The Health Initiative Program for Kids (HIP Kids): effects of a 1-year multidisciplinary lifestyle intervention on adiposity and quality of life in obese children and adolescents--a longitudinal pilot intervention study

A Multidisciplinary Approach to Pediatric Obesity Shows Improvement Postintervention

OBJECTIVE

Outpatient management of pediatric obesity can be difficult, requiring a significant time commitment from both provider and patient. Multidisciplinary clinic-based programs have shown promising effects in reducing BMI during intervention, but whether these changes are sustained over time is not well studied. The purpose of this study was to determine the post-treatment outcomes of children seen in a multidisciplinary pediatric obesity clinic (MPOC).

METHODS

A retrospective chart review was performed using the MPOC database, which included all clinic patients from January 2008 to August 2016 who attended a minimum of 2 visits (n = 472). The primary outcome was the absolute change in BMI Z-score (BMIZ) from the final intervention visit compared to 1- and 2-years post-intervention. Multivariate regression analysis was performed to characterize predictors of change in BMIZ.

RESULTS

MPOC patients ranged in age from 3 to 18 years. Mean BMIZ decreased significantly during intervention (-0.13 ± 1.47, P < .001) and was maintained at 1- and 2-years post-intervention. In participants ages 3 to 5, BMIZ further decreased at 1 year post intervention (-0.27 ± 0.26, P < .001). Age at time of referral was the only significant predictor of change in BMIZ.

CONCLUSIONS

Outpatient, multidisciplinary intervention for pediatric obesity was effective in reducing or stabilizing BMIZ during and beyond the intervention, particularly when patients were referred at an early age. Although primary prevention is the ideal management, multidisciplinary clinic intervention can be effective in the sustained treatment of pediatric obesity.

Two-year effects of the community-based overweight and obesity intervention program Gezond Onderweg! (GO!) in children and adolescents living in a low socioeconomic status and multi-ethnic district on Body Mass Index-Standard Deviation Score and quality of life

BACKGROUND

In most childhood obesity interventions, disadvantaged groups are underrepresented, and results are modest and not maintained. A long-term collaborative community-based approach is necessary to reach out to children from multi-ethnic backgrounds and achieve sustainable behavior change, resulting in sustained Body Mass Index-Standard Deviation Score (BMI-SDS) reductions. The objective is to determine the effects of GO! on BMI-SDS and Health-Related Quality of Life (HRQoL) for children and adolescents having overweight or obesity.

METHODS

A prospective, longitudinal cohort study was used to collect two-year follow-up data from November 2014 to July 2019. Children and adolescents (4-19 years old) from the low socioeconomic status and multi-ethnic district of Malburgen in the Dutch city of Arnhem were included. 178 children having overweight or obesity were recruited, with 155 children measured at baseline and after two years as a minimum, while 23 were lost to follow up. Participants attending the program for over six months were defined as completers (n=107) and participants attending the program for less than six months were defined as non-completers (n=48). The child health coach (CHC) acts as a central care provider in the collaborative community with healthcare providers from both medical and social fields. This coach coordinates, monitors and coaches healthy lifestyles, while increasing self-management for both children and parents. This is done in a customized and neighborhood-oriented manner and provided by all the stakeholders involved in GO!. The main outcomes are the change in BMI-SDS scores and HRQoL scores reported by participants.

FINDINGS

After 24 months, completers showed a decrease in BMI-SDS of -0·32 [95% CI: -0·42, -0·21], compared with -0·14 [95% CI: -0·29, 0·01] for non-completers (adjusted for gender and ethnicity; P=0.036). While 25% suffered from overweight and 75% from obesity at the start, following the intervention 5% showed normal weight, with 33% overweight and 62% with obesity. HRQoL reported by participants improved over time, showing no differences between completers and non-completers, gender and ethnicity after two years.

INTERPRETATION

Our results suggest that the GO! program might be effective in reaching out and reducing BMI-SDS for participants in a low socioeconomic status and multi-ethnic district over a two-year period. We noticed also trends to beneficial shifts in obesity grades. HRQoL improved regardless of the participation rate, gender and ethnic background. In light of the study limitations, further studies are needed to corroborate our observations.

FUNDING

Dullerts-foundation, Nicolai Broederschap foundation, Burger en Nieuwe weeshuis foundation, Rijnkind foundation, Arnhems Achterstandswijken foundation, Menzis-foundation, the municipalities of Arnhem, Rheden, Overbetuwe and Lingewaard, the Association of Dutch municipalities, and Province of Gelderland.

Gamification for Family Engagement in Lifestyle Interventions: A Systematic Review

The majority of chronic conditions that plague the USA are modifiable by lifestyle change. Lifestyle interventions that incorporate family members for social support and that use game design elements to engage family members have the potential to improve upon traditional interventions, which have largely been unsustainable. Determining the populations where family member support in a lifestyle intervention are present and the extent of gamification of lifestyle intervention components that engage these family members is an important and underexplored area of work. A systematic review of lifestyle interventions involving family members were reviewed for game design elements using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. Game design elements related to engaged learning and motivational affordances from previous literature were included. Sixty-one studies met inclusion criteria. These studies reported on 50 independent interventions that were reviewed. Thirty-one of these interventions addressed lifestyle in those with a chronic condition, and 19 addressed lifestyle in those at high risk for chronic conditions. The majority of the lifestyle interventions included at least one game design element, yet overall there were limited elements utilized together. Compared with successful gamified programs that have greatly impacted a population's health behaviors, there were relatively a limited number of elements reported, particularly those that support social relatedness, such as meaningful storylines. Meaningfulness of the game design elements chosen and their arrangement was not apparent. Technology was under-utilized as a potential modality for intervention component delivery. Developing products to train researchers to properly apply game design elements to intervention components, as well as test their effectiveness, are areas for future research.

Mobile Health Interventions Addressing Childhood and Adolescent Obesity in Sub-Saharan Africa and Europe: Current Landscape and Potential for Future Research

Child and adolescent overweight is a growing public health problem globally. Europe and low and middle-income (LMIC) countries in Sub-Saharan Africa provide sufficiently suitable populations to learn from with respect to the potential for mobile health (mHealth) interventions in this area of research. The aim of this paper is to identify mHealth interventions on prevention and treatment of childhood and adolescent obesity in Sub-Saharan Africa and Sweden and report on their effects, in order to inform future research in this area. A search of peer-reviewed publications was performed using PubMed, ScienceDirect, EBSCOhost, and Scopus. The search included all articles published up to August 2019. The search strings consisted of MeSH terms related to mHealth, overweight or obesity, children, adolescents or youth and individual countries in Europe and Sub-Saharan Africa. Second, a combination of free-text words; mobile phone, physical activity, exercise, diet, weight, BMI, and healthy eating was also used. Seven studies were reported from Europe and no eligible studies from Sub-Saharan Africa. The results of this narrative review indicate a lack of research in the development and testing of mHealth interventions for childhood and adolescent obesity. There is a need for an evidence base of mHealth interventions that are both relevant and appropriate in order to stem the epidemic of overweight and obesity among children and adolescents in these countries. Uptake of such interventions is likely to be high as there is high penetrance of mobile phone technology amongst adolescents, even within poor communities in Africa.

Effects of physical activity interventions on cognitive performance of overweight or obese children and adolescents: a systematic review and meta-analysis

BACKGROUND

Physical activity (PA) and obesity were linked with poor cognition. Our study assessed PA interventions could improve domain-specific cognition among overweight/obese youth.

METHODS

Systematically searched PubMed to identify relevant studies published up to October 2019. Standardized mean differences (SMD) of pre-post intervention were calculated in meta-analysis. The level of study heterogeneity represented by I² was interpreted as small (I² ≤ 25%), moderate (25% < I² ≤ 50%), substantial (50% < I² ≤ 75%), or considerable (I² > 75%).

RESULTS

Seventeen studies met the inclusion criteria; eight were included in the meta-analysis. Meta-analysis revealed that PA interventions improved core executive functions (core-EFs) (SMD = 0.301; 95% CI = 0.002-0.600; I²% = 80.6%) and non-EFs (SMD = 0.159; 95% CI = 0.029-0.289; I²% = 0.0%), but not metacognition and academic performance. Core-EFs benefited from enriched PA (SMD = 0.535; 95% CI = 0.020-1.051; I²% = 72.0%) and enhanced and enriched PA (SMD = 1.005; 95% CI = 0.017-1.993; I²% = 90.8%) interventions, while the non-EFs benefited more from enhanced PA (SMD = 0.166; 95% CI = 0.018-0.314; I²% = 0.0%). Interventions with a favorable effect on adiposity measures resulted in a significantly greater improvement in core-EFs (SMD = 0.438; 95% CI = 0.047-0.829; I²% = 58.8%) than those with no effects.

CONCLUSIONS

PA interventions can improve several domains of cognition, especially core-EFs and non-EFs, and the effects are affected by PA characteristics among overweight and obese youth.

IMPACT

Our study is the first to quantify the effect of PA interventions on CP among overweight or obese children and adolescents. Physical activity interventions positively affect cognitive performance, especially core executive functions (core-EFs) and non-EFs. Physical activity interventions seem to not positively affect metacognition (higher-level EFs and cognitive life skills) and academic performance. Physical task characteristics could influence the effect of chronic exercise on cognitive performance. Short-term physical activity programs may be particularly beneficial to affect core-EFs.

What Change in Body Mass Index Is Required to Improve Cardiovascular Outcomes in Childhood and Adolescent Obesity through Lifestyle Interventions: A Meta-Regression

Background: Using meta-regression, this article aims at establishing the minimum change in BMI-standard deviation score (SDS) needed to improve lipid profiles and blood pressure in children and adolescents with obesity, to aid future trials and guidelines. Methods: Studies with participants involved in lifestyle interventions, aged 4-19 years, with a diagnosis of obesity according to defined BMI thresholds, were considered for inclusion in a large systematic review. Interventions had to report pre- and post-intervention (or mean change in) BMI-SDS, plus either systolic blood pressure (SBP), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and/or triglycerides (TGs). Random-effects meta-regression quantified the relationship between mean change in BMI-SDS and mean change in cardiovascular outcomes. Results: Seventy-one papers reported various cardiovascular measurements and mean change in BMI-SDS. Fifty-four, 59, 46, and 54 studies were analyzed, reporting a change in SBP, HDL, LDL, and TG, respectively. Reduction in mean BMI-SDS was significantly related to improvements in SBP, LDL, TG, and HDL (p < 0.05); BMI-SDS reductions of 1, 1.2, and 0.7 ensured a mean reduction of SBP, LDL, and TG, respectively, although an equivalent value for HDL improvement was indeterminate. Conclusion: Reductions in mean BMI-SDS of >1, >1.2, or >0.7 are likely to reduce SBP, LDL, and TG, respectively. Further studies are needed to clarify the optimal duration, intensity, and setting for interventions. Consistency is required regarding derived BMI values to facilitate future systematic reviews and meta-analyses.

Integrating nutrition and physical activity promotion: A scoping review

BACKGROUND

This paper investigates actions that combine nutrition and physical activity which hold potential for 'double duty action' to tackle multiple forms of malnutrition simultaneously. Expanding on previous research on single component actions, we assessed the state of the literature to map integrated interventions across the life course to analyse potential double duty effects, and identify knowledge gaps and needs for future design, implementation, evaluation and research for effective double duty action.

METHODS

A scoping review of peer-reviewed and grey literature was conducted to explore the pathways that extend from combined physical activity and nutrition promotion interventions, with potential synergistic effects on outcomes other than obesity. Electronic databases were searched for studies published between 1 January 2010 and 31 January 2020. Out of 359 articles retrieved, 31 peer-reviewed and 5 grey literature sources met inclusion criteria. Findings from 36 papers reporting on 34 interventions/initiatives were organised into 6 categories, based on implementation across multiple stages of the life course. Double-duty potential was assessed through a further stage of analysis.

FINDINGS

This review has identified actions that hold potential for tackling not only obesity, but healthy diets, sedentary behaviour and quality of life more generally, as well as actions that explicitly tackle multiple forms of malnutrition. Importantly, it has identified crucial gaps in current methods and praxis that call for further practice-oriented research, in order to better understand and exploit the synergistic effects of integrated interventions on outcomes other than obesity.

CONCLUSIONS

Findings from across implementation settings suggest that even in situations where interventions are aimed at, or framed in terms of, obesity prevention and control, there are unexploited pathways for broader outcomes of relevance to nutrition and health and wellbeing more generally. Future design and evaluation of multisectoral approaches will benefit from an explicit framing of interventions as double-duty oriented.

Change in obesity-related metabolic abnormalities associated with body mass index improvement through life-style intervention: A meta-regression

The reduction in body mass index standard deviation score (BMI-SDS) associated with improvement in biomarkers relating to metabolic health in obese children is unknown. We aimed to establish the change in BMI-SDS associated with improved inflammation, liver function, and insulin resistance to inform clinical guidelines for pediatric weight management interventions and to assess the efficacy of future trials. A large-scale systematic review was conducted to identify relevant studies. Studies of children with a diagnosis of obesity according to defined BMI thresholds, participating in lifestyle interventions to reduce obesity, were included. Studies must have reported baseline (pre-) and postintervention (or change of) BMI-SDS and either fasting glucose, homeostatic model of insulin resistance (HOMA-IR), alanine aminotransferase (ALT), C-reactive protein (CRP), or interleukin-6 (IL-6). A series of meta-regressions were conducted to establish links between BMI-SDS change scores and change in metabolic markers of health. Sixty-eight articles were identified. From the meta-regression analyses, across all study subsets, greater mean falls in all four parameters, (HOMA-IR, Glucose, ALT, and CRP) were observed with greater mean loss of BMI-SDS, but the trends were only statistically significant for HOMA-IR and CRP (P = .003; P = .021). However, we could not find minimum changes in BMI-SDS that would ensure a fall in these outcomes. At this time, we are unable to recommend a definitive value of BMI-SDS reduction needed to improve the markers of metabolic health. Future trials should aim to report additional indices of derived BMI values, which may better reflect changes in actual adiposity.

What change in body mass index is associated with improvement in percentage body fat in childhood obesity? A meta-regression

OBJECTIVE

Using meta-regression this paper sets out the minimum change in body mass index-SD score (BMI-SDS) required to improve adiposity as percentage body fat for children and adolescents with obesity.

DESIGN

Meta-regression.

SETTING

Studies were identified as part of a large-scale systematic review of the following electronic databases: AMED, Embase, MEDLINE via OVID, Web of Science and CENTRAL via Cochrane library.

PARTICIPANTS

Individuals aged 4-19 years with a diagnosis of obesity according to defined BMI thresholds.

INTERVENTIONS

Studies of lifestyle treatment interventions that included dietary, physical activity and/or behavioural components with the objective of reducing obesity were included. Interventions of <2 weeks duration and those that involved surgical and/or pharmacological components (eg, bariatric surgery, drug therapy) were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

To be included in the review, studies had to report baseline and post-intervention BMI-SDS or change measurements (primary outcome measures) plus one or more of the following markers of metabolic health (secondary outcome measures): adiposity measures other than BMI; blood pressure; glucose; inflammation; insulin sensitivity/resistance; lipid profile; liver function. This paper focuses on adiposity measures only. Further papers in this series will report on other outcome measures.

RESULTS

This paper explores the potential impact of BMI-SDS reduction in terms of change in percentage body fat. Thirty-nine studies reporting change in mean percentage body fat were analysed. Meta-regression demonstrated that reduction of at least 0.6 in mean BMI-SDS ensured a mean reduction of percentage body fat mass, in the sense that the associated 95% prediction interval for change in mean percentage body fat was wholly negative.

CONCLUSIONS

Interventions demonstrating reductions of 0.6 BMI-SDS might be termed successful in reducing adiposity, a key purpose of weight management interventions.

TRIAL REGISTRATION NUMBER

CRD42016025317.

Effects of a Healthy Lifestyle Education on the Incidence of Metabolic Syndrome in Children during a 13-Year Follow-up

PURPOSE

This study aimed to determine effects of community-based healthy lifestyle education on the incidence of metabolic syndrome (MetS) in Tehranian children considering parental factors during a 13-year follow-up.

METHODS

This study was conducted within the framework of the Tehran Lipid and Glucose Study (TLGS) on 1603 healthy children, aged 8-18 years, who had complete parental data. Parental factors including MetS, education, age, occupation, and smoking were considered to distinguish parental clusters which could potentially predispose children to MetS. Lifestyle interventions were aimed at achieving healthy dietary patterns and increasing physical activity. Cluster analysis and survival Cox model were used to determine potential low and high risk parental clusters and the effect of intervention on the hazard of MetS in children respectively.

RESULTS

In a model adjusted for children's age and sex, the hazard of the MetS incidence was 36% higher in children from high-risk parental cluster than those from low-risk parental cluster (HR = 1.36, 95% CI = 1.07-1.73). Moreover, the intervention group showed a 39% lower risk for MetS incidence (HR = 0.61, 95% CI = 0.44-0.85) compared to controls, during the first 6 years after baseline assessment (short term), although the risk lowering effect of the intervention was not maintained long term.

CONCLUSION

A healthy lifestyle education was successful in reducing the short-term risk of MetS in children. To identify ways of maintaining long-term results, further research is definitely warranted.

TRIAL REGISTRATION

This study was funded by National Research Council and Planning and Management Organization and has been reviewed and approved by the Iranian registry of clinical trials (ISRCTN52588395).

Obesity intervention programs among adolescents using social cognitive theory: a systematic literature review

Social cognitive theory (SCT) is a well-known theory for designing nutrition education and physical activity programs for adolescents. This systematic review aimed to evaluate the efficacy of intervention studies based on SCT in reducing or preventing overweight and obesity in adolescents. An electronic literature search in PubMed-Medline, Web of Science and Scopus was performed to identify intervention studies based on SCT aiming at preventing or reducing obesity in adolescents. All the articles published up to July 2016 were included. Only studies reporting body mass index (BMI) or its variant as one of the outcome measures were included. From 240 initially identified studies, 12 met the eligibility criteria. Seven had moderate or strong study quality. Two of the eight randomized controlled trials (RCT) and two of the four quasi-experimental studies showed significant reduction in BMI among intervened participants compared to control. Impacts on diet and physical activity were mixed, but were mostly not significant. The current systematic review found only weak evidence for the efficacy of SCT-based interventions in treating and preventing obesity in adolescents. Further studies systematically using effective behavior change strategies or techniques, larger population sizes, better measurement tools and more robust designs are warranted for a conclusive judgment.

Preschoolers' health-related quality of life following the implementation of a childcare physical activity intervention

Being active offers many physical and emotional benefits contributing to a higher health-related quality of life (HRQoL); however, this relationship remains unexplored among preschoolers (aged 2.5-5 years). This study examined the impact of the Supporting Physical Activity in the Childcare Environment (SPACE), which was an intervention implemented using a cluster randomized controlled trial on preschoolers' HRQoL. Childcare centres were randomly allocated to the experimental (n = 11) or control (n = 11) conditions, and preschoolers' HRQoL was measured using the parent-report Pediatric Quality of Life Inventory 4.0 (3 subscales: physical, psychosocial, and total HRQoL) at baseline, post-intervention (i.e., week 8), and 6- and 12-month follow-up. A linear mixed-effects model was used to determine if preschoolers in the experimental condition displayed an increased HRQoL post-intervention and at follow-up compared with preschoolers in the control condition. Preschoolers (n = 234) with HRQoL data at baseline and one additional time-point were retained for analyses. Body mass index was not found to impact significantly on the intervention, and no statistically significant interaction effects were found for any of the 3 HRQoL variables. In conclusion, the SPACE intervention had no impact on preschoolers' HRQoL. Given the scarcity of research in this population, additional exploration is necessary to better understand the potential impact of physical activity participation on preschoolers' HRQoL.

Subjective evaluation of psychosocial well-being in children and youths with overweight or obesity: the impact of multidisciplinary obesity treatment

PURPOSE

To investigate the effects of a multidisciplinary childhood obesity treatment programme on subjective evaluations of psychosocial well-being and quality of life.

METHODS

This longitudinal observational study included 1291 children, adolescents and young adults, 6-22 years of age, with overweight or obesity. At entry and after 2-82 months of obesity treatment, the patients evaluated the following domains of psychosocial well-being on a visual analogue scale: quality of life, mood, appetite, bullying, motivation for weight loss and body image satisfaction. The degree of overweight was calculated using a body mass index (BMI) standard deviation score (SDS) at each visit.

RESULTS

At entry, the mean BMI SDS was 2.81 (range: 1.35-6.65, 95% confidence interval (95% CI): 2.44-3.18). After a median of 14 months of treatment, the median reduction in BMI SDS was 0.29 (95% CI: 0.26-0.31, p < 0.0001). Improvements were observed in the domains of quality of life, mood, appetite, bullying and body image satisfaction (p < 0.0001). Larger reductions in BMI SDS were associated with greater improvements in the domains of quality of life (p = 0.001), mood (p = 0.04) and body image satisfaction (p < 0.0001), independent of BMI SDS at entry. However, improvements in psychosocial well-being were also observed in those increasing their BMI SDS (n = 315).

CONCLUSIONS

In a large group of children and youths, psychosocial well-being improved during a multidisciplinary childhood obesity treatment programme, irrespective of the degree of obesity at treatment entry. Greater reductions in BMI SDS were associated with greater improvements in psychosocial well-being, but even in the group increasing their BMI SDS improvements were observed.

Effects of aerobic or resistance training or both on health-related quality of life in youth with obesity: the HEARTY Trial

This study examined the effects of aerobic and resistance training, and their combination on health-related quality of life (HRQoL) in adolescents with overweight or obesity. After a 4-week run-in period, 304 (91 males, 213 females) post-pubertal adolescents aged 14-18 years, were randomized to 4 groups for 22 weeks of: aerobic training (n = 75), resistance training (n = 78), combined aerobic and resistance training (n = 75), or nonexercising control (n = 76). All participants received dietary counseling with a daily energy deficit of 250 kcal. Indicators of HRQoL such as overall HRQoL, and physical and psychosocial (an aggregate of emotional, social, and school functioning) HRQoL at baseline and 6 months postintervention were measured by the Pediatric Quality of Life questionnaire. The trial began in March 2005 and was completed in June 2011. In the intention-to-treat analyses, all groups showed significant improvements at 6 months on all HRQoL indicators. The aerobic group showed greater improvements than controls on physical HRQoL (mean differences of 5.5; 95% CI; 1.4-9.6, p = 0.009). In participants with ≥70% adherence, combined training produced greater improvements than control on overall HRQoL (mean differences of 4.8, 95% CI; 0.7-9.0, p = 0.02), physical HRQoL (mean differences of 5.8; 95% CI: 0.6-10.7; p = 0.03), social HRQoL (mean differences of 7.6; 95% CI: 1.0-14.2; p = 0.02), and school-based HRQoL (mean differences of 7.6; 95% CI: 1.0-14.2; p = 0.02). These findings highlight the potential importance of including resistance exercise into traditional aerobic exercise programs to maximize HRQoL in adolescents with obesity.

Multidisciplinary care management has a positive effect on paediatric obesity and social and individual factors are associated with better outcomes

AIM

The RePPOP Aquitaine network, which was established in south-west France to prevent and treat paediatric obesity, has developed a multidisciplinary approach based on multicomponent lifestyle interventions and family-based actions. This study assessed the impact of its care management programme and investigated the factors associated with better outcomes.

METHODS

The impact of the RePPOP care management programme was assessed by changes in the body mass index (BMI) Z score, between baseline and the end-of-care management. We focused on 982 overweight or obese children (59.9% girls) with a mean age of 10.64 years and a range of 2.4-17.9 years. A multivariate analysis examined the independent factors associated with better outcomes.

RESULTS

At the end-of-care management programme, 75.5% of children had decreased their BMI Z score. Initial characteristics significantly associated with better outcomes were as follows: the age at baseline between five years and 15 years of age, playing sport at a club, being followed up by RePPOP for longer than 10 months, no parental obesity and no academic difficulties.

CONCLUSION

This study confirmed that multidisciplinary treatment had a significant positive effect on paediatric obesity and that social and individual factors affected the efficiency of the care management.