Efficacy of very low-energy diet programs for weight loss: A systematic review with meta-analysis of intervention studies in children and adolescents with obesity

Symptoms of Depression, Eating Disorders, and Binge Eating in Adolescents With Obesity: The Fast Track to Health Randomized Clinical Trial

Importance

Depression and eating disorders are heightened for adolescents with obesity. Clinical reviews alongside self-report questionnaires are important to ensure appropriate intervention.

Objective

To evaluate changes in self-report symptoms of depression, eating disorders, and binge eating in adolescents with obesity during the Fast Track to Health trial.

Design, Setting, and Participants

This was a randomized clinical trial conducted from 2018 to 2023. It was a multisite trial conducted at children's hospitals in Sydney, New South Wales, and Melbourne, Victoria, Australia, and included adolescents (13-17 years) with obesity (defined as adult equivalent body mass index ≥30; calculated as weight in kilograms divided by height in meters squared) and 1 or more related complications.

Interventions

Duration was 52 weeks including a very low energy diet for 4 weeks followed by intermittent energy restriction (IER) or continuous energy restriction (CER).

Main Outcomes and Measures

Self-report symptoms of depression (Center for Epidemiologic Studies Depression Scale-Revised 10-Item Version for Adolescents [CESDR-10]; scores 0-30), eating disorders (Eating Disorder Examination Questionnaire [EDE-Q]; scores 0-6), and binge eating (Binge Eating Scale [BES]; scores 0-46) were assessed. Adolescents were screened for depression and eating disorders (weeks 0, 4, 16, and 52) and monitored for the onset of new symptoms of disordered eating during dietetic consults.

Results

Of 141 adolescents (median [IQR] age, 14.8 [12.9-17.9] years; 71 male [50.4%]) enrolled, median baseline EDE-Q score was 2.28 (IQR, 1.43-3.14), median baseline CESDR-10 score was 9.00 (IQR, 4.00-14.50), and median baseline BES score was 11.00 (IQR, 5.00-17.00). There were no differences between groups for change in CESDR-10 (mean difference at week 52, 0.75; 95% CI, -1.86 to 3.37), EDE-Q (mean difference at week 52, 0.02; 95% CI, -0.41 to 0.45), or BES (mean difference at week 52, -2.91; 95% CI, -5.87 to 0.05). The within-group reductions at week 4 were maintained at week 52, for CESDR-10 and EDE-Q, indicating reduced symptoms of depression and eating disorders. Within-group reductions on the BES were maintained in the IER group only. Seventeen adolescents (12.1%) required support or referral for depression and/or disordered eating, including 7 (5%; 5 IER, 2 CER) adolescents who experienced the onset or reemergence of symptoms during the intervention.

Conclusions and Relevance

Results suggest that many treatment-seeking adolescents with obesity self-reported symptoms of depression and eating disorders. Although symptoms reduced for most, some required additional support. Obesity treatment is an opportune time to screen and monitor for depression and disordered eating.

Trial Registration

Australian New Zealand Clinical Trials Registry: ACTRN12617001630303.

Efficacy, Safety and Acceptability of a Very-Low-Energy Diet in Adolescents with Obesity: A Fast Track to Health Sub-Study

The aim of this study was to determine the efficacy, safety and acceptability of a 4-week very-low-energy diet (VLED) program for adolescents with obesity. Adolescents (13-17 years) with obesity and ≥1 obesity-related complication were Fast Track to Health 52-week randomized controlled trial participants. Adolescents undertook a 4-week micronutrient-complete VLED (800 kcal/day), with weekly dietitian support. Anthropometric data were recorded at baseline and week-4 and side-effects at day 3-4, week-1, -2, -3 and -4. Adolescents completed an acceptability survey at week-4. A total of 134 adolescents (14.9 ± 1.2 years, 50% male) had a 5.5 ± 2.9 kg (p < 0.001) mean weight loss at week-4: 95% experienced ≥1 and 70% experienced ≥3 side-effects during the VLED program, especially during the first week. Hunger, fatigue, headache, irritability, loose stools, constipation and nausea were most common. Reporting more side-effects at day 3-4 correlated with greater weight loss at week-4 (r = -0.188, p = 0.03). Adolescents reported 'losing weight' (34%) and 'prescriptive structure' (28%) as the most positive aspects of VLED, while 'restrictive nature' (45%) and 'meal replacement taste' (20%) were least liked. A dietitian-monitored short-term VLED can be implemented safely and is acceptable for many adolescents seeking weight loss, despite frequent side-effects. Investigating predictors of acceptability and effectiveness could determine adolescents most suited to VLED programs.

The latest evidence and clinical guidelines for use of meal replacements in very-low-calorie diets or low-calorie diets for the treatment of obesity

Obesity is a complex chronic disease with increasing prevalence across the globe. Medical nutrition therapy (MNT) is an important component of obesity treatment, and low-calorie diets (LCDs) and very-low-calorie diets (VLCDs) are part of the MNT toolbox. This narrative review focuses on the latest evidence and clinical guidelines regarding the use and impact of meal replacements (MRs) as part of LCDs/VLCDs for the treatment of obesity and some associated complications. MRs can be used in conjunction with food as partial diet replacement (PDR) or can be used exclusively to serve as the sole source of dietary energy (total diet replacement [TDR]). Use of MR may be associated with better control of cravings and hunger typically observed during reduced calorie intake through effects of ketosis or stimuli narrowing, although the exact mechanisms for these effects remain unclear. Several clinical guidelines have endorsed the use of MRs as a part of MNT for obesity, primarily based on evidence that shows an average weight reduction of ~10 kg or more with TDR over at least 12 months in large, randomized controlled trials. When compared to usual care controls, these effects are 6-8 kg greater, and when compared to food-based diets, the effects are nearly twice the effect of a food-based diet. MR-based diets have been found to be safe and associated with improvements in quality of life. These diets are also effective for improving key cardiometabolic health outcomes, including dysglycaemia, blood pressure, lipids, and metabolic associated fatty liver. The effectiveness, safety, and associated health improvement makes MRs use a valuable strategy for several higher risk clinical scenarios where weight reduction is indicated.

Eating Disorders In weight-related Therapy (EDIT) Collaboration: rationale and study design

The cornerstone of obesity treatment is behavioural weight management, resulting in significant improvements in cardio-metabolic and psychosocial health. However, there is ongoing concern that dietary interventions used for weight management may precipitate the development of eating disorders. Systematic reviews demonstrate that, while for most participants medically supervised obesity treatment improves risk scores related to eating disorders, a subset of people who undergo obesity treatment may have poor outcomes for eating disorders. This review summarises the background and rationale for the formation of the Eating Disorders In weight-related Therapy (EDIT) Collaboration. The EDIT Collaboration will explore the complex risk factor interactions that precede changes to eating disorder risk following weight management. In this review, we also outline the programme of work and design of studies for the EDIT Collaboration, including expected knowledge gains. The EDIT studies explore risk factors and the interactions between them using individual-level data from international weight management trials. Combining all available data on eating disorder risk from weight management trials will allow sufficient sample size to interrogate our hypothesis: that individuals undertaking weight management interventions will vary in their eating disorder risk profile, on the basis of personal characteristics and intervention strategies available to them. The collaboration includes the integration of health consumers in project development and translation. An important knowledge gain from this project is a comprehensive understanding of the impact of weight management interventions on eating disorder risk.

Current insights and emerging trends in early-onset type 2 diabetes

Type 2 diabetes diagnosed in childhood or early adulthood is termed early-onset type 2 diabetes. Cases of early-onset type 2 diabetes are increasing rapidly globally, alongside rising obesity. Compared with a diagnosis later in life, an earlier-onset diagnosis carries an unexplained excess risk of microvascular complications, adverse cardiovascular outcomes, and earlier death. Women with early-onset type 2 diabetes also have a higher risk of adverse pregnancy outcomes. The high burden of complications renders individuals with early-onset type 2 diabetes at future risk of multimorbidity and interventions to reverse these concerning trends should be a priority. Within the early-onset cohort, disease pathophysiology and interventions have been better studied in paediatric-onset (<19 years) type 2 diabetes compared to adults; however, young adults aged 19-39 years (a larger number proportionally) are not well characterised and are also invisible in the current evidence base supporting management, which is derived from trials in later-onset type 2 diabetes. Young adults with type 2 diabetes face challenges in self-management that older individuals are less likely to experience (being in education or of working age, higher diabetes distress, and possible obesity-related stigma and diabetes-related stigma). There is a major research gap as to the optimal strategies to deploy in managing type 2 diabetes in adolescents and young adults, given that current models of care appear to not work as well in this age group. In the face of manifold risk factors (obesity, female sex, social deprivation, non-White European ethnicity, and genetic risk factors) prevention strategies with tailored lifestyle interventions, where needed, are likely to have greater success, but more evidence is needed. In this Review, we draw on evidence from both adolescents and young adults to provide a contemporary update on the current insights and emerging trends in early-onset type 2 diabetes.

The Effectiveness of Nutritional Strategies in the Treatment and Management of Obesity: A Systematic Review

Obesity, a condition primarily resulting from positive energy balance, has become a significant global health concern. Numerous studies have demonstrated that obesity is a major risk factor for various illnesses, including different types of cancer, coronary heart disease, sleep apnea, CV stroke, type II diabetes mellitus, etc. To effectively address this issue, prevention and treatment approaches to manage body weight are crucial. There are several evidence-based approaches available for the treatment and management of obesity, taking into account factors such as body mass index classification, individual weight history, and existing comorbidities. To facilitate successful obesity treatment and management, there are pragmatic approaches and tools available, including the reduction of energy density, portion control, and diet quality enhancement. These approaches encompass the use of medications, lifestyle interventions, bariatric surgery, and formula diets. Regardless of the specific method employed, behavior change, reduction of energy intake, and increased energy expenditure are integral components for successful treatment and management of obesity. These measures allow patients to personalize and customize their dietary patterns, leading to effective and sustainable weight reduction. Incorporating physical activities and self-monitoring of individual diets are effective techniques for promoting behavior change in obesity and weight management. The main objective of this systematic review is to evaluate the effectiveness of dietary/nutritional interventions in the treatment and management of obesity through provision of valuable insights into the effectiveness of such nutritional strategies. To attain this, a comprehensive analysis of various dietary approaches and their impacts on weight will be conducted.

The treatment of obesity in children and adolescents: consensus position statement of the Italian society of pediatric endocrinology and diabetology, Italian Society of Pediatrics and Italian Society of Pediatric Surgery

This Position Statement updates the different components of the therapy of obesity (lifestyle intervention, drugs, and surgery) in children and adolescents, previously reported in the consensus position statement on pediatric obesity of the Italian Society of Pediatric Endocrinology and Diabetology and the Italian Society of Pediatrics. Lifestyle intervention is the first step of treatment. In children older than 12 years, pharmacotherapy is the second step, and bariatric surgery is the third one, in selected cases. Novelties are available in the field of the medical treatment of obesity. In particular, new drugs demonstrated their efficacy and safety and have been approved in adolescents. Moreover, several randomized control trials with other drugs are in process and it is likely that some of them will become available in the future. The increase of the portfolio of treatment options for obesity in children and adolescents is promising for a more effective treatment of this disorder.

Nutritional Approaches in Children with Overweight or Obesity and Hepatic Steatosis

Childhood obesity is a global public health problem. Worldwide, 41 million children under 5 years and 340 million children and adolescents between 5 and 19 years are overweight. In addition, the recent COVID-19 epidemic has further amplified this social phenomenon. Obesity is a condition associated with various comorbidities, such as nonalcoholic fatty liver disease (NAFLD). The pathophysiology of NAFLD in obesity is intricate and involves the interaction and dysregulation of several mechanisms, such as insulin resistance, cytokine signaling, and alteration of the gut microbiota. NAFLD is defined as the presence of hepatic steatosis in more than 5% of hepatocytes, evaluated by histological analysis. It can evolve from hepatic steatosis to steatohepatitis, fibrosis, cirrhosis, hepatocellular carcinoma, and end-stage liver failure. Body weight reduction through lifestyle modification remains the first-line intervention for the management of pediatric NAFLD. Indeed, studies suggest that diets low in fat and sugar and conversely rich in dietary fibers promote the improvement of metabolic parameters. This review aims to evaluate the existing relationship between obesity and NAFLD in the pediatric population and to assess the dietary patterns and nutritional supplementations that can be recommended to prevent and manage obesity and its comorbidities.

Child and adolescent obesity

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

Laparoscopic sleeve gastrectomy for obesity treatment in adolescents and young adults: a systematic review and meta-analysis

BACKGROUND

The incidence of obesity has been increasing in younger population, posing a significant impact on adolescents' life and health care system worldwide.

METHODS

We critically analyzed the existing literature on the use of laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity. We performed an in-depth evaluation of 37 studies and analyzed the effect of LSG in 2300 patients, aged ≤ 22 years.

RESULTS

Mean body mass index (BMI) loss after LSG was 17.81 kg/m2. Gastroesophageal reflux was the most common complication. Most of the patients showed remission of comorbidities including hypertension, diabetes, and obstructive sleep apnea after LSG.

CONCLUSIONS

These findings suggest that surgical intervention is highly beneficial for reducing BMI in appropriately selected adolescents and young adults suffering from obesity and comorbidities such as life-threatening obstructive sleep apnea.

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

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

The Effect of Healthy Lifestyle Strategies on the Management of Insulin Resistance in Children and Adolescents with Obesity: A Narrative Review

Childhood obesity is characterized by an increased risk of several metabolic derangements including insulin resistance (IR). The strongest recommendations to prevent obesity and related complications are a balanced and adequate diet and practicing physical activity from early childhood. In this review, we propose to present the effects of healthy lifestyle strategies, including physical exercise and dietary approaches, on the management of IR and related metabolic derangements. All types of exercise (aerobic, resistance and combined training) effectively reduce IR in pediatric patients with obesity; it seems that aerobic and combined training stimulate greater improvements in IR compared to resistance training. Balanced normocaloric or hypocaloric dietary approaches are also valid strategies to address IR; it is not possible to assess the long-term impact of varying macronutrients on cardiometabolic risk. The glycemic index/load evaluation is a useful dietary approach to glucose metabolism control. Similarly, they should adopt the principle of the Mediterranean diet. Randomized studies with longer monitoring are needed to define the benefits of nutritional supplementation on IR. Considering that healthy style acquisition could track to later ages, programs of healthy lifestyle starting with children offer a better preventive strategy to preserve metabolic control and children's health.

Guidelines for treating child and adolescent obesity: A systematic review

Obesity is a chronic disease that compromises the physical and mental health of an increasing proportion of children globally. In high-income countries, prevalence of paediatric obesity is increasing faster in those from marginalised populations such as low-income households, suggesting the disease as one that is largely systemic. Appropriate treatment should be prioritised in these settings to prevent the development of complications and co-morbidities and manage those that already exist. An array of clinical practice guidelines are available for managing overweight and obesity in children and adolescents, but no systematic review has yet compared their quality or synthesised their recommendations. We aimed to narratively review clinical practice guidelines published in English for treating child and adolescent obesity, to identify the highest quality guidelines, and assess similarities, conflicts, and gaps in recommendations. We systematically searched academic databases and grey literature for guidelines published. We used the AGREE II tool to assess the quality, and identified nine high quality guidelines for inclusion in a narrative review of recommendations. Guidelines predominantly recommended the delivery of multi-component behaviour-change interventions aimed at improving nutrition and physical activity. Treatment outcomes were generally focussed on weight, with less emphasis on managing complications or improving quality-of-life. There was no evidence-based consensus on the best mode of delivery, setting, or treatment format. The guidelines rarely included recommendations for addressing the practical or social barriers to behaviour change, such as cooking skills or supervised physical activity. There is insufficient evidence to evaluate pharmaceutical and surgical interventions in children, and these were generally not recommended. It should be noted that this review addressed documents published in English only, and therefore the included guidelines were applicable predominantly to high-resource settings.

Translation and Modification of a Mindful Eating Questionnaire for Children Assisted by Item Response Theory in Chinese Children and Adolescents

Mindful eating has gained attention in studies on healthy eating. However, measurement of it is scarce, particularly in pediatrics. This study aimed to translate and modify the 12-item Mindful Eating Questionnaire for Children (MEQ-C) using techniques based on both classical test theory (ICC) and item response theory (IRT) in Chinese children and adolescents. Of the 426 participants enrolled and randomly grouped, the test (n = 223) and validation (n = 203) subsamples were well-matched in age, gender, body mass index z score (BMIz), and waist to height ratio (WHtR) (p > 0.556). Three items were eliminated due to deviating from the mindful eating concept (content validity index < 0.71) and presenting as an independent dimension in parallel analysis, or yielding a poor distribution (−4.331 < b < −0.111). The final 5-item Mindless Eating and 4-item Awareness subscales were identified with sound Cronbach’s α of 0.802 and 0.779, respectively. The remaining items functioned well (a > 1, −3 < b < 3), and the Mindless Eating subscale was accurate for the low-to-medium range (−2 to 0) of the mindful eating measure. The Awareness one was reliable for the relatively high range (0 to 2). Participants’ mindful eating characteristics should be taken into consideration in practice.

Effects of Different Doses of Exercise on Inflammation Markers Among Adolescents With Overweight/Obesity: HEPAFIT Study

PROPOSE

Obesity-related metabolic risk factors in adolescents who are overweight/obese may be associated with systemic low-grade inflammation; therefore, we investigated whether 6 months of exercise training altered markers of inflammation.

METHODS

Secondary analyses of a randomized controlled exercise-based intervention trial (September 2017-December 2018). Adolescents aged 11 to 17 years (Tanner stage II-V), 70% girls, with a body mass index z-score at or above the 85th percentile, and/or with excess of adiposity (body fat ≥ 30%). The participants were randomly assigned to the following 4 groups for 6 months: (1) standard physical education lessons, as a control (CTRL); (2) high-intensity physical education class (HIPE); (3) low-to-moderate intensity physical education class (LIPE); (4) a combined group (PLUS). Inflammatory markers and immune molecules including chemokines, cytokines, and growth factors (n = 65 biomarkers) were determined by cytokine antibody array.

RESULTS

Of the 120 randomly assigned participants, 95 were included in the analysis. Considering these 22 proteins, the LIPE group shows statistical significance in 9 proteins with log-fold change (logFC) and P < 0.05 (in BLC, eotaxin, fibroblast growth factor-6 [FGF-6], GCP-2, I-309, IGFBP-4, MCP-4, NAP-2, and PARC), followed by the PLUS group in 9 proteins (BLC, pro-epidermal growth factor, eotaxin, FGF-6, MCP-4, NAP-2, osteopontin, PARC, and RANTES), the HIPE group in 7 proteins (FGF-4, FGF-7, GCP-2, IGF-1, IGFBP-1, IGFBP-4, and MIP-1 delta), and the CTRL group in 6 proteins (FGF-4, IP-10, Leptin, MCP-1, MIG, and MIP-1 delta). However, subanalysis performed to detect differentially expressed proteins at baseline and after intervention, with significance at an adjusted P value ≤ 0.05 and absolute log fold-change (logFC) ≥ 1.0, showed 3 downregulated proteins in the LIPE group (BLC(logFC) = 1.27, eotaxin(logFC) = 1.18, and MCP-4(logFC) = 1.14), and 4 proteins in the HIPE group (BLC(logFC) = 1.45, FGF-6(logFC) = 1.20, MCP-4(logFC) = 1.50, and PARC(logFC) = 1.33), supporting that the changes we observed in the exercise groups were not time-related changes but occurred in response to exercise.

CONCLUSIONS

Implementing a 6-month physical exercise program in overweight/obese adolescents, based on LIPE and PLUS groups, significantly change several circulating inflammatory levels. Interventions involving supervised physical exercise may reduce the associated effects of systemic low-grade inflammation, thus preventing the development of obesity-related metabolic diseases in adolescents with overweight/obesity.

Management of type 2 diabetes in young adults aged 18-30 years: ADS/ADEA/APEG consensus statement

INTRODUCTION

Type 2 diabetes in young adults (nominally, 18-30 years of age) is a more aggressive condition than that seen in older age, with a greater risk of major morbidity and early mortality. This first Australian consensus statement on the management of type 2 diabetes in young adults considers areas where existing type 2 diabetes guidance, directed mainly towards older adults, may not be appropriate or relevant for the young adult population. Where applicable, recommendations are harmonised with current national guidance for type 2 diabetes in children and adolescents (aged < 18 years). The full statement is available at https://www.diabetessociety.com.au, https://www.adea.com.au and https://www.apeg.org.au.

MAIN RECOMMENDATIONS

Advice is provided on important aspects of care including screening, diabetes type, psychological care, lifestyle, glycaemic targets, pharmacological agents, cardiovascular disease risk management, comorbidity assessment, contraception and pregnancy planning, and patient-centred education. Special considerations for Aboriginal and Torres Strait Islander Australians are highlighted separately.

CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT

Management recommendations for young adults, which differ from those for adults, include: ▪screening for diabetes in young adults with overweight or obesity and additional risk factors, including in utero exposure to type 2 diabetes or gestational diabetes mellitus; ▪more stringent glucose targets (glycated haemoglobin ≤ 6.5% [≤ 48 mmol/mol]); ▪in the context of obesity or higher cardio-renal risk, glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter 2 inhibitors are preferred second line agents; ▪β-cell decline is more rapid, so frequent review, early treatment intensification and avoidance of therapeutic inertia are indicated; ▪a blood pressure target of < 130/80 mmHg, as the adult target of ≤ 140/90 mmHg is too high; ▪absolute cardiovascular disease risk calculators are not likely to be accurate in this age group; early statin use should therefore be considered; and ▪a multidisciplinary model of care including an endocrinologist and a certified diabetes educator.

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

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

Dietary Counseling Aimed at Reducing Sugar Intake Yields the Greatest Improvement in Management of Weight and Metabolic Dysfunction in Children with Obesity

Pediatric obesity is a significant public health problem, the negative outcomes of which will challenge individual well-being and societal resources for decades to come. The objective of this study was to determine the effects of dietary counseling on weight management and metabolic abnormalities in children with obesity. One hundred and sixty-five patients aged 2−18 years old were studied over a two and a half year period. Data collected included demographic information, anthropometric assessment, laboratory measurements, and self-reported eating behaviors. Dietary counseling was provided at each visit. The data was analyzed from the first and last visits and the subjects were retrospectively divided into responders and non-responders based on a decrease in their BMI. After receiving dietary guidance, BMI decreased in 44% of the children, and these participants were classified as responders (BMI-R; n = 72). However, BMI did not improve in 56% of the participants, and these were classified as non-responders (BMI-NR; n = 93). At the initial visit, anthropometric measurements and dietary habits were similar between the groups. At the time of the last visit, mean change in BMI was −1.47 (SD 1.31) for BMI-R and +2.40 (SD 9.79) for BMI-NR. Analysis of food intake revealed that BMI-R significantly improved their dietary habits (p = 0.002) by reducing the intake of sugar-sweetened beverages (p = 0.019), processed foods (p = 0.002), sweets (p < 0.001), and unhealthy snacks (p = 0.009), as compared with BMI-NR. There was no change in the intake of second helpings, portion sizes, skipping meals, frequency of meals eaten at school, condiment use, intake of fruits and vegetables and consumption of whole grains between the groups. BMI-R also achieved an improvement in fasted glucose (p = 0.021), triglycerides (p < 0.001), and total cholesterol (p = 0.023), as compared to BMI-NR. In conclusion, children with obesity who were able to decrease their BMI implemented a significant reduction in consumption of foods with high sugar content. Focusing on reducing sugar intake may yield the biggest impact in terms of weight management and the improvement of metabolic abnormalities.

Development and Reliability Testing of a Nutrition Knowledge Questionnaire for Australian Children (the CNK-AU)

OBJECTIVE

To adapt and test an existing questionnaire to assess Australian children's level of nutrition knowledge.

DESIGN

The child nutrition knowledge questionnaire for Australian children consists of 8 nutrition-related categories: healthy choices, portion and serving sizes, balanced meals, nutrition labels, nutrient functions, and food sources, safety, and categories. Participants completed the questionnaire at 2 time points, with 1 week in between.

SETTING

The questionnaire was completed online in a primary school classroom using an Android tablet.

PARTICIPANTS

Fifth- and sixth-year students (n = 94; aged 10.9 years; SD, 0.76) at a primary school in New South Wales, Australia.

VARIABLES MEASURED

Item difficulty, item discrimination, and reliability.

ANALYSIS

Item analysis, interrater reliability, and test-retests.

RESULTS

The intrarater reliability per item between the first visit and 1 week later was moderate to substantial for the majority of items (mean κ = 0.50; SD, 0.21). Test-retest found a significant correlation for total score (r = 0.756), with all categories except portion and serving sizes showing significant correlations above r = 0.502.

CONCLUSIONS AND IMPLICATIONS

The child nutrition knowledge questionnaire for Australian children has the potential to be a reliable and practical questionnaire for measuring Australian children's nutrition knowledge. The questionnaire may be useful for future work evaluating the effectiveness of nutrition education interventions and would potentially be adapted to other cultures.

Treatment of Pediatric Overweight and Obesity: Position of the Academy of Nutrition and Dietetics Based on an Umbrella Review of Systematic Reviews

This Academy of Nutrition and Dietetics Position Paper describes current evidence on multi-component interventions with nutrition to treat pediatric overweight and obesity and discusses implications for RDNs. An umbrella review of eight systematic reviews provides evidence that multi-component interventions that include nutrition improve body mass index z-scores in all ages and in a variety of settings. More evidence is needed regarding appropriate body mass index measures to track weight and health status changes in children and adolescents with overweight and obesity. Current evidence indicates that multi-component interventions that include nutrition do not negatively impact psychosocial outcomes, but research on long-term outcomes is needed. Evolving technology and societal circumstances have created opportunities to provide innovative, collaborative, and engaging interventions through telehealth. RDNs specializing in pediatric overweight and obesity treatment play a crucial role in providing a wide range of evidence-based interventions in a variety of settings. These skills are important for tailoring treatment to each child or adolescent while accounting for community and societal factors, which can lead to improved health across the lifespan.

Childhood obesity: A review of current and future management options

Obesity is becoming increasingly prevalent in paediatric populations worldwide. In addition to increasing prevalence, the severity of obesity is also continuing to rise. Taken together, these findings demonstrate a worrying trend and highlight one of the most significant challenges to public health. Childhood obesity affects multiple organs in the body and is associated with both significant morbidity and ultimately premature mortality. The prevalence of complications associated with obesity, including dyslipidaemia, hypertension, fatty liver disease and psychosocial complications are becoming increasingly prevalent within the paediatric populations. Treatment guidelines currently focus on intervention with lifestyle and behavioural modifications, with pharmacotherapy and surgery reserved for patients who are refractory to such treatment. Research into adult obesity has established pharmacological novel therapies, which have been approved and established in clinical practice; however, the research and implementation of such therapies in paediatric populations have been lagging behind. Despite the relative lack of widespread research in comparison to the adult population, newer therapies are being trialled, which should allow a greater availability of treatment options for childhood obesity in the future. This review summarizes the current evidence for the management of obesity in terms of medical and surgical options. Both future therapeutic agents and those which cause weight loss but have an alternative indication are also included and discussed as part of the review. The review summarizes the most recent research for each intervention and demonstrates the potential efficacy and limitations of each treatment option.

Pediatric quality of life multidimensional fatigue scale (PedsQL-MFS) detects the effects of a 3-week Inpatient body weight reduction program for children and adolescents with obesity

BACKGROUND

Fatigue is a frequent complaint amongst children and adolescents with obesity, and it interferes with adherence to dietary and exercise regimes that could reduce obesity. The present study evaluated the effect of an inpatient 3-week body weight reduction program on body weight and fatigue.

METHOD

One hundred children and adolescents with obesity (64% female; aged 11-18 years) undertook an inpatient program of personalized diet, daily exercise, education, and counselling.

RESULTS

The sample evidenced a mean reduction in body mass (females: ΔM = 4.3 (sd = 2.1) kg, p < .001), males: ΔM = 6.2 (sd = 2.6) kg, p < .001), BMI standard deviation score (females: ΔM = 0.17 (sd = 0.07), males: ΔM = 0.24 (sd = 0.08), p < .001) and fatigue (females: ΔM = 7.8 (sd = 9.7), males: ΔM = 5.0 (sd = 6.9), p < .001) as measured by the Pediatric Quality of Life Multidimensional Fatigue Scale (PedsQL-MFS) and improvements on the Attention problems subscale of the Youth Self Report (total sample: ΔM = 0.89 (sd = 2.44), p < .001). Reliable change analyses revealed fatigue changes were achieved by up to 34% females and 17% males, but the majority did not achieve reliable change and changes in fatigue were not correlated with changes in body mass.

CONCLUSIONS

The program achieved clinically significant improvements in some children and adolescents. Future studies should explore predictors of treatment responsiveness. Trial registration Observational study. Not registered.

Assessment and management of obesity and metabolic syndrome in children with CKD stages 2-5 on dialysis and after kidney transplantation-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

Obesity and metabolic syndrome (O&MS) due to the worldwide obesity epidemic affects children at all stages of chronic kidney disease (CKD) including dialysis and after kidney transplantation. The presence of O&MS in the pediatric CKD population may augment the already increased cardiovascular risk and contribute to the loss of kidney function. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists who develop clinical practice recommendations (CPRs) for the nutritional management of children with kidney diseases. We present CPRs for the assessment and management of O&MS in children with CKD stages 2-5, on dialysis and after kidney transplantation. We address the risk factors and diagnostic criteria for O&MS and discuss their management focusing on non-pharmacological treatment management, including diet, physical activity, and behavior modification in the context of age and CKD stage. The statements have been graded using the American Academy of Pediatrics grading matrix. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. The CPRs will be periodically audited and updated by the PRNT.

Diabetic kidney disease in children and adolescents: an update

Diabetic kidney disease (DKD), previously encountered predominantly in adult patients, is rapidly gaining center stage as a childhood morbidity and one that pediatric nephrologists are likely to encounter with increasing frequency. This is in large part due to the obesity epidemic and the consequent rise in type 2 diabetes in children and adolescents, as well as the more aggressive diabetes phenotype in today's youth with more rapid β-cell decline and faster development and progression of diabetes-related complications along with lower responsiveness to the treatments used in adults. DKD, an end-organ complication of diabetes, is at the very least a marker of, and more likely a predisposing factor for, the development of adverse cardiovascular outcomes and premature mortality in children with diabetes. On an optimistic note, several new therapeutic approaches are now available for the management of diabetes in adults, such as GLP1 receptor agonists, SGLT2 inhibitors, and DPP4 inhibitors, that have also been shown to have a favorable impact on cardiorenal outcomes. Also promising is the success of very low-energy diets in inducing remission of diabetes in adults. However, the addition of these pharmacological and dietary approaches to the management toolbox of diabetes and DKD in children and adolescents awaits thorough assessment of their safety and efficacy in this population. This review outlines the scope of diabetes and DKD, and new developments that may favorably impact the management of children and young adults with diabetes and DKD.

Novel dietary interventions for adolescents with obesity: A narrative review

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

Eating disorder risk in adolescents with obesity

The intersection between adolescent obesity and eating disorder risk is one that requires urgent attention. This review aimed to synthesize the literature on the risk of clinical eating disorders in adolescents with obesity, discuss challenges with assessing risk, and examine implications for clinical practice and future research. Obesity and eating disorders can coexist resulting in exacerbated physical and psychological health issues. Recognized eating disorder risk factors, including body dissatisfaction, poor self-esteem, depression, and engaging in dieting behaviors, are elevated and frequently reported in adolescents with obesity, highlighting a vulnerability to the development of eating disorders. Unsupervised dieting to manage weight may exacerbate eating disorder risk, while structured and supervised weight management is likely to reduce eating disorder risk for most adolescents. However, some adolescents may present to an obesity service with an undiagnosed eating disorder or may develop an eating disorder during or following treatment. We conclude that a risk management approach, with screening or monitoring for eating disorder-related risk factors and behaviors, should be utilized to identify those at risk. Future research to identify eating disorder risk factors specific to adolescents with obesity is required to inform screening and monitoring protocols, patient care, and address current knowledge gaps.

Legend of Weight Loss: a Crosstalk Between the Bariatric Surgery and the Brain

In recent years, plenty of researches have reported in obese individuals with abnormal brain processes implicated in homeostatic regulation, reward, emotion, memory, attention, and executive function in eating behaviors. Thus, treating obesity cannot remain "brainless." Behavioral and psychological interventions activate the food reward, attention, and motivation system, leading to minimal weight loss and high relapse rates. Pharmacotherapy is an effective weight loss method and regulate brain activity but with concerns about its brain function safety problems. Obesity surgery, the most effective therapy currently available for obesity, shows pronounced effects on brain activity, such as deactivation of reward and attention system, and activation of inhibition control toward food cues. In this review, we present an overview of alterations in the brain after the three common weight loss methods.

Psychopathology and Adolescent Bariatric Surgery: A Topical Review to Support Psychologists in Assessment and Treatment Considerations

The rising rates of severe obesity among adolescents in the United States indicate a dire need for more intensive weight management strategies. While current evidence suggests that bariatric surgery is a safe and efficacious intervention for adolescents, the linkages with psychopathology before and after surgery are not well understood. Psychologists are an integral part of the interdisciplinary surgery team and play an important role in preparing youth for bariatric surgery as well as supporting adolescents post-surgery. The present manuscript reviews the literature on psychopathology in the context of adolescent bariatric surgery, discusses consideration of psychopathology as a contraindication for surgery, and provides recommendations on how psychologist members of the bariatric surgery team may balance attention to motivation and adherence to medical recommendations with assessment and treatment of psychopathology. Finally, the importance of continued research to confirm clinical consensus regarding decision-making and expansion of psychological resources within adolescent bariatric surgery programs are discussed.

Current Systems-Level Evidence on Nutrition Interventions to Prevent and Treat Cardiometabolic Risk in the Pediatric Population: An Evidence Analysis Center Scoping Review

Improving and maintaining cardiometabolic health remains a major focus of health efforts for the pediatric population. Recent research contributes understanding of the systems-level nutrition factors influencing cardiometabolic health in pediatric individuals. This scoping review examines current evidence on interventions and exposures influencing pediatric cardiometabolic health to inform registered dietitian nutritionists working at each systems level, ranging from individual counseling to public policy. A literature search of MEDLINE, CINAHL, Cochrane Databases of Systematic Reviews, and other databases was conducted to identify evidence-based practice guidelines, systematic reviews, and position statements published in English from January 2017 until April 2020. Included studies addressed nutrition interventions or longitudinal exposures for participants 2 to 17 years of age who were healthy or had cardiometabolic risk factors. Studies were categorized according level of the social-ecological framework addressed. The databases and hand searches identified 2614 individual articles, and 169 articles were included in this scoping review, including 6 evidence-based practice guidelines, 141 systematic reviews, and 22 organization position statements. The highest density of systematic reviews focused on the effects of dietary intake (n = 58) and interventions with an individual child or family through counseling or education (n = 54). The least frequently examined levels of interventions or exposures were at the policy level (n = 12). Registered dietitian nutritionists can leverage this considerable body of recent systematic reviews to inform a systems-level, collaborative approach to prevention and treatment of pediatric cardiometabolic risk factors.

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

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

Efficacy of Weight Reduction on Pediatric Nonalcoholic Fatty Liver Disease: Opportunities to Improve Treatment Outcomes Through Pharmacotherapy

Obesity is the single greatest risk factor for nonalcoholic fatty liver disease (NAFLD). Without intervention, most pediatric patients with NAFLD continue to gain excessive weight, making early, effective weight loss intervention key for disease treatment and prevention of NAFLD progression. Unfortunately, outside of a closely monitored research setting, which is not representative of the real world, lifestyle modification success for weight loss in children is low. Bariatric surgery, though effective, is invasive and can worsen NAFLD postoperatively. Thus, there is an evolving and underutilized role for pharmacotherapy in children, both for weight reduction and NAFLD management. In this perspective article, we provide an overview of the efficacy of weight reduction on pediatric NAFLD treatment, discuss the pros and cons of currently approved pharmacotherapy options, as well as drugs commonly used off-label for weight reduction in children and adolescents. We also highlight gaps in, and opportunities for, streamlining obesity trials to include NAFLD assessment as a valuable, secondary, therapeutic outcome measure, which may aid drug repurposing. Finally, we describe the already available, and emerging, minimally-invasive biomarkers of NAFLD that could offer a safe and convenient alternative to liver biopsy in pediatric obesity and NAFLD trials.

Current Perspectives on the Role of Very-Low-Energy Diets in the Treatment of Obesity and Type 2 Diabetes in Youth

In both developed and developing countries, pediatric obesity and type 2 diabetes are an increasing public health concern: globally 5.6% of girls and 7.8% of boys aged ≥5 years have obesity. The incidence of type 2 diabetes has increased in youth in recent decades and disproportionately affects those from ethnic/racial minority groups and disadvantaged backgrounds. For the treatment of both conditions, conventional lifestyle intervention is frequently ineffective, access to bariatric surgery is very limited and many young people are unsuitable or unwilling to undergo surgery. A very-low-energy diet (VLED) provides a viable alternative and may be effective for weight reduction and improved glycemic control in youth, based on one systematic review. In particular, in the treatment of type 2 diabetes, a chart review and a pilot study both demonstrated that a VLED can reduce the requirement for medications, including insulin, and lead to the remission of diabetes. However, long-term follow-up and safety data remain limited and therefore a VLED is inconsistently recommended by clinical practice guidelines for the treatment of pediatric obesity and type 2 diabetes. In clinical practice, VLED use in children and adolescents is uniquely challenging due to intolerance of expected side effects, difficulty adhering to the highly restrictive diet and difficulty with behaviour change within the current social context and environment. Ultimately, more research, including larger, longer-term trials with comprehensive safety monitoring are required to strengthen the evidence base. This would inform clinical practice guidelines, which may facilitate more widespread utilization of VLED programs in the management of obesity and type 2 diabetes in youth.

Low-carbohydrate interventions for adolescent obesity: Nutritional adequacy and guidance for clinical practice

Low-carbohydrate dietary patterns are re-emerging as a popular method of weight reduction. However, their nutritional adequacy to meet the needs of growing adolescents should be considered. This study aimed to design theoretical low-carbohydrate meal plans for clinical use in the management of adolescent obesity and assess nutritional adequacy. Meal plans were created for three levels of carbohydrate restriction (≤30, ≤50 and ≤120 g/day) without energy, protein or total fat restriction. Nutrient analysis was conducted using the FoodWorks Australia Ltd software (databases: AUSNUT 2013, AusBrands 2017, AusFoods 2017, NUTTAB 2010, New Zealand FOODfiles 2016), and compared with Australian Nutrient Reference Values for male and female adolescents aged 14 to 18 years. All low-carbohydrate meal plans met the Recommended Dietary Intake, Adequate Intake or Estimated Average Requirements for most micronutrients at an energy intake of 6.3 to 7.2 MJ/day (1510-1730 kcal/day). The proportion of energy from saturated fat exceeded recommendations across all models (11.3%-17.1%). Dietary manipulation was required to minimize saturated fat and reach micronutrient adequacy, particularly for calcium in males and females, and iron for females. In practice, this may be challenging considering individual lifestyle and preferences. Therefore, the use of low-carbohydrate diets with adolescents should be monitored by a trained professional to ensure nutritional adequacy.

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

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

Strategies in the Management of Adolescent Obesity

Purpose of Review

We review the current options to manage adolescent obesity which include nutrition, physical activity, behavior modification, sleep management, pharmacotherapy and surgery. Since lifestyle interventions alone are often not effective in adolescents, a multi-disciplinary treatment approach is necessary in management.

Recent Findings

Medications (often used off-label) and metabolic/bariatric surgery are effective treatment strategies to treat adolescents with severe obesity.

Summary

The use of pharmacotherapy and surgery is limited due to lack of pediatric obesity tertiary care centers. With more centers, the treatment of adolescent obesity will improve and aid to decrease the prevalence of adult obesity.

Efficacy of Intermittent or Continuous Very Low-Energy Diets in Overweight and Obese Individuals with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analyses

OBJECTIVE

This study is aimed at investigating the efficacy of a very low-energy diet (VLED) in overweight and obese individuals with type 2 diabetes mellitus (T2DM).

METHODS

We thoroughly searched eight electronic resource databases of controlled studies concerning the efficacy and acceptability of intermittent or continuous VLEDs in patients with T2DM compared with other energy restriction interventions.

RESULTS

Eighteen studies (11 randomized and seven nonrandomized controlled trials) with 911 participants were included. The meta-analyses showed that compared with a low-energy diet (LED) and mild energy restriction (MER), VLED is superior in the reduction of body weight (mean difference (MD) MD_LED = -2.77, 95% confidence interval (CI) CI_LED = -4.81 to - 0.72, P _LED = 0.008; MD_MER = -6.72, 95%CI_MER = -10.05 to - 3.39, P _LED = 0.008; MD_MER = -6.72, 95%CI_MER = -10.05 to - 3.39, P _LED = 0.008; MD_MER = -6.72, 95%CI_MER = -10.05 to - 3.39, P _LED = 0.008; MD_MER = -6.72, 95%CI_MER = -10.05 to - 3.39, P _LED = 0.008; MD_MER = -6.72, 95%CI_MER = -10.05 to - 3.39, P _LED = 0.008; MD_MER = -6.72, 95%CI_MER = -10.05 to - 3.39, P _LED = 0.008; MD_MER = -6.72, 95%CI_MER = -10.05 to - 3.39, I ² = 0%) and TG level (MD = -0.25, 95%CI = -0.55 to 0.06, P _LED = 0.008; MD_MER = -6.72, 95%CI_MER = -10.05 to - 3.39, I ² = 0%) and TG level (MD = -0.25, 95%CI = -0.55 to 0.06, P _LED = 0.008; MD_MER = -6.72, 95%CI_MER = -10.05 to - 3.39, P _LED = 0.008; MD_MER = -6.72, 95%CI_MER = -10.05 to - 3.39, P _LED = 0.008; MD_MER = -6.72, 95%CI_MER = -10.05 to - 3.39, P _LED = 0.008; MD_MER = -6.72, 95%CI_MER = -10.05 to - 3.39, P _LED = 0.008; MD_MER = -6.72, 95%CI_MER = -10.05 to - 3.39.

CONCLUSION

Dietary intervention through VLEDs is an effective therapy for rapid weight loss, glycemic control, and improved lipid metabolism in overweight and obese individuals with T2DM. Thus, VLEDs should be encouraged in overweight and obese individuals with T2DM who urgently need weight loss and are unsuitable or unwilling to undergo surgery. As all outcome indicators have low or extremely low quality after GRADE evaluation, further clinical trials that focus on the remission effect of VLEDs on T2DM are needed.

Fast track to health - Intermittent energy restriction in adolescents with obesity. A randomised controlled trial study protocol

BACKGROUND

Intermittent energy restriction (IER) has shown early success in adolescents with obesity, however efficacy trials are needed. This study aims to determine if IER results in lower body mass index (BMI) z-score after 52 weeks in metabolically unhealthy adolescents with obesity compared with continuous energy restriction (CER).

METHODS/DESIGN

This is a prospective, randomised, multi-centre trial conducted in tertiary care settings, with three phases: jumpstart (weeks 0-4); intensive intervention (weeks 5-16); continued intervention and/or maintenance (weeks 17-52). During the jumpstart phase, all participants follow a very low energy diet (∼800kcal/3350kJ/day), then transition to their allocated intervention: IER or CER. IER involves three energy-restricted days/week, consuming one-third of daily energy requirements (∼600-700kcal/2500-2950kJ/day), and four days/week of a healthy meal plan. The CER, which is current standard care, has individually tailored energy prescription based on age and sex (13-14years, 1430-1670kcal/6000-7000kJ/day; 15-17years, 1670-1900kcal/7000-8000kJ/day). The study will recruit 186 (93 per arm) treatment-seeking adolescents aged 13-17years with obesity and at least one metabolic co-morbidity. The primary outcome is change in BMI z-score at 52 weeks. Secondary outcomes are changes at 4, 16 and 52 weeks in: body composition; diet quality, food choices and food patterns; cardio-metabolic risk factors; physical activity and sedentary behaviour; sleep and psycho-behavioural measures.

DISCUSSION

This study challenges existing clinical paradigms that CER is the only method for weight management in metabolically unhealthy adolescents. If successful, IER may offer an alternate medical nutrition therapy approach for those seeking treatment in tertiary settings.

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12617001630303.

Adolescent Obesity: Diet Quality, Psychosocial Health, and Cardiometabolic Risk Factors

Obesity is a multifaceted chronic condition with several contributing causes, including biological risk factors, socioeconomic status, health literacy, and numerous environmental influences. Of particular concern are the increasing rates of obesity in children and adolescents, as rates of obesity in youth in the United States have tripled within the last three decades. Youth from historically disadvantaged backgrounds tend to have higher rates of obesity compared to other groups. Adolescents often do not meet intake recommendations for certain food groups and nutrients, which may contribute to a heightened risk of obesity. With obesity disproportionately affecting adolescents (ages 12–19 years), negative effects of excess adiposity may be particularly salient during this critical period of development. The presentation of chronic cardiometabolic disease symptoms typically observed in adults, such as hypertension, hyperglycemia, dyslipidemia, and inflammation, are becoming increasingly common in adolescents with obesity. Additionally, there is dynamic interplay between obesity and psychosocial health, as adolescents with obesity may have increased levels of stress, depressive symptoms, and reduced resilience. To reduce and prevent adolescent obesity, the implementation of theory-driven multicomponent school- and community-based interventions have been suggested. These interventions promote knowledge and self-efficacy for healthful practices that have the potential to progress to sustained behavior change.

Trends in Self-perceived Weight Status, Weight Loss Attempts, and Weight Loss Strategies Among Adults in the United States, 1999-2016

IMPORTANCE

The self-perception of weight and weight loss attempts might promote weight loss and maintenance.

OBJECTIVE

To examine trends in current measured body mass index (BMI) and weight, self-reported weight, self-perceived weight status, weight loss attempts, and weight loss strategies among adults in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This national cross-sectional study used data from continuous National Health and Nutrition Examination Survey (NHANES) data sets (1999-2000 to 2015-2016). Participants were US residents older than 20 years. Data were analyzed from January 2018 to December 2018.

MAIN OUTCOMES AND MEASURES

Current measured BMI and weight, self-reported weight, self-perceived weight status, weight loss attempts, and applied weight loss strategies. Adjusted, self-reported, prior-year weight was calculated using correction equations that considered age, sex, race/ethnicity, and quartile of self-reported prior-year weight.

RESULTS

Data were collected from 48 026 participants (19 792 [41.2%] aged 40-64 years; 24 255 [50.5%] women; 21 725 [45.2%] white) through 9 surveys from 1999-2000 to 2015-2016. Increasing trends were observed in current measured BMI (difference, 1.20; 95% CI, 0.92-1.47; P for trend < .001), current measured weight (difference 2.77 kg; 95% CI, 1.92-3.61 kg; P for trend < .001), adjusted, self-reported, prior-year weight (difference, 2.36 kg; 95% CI, 1.52-3.21 kg; P for trend < .001), and the difference between measured and adjusted self-reported weight (difference 0.70 kg; 95% CI, 0.34-1.07 kg; P for trend < .001). During this period, the proportion of overall participants who had attempted to lose weight increased from 34.3% to 42.2% (difference, 8.0%; 95% CI, 4.1%-10.5%; P for trend < .001). The most commonly reported weight loss strategies with the most rapidly increasing prevalence during the study period were reduced food consumption (21.2%-31.9%; difference, 11.1%; 95% CI, 8.2%-13.3%; P for trend < .001), exercise (18.2%-31.5%; difference, 14.4%; 95% CI, 11.3%-16.9%; P for trend < .001), and frequent water intake (0.2%-26.3%; difference, 26.2%; 95% CI, 24.1%-29.0%; P for trend < .001). Between 2005-2006 and 2015-2016, increases were also observed for the reported consumption of more fruits, vegetables, and salads (0.1%-29.4%; difference, 30.3%; 95% CI, 28.1%-31.2%; P for trend < .001), changing eating habits (0.3%-20.5%; difference, 20.2%; 95% CI, 19.1%-22.3%; P for trend < .001), and the consumption of less sugar, candy, and sweets (0.2%-20.9%; difference, 21.7%; 95% CI, 19.3%-22.6%; P for trend < .001).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, our data indicated an increasing trend in the proportion of participants who attempted to lose weight and a parallel increasing trend in current measured BMI and weight among adults in the United States.

Time-Limited Eating in Pediatric Patients with Obesity: A Case Series

Background

Time Limited Eating (TLE) is an effective strategy for management of obesity in adults, but there is a paucity of data that have examined its use in the clinical management of children with obesity. A TLE approach involves interspersing normal daily caloric intake with periods of prolonged calorie restriction several times per week. TLE may actually be more feasible, non-stigmatizing, flexible and effective in children, especially for adolescents, compared to alternatives like daily caloric or macronutrient restriction. This is because TLE removes the need for intensive counting of daily calorie intake or macronutrient content and focuses on a straightforward task of consuming food during a pre-specified time period. Also it avoids periods of extended caloric restriction which may interfere with growth and/or risk evoking development of eating behaviors. This case series describes four patients who trialed a TLE approach in a clinical weight management clinic and describes BMI reduction at 4 months.

Case Presentation

To date, 4 patients, ages 5-15, with varying underlying pathologies (i.e. Bardet Biedl Syndrome (BBS), previously healthy, craniopharyngioma and epilepsy) have tried a TLE type approach (16-hour fast/8-hour feed for 3-5 days per week) for 4 months and have demonstrated an average decrease in their BMI z-score compared to baseline of -0.24 SD. Patients and their families reported high degrees of satisfaction with this dietary approach.

Conclusions

Families were very satisfied with the TLE intervention and reported it was feasible, flexible and sustainable to implement in a real life setting and associated with decreased zBMI. Further investigation is required to determine if this approach is effective in both the short and long term as a weight management technique.