Defining "Success" in Childhood Obesity Interventions in Primary Care

Changes in weight status of caregivers of children and adolescents enrolled in a community-based healthy lifestyle programme: Five-year follow-up

Whānau Pakari is a family-centred healthy lifestyle programme for children/adolescents with overweight/obesity in New Zealand. This secondary analysis from our randomised trial within the clinical service assessed 5-year BMI changes in accompanying caregivers (n = 23), mostly mothers. Overall, baseline and 5-year caregivers' BMI were similar (32.50 vs 31.42 kg/m2, respectively; p = 0.31) but two-thirds (65%) experienced BMI reductions. Five-year BMI change was similar in High-intensity and Low-intensity randomisation groups [-1.37 kg/m2 (-4.95, 2.21); p = 0.44]. Caregiver's BMI change was not associated with child's BMI change. Despite no overall BMI reduction, our findings contrast with upward BMI trajectories predicted for NZ adults with overweight/obesity.

American Heart Association's Children's Strategically Focused Research Network Experience

The American Heart Association's Strategically Focused Children's Research Network started in July 2017 with 4 unique programs at Children's National Hospital in Washington, DC; Duke University in Durham, North Carolina; University of Utah in Salt Lake City, Utah; and Lurie Children's Hospital/Northwestern University in Chicago, Illinois. The overarching goal of the Children's National center was to develop evidence-based strategies to strengthen the health system response to rheumatic heart disease through synergistic basic, clinical, and population science research. The overall goals of the Duke center were to determine risk factors for obesity and response to treatment including those that might work on a larger scale in communities across the country. The integrating theme of the Utah center focused on leveraging big data-science approaches to improve the quality of care and outcomes for children with congenital heart defects, within the context of the patient and their family. The overarching hypothesis of the Northwestern center is that the early course of change in cardiovascular health, from birth onward, reflects factors that result in either subsequent development of cardiovascular risk or preservation of lifetime favorable cardiovascular health. All 4 centers exceeded the original goals of research productivity, fellow training, and collaboration. This article describes details of these accomplishments and highlights challenges, especially around the COVID-19 pandemic.

Sustainability of weight loss from a family-centered pediatric weight management program integrated in primary care

BACKGROUND

A 6-month pediatric weight loss program showed modest success, but the sustainability of this success after 12 months was unclear. The present study aims tomeasure the medium-term effectiveness of family-based weight management in pediatric primary care to reduce body weight in children living with obesity.

METHODS

In a retrospective cohort study, children ages 3 to 17 years with obesity in Kaiser Permanente Orange County, California, who enrolled in a weight management program between April 2014 and December 2018 (FB-WMG, n = 341) were compared to children referred but not enrolled (Ref-CG, n = 317) and controls matched by sex, age, zip code and BMI (Area-CG, n = 801). The relative distance from the median BMI-for-age at months 0, 6, and 12 were expressed as difference-in-differences (DID) using multivariable linear regressions with robust standard error.

RESULTS

The baseline BMI-for-age was 98.6 (SD 1.08) percentile in FB-WMG, 98.2 (SD 1.22) percentile in Ref-CG, and 98.6 (1.13 in Area-CG). FB-WMG had a median of 3 visits (P25 1 visit, P75 5 visits) in the first 6 months. Despite a more considerable decrease in the relative distance to the median BMI-for-age in FB-WMG children with 3+ visits after 6 months, the success obtained was not sustained at 12 months (DID FB-WMG vs Area-CG -0.34, 95% CI - 3.00 to 2.33%, FB-WMG vs Ref-CG -0.39, 95% CI - 3.14 to 2.35%). At 12 months, there was no statistical significant difference between the three groups (FB-WWG, Ref-CG, Area-CG).

CONCLUSIONS

The initial success in weight management was not sustained in the absence of continued support for healthy lifestyle changes. Based on current evidence, continued support is necessary to maintain and promote success beyond a brief 6 month intervention. Long-term pediatric weight management programs are needed to promote continuing progress.

Five-year follow-up of a family-based multidisciplinary program for children with obesity

OBJECTIVE

This study aimed to determine 5-year outcomes from a 12-month, family-based, multidisciplinary lifestyle intervention program for children.

METHODS

This study was the 5-year follow-up of a randomized clinical trial comparing a low-intensity control group (home-based assessments) with a high-intensity intervention group (assessments plus weekly sessions) in New Zealand. Participants were aged 5 to 16 years with BMI ≥ 98th centile or > 91st centile with weight-related comorbidities. The primary outcome was BMI standard deviation score (BMISDS). Secondary outcomes included various health markers.

RESULTS

Of the 199 children included in the study at baseline (47% who identified as Māori, 53% who identified as female, 28% in the most deprived quintile, mean age = 10.7 years, mean BMISDS = 3.12), 86 completed a 5-year assessment (43%). BMISDS reduction at 12 months was not retained (control = 0.00 [95% CI: -0.22 to 0.21] and intervention = 0.17 [95% CI: -0.01 to 0.34]; p = 0.221) but was greater in participants aged <10 years versus >10 years at baseline (-0.15 [95% CI: -0.33 to 0.03] vs. 0.21 [95% CI: 0.03 to 0.40]; p = 0.008). BMISDS trajectory favored participants with high attendance (p = 0.013). There were persistent improvements in water intake and health-related quality of life in both groups as well as reduced sweet drink intake in the intervention group.

CONCLUSIONS

This intervention, with high engagement from those most affected by obesity, did not achieve long-term efficacy of the primary outcome. Attendance and age remain important considerations for future interventions to achieve long-term BMISDS reduction.

Health system barriers to accessing care for children with weight issues in New Zealand: An interview-based study

OBJECTIVE

To identify barriers created and maintained by the health system affecting engagement in a family-based multidisciplinary healthy lifestyle programme for children and adolescents in New Zealand.

METHODS

We conducted 64 semi-structured interviews with participants of the programme (n = 71) with varying levels of engagement, including those who declined contact after their referral. Half the interviews were with families with Māori children, allowing for appropriate representation. Interviews were analysed using thematic analysis.

RESULTS

Five health system factors affecting engagement were identified: the national policy environment, funding constraints, lack of coordination between services, difficulty navigating the health system, and the cost of primary health care.

CONCLUSIONS

Engaging with a health system that creates and maintains substantial barriers to accessing services is difficult, affecting programme engagement, even where service-level barriers have been minimised. Lack of access remains a crucial barrier to improved health outcomes for children and their families experiencing childhood obesity in New Zealand. There is a need for comprehensive approaches that are accompanied by a clear implementation strategy and coordinated across sectors.

Participants' and caregivers' experiences of a multidisciplinary programme for healthy lifestyle change in Aotearoa/New Zealand: a qualitative, focus group study

OBJECTIVE

Child and adolescent obesity continues to be a major health issue internationally. This study aims to understand the views and experiences of caregivers and participants in a child and adolescent multidisciplinary programme for healthy lifestyle change.

DESIGN

Qualitative focus group study.

SETTING

Community-based healthy lifestyle intervention programme in a mixed urban-rural region of Aotearoa/New Zealand.

PARTICIPANTS

Parents/caregivers (n=6) and children/adolescents (n=8) who participated in at least 6 months of an assessment and weekly session, family-based community intervention programme for children and adolescents affected by obesity.

RESULTS

Findings covered participant experiences, healthy lifestyle changes due to participating in the programme, the delivery team, barriers to engagement and improvements. Across these domains, four key themes emerged from the focus groups for participants and their caregivers relating to their experience: knowledge-sharing, enabling a family to become self-determining in their process to achieve healthy lifestyle change; the importance of connectedness and a family-based programme; the sense of a collective journey and the importance of a nonjudgemental, respectful welcoming environment. Logistical challenges and recommendations for improvement were also identified.

CONCLUSIONS

Policymakers need to consider the experiences of participants alongside quantitative outcomes when informing multidisciplinary intervention programmes for children and adolescents affected by obesity.Trial registration number Australian New Zealand Clinical Trials Registry (ANZCTR):12611000862943; Post-results.

Challenges of making healthy lifestyle changes for families in Aotearoa/New Zealand

Objective:

The objective of the current study was to identify challenges of making and sustaining healthy lifestyle changes for families with children/adolescents affected by obesity, who were referred to a multicomponent healthy lifestyle assessment and intervention programme in Aotearoa/New Zealand (NZ).

Design:

Secondary qualitative analysis of semi-structured interviews.

Setting:

Taranaki region of Aotearoa/NZ.

Participants:

Thirty-eight interviews with parents/caregivers (n 42) of children/adolescents who had previously been referred to a family-focused multidisciplinary programme for childhood obesity intervention, who identified challenges of making healthy lifestyle changes. Participants had varying levels of engagement, including those who declined contact after their referral.

Results:

Participant-identified challenges included financial cost, impact of the food environment, time pressures, stress, maintaining consistency across households, independence in adolescence, concern for mental health and frustration when not seeing changes in weight status.

Conclusions:

Participants recognised a range of factors that contributed towards their ability to make and sustain change, including factors at the wider socio-environmental level beyond their immediate control. Even with the support of a multidisciplinary healthy lifestyle programme, participants found it difficult to make sustained changes within an obesogenic environment. Healthy lifestyle intervention programmes and families’ abilities to make and sustain changes require alignment of prevention efforts, focusing on policy changes to improve the food environment and eliminate structural inequities.

Creating a Learning Televillage and Automated Digital Child Health Ecosystem

This article explores the impact of digital technologies, including telehealth, teleconsultations, wireless devices, and chatbots, in pediatrics. Automated digital health with the Internet of things will allow better collection of real-world data for generation of real-world evidence to improve child health. Artificial intelligence with predictive analytics in turn will drive evidence-based decision-support systems and deliver personalized care to children. This technology creates building blocks for a learning child health and health care ecosystem.

Family-centeredness of childhood obesity interventions: psychometrics & outcomes of the family-centered care assessment tool

BACKGROUND

Incorporating family-centered care principles into childhood obesity interventions is integral for improved clinical decision making, better follow-through, and more effective communication that leads to better outcomes and greater satisfaction with services. The purpose of this study is to evaluate the psychometric properties of a modified version of the Family Centered-Care Assessment (mFCCA) tool and to assess the family-centeredness of two clinical-community childhood obesity interventions.

METHODS

Connect for Health was a randomized trial testing the comparative effectiveness of two interventions that enrolled 721 children, ages 2-12 years, with a body mass index (BMI) ≥ 85th percentile. The two arms were (1) enhanced primary care; and (2) enhanced primary care plus contextually-tailored, health coaching. At the end of the one-year intervention, the mFCCA was administered. We used Rasch analyses to assess the tool's psychometrics and examined differences between the groups using multiple linear regression.

RESULTS

629 parents completed the mFCCA resulting in an 87% response rate. The mean (SD) age of children was 8.0 (3.0) years. The exploratory factor analysis with 24 items all loaded onto a single factor. The Rasch modeling demonstrated good reliability as evidenced by the person separation reliability coefficient (0.99), and strong validity as evidenced by the range of item difficulty and overall model fit. The mean (SD, range) mFCCA score was 4.14 (0.85, 1-5). Compared to parents of children in the enhanced primary care arm, those whose children were in the enhanced primary care plus health coaching arm had higher mFCCA scores indicating greater perception of family-centeredness (β = 0.61 units [95% CI: 0.49, 0.73]).

CONCLUSIONS

Using the mFCCA which demonstrated good psychometric properties for the assessment of family-centered care among parents of children with obesity, we found that individualized health coaching is a family-centered approach to pediatric weight management.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02124460.

Community engagement and pediatric obesity: Incorporating social determinants of health into treatment

Childhood obesity is a complex and multi-faceted problem, with contributors ranging from individual health behaviors to public policy. For clinicians who treat pediatric obesity, environmental factors that impact this condition in a child or family can be difficult to address in a clinical setting. Community-clinic partnerships are one method to address places and policies that influence a person’s weight and health; however, such partnerships are typically geared toward community-located health behavior change rather than the deeper social determinants of health (SDH), limiting effective behavioral change. Community-engaged research offers a framework for developing community-clinic partnerships to address SDH germane to obesity treatment. In this paper, we discuss the relationship between SDH and pediatric obesity treatment, use of community-clinic partnerships to address SDH in obesity treatment, and how community engagement can be a framework for creating and harnessing these partnerships. We present examples of programs begun by one pediatric obesity clinic using community-engagement principles to address obesity.

Waist Circumference and Healthy Lifestyle Preferences/Knowledge Monitoring in a Preschool Obesity Prevention Program

Weight and body mass index (BMI) changes appear to be poor measures for assessing the success of most pediatric obesity prevention programs (POPP). The aim of this study is to evaluate the effectiveness of the preschool-age prevention program (3P) in improving and maintaining overtime preschoolers' knowledge/preferences about healthy nutrition and physical activity (PA), and the relationship between acquired healthy behaviors and anthropometrics including waist circumference (WC). Twenty-five preschoolers underwent a 24-month healthy lifestyle multi-component pilot intervention followed by a one-year wash-out period; 25 age-matched served as controls. Anthropometric/behavioral data were monitored. After the 2-year study and wash-out, the rates of children overweight and with obesity decreased only in the intervention group, where, also, normal-weight children with visceral obesity attained WC normal values (p = 0.048). While mean values of BMI Z-scores remained unchanged in both the intervention and control groups, WC (values and percentiles) showed a significant reduction only in the intervention group. Children's adherence to the Mediterranean diet remained acceptable among the entire sample. Although daily sweet beverage consumption remained unchanged in both groups, knowledge/preferences improved significantly more in the intervention group. In conclusion, WC may be more sensitive than BMI for monitoring preschoolers in POPP and reflects healthy behavioral changes acquired during the intervention.

Go Girls!-Dance-Based Fitness to Increase Enjoyment of Exercise in Girls at Risk for PCOS

Weight loss can reduce the hyperandrogenemia associated with polycystic ovary syndrome (PCOS) in peripubertal girls. Yet, adolescent girls have the lowest rates of physical activity and enjoyment of exercise. We created a dance-based support group (Go Girls!) to entice physical activity and improve enjoyment. Girls ages 7–21 over the 85th BMI percentile were recruited and attended once-weekly sessions for 3–6 months. We assessed changes in Physical Activity Enjoyment Scale (PACES), anthropometrics, laboratory data, and amounts of home exercise at 0, 3, and 6 months. Sixteen girls completed either 3 or 6 months. PACES scores were surprisingly high at baseline and remained high. Systolic blood pressure percentile decreased post-intervention. Although no group differences were observed, the majority of individual girls had decreased waist circumference, triglycerides, and metabolic syndrome severity score. Forty percent had decreased free testosterone levels. More girls enjoyed physical education class, got exercise outside of school, and made other lifestyle changes. This dance-based support group was enjoyed by girls and demonstrated health benefits. Continued efforts to engage girls in physical activity are necessary to protect girls from the consequences of obesity, including PCOS and metabolic syndrome. Dance exercise remains a promising tool to encourage physical activity in girls.

Obesity Prevention and Treatment in Primary Care

Despite extensive public health and clinical interventions, obesity rates remain high, and evidence-based preventive strategies are elusive. Many consensus guidelines suggest that providers should screen all children after age 2 years for obesity by measuring height and weight, calculating body mass index (BMI), and sensitively communicating weight status in the context of health to the family at each visit. However, preventive counseling should begin in infancy and focus on healthy feeding, activity, and family lifestyle behaviors. For children with overweight or obesity, the American Academy of Pediatrics outlines 4 stages of treatment: 1) Primary care providers should offer "prevention plus," the use of motivational interviewing to achieve healthy lifestyle modifications in family behaviors or environments; 2) children requiring the next level of obesity treatment, structured weight management, need additional support beyond the primary care provider (such as a dietitian, physical therapist, or mental health counselor) and more structured goal setting with the team, including providers adept at weight management counseling; 3) children with severe obesity and motivated families may benefit from referral to a comprehensive multidisciplinary intervention, such as an obesity treatment clinic; and 4) tertiary care interventions are provided in a multidisciplinary pediatric obesity treatment clinic with standard clinical protocols for evaluation of interventions, including medications and surgery. Although it is certainly a challenge for providers to fit in all the desired prevention and treatment counseling during preventive health visits, by beginning to provide anticipatory guidance at birth, providers can respond to parents' questions, add to parents' knowledge base, and partner with parents and children and adolescents to help them grow up healthy. This is especially important in an increasingly toxic food environment with numerous incentives and messages to eat unhealthfully, barriers to appropriate physical activity, and concomitant stigma about obesity. Focusing on key nutrition and physical activity habits and establishing these healthy behaviors at an early age will allow children to develop a healthy growth trajectory. However, much more work is needed to determine the best evidence-based practices for providers to counsel families on improving target behaviors, environmental modifications, and parenting skills and to decrease abundant disparities in obesity prevalence and treatment.

Evidence Base for Multidisciplinary Care of Pediatric/Adolescent Bariatric Surgery Patients

PURPOSE OF REVIEW

Severe childhood obesity, defined as having a body mass index (BMI) greater than the 99th percentile for age and gender, is rising in most countries and is associated with early morbidity and mortality. Optimal management of the health of the child with obesity requires a multidisciplinary approach that identifies and treats associated derangements.

RECENT FINDINGS

Lifestyle interventions such as diet, exercise, and behavioral therapy for the severely obese pediatric patient are generally not effective. Few centers worldwide offer bariatric surgery for adolescents in a multidisciplinary setting, and we are the only center that offers a multidisciplinary approach that incorporates bariatric surgery for severely obese children and adolescents across all age groups. In this paper, we review up-to-date evidence in this subject including ours, and provide details on the multidisciplinary approach to pediatric obesity that accommodates bariatric surgery for children across all age groups.

Study of the effects of nesfatin-1 on gastric function in obese rats

AIM

To investigate the effects of nesfatin-1 on gastric function in obese rats.

METHODS

The obese rat model was induced by a high-fat diet. The gastric emptying rate and gastric acid secretory capacity of the rats were determined after treatment with different drug concentrations of nesfatin-1 and administration routes. Based on this, the expression of H+/K+-ATPase was measured using RT-PCR and western blot to preliminarily explore the mechanism of gastric acid secretion changes.

RESULTS

Body weight, body length, and Lee’s index of the rats significantly increased in the high-fat diet-induced obese rat model. Two hours after lateral intracerebroventricular injection of nesfatin-1, the gastric emptying rate and gastric acid secretory capacity of rats decreased. Four hours after injection, both were restored to normal levels. In addition, the expression of H+/K+-ATPase decreased and moved in line with changes in gastric acid secretory capacity. This in vivo experiment revealed that intracerebroventricular injection of nesfatin-1, rather than intravenous injection, could suppress gastric function in obese rats. Moreover, its effect on the gastric emptying and gastric acid secretory capacity of rats is dose-dependent within a certain period of time.

CONCLUSION

Through this research, we provide a theoretical basis for further studies on nesfatin-1, a potential anti-obesity drug.