 5.4 cm; p < 0.001). "Metabolically healthy" patients, but with insulin resistance, had higher blood pressure, glucose, uric acid and triglyceride levels than those without insulin resistance (all p < 0.05). Preservation of the "metabolically healthy" status was associated with BMI improvement. Conclusions: Behavioral management of children with obesity can be effective and does not impair growth but is highly conditioned by high attrition. The best results regarding BMI reduction and metabolic improvement are achieved in the first year of intervention and can be preserved if follow-up is retained.

Waitlist management in a pediatric weight management clinic: implementing an orientation session

BACKGROUND

This study evaluates implementation of an orientation session to address a waitlist of more than 2000 referrals to a pediatric weight management clinic in the Mid-South United States.

METHODS

An hour-long group-based orientation to the pediatric weight management clinic was implemented to provide information about the structure and expectations of the clinic as well as education on healthy lifestyle recommendations. Families were contacted from the waitlist by telephone and invited to attend an orientation session prior to scheduling a clinic appointment.

RESULTS

Of 2251 patients contacted from the waitlist, 768 scheduled an orientation session, of which 264 (34 %) attended. Of the 264 orientation participants, 246 (93 %) scheduled a clinic appointment. Of those, 193 (79 %) completed a clinic visit. Waitlist times decreased from 297.8 ± 219.4 days prior to implementation of orientation sessions to 104.1 ± 219.4 days after.

CONCLUSIONS

Orientation has been an effective and efficient way to triage patient referrals while maximizing attendance in limited clinic slots for patients and families demonstrating interest and motivation. Elements of this approach are likely generalizable to other pediatric clinical settings that must strategically manage a large volume of patient referrals.

Protocol for the Rhode Island CORD 3.0 Study: Adapting, Testing, and Packaging the JOIN for ME Family-Based Childhood Obesity Program in Low-Income Communities

Background: Overweight and obesity in children is a public health crisis in the United States. Although evidence-based interventions have been developed, such programs are difficult to access. Dissemination of evidence-based pediatric weight management interventions (PWMIs) to families from diverse low-income communities is the primary objective of the CDC Childhood Obesity Research Demonstration (CORD) projects. Methods: The goal of the Rhode Island CORD 3.0 project is to adapt the evidence-based PWMI, JOIN for ME, for delivery among diverse families from low-income backgrounds and to test it in a hybrid effectiveness-implementation trial design in which the aims are to examine implementation and patient-centered outcomes. Children between the ages of 6 and 12 years with BMI ≥85th percentile and a caregiver will be recruited through two settings, a federally qualified health center, which serves as a patient-centered medical home, or low-income housing. Dyads will receive a remotely delivered group-based intervention that is 10 months in duration and includes 16 weekly sessions, followed by 4 biweekly and 4 monthly meetings. Assessments of child and caregiver weight status and child health-related quality of life will be conducted at baseline, and at 4 and 10 months after the start of intervention. Implementation outcomes assessing intervention acceptability, adoption, feasibility, fidelity, and penetration/reach will be collected to inform subsequent dissemination. Conclusions: If the adapted version of the JOIN for ME intervention can be successfully implemented and is shown to be effective, this project will provide a model for a scalable PWMI for families from low-income backgrounds. ClinicalTrials.gov no. NCT04647760.

Reactions to the U.S. Preventive Services Task Force guidelines for the management of adolescent obesity: A multi-informant qualitative approach

The U.S. Preventive Services Task Force (USPSTF) has set forth recommendations for clinicians to screen youth (6-18 years) for obesity. Those identified should be referred to comprehensive weight management programs consisting of at least 26 contact hours and focus on multiple targets of behaviour (ie, diet, physical activity, behaviour change). However, these recommendations are primarily based upon outcomes from randomized controlled trials and the feasibility of meeting these guidelines for adolescents in a clinical setting is unknown. The present study employed a multi-informant qualitative approach with adolescents, parents, and physicians, to identify and understand multiple perspectives on the feasibility and acceptability of implementing the USPSTF guidelines. In-depth interviews with seven adolescents, seven parents, and four physicians were analysed. Generally, participants viewed the guidelines positively but identified changes that may be necessary to increase the feasibility of adolescents engaging in programs that meet these guidelines. Participants also noted the importance of flexibility within programs, indicating that it would be difficult for many adolescents to participate in a program that was not tailored to their needs and resources. Future research should focus on adapting clinical weight management programs to meet both USPSTF guidelines and the needs of adolescents and their families.

Does Motivational Interviewing Improve the Weight Management Process in Adolescents? A Systematic Review and Meta-analysis

BACKGROUND

Due to the complex nature and high heterogeneity of motivational interviewing (MI) trials, available data on the effectiveness of these interventions on weight management in the early years of life is not yet conclusive. This study aimed to (1) evaluate the effectiveness of MI-based interventions on modifying obesity-related behaviors and consequently controlling weight in adolescents, and (2) determine characteristics of participants and interventions through sub-group analysis.

METHODS

Electronic databases, i.e., Medline, Elsevier, ISI, Cochrane Central Register of Controlled Trials (Clinical Trials), PsycINFO, and subject-related key journals were searched for randomized controlled trials that investigated the effect of MI-based interventions on weight management in overweight/obese adolescents. Primary outcomes were BMI, BMI Z-score, waist circumference, and fat percentage. Secondary outcomes were related behaviors (dietary intake and physical activity) and cognitive abilities (self-efficacy, self-regulation, self-control). Of the 3673 studies initially screened for eligibility, nineteen studies met the inclusion criteria and eighteen studies were entered in the meta-analysis. Meta-regression and sub-group analyses were conducted to control the high heterogeneity of studies. Sensitivity analysis has been conducted based on the Cochrane guidelines using the leave-one-out methods.

RESULTS

MI-based interventions did not affect on all primary outcomes, including BMI, BMI Z-score, waist circumference, and fat percentage; however, in terms of secondary outcomes, only sugary beverage intake was reduced in adolescents (SMD =  - 0.47, K = 3, I² = 26.2%). Physical activity and cognitive variables were not considered in the current analysis due to limited data and high heterogeneity in measurements and reports. In addition, findings of sensitivity results showed that MI could significantly reduce waist circumference among adolescents (SMD =  - 0.51, 95% CI - 0.91 to - 0.11). In terms of subgroup analysis, our results showed that various characteristics of participants (age, sex, weight status) and interventions (parental involvement, study duration, fidelity assessment, type of the control groups) could affect related primary and secondary outcomes among adolescents.

CONCLUSION

MI-based behavioral interventions had minor effects on reducing sugary beverage intake in all adolescents while a reduction in central obesity was noted predominantly among girls and those with complete participation. The current results indicate that the main characteristics influencing goal achievement in MI interventions are the age of participants, MI fidelity assessment, parental involvement, duration of interventions, and type of the control groups.

Nutritional Approach to Prevention and Treatment of Cardiovascular Disease in Childhood

Coronary Heart Disease (CHD) is a major mortality and morbidity cause in adulthood worldwide. The atherosclerotic process starts even before birth, progresses through childhood and, if not stopped, eventually leads to CHD. Therefore, it is important to start prevention from the earliest stages of life. CHD prevention can be performed at different interventional stages: primordial prevention is aimed at preventing risk factors, primary prevention is aimed at early identification and treatment of risk factors, secondary prevention is aimed at reducing the risk of further events in those patients who have already experienced a CHD event. In this context, CHD risk stratification is of utmost importance, in order to tailor the preventive and therapeutic approach. Nutritional intervention is the milestone treatment in pediatric patients at increased CHD risk. According to the Developmental Origin of Health and Disease theory, the origins of lifestyle-related disease is formed in the so called “first thousand days” from conception, when an insult, either positive or negative, can cause life-lasting consequences. Nutrition is a positive epigenetic factor: an adequate nutritional intervention in a developmental critical period can change the outcome from childhood into adulthood.

Executive Functioning, Depressive Symptoms, and Intervention Engagement in a Sample of Adolescents Enrolled in a Weight Management Program

Purpose: This study examines how baseline demographics, psychosocial characteristics, and intervention delivery predict engagement among adolescents with overweight and obesity seeking treatment. Methods: Data originates from a multisite randomized control trial evaluating the efficacy of an app-based weight loss intervention, compared with standard in-clinic model in adolescents with overweight and obesity. Participants were randomized to one of the three arms: (1) AppCoach, (2) AppAlone, or (3) Control. Demographic, executive functioning (EF), and depression questionnaires were completed at baseline. Percent engagement was compared within and between groups defined by demographics and depressive symptoms. Quantile regression was used to evaluate the association between age and EF on percent engagement. Results: Baseline demographics were not associated with engagement within or between groups. Neither baseline self-reported depressive symptoms (p = 0.244) nor deficits in EF (p = 0.34) were predictors of engagement. Univariate analysis found that the control arm had the highest engagement (83%) compared with AppCoach (63.5%) and AppAlone (22.5%, p = 0.02). Hispanic ethnicity was predictive of higher engagement in the control arm (p = 0.02). On multivariate quartile regression no other baseline characteristics were significant predictors of engagement. Conclusion: Baseline demographics and individual psychosocial characteristics were not related to engagement in this cohort. The intervention arm that required parental involvement resulted in the greatest engagement suggesting that family involvement may overshadow individual behavioral phenotype and thus promote better engagement. Further investigation is needed to understand how program delivery can be leveraged to optimize treatment engagement and outcomes in adolescence. Clinical Trial Registration number: NCT03500835.

Stay in treatment: Predicting dropout from pediatric weight management study protocol

INTRODUCTION

Childhood obesity is a serious public health concern. Multidisciplinary pediatric weight management programs have been deemed effective. However, effectiveness of these programs is impacted by attrition, limiting health benefits to children, and inefficiently utilizing scarce resources.

METHODS

We have developed a model (the Outcomes Forecasting System, OFS) that isolates variables associated with attrition from pediatric weight management, with the potential to forecast participant dropout. In Aim 1, we will increase the power and precision of the OFS and then validate the model through the consistent acquisition of key patient, family, and treatment data, from three different weight management sites. In Aim 2, external validity will be established through the application of the OFS at a fourth pediatric weight management program. Aim 3 will be a pilot clinical trial, incorporating an intervention built on the results of Aims 1 and 2 and utilizing the OFS to reduce attrition.

DISCUSSION

A greater understanding of the patient, family, and disease-specific factors that predict dropout from pediatric weight management can be utilized to prevent attrition. The goal of the current study is to refine the OFS to a level of precision and efficiency to be a valuable tool to any weight management program. By identifying the most pertinent factors driving attrition across weight management sites, new avenues for treatment will be identified. This study will result in a valuable forecasting tool that will be applicable for diverse programs and populations, decrease program costs, and improve patient retention, adherence, and outcomes.

CLINICALTRIALSGOV IDENTIFIER

NCT04364282.

Current Intervention Treatments for Food Addiction: A Systematic Review

Research on the concept of food addiction (FA) has steadily grown and, based on a widely used self-report, FA is estimated to affect between 16-20% of the adult population. However, there are few interventions available for people with self-reported FA, and their efficacy is unclear. The primary aim of the review was to examine the efficacy of different interventions, including behavioural/lifestyle, medication and surgical approaches, for reducing symptoms and/or changing diagnosis of FA among adolescents and adults. A secondary aim was to examine the influence of sex as a moderator of intervention effects. A systematic search was performed from 2008-2020 to identify studies that used the YFAS to assess the effectiveness of interventions on FA. Nine studies were identified (n = 7 adults, n = 2 adolescents) including a total of 812 participants (range 22-256) with an average of 69% females per study. The types of interventions included medications (n = 3), lifestyle modification (n = 3), surgical (n = 2) and behavioural (n = 1), with FA being assessed as a secondary outcome in all studies. Five studies in adults reported a significant reduction in FA symptoms or diagnosis from pre to post-intervention, two when compared to a control group and three in the intervention group only. Efficacious interventions included: medication (combination of naltrexone and bupropion, as well as pexacerfont), bariatric surgery and lifestyle modification. No significant changes in FA were reported in adolescent studies. Given few studies were identified by the review, there is insufficient evidence to provide clear recommendations for practice; however, some interventions show potential for reducing self-reported FA outcomes in adults. Future research should explore the longer-term efficacy of interventions and the effectiveness of treatments with sufficient sample sizes.

Professional stakeholder's views of adolescent weight management programmes: a qualitative study

OBJECTIVE

Family-based multi-component weight management programmes are recommended for adolescents with obesity in England and Wales, however, these programmes suffer from poor uptake and high attrition rates. This study aimed to gather the views of professional stakeholders in a UK weight management programme to identify potential areas to target to improve engagement and success for such programmes.

RESULTS

Semi-structured interviews were conducted with those involved in the commissioning, referral, coordination or delivery of a weight management programme (n = 11). Interviews were analysed using qualitative content analysis. Three main categories developed: professional support, tailoring and intervention content. Participants recognised the importance of support from experienced professionals, as well as family and peers. There was agreement that longer-term support was needed for adolescents with obesity; suggestions included integrating follow-up support with schools and leisure services. Emotional and psychological support must be prioritised. Having a variety of delivery modes, such as group and one to one, particularly in the home environment, were recommended. Stakeholders agreed that weight management programmes for adolescents need to be more proactive at incorporating technology. By acting on the views of those that work closely with adolescents, engagement with weight management programmes may be improved.

Strategies to reduce attrition in managing paediatric obesity: A systematic review

OBJECTIVE

To conduct a systematic review of the literature for strategies designed to reduce attrition in managing paediatric obesity.

METHODS

We searched Ovid Medline (1946 to May 6, 2020), Ovid Embase (1974 to May 6, 2020), EBSCO CINAHL (inception to May 6, 2020), Elsevier Scopus (inception to April 14, 2020), and ProQuest Dissertations & Theses (inception to April 14, 2020). Reports were eligible if they included any obesity management intervention, included 2 to 18 year olds with overweight or obesity (or if the mean age of participants fell within this age range), were in English, included experimental study designs, and had attrition reduction as a main outcome. Two team members screened studies, abstracted data, and appraised study quality.

RESULTS

Our search yielded 5,415 original reports; six met inclusion criteria. In three studies, orientation sessions (n = 2) and motivational interviewing (MI) (n = 1) were used as attrition-reduction strategies before treatment enrollment; in three others, text messaging (n = 2) and MI (n = 1) supplemented existing obesity management interventions. Attrition-reduction strategies led to decreased attrition in two studies, increased in one, and no difference in three. For the two strategies that reduced attrition, (a) pre-treatment orientation and (b) text messaging between children and intervention providers were beneficial. The quality of the six included studies varied (good [n = 4]; poor [n = 2]).

CONCLUSION

Some evidence suggests that attrition can be reduced. The heterogeneity of approaches applied and small number of studies included highlight the need for well-designed, experimental research to test the efficacy and effectiveness of strategies to reduce attrition in managing paediatric obesity.

A Pilot Feasibility Study of Interpersonal Psychotherapy for the Prevention of Excess Weight Gain Among Adolescent Military-dependent Girls

INTRODUCTION

Adolescent military-dependents face unique psychosocial stressors due to their parents' careers, suggesting they may be particularly vulnerable to excess weight gain and symptoms of depression and anxiety. Despite these risk factors, there is a lack of tested preventative interventions for these youths. Given the transient nature of military family deployments, research may be hindered due to difficulty in collecting long-term prospective outcome data, particularly measured height and weight. The primary aim of this study was to examine the feasibility and acceptability of collecting body mass index (BMI, kg/m2) outcome data up to 2 years following a randomized controlled pilot trial of an adapted interpersonal psychotherapy (IPT) program aimed at preventing excess weight gain and improving psychological functioning for adolescent military-dependents. In exploratory analyses, patterns in body composition over time were examined.

MATERIALS AND METHODS

Twenty-seven adolescent military-dependent girls (baseline: Mage: 14.4 ± 1.6 years; MBMI: 30.7 ± 4.9 kg/m2; MBMI-z: 1.9 ± 0.4) participated in this study. After a baseline assessment, utilizing a computerized program to create a randomization string, girls were assigned to either an IPT or a health education (HE) program. Participants completed three follow-up visits (posttreatment, 1-year follow-up, and 2-year follow-up). Girls completed a Treatment Acceptability Questionnaire at posttreatment; at all time points, height and fasting weight were collected. For the primary aim, Fisher's exact tests examined the rate of obtained follow-up data and lost to follow-up status between the two groups, Mann-Whitney U tests examined the session attendance between groups, and treatment acceptability ratings were compared between the two groups at posttreatment using an independent samples t-test. For the exploratory aim, one-way analyses of covariance (ANCOVAs) examined the group differences in BMI at each time point, adjusting for baseline values, and paired samples t-tests examined the within-group differences at each time point relative to baseline. Using imputed data in the full intent-to-treat sample, mixed model ANCOVAs were conducted to examine the group differences over time.

RESULTS

Across both groups, girls attended an average of 72.0% of sessions. At least partial data were collected at posttreatment, 1-year follow-up, and 2-year follow-up for 96.3%, 85.2%, and 74.1% of the participants, respectively. There were no significant group differences in follow-up data collection rates, follow-up status, number of sessions attended, or treatment acceptability. BMI-z stabilized across groups, and there were no group differences in BMI-z. In adjusted ANCOVA models with imputed data, no significant group-by-time effects emerged.

CONCLUSIONS

For this randomized controlled prevention trial, long-term outcome data collection of measured BMI was possible in adolescent military-dependents and IPT was an acceptable and feasible intervention. An adequately powered trial is required to assess the efficacy of this intervention among military-dependents for obesity prevention and improvements in BMI.

Assets and Challenges to Recruiting and Engaging Families in a Childhood Obesity Treatment Research Trial: Insights From Academic Partners, Community Partners, and Study Participants

Background: There is need for the childhood obesity treatment literature to identify effective recruitment and engagement strategies for rural communities that are more likely to lack supportive infrastructure for healthy lifestyles and clinical research relative to their urban counterparts. This community case study examines recruitment and engagement strategies from a comparative effectiveness research (CER) trial of two family-based childhood obesity (FBCO) treatment interventions conducted in a medically underserved, rural region. Guided by a Community Based Participatory Research (CBPR) and systems-based approach, the primary aim was to analyze interviews from academic partners, community partners, and parent study participants for recruitment and engagement assets, challenges, and lessons learned. Methods: Over the 3-year lifespan of the study, researchers conducted 288 interviews with Community Advisory Board members (n = 14), Parent Advisory Team members (n = 7), and study participants (n = 100). Using an inductive-deductive approach, interviews were broadly coded for recruitment and engagement assets, challenges, and recommendations; analyzed for descriptive sub-coding; and organized into stakeholder/organization and participant level themes. Codes were analyzed aggregately across time and examined for differences among stakeholders and parent study participants. Results: Adherence to CBPR principles and development of strong community partnerships facilitated recruitment and engagement; however, variability in recruitment and engagement success impacted partner confidence, threatened outcome validity, and required additional resources. Specifically, assets and challenges emerged around eight key needs. Three were at the stakeholder/organization level: (1) readiness of stakeholders to conduct CBPR research, (2) development of sustainable referral protocols, and (3) development of participant engagement systems. The remaining five were at the participant level: (1) comfort and trust with research, (2) awareness and understanding of the study, (3) intervention accessibility, (4) intervention acceptability, and (5) target population readiness. Future recommendations included conducting readiness assessments and awareness campaigns, piloting and evaluating recruitment and engagement strategies, identifying participant barriers to engagement and finding a priori solutions, and fostering stakeholder leadership to develop sustainable protocols. Conclusion: Collective findings from multiple perspectives demonstrate the need for multi-leveled approaches focusing on infrastructure supports and strategies to improve stakeholder and participant awareness of, and capacity for, recruiting and engaging medically underserved, rural families in a FBCO CER trial.