Clinical potential of fasting in type 1 diabetes

Most adults with type 1 diabetes (T1DM) are either overweight or obese. As such, dietary management is recommended as an adjunct to insulin treatment to improve glycemic control and facilitate weight loss in these patients. Time-restricted eating (TRE) is a form of intermittent fasting that offers a simplified approach to treating obesity in T1DM. TRE typically involves restricting eating to 6 to 10 h per day, with water and medications allowed outside the eating window. This review examines the efficacy of TRE and other fasting protocols in improving weight and glycemic control in patients with obesity and T1DM. This review will also evaluate the safety of these regimens and provide advice to clinicians on implementing intermittent fasting in T1DM.

Decline in case rates of youth onset type 2 diabetes in year three of the COVID-19 pandemic

OBJECTIVES

To determine changes in case rates of youth onset type 2 diabetes in the three years following the COVID-19 pandemic.

METHODS

A single-center, retrospective medical record review was conducted for patients newly diagnosed with T2D between 3/1/18 and 2/28/23 at a pediatric tertiary care center. The number of patients referred to CHLA with a T2D diagnosis date between 3/1/2020 and 2/28/2023 was compared to historical rates between 3/1/2018 and 2/29/2020. χ2 or Fisher's exact test was used to compare categorical variables between each year and 2019.

RESULTS

Compared to prepandemic baseline (3/1/19-2/29/20, 11.8±3.7 cases/month), there was a significant increase in new T2D monthly case rates in pandemic year 1 (3/1/20-2/28/21, 20.1±6.0 cases/month, 171 %, p=0.005) and pandemic year 2 (3/1/21-2/28/22, 25.9±8.9 cases/month, 221 %, p=0.002). Case rates declined in pandemic year 3 to 14.5±4.1 cases/month (3/1/22-2/28/23, p=0.43). Compared to prepandemic year 1, the frequency of DKA at diagnosis was higher in pandemic year 1 (13.3 vs. 5.0 %, p=0.009). The DKA rate in pandemic years 2 (6.8 %) and 3 (3.4 %) were comparable to prepandemic year 1 (p=0.53 and 0.58, respectively).

CONCLUSIONS

Youth onset type 2 diabetes cases and DKA rates in year 3 of the pandemic have returned to prepandemic level.

Wearable Devices Beyond Activity Trackers in Youth With Obesity: Summary of Options

Background: Current treatment protocols to prevent and treat pediatric obesity focus on prescriptive lifestyle interventions. However, treatment outcomes are modest due to poor adherence and heterogeneity in responses. Wearable technologies offer a unique solution as they provide real-time biofeedback that could improve adherence to and sustainability of lifestyle interventions. To date, all reviews on wearable devices in pediatric obesity cohorts have only explored biofeedback from physical activity trackers. Hence, we conducted a scoping review to (1) catalog other biofeedback wearable devices available in this cohort, (2) document various metrics collected from these devices, and (3) assess safety and adherence to these devices. Methods: This scoping review was conducted adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Fifteen eligible studies examined the use of biofeedback wearable devices beyond activity trackers in pediatric cohorts, with an emphasis on feasibility of these devices. Results: Included studies varied in sample sizes (15-203) and in ages 6-21 years. Wearable devices are being used to capture various metrics of multicomponent weight loss interventions to provide more insights about glycemic variability, cardiometabolic function, sleep, nutrition, and body fat percentage. High safety and adherence rates were reported among these devices. Conclusions: Available evidence suggests that wearable devices have several applications aside from activity tracking, which could modify health behaviors through real-time biofeedback. Overall, these devices appear to be safe and feasible so as to be employed in various settings in the pediatric age group to prevent and treat obesity.

Limitations of BMI z scores for assessing weight change: A clinical tool versus individual risk

Although pediatric growth curves provide clinical utility, using these metrics for within-person change over time can be misleading. As research is focused on understanding cardiometabolic consequences of weight gain, it is important to use precise metrics to analyze these longitudinal research questions. Despite several foundational recommendations to limit the use of reference pediatric growth curves (e.g., BMI z scores) for within-person longitudinal research, it has evolved into the "gold standard" for using growth curves for pediatric weight gain analyses. Therefore, the objective of this paper is to discuss (A) the methodology used to create reference growth curves; (B) the appropriate use of reference pediatric BMI growth curves within the context of cross-sectional and longitudinal analyses in research; and (C) how to select metrics based on desired evaluations. Careful consideration using standardized references scores is essential when assessing obesity-related questions and comorbid risk over time in pediatric populations.

Cost-effectiveness analysis of individual-level obesity treatment in paediatrics: A scoping review

OBJECTIVES

This scoping review informs a health economics perspective on the treatment of paediatric obesity. The results detail recently published research findings on the cost-effectiveness of paediatric obesity treatments and identify key characteristics of cost-effective interventions.

METHODS

A structured search was applied to six databases with no data restriction through March 2023: Medline, Embase, Cochrane CENTRAL, CINAHL, and PsycINFO. Studies that included a cost analysis of an individual level, weight management intervention (behavioural, pharmacotherapy, and surgical) in youth, with obesity, ages 2 to 21 years were eligible for inclusion.

RESULTS

Of the 4371 records identified in the initial search, 353 underwent full-text review, 39 studies met the pre-specified inclusion criteria. The majority were published after 2010 (n = 36/39, 92%) and applied to high-income countries (n = 39/39, 100%). Thirty-five of the studies assessed the cost-effectiveness of lifestyle interventions (90%), and four studies assessed surgical outcomes (10%). No pharmacotherapy studies met eligibility criteria. Although the outcome measures differed across the studies, all four surgical interventions were reported to be cost-effective. Thirty of the 35 (85%) lifestyle modification studies were reported to be cost-effective compared to the study comparator examined.

CONCLUSIONS

There is a small amount of evidence that individual-level paediatric obesity treatment interventions are cost-effective and, in some cases cost-saving, with most of this work conducted on behavioural interventions. The economic evaluation of paediatric obesity interventions poses various methodologic challenges, which should be addressed in future research to fully use the potential of economic evaluation as an aid to decision-making.

Assessment of Adverse Childhood Experiences and Social Determinants of Health: A Survey of Practices in Pediatric Weight Management Programs

Introduction: Adverse childhood experiences (ACEs) and social determinants of health (SDoH) are associated with increased incidence of pediatric obesity. Recent literature highlights an imperative need to assess ACEs and SDoH among youth and families with obesity to identify those individuals requiring targeted interventions. The primary objective of the present study was to examine the frequency, methodology, and barriers in evaluation of ACEs and SDoH within pediatric weight management programs (PWMPs). Methods: Invitations were e-mailed to a comprehensive directory of 92 PWMPs in the United States with a link to complete an electronic survey. Results: Forty-one PWMPs from 26 states completed the survey. Assessment of one or more ACEs and SDoH was common and typically took place during the initial patient visit by the psychologist or medical practitioner through unstructured conversations. Reported barriers to assessment included lack of time to assess and to follow-up, lack of clinic protocols, and inadequate referral resources. Programs offering bariatric surgery and those with embedded mental health clinicians reported fewer barriers to ACEs/SDoH referral resources, while family-based and healthy lifestyle-focused programs perceived more barriers related to insufficient support staff and time to follow-up with families. Conclusions: Most PWMPs assess a subset of ACEs and SDoH; however, approaches to assessment vary, are often unstructured, and several barriers remain to optimizing assessment and follow-up. Future research should evaluate standardized ACEs/SDoH assessment protocols, ideal workflow, and their impact on obesity treatment and related health outcomes.

Impact of 8-hour time-limited eating on sleep in adolescents with obesity

STUDY OBJECTIVES

The relationship between time-limited eating (TLE) and sleep quality is a topic of growing interest in the field of chronobiology. Data in adult cohorts shows that TLE may improve sleep quality, but this has not been evaluated in adolescents. The aim of this secondary analysis was to (1) examine the impact of 8-hour TLE on sleep parameters in youth with obesity and (2) explore if there was any association between sleep patterns and glycemic profiles.

METHODS

Adolescents with obesity were randomized into one of three groups: 8-hour TLE (participants self-selected their eating window) + real-time continuous glucose monitor, 8-hour TLE + blinded continuous glucose monitor, or a prolonged eating window. In the primary analysis, it was found that participants in the real-time continuous glucose monitor group + 8-hour TLE group did not access their continuous glucose monitor data and thus for this analysis the two TLE groups were combined and only completers who had available Pittsburgh Sleep Quality Index (PSQI) data at all three time points were included. Participants completed the PSQI at baseline, week 4, and week 12. Mixed-effects generalized linear regression models were utilized to examine the change in PSQI score and assess association between glycemic variability and PSQI total score overtime by intervention arm.

RESULTS

The median PSQI total score for the TLE groups (n = 27) was 6 at week 0 (interquartile range = 5 to 10) and 5 at week 12 (interquartile range = 2 to 7). There was no significant difference in the change in total PSQI score or sleep latency between TLE and control over the study period (P > .05). There was no association between PSQI score and change in weight or glycemic profile between groups (all P values > 0.05).

CONCLUSIONS

These results suggest that in adolescents with obesity, an 8-hour TLE approach did not negatively impact sleep quality or efficiency when compared to a prolonged eating window. The potential effects of TLE on sleep should be further investigated in larger randomized trials.

CITATION

Jayakumr A, Gillett ES, Wee CP, Kim A, Vidmar AP. Impact of 8-hour time-limited eating on sleep in adolescents with obesity. J Clin Sleep Med. 2023;19(11):1941-1949.

Use of Continuous Glucose Monitors by People Without Diabetes: An Idea Whose Time Has Come?

BACKGROUND

Continuous glucose monitor (CGM) systems were originally intended only for people with diabetes. Recently, there has been interest in monitoring glucose concentrations in a variety of other situations. As data accumulate to support the use of CGM systems in additional states unrelated to diabetes, the use of CGM systems is likely to increase accordingly.

METHODS

PubMed and Google Scholar were searched for articles about the use of CGM in individuals without diabetes. Relevant articles that included sufficient details were queried to identify what cohorts of individuals were adopting CGM use and to define trends of use.

RESULTS

Four clinical user cases were identified: (1) metabolic diseases related to diabetes with a primary dysregulation of the insulin-glucose axis, (2) metabolic diseases without a primary pathophysiologic derangement of the insulin-glucose axis, (3) health and wellness, and (4) elite athletics. Seven trends in the use of CGM systems in people without diabetes were idenfitied which pertained to both FDA-cleared medical grade products as well as anticipated future products, which may be regulated differently based on intended populations and indications for use.

CONCLUSIONS

Wearing a CGM has been used not only for diabetes, but with a goal of improving glucose patterns to avoid diabetes, improving mental or physical performance, and promoting motivate healthy behavioral changes. We expect that clinicians will become increasingly aware of (1) glycemic patterns from CGM tracings that predict an increased risk of diabetes, (2) specific metabolic glucotypes from CGM tracings that predict an increased risk of diabetes, and (3) new genetic and genomic biomarkers in the future.

Effect of Time-Restricted Eating on Weight Loss in Adults With Type 2 Diabetes: A Randomized Clinical Trial

Importance

Time-restricted eating (TRE) has become increasingly popular, yet longer-term randomized clinical trials have not evaluated its efficacy and safety in patients with type 2 diabetes (T2D).

Objective

To determine whether TRE is more effective for weight reduction and glycemic control than daily calorie restriction (CR) or a control condition in adults with T2D.

Design, Setting, and Participants

This 6-month, parallel-group, randomized clinical trial was performed between January 25, 2022, and April 1, 2023, at the University of Illinois Chicago. Participants were aged 18 to 80 years with obesity and T2D. Data analysis was based on intention to treat.

Interventions

Participants were randomized to 1 of 3 groups: 8-hour TRE (eating 12 to 8 pm only, without calorie counting), CR (25% energy restriction daily), or control.

Main Outcomes and Measures

The primary outcome measure was change in body weight by month 6. Secondary outcomes included changes in hemoglobin A1c (HbA1c) levels and metabolic risk factors.

Results

Seventy-five participants were enrolled with a mean (SD) age of 55 (12) years. The mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 39 (7) and the mean (SD) HbA1c level was 8.1% (1.6%). A total of 53 participants (71%) were women. One participant (1%) was Asian, 30 (40%) were Hispanic White, 40 (53%) were non-Hispanic Black, and 4 (5%) were non-Hispanic White. Participants in the TRE group were adherent with their eating window on a mean (SD) of 6.1 (0.8) days per week, and 17 (68%) in the CR group were adherent with their prescribed calorie goals over 6 months. The mean (SD) reduction in energy intake was -313 (509) kcal/d for TRE, -197 (426) kcal/d for CR, and -16 (439) kcal/d for controls. By month 6, body weight decreased significantly in the TRE group (-3.56% [95% CI, -5.92% to -1.20%]; P = .004) but not the CR group (-1.78% [95% CI, -3.67% to 0.11%]; P = .06), relative to controls. Levels of HbA1c decreased in the TRE (-0.91% [95% CI, -1.61% to -0.20%]) and CR (-0.94% [95% CI, -1.59% to -0.30%]) groups, relative to controls, with no differences between the TRE and CR groups. Time in euglycemic range, medication effect score, blood pressure, and plasma lipid levels did not differ among groups. No serious adverse events were reported.

Conclusions and relevance

This randomized clinical trial found that a TRE diet strategy without calorie counting was effective for weight loss and lowering of HbA1c levels compared with daily calorie counting in a sample of adults with T2D. These findings will need to be confirmed by larger RCTs with longer follow-up.

Trial Registration

ClinicalTrials.gov Identifier: NCT05225337.

Association Between COVID-19 and Severity of Illness for Children With Hyperglycemic Crisis

OBJECTIVES

Admissions to the ICU for children with hyperglycemic crisis (HGC, defined as diabetic ketoacidosis, hyperglycemic hyperosmolar syndrome, or hyperosmolar ketoacidosis) increased during the COVID-19 pandemic. We sought to identify if severity of illness for HGC also increased from prepandemic to pandemic years 1 and 2.

METHODS

Retrospective study of children aged ≤18 years hospitalized in the Pediatric Health Information System for HGC. Pre-COVID-19 years were defined as March 2017-February 2020, COVID-19 year 1 as March 2020-February 2021, and COVID-19 year 2 as March 2021-February 2022. The primary outcome was ICU admission. Secondary outcomes included mortality, length of stay, cost, and use of neurologic therapies, mechanical ventilation, or vasoactive support.

RESULTS

There were 46 425 HGC admissions to 42 hospitals, 20 045 (43.2%) of which were ICU admissions. In comparison with pre-COVID-19, children admitted in COVID-19 year 1 (odds ratio, 1.31 [95% confidence interval, 1.25-1.38], P < .0001) and year 2 (odds ratio, 1.17 [95% confidence interval, 1.11-1.22], P < .0001) had a higher odds of ICU admission in multivariable modeling after controlling for confounding variables. Severity of illness was higher during COVID-19 years when considering secondary outcomes, although these associations were not consistent across outcomes and year. There was no difference in mortality.

CONCLUSIONS

Children with HGC had a higher severity of illness during the pandemic which was sustained over 2 years. Reduction in social distancing and evolving variants of SARS-CoV-2 over the 2 years of the pandemic did not significantly alter the relationship between HGC and higher requirement for ICU care.

Parental Perceptions of Medication Use for the Treatment of Obesity in Youth

Background: This survey-based study identified views on antiobesity medications in youth referred to a weight management program. Methods: One parent completed a 14-item Research Electronic Data Capture (REDcap) survey regarding openness to medication use in youth with obesity at their first visit in a weight management program. Medical data were extracted from the medical records of all responders. Results: Ninety-four percent (116/125) of parents approached completed the survey (youths' demographic: mean age = 14.1 years old, 46.8% female, 68.8% Hispanic). Results indicate that 75% of parents surveyed were open to medication use. There was no difference in sex, age, insurance, severity of obesity, or family history between parents who were and were not open to medication (all p > 0.05). Hispanic ethnicity was associated with greater openness to medication use (odds ratio: 3.4, 95% confidence interval: 1.4-8.5, p = 0.007). Conclusions: These results highlight the importance of parental perceptions of medication use for obesity treatment and suggest a need for improved education about the role of medication in the management of pediatric obesity.

A Narrative Review: Phentermine and Topiramate for the Treatment of Pediatric Obesity

The prevalence of pediatric obesity has increased exponentially over the past four decades. The American Academy of Pediatrics recently released updated clinical practice guidelines highlighting the importance of identifying pediatric obesity as a chronic disease. The guidelines support consideration of concurrent treatment with intensive lifestyle interventions, obesity pharmacotherapy, and bariatric surgery. The dramatic rise in pediatric obesity has spurred interest in utilizing obesity pharmacotherapy to support sustained weight reduction in pediatric cohorts, in the hopes of preventing the emergence of later-appearing, significant co-morbidities. Despite the enormous demand, the obstacles posed by performance of needed clinical trials in the pediatric population markedly limits available pharmacotherapy for the treatment of obesity in pediatrics. Currently, there are five medications approved by the Food and Drug Administration for use in youth with obesity. In 2022, the phentermine/topiramate (PHEN/TPM), once-daily, controlled-release, combination product received FDA approval, for the indication of chronic weight management, in youth with obesity, ages 12 years and older. The objectives of this narrative review are to: (1) Review the mechanism of action of phentermine and topiramate, (2) Summarize the safety and efficacy data of topiramate and phentermine use as both monotherapies and in combination, and (3) Discuss clinical practice guidelines and clinical implications, for the use of these agents in youths with obesity.

Eating disorders in weight-related therapy (EDIT): Protocol for a systematic review with individual participant data meta-analysis of eating disorder risk in behavioural weight management

The Eating Disorders In weight-related Therapy (EDIT) Collaboration brings together data from randomised controlled trials of behavioural weight management interventions to identify individual participant risk factors and intervention strategies that contribute to eating disorder risk. We present a protocol for a systematic review and individual participant data (IPD) meta-analysis which aims to identify participants at risk of developing eating disorders, or related symptoms, during or after weight management interventions conducted in adolescents or adults with overweight or obesity. We systematically searched four databases up to March 2022 and clinical trials registries to May 2022 to identify randomised controlled trials of weight management interventions conducted in adolescents or adults with overweight or obesity that measured eating disorder risk at pre- and post-intervention or follow-up. Authors from eligible trials have been invited to share their deidentified IPD. Two IPD meta-analyses will be conducted. The first IPD meta-analysis aims to examine participant level factors associated with a change in eating disorder scores during and following a weight management intervention. To do this we will examine baseline variables that predict change in eating disorder risk within intervention arms. The second IPD meta-analysis aims to assess whether there are participant level factors that predict whether participation in an intervention is more or less likely than no intervention to lead to a change in eating disorder risk. To do this, we will examine if there are differences in predictors of eating disorder risk between intervention and no-treatment control arms. The primary outcome will be a standardised mean difference in global eating disorder score from baseline to immediately post-intervention and at 6- and 12- months follow-up. Identifying participant level risk factors predicting eating disorder risk will inform screening and monitoring protocols to allow early identification and intervention for those at risk.

Paediatric obesity: Documentation, screening, and pharmacotherapy in a national cohort

BACKGROUND

Multiple organizations have published guidelines for the screening and treatment of obesity and related comorbidities in youth, including the use of anti-obesity medications (AOM). This study aimed to determine which paediatric patients: (1) receive a diagnostic code for obesity; (2) are most likely to be screened for hyperlipidaemia, non-alcoholic fatty liver disease, and type 2 diabetes mellitus; and (3) are most likely to be prescribed AOM.

METHODS

A cohort of 35 898 patients 9 years 4 months to 17 years 6 months of age with a BMI > 30 or greater than the 95th% on three separate outpatient encounters was generated using the TriNetX database. Logistic regression models were used to estimate the associations between demographics in the study population and the likelihood of diagnosis of obesity, screening for comorbidities, and prescription of AOMs.

RESULTS

Asian, Black, and Hispanic youths had increased odds of having a diagnosis of obesity and being screened for all three comorbidities. Documentation of obesity was associated with increased odds of screening for all comorbidities. Female sex, documentation of obesity, and higher BMIs were associated with increased odds of being prescribed AOMs. Black and Native American races decreased the likelihood of being prescribed AOM.

CONCLUSIONS

Management of obesity in terms of documentation of disease, screening for comorbidities, and initiation of AOM continues to fall short of the guidelines put forth by multiple organizations. Race/ethnicity, sex, and BMI correlate with differences in care provided to obese paediatric patients. Further research is needed to identify the barriers to and causes of these disparities.

Intranasal Carbetocin Reduces Hyperphagia, Anxiousness, and Distress in Prader-Willi Syndrome: CARE-PWS Phase 3 Trial

CONTEXT

Prader-Willi syndrome (PWS) is a rare genetic disorder characterized by endocrine and neuropsychiatric problems including hyperphagia, anxiousness, and distress. Intranasal carbetocin, an oxytocin analog, was investigated as a selective oxytocin replacement therapy.

OBJECTIVE

To evaluate safety and efficacy of intranasal carbetocin in PWS.

DESIGN

Randomized, double-blind, placebo-controlled phase 3 trial with long-term follow-up.

SETTING

Twenty-four ambulatory clinics at academic medical centers.

PARTICIPANTS

A total of 130 participants with PWS aged 7 to 18 years.

INTERVENTIONS

Participants were randomized to 9.6 mg/dose carbetocin, 3.2 mg/dose carbetocin, or placebo 3 times daily during an 8-week placebo-controlled period (PCP). During a subsequent 56-week long-term follow-up period, placebo participants were randomly assigned to 9.6 mg or 3.2 mg carbetocin, with carbetocin participants continuing at their previous dose.

MAIN OUTCOME MEASURES

Primary endpoints assessed change in hyperphagia (Hyperphagia Questionnaire for Clinical Trials [HQ-CT]) and obsessive-compulsive symptoms (Children's Yale-Brown Obsessive-Compulsive Scale [CY-BOCS]) during the PCP for 9.6 mg vs placebo, and the first secondary endpoints assessed these same outcomes for 3.2 mg vs placebo. Additional secondary endpoints included assessments of anxiousness and distress behaviors (PWS Anxiousness and Distress Behaviors Questionnaire [PADQ]) and clinical global impression of change (CGI-C).

RESULTS

Because of onset of the COVID-19 pandemic, enrollment was stopped prematurely. The primary endpoints showed numeric improvements in both HQ-CT and CY-BOCS which were not statistically significant; however, the 3.2-mg arm showed nominally significant improvements in HQ-CT, PADQ, and CGI-C scores vs placebo. Improvements were sustained in the long-term follow-up period. The most common adverse event during the PCP was mild to moderate flushing.

CONCLUSIONS

Carbetocin was well tolerated, and the 3.2-mg dose was associated with clinically meaningful improvements in hyperphagia and anxiousness and distress behaviors in participants with PWS.

CLINICAL TRIALS REGISTRATION NUMBER

NCT03649477.

Rapid Decline in β-Cell Function and Increasing Adiposity Are Associated With Conversion to Type 2 Diabetes in At-Risk Latino Youth

Youth-onset type 2 diabetes (T2D) is becoming increasingly prevalent, especially among Latino youth, and there is limited information on its pathophysiology and causative factors. Here, we describe findings from a longitudinal cohort study in 262 Latino children with overweight/obesity at risk of developing T2D with annual measures of oral and intravenous glucose tolerance (IVGTT), body composition, and fat distribution. Logistic binomial regression was used to identify significant predictors in those who developed T2D compared with matched control participants, and mixed-effects growth models were used to compare rates of change in metabolic versus adiposity measures between groups. Overall conversion rate to T2D at year 5 was 2% (n = 6). Rate of decline in disposition index (DI), measured with an IVGTT, over 5 years was three times higher in case patients (-341.7 units per year) compared with the extended cohort (-106.7 units per year) and 20 times higher compared with control participants (-15.2 units per year). Case patients had significantly higher annual increases in fasting glucose, hemoglobin A1c (HbA1c), waist circumference, and trunk fat, and there was an inverse correlation between rate of decline in DI and rates of increase in adiposity measures. T2D development in at-risk Latino youth is associated with a substantial and rapid decrease in DI that is directly correlated with increases in fasting glucose, HbA1c, and adiposity.

ARTICLE HIGHLIGHTS

Youth-onset type 2 diabetes is becoming increasingly prevalent, especially among Latino youth, and there is limited information on its pathophysiology and causative factors. Overall conversion rate to type 2 diabetes over 5 years was 2%. In youth who converted to type 2 diabetes, disposition index decreased rapidly by 85% compared with that in patients who did not convert during the study period. There was an inverse correlation between rate of decline in disposition index and rates of increase in various adiposity measures.

Glucagon-like Peptide-1 Receptor Agonists for the Treatment of Type 2 Diabetes in Youth

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have gained traction for the management of type 2 diabetes and obesity. Unlike several classes of antidiabetic medications that contribute to weight gain, GLP-1RAs not only reduce haemoglobin A1c, but also promote weight loss. While there is a large body of evidence supporting its safety and efficacy in adults, paediatric clinical trial data have only emerged in recent years. This review will discuss the limited treatment options for paediatric type 2 diabetes and the mechanism of action of GLP-1RAs as it pertains to physiological pathways relevant for type 2 diabetes, obesity and their related comorbidities. The outcomes of paediatric trials evaluating liraglutide, exenatide, semaglutide and dulaglutide in paediatric type 2 diabetes and obesity will be closely examined, including differences compared with adult studies. Finally, potential barriers and strategies to expanding GLP-1RA access in adolescents will be discussed. Future studies are needed to determine if the cardio-and renal-protective benefits of GLP-1RAs apply to youth-onset type 2 diabetes.

An addiction-based digital weight loss intervention: A multi-centre randomized controlled trial

OBJECTIVE

This randomized clinical trial tested the effectiveness of an addiction-based digital weight-loss intervention, focusing on withdrawal/abstinence from self-identified problem foods, snacking and excessive amounts at meals, and discomfort displacement, with and without coaching, compared to an in-person, multi-disciplinary, care model among adolescents with obesity. We hypothesized that the digital intervention with coaching would yield greater weight loss and lower delivery burden than the standard clinical arm, and greater participant engagement than the digital arm without coaching.

METHODS

Adolescents were randomized to app intervention, with or without coaching, or in-person multidisciplinary obesity intervention for 6 months. The primary outcome was change in %BMIp95 at weeks 12 and 24. A mixed-effects linear regression model was used to assess the association between change in %BMIp95 and intervention arm. We were also interested in assessing delivery burden, participant engagement and evaluating the relationships between weight change and demographic characteristics, mood, executive function and eating behaviours.

RESULTS

All adolescents (n = 161; BMI ≥95th%, age 16 ± 2.5 year; 47% Hispanic, 65% female, 59% publicly insured) lost weight over 24-weeks (-1.29%, [-1.82, -0.76], p < 0.0001), with no significant weight loss difference between groups (p = 0.3). Girls lost more weight than boys, whereas binge eating behaviour at baseline was associated with increase in %BMIp95 when controlling for other covariates. There was no association between ethnicity, mood, timing of intervention in relation to the pandemic, or executive function and change in %BMIp95 .

CONCLUSIONS

Contrary with our hypothesis, our results showed no difference in the change in BMI status between treatment arms. Since efficacy of this digital intervention was not inferior to in-person, multi-disciplinary care, this could offer a reasonable weight management option for clinicians, based on youth and family specific characteristics, such as accessibility, resources, and communication styles.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT035008353.

Weight Loss During Topiramate Treatment in a Severely Obese Adolescent with Congenital Adrenal Hyperplasia and Migraine

Youth with classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency exhibit an increased prevalence of obesity, early adiposity rebound, and increased abdominal adiposity compared to unaffected youth. Current obesity management in CAH largely focuses on lifestyle modifications. There is evidence that topiramate therapy is effective in reducing body mass index (BMI), as well as visceral adipose tissue (VAT), in unaffected adolescents with exogenous obesity. However, little is known about the efficacy of topiramate in patients with classical CAH. We report on a 17-year-old female with severe obesity and salt-wasting CAH due to 21-hydroxylase deficiency, who demonstrated reductions in BMI, as well as abdominal visceral and subcutaneous adipose tissue (SAT) while on topiramate therapy. The patient was diagnosed with classical CAH as a newborn with a 17-hydroxyprogesterone 11,000 ng/dL. She had a BMI over the 95^th percentile at 3 years of age, followed by unremitting obesity. At 17 years old, she was started on topiramate to treat chronic migraines. Following three years of topiramate therapy, her BMI z-score decreased from +2.6 to +2.1. After four years of therapy, her waist circumference decreased from 110 to 101 cm, abdominal VAT decreased substantially by 34.2%, and abdominal SAT decreased by 25.6%. Topiramate therapy was associated with effective weight loss and reduced central adiposity in an adolescent with classical CAH and severe obesity, without any side effects. Further study is warranted regarding topiramate therapy in obese youth with classical CAH and increased central adiposity, who are at higher risk for significant morbidity.

Inpatient medical management of severe pediatric obesity: Literature review and case reports

Pediatric obesity rates continue to rise steeply with significant adverse effects on health outcomes across the lifespan. Significant obesity can affect the efficacy, side effects, and ability to use certain treatment, medication, or imaging modalities needed in the evaluation and management of acute pediatric conditions. Inpatient settings are rarely used as an opportunity for weight counseling and thus there is a paucity of clinical guidelines on how to manage severe obesity in the inpatient setting. We present a literature review and three patient cases with single-center protocol for non-surgical management of severe obesity in children admitted for other acute medical reasons. We performed a PubMed review from January 2002 to February 2022 utilizing keywords: "inpatient," "obesity," and "intervention." For our cases, we identified three patients with severe obesity acutely impacting their health while admitted for medical treatment who concurrently underwent acute, inpatient, weight loss regimens at a single children's hospital. The literature search yielded 33 articles describing inpatient weight loss treatments. Three patients met case criteria, all three of which demonstrated a decrease in their weight in excess percent of the 95th percentile after inpatient weight-management protocol implementation (% reduction BMI_p95: 16%-30%). This highlights obesity acutely limits or impacts specific medical care required during inpatient admissions in pediatric patients. It also suggests that implementation of an inpatient weight-management protocol during admission may provide an opportune setting to support acute weight loss and overall improved health outcomes in this high-risk cohort.

Integration of Time-Based Recommendations with Current Pediatric Health Behavior Guidelines: Implications for Obesity Prevention and Treatment in Youth

PURPOSE OF REVIEW

Youth-onset obesity is associated with negative health outcomes across the lifespan including cardiovascular diseases, type 2 diabetes, obstructive sleep apnea, dyslipidemias, asthma, and several cancers. Pediatric health guidelines have traditionally focused on the quality and quantity of dietary intake, physical activity, and sleep.

RECENT FINDINGS

Emerging evidence suggests that the timing (time of day when behavior occurs) and composition (proportion of time spent allocated to behavior) of food intake, movement (i.e., physical activity, sedentary time), and sleep may independently predict health trajectories and disease risks. Several theoretically driven interventions and conceptual frameworks feature behavior timing and composition (e.g., 24 h movement continuum, circadian science and chronobiology, intermittent fasting regimens, structured day hypothesis). These literatures are, however, disparate, with little crosstalk across disciplines. In this review, we examine dietary, sleep, and movement guidelines and recommendations for youths ages 0-18 in the context of theoretical models and empirical findings in support of time-based approaches. The review aims to inform a unifying framework of health behaviors and guide future research on the integration of time-based recommendations into current quantity and quality-based health guidelines for children and adolescents.

Topiramate for Weight Management in Children with Severe Obesity

Background: Topiramate has been shown to result in significant weight loss compared to placebo in adults with obesity. However, there are no consensus guidelines on the acceptability, safety, and efficacy of topiramate for weight loss in children. We present a literature review and case series on topiramate use in young children with severe obesity. Methods: We performed a PubMed search from January 2000 to February 2022 utilizing keywords, "topiramate" and "obesity" and "children" and "adolescent." For our case series, children were identified through retrospective chart review from a multidisciplinary weight management program. Eligibility criteria: age ≤12 years, class II or III obesity, completed 16 weeks of topiramate therapy as adjunct to lifestyle modifications. Semistructured interviews were conducted with one parent to review side effects. Results: Literature search yielded nine articles. All studies reported trends toward BMI reduction and weight loss with topiramate monotherapy. Five children met case series eligibility (mean age 10 years 3 months ±1.5 years, 60% female). After 16 weeks of topiramate, all children had a decrease in BMI as a percentage of the 95th percentile (mean -12% [-5% to -18%]). Parents reported improvement in impulsive eating and decreased desire to overeat compared to baseline. Four out of five reported no side effects, one reported drowsiness which resolved by dosing at nighttime. Conclusions: Results suggest that topiramate is well tolerated and may be utilized for weight management in younger children. A randomized controlled trial investigating the impact of topiramate for weight management in this age group is warranted.

Weight management in youth with rapid-onset obesity with hypothalamic dysregulation, hypoventilation, autonomic dysregulation, and neural crest tumor (ROHHAD-NET): literature search and case report

OBJECTIVES

Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, autonomic dysregulation, and neural endocrine tumor (ROHHAD-NET) syndrome is a youth-onset constellation of symptoms including rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation. Despite growing understanding of the clinical classification of this syndrome there is limited investigation into treatment of the rapid-onset obesity which can be progressive and life-limiting. The purpose of this case report is to describe the clinical timeline and treatment of severe obesity in a patient with of ROHHAD-NET and propose recommendations for the treatment of associated obesity.

CASE PRESENTATION

We present the case of a 10-year-old female with a clinical presentation consistent with ROHHAD-NET who achieved clinically meaningful weight loss with a combination of lifestyle modification and anti-obesity pharmacotherapies. We report on the use of three separate pharmacological agents and ultimately the referral for bariatric surgery.

CONCLUSIONS

Given that early-onset obesity and hypoventilation are life-limiting components of this condition, early recognition and treatment are essential to improve health outcomes.

Can a Behavioral Weight-Loss Intervention Change Adolescents' Food Addiction Severity?

Objective: This study examines changes in the Yale Food Addiction Scale symptom count over a 24-week, weight-loss mobile Health (mHealth) intervention incorporating elements of addiction medicine. Methods: Adolescents (n = 117) with obesity (15.5 ± 1.3 years; 66% Hispanic) were randomized to the following: (1) mHealth intervention (AppAlone), (2) mHealth intervention+coaching (AppCoach), or (3) in-person intervention (Control). A multivariate mixed Poisson regression model was used to evaluate changes in symptom counts across intervention arms after adjusting for sex, age, depressive symptomatology, stress, and executive function. Results: After the intervention, 57% of adolescents showed a decrease in symptom count (median change: -0.3 [0 to -1.5]), with a significant change by intervention arm in the intention-to-treat analysis (p = 0.045). There was a positive linear relationship between change in symptom count and change in depressive symptomatology (p < 0.01) and stress (p < 0.01), with no association with change in weight (p = 0.3). Discussion: Both mHealth and in-person obesity interventions seemed to confer benefits in food addiction symptomatology associated with change in mood and stress. Clinical Trial Registration number: NCT035008353.

Continuous Glucose Monitoring in Adolescents With Obesity: Monitoring of Glucose Profiles, Glycemic Excursions, and Adherence to Time Restricted Eating Programs

Background

Randomized controlled trials of time restricted eating (TRE) in adults have demonstrated improvements in glucose variability as captured by continuous glucose monitors (CGM). However, little is known about the feasibility of CGM use in TRE interventions in adolescents, or the expected changes in glycemic profiles in response to changes in meal-timing. As part of a pilot trial of TRE in adolescents with obesity, this study aimed to 1) assess the feasibility of CGM use, 2) describe baseline glycemic profiles in adolescents with obesity, without diabetes, and 3) compare the difference between glycemic profiles in groups practicing TRE versus control.

Methods

This study leverages data from a 12-week pilot trial (ClinicalTrials.gov Identifier: NCT03954223) of late TRE in adolescents with obesity compared to a prolonged eating window. Feasibility of CGM use was assessed by monitoring 1) the percent wear time of the CGM and 2) responses to satisfaction questionnaires. A computation of summary measures of all glycemic data prior to randomization was done using EasyGV and R. Repeat measures analysis was conducted to assess the change in glycemic variability over time between groups. Review of CGM tracings during periods of 24-hour dietary recall was utilized to describe glycemic excursions.

Results

Fifty participants were enrolled in the study and 43 had CGM and dietary recall data available (16.4 + 1.3 years, 64% female, 64% Hispanic, 74% public insurance). There was high adherence to daily CGM wear (96.4%) without negative impacts on daily functioning. There was no significant change in the glycemic variability as measured by standard deviation, mean amplitude glycemic excursion, and glucose area under the curve over the study period between groups.

Conclusions

CGM use appears to be a feasible and acceptable tool to monitor glycemic profiles in adolescents with obesity and may be a helpful strategy to confirm TRE dosage by capturing glycemic excursions compared to self-reported meal timing. There was no effect of TRE on glucose profiles in this study. Further research is needed to investigate how TRE impacts glycemic variability in this age group and to explore if timing of eating window effects these findings.

Kids N Fitness Junior: Outcomes of an Evidence-Based Adapted Weight Management Program for Children Ages Three-Seven Years

Background: Few weight management interventions target young children with obesity from low-income minority families. Objective: To conduct a nonrandomized, pragmatic, pilot study of an adapted, evidence-based, weight management program (Kids N Fitness [KNF]) customized for children ages 3-7 years (Kids N Fitness Jr. [KNF-JR]) on changes in adiposity, nutrition, and physical activity behaviors. Methods: One hundred eighty children (ages 3-16) with ≥85th percentile BMI and their parents participated in one of two 6-week weight management interventions dependent on the child's age: KNF-JR: 3-7 or regular KNF: 8-16. Comparisons were made between baseline anthropometrics and health questionnaire responses, and those from weeks 6 to 18. Two-sample tests for equality of proportions with continuity were used to measure proportions of success between KNF-JR and KNF. Results: At week 6, both cohorts showed a mean decrease in BMI z-score (zBMI) of -0.02 (p = 0.3 for KNF-JR [n = 43]; p = 0.02 for KNF [n = 59], with no significant group differences. Among program completers, 75% of KNF-JR and 83% of KNF maintained or lowered zBMI at week 18 (within-group difference p < 0.01). On average across all participants, at week 18 vs. baseline, improvements occurred in screen time (p < 0.01 KNF-JR, p < 0.02 KNF), sweetened beverage intake (p < 0.01 KNF-JR, p = 0.03 KNF), physical activity (p < 0.01 KNF-JR and KNF), and water (p = 0.01 KNF-JR, non-significant KNF) and vegetable (p < 0.01 KNF-JR, p = 0.02 KNF) consumption. Conclusion: This pilot demonstrated that an evidence-based weight management program can be adapted for all age groups and results in improved BMI status. Larger, randomized controlled trials are needed to verify effectiveness and sustained impact.

Time-Limited Eating and Continuous Glucose Monitoring in Adolescents with Obesity: A Pilot Study

Due to its simplicity, time-limited eating (TLE) may represent a more feasible approach for treating adolescents with obesity compared to other caloric restriction regimens. This pilot study examines the feasibility and safety of TLE combined with continuous glucose monitoring (CGM) in adolescents. Fifty adolescents with BMI ≥95th percentile were recruited to complete a 12-week study. All received standard nutritional counseling, wore a CGM daily, and were randomized to: (1) Prolonged eating window: 12 h eating/12 h fasting + blinded CGM; (2) TLE (8 h eating/16 h fasting, 5 days per week) + blinded CGM; (3) TLE + real-time CGM feedback. Recruitment, retention, and adherence were recorded as indicators of feasibility. Weight loss, dietary intake, physical activity, eating behaviors, and quality of life over the course of the intervention were explored as secondary outcomes. Forty-five participants completed the study (16.4 ± 1.3 years, 64% female, 49% Hispanic, 75% public insurance). There was high adherence to prescribed eating windows (TLE 5.2 d/wk [SD 1.1]; control 6.1 d/wk [SD 1.4]) and daily CGM wear (5.85 d/wk [SD 4.8]). Most of the adolescents (90%) assigned to TLE reported that limiting their eating window and wearing a CGM was feasible without negative impact on daily functioning or adverse events. There were no between-group difference in terms of weight loss, energy intake, quality of life, physical activity, or eating behaviors. TLE combined with CGM appears feasible and safe among adolescents with obesity. Further investigation in larger samples, with a longer intervention duration and follow-up assessments are needed.

Use of continuous glucose monitoring in obesity research: A scoping review

BACKGROUND

This scoping review provides a timely synthesis of the use of continuous glucose monitoring in obesity research with considerations to adherence to continuous glucose monitor devices and metrics most frequently reported.

METHODS

This scoping review was conducted adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. Eligible studies (n = 31) evaluated continuous glucose monitor use in research on participants, of all ages, with overweight or obesity.

RESULTS

Reviewed studies varied in duration from one to 84 days (mean: 8.74 d, SD 15.2, range 1-84 d) with 889 participants total (range: 11-118 participants). Across all studies, the mean percent continuous glucose monitor wear time (actual/intended wear time in days) was 92% (numerator - mean: 266.1 d, SD: 452, range: 9-1596 d/denominator - mean: 271.6 d, SD: 451.5, range: 9-1596 d). Continuous glucose monitoring was utilized to provide biofeedback (n = 2, 6%), monitor dietary adherence (n = 2, 6%), and assess glycemic variability (n = 29, 93%). The most common variability metrics reported were standard deviation (n = 19, 62%), area under the curve (n = 12, 39%), and glycemic range (n = 12, 39%).

CONCLUSIONS

Available evidence suggests that continuous glucose monitoring is a well-tolerated and versatile tool for obesity research in pediatric and adult patients. Future investigation is needed to substantiate the feasibility and utility of continuous glucose monitors in obesity research and maximize comparability across studies.

Timing of food consumption in Hispanic adolescents with obesity

BACKGROUND

Little is known about the normal eating time periods in adolescents with obesity and how these patterns change throughout development. As the obesity epidemic continues to rise in adolescence, it becomes imperative to understand developmentally appropriate eating behaviours and to create weight management strategies that build on those innate patterns and preferences. The purpose of this study was to determine the most common habitual eating windows observed in adolescents with obesity.

METHODS

Participants were 101 Hispanic adolescents (mean age 14.8 ± 2.1 years; 48 male/53 female) with obesity (BMI ≥95th percentile) who were recruited as part of a larger clinical trial. Dietary intake and meal timing was determined using multiple pass 24-hours recalls. Histograms were utilized to determine the natural distribution of percent consumption of total kilocalories, carbohydrates and added sugar per hour.

RESULTS

The majority of total kilocalories (65.4%), carbohydrates (65.3%) and added sugar (59.1%) occurred between 11:00 and 19:00. Adolescents were 2.5 to 2.9 times more likely to consume kilocalories, carbohydrates, and added sugar during the 8-hour window between 11:00 am and 19:00 pm than other time windows examined (all P < .001). The consumption of these calories did not differ between weekdays and weekend (P > .05) or by sex.

CONCLUSIONS

In this cohort, more than 60% of calories, carbohydrates and added sugar were consumed between 11:00 am and 19:00 pm, which is concordant with an afternoon/evening chronotype that is common in adolescents. Our findings support this 8-hour period as a practical window for weight loss interventions that target pre-specified eating periods in this population.

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

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

Spike in Diabetic Ketoacidosis Rates in Pediatric Type 2 Diabetes During the COVID-19 Pandemic

OBJECTIVE

The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) on the incidence of new-onset type 2 diabetes and diabetic ketoacidosis (DKA) is unclear. It is unknown whether the coincidence of DKA noted in adult patients with type 2 diabetes is an issue for youth during the coronavirus disease 2019 pandemic.

RESEARCH DESIGN AND METHODS

A retrospective single-center medical record review was conducted in a large, urban children's hospital of pediatric subjects presenting with new-onset type 2 diabetes between March and August of 2018 to 2020.

RESULTS

The proportion of subjects presenting with new-onset type 2 diabetes in DKA dramatically increased in 2020 (9% in 2018, 3% in 2019, and 20% in 2020, P = 0.029).

CONCLUSIONS

In 2020, youth with new-onset type 2 diabetes had a greater incidence of DKA at presentation than previously observed. Future studies should examine the impact of SARS-CoV2 exposure on the presentation of type 2 diabetes in all age-groups to inform better patient care.

Food addiction, executive function and mood in adolescents with obesity seeking treatment

BACKGROUND

The relationships between food addiction, executive functions and mood in adolescence are not well-understood. This study examines differences in executive functioning, depression symptoms and perceived stress among adolescents with obesity with- and without food addiction.

METHODS

A total of 110 adolescents with obesity (74 females; age = 15.59 ± 1.3 y; 67% Hispanic; 74% public insurance) completed the Behavior Rating Inventory of Executive Function-2 (BRIEF-2), the Yale Food Addiction Scale for children (YFAS-c), the Perceived Stress Scale (PSS) and the Center for Epidemiologic Studies Depression scale (CES-DC). Chi-squared and Fisher's exact tests were used to evaluate differences in BRIEF-2, CES-DC and PSS scores between participants with and without food addiction. A logistic regression model assessed the associations between executive dysfunction, depression and stress on food addiction individually. Multiple logistic regression was utilized to further examine the association between executive dysfunction and food addiction when accounting for depression and stress.

RESULTS

More than a third of participants (34.5%) met the criteria for food addiction. Females were 2.89 times more likely than males to have food addiction (95th%CI = 1.12-7.46, p = 0.03). Participants with FA had significantly higher BRIEF-2 T-scores (all p < 0.05) and higher PSS and CES-DC scores (all p < 0.05). Multiple logistic regression analysis showed depression was strongly correlated with FA when controlling for executive dysfunction and stress (p = 0.010).

CONCLUSIONS

Among obesity treatment-seeking adolescents, youths with food addiction displayed greater impairments in executive functioning and higher levels of stress and depressive symptoms than adolescents without food addiction. Prospective studies are needed to determine how this behavioral phenotype helps predict intervention outcomes.

New onset diabetes with diabetic ketoacidosis in a child with multisystem inflammatory syndrome due to COVID-19

INTRODUCTION

Multisystem inflammatory syndrome in children (MIS-C) is a unique clinical complication of SARS-CoV-2 infection observed in pediatric patients. COVID-19 is emerging as a potential trigger for the development of diabetes in children. Here, we report a patient presenting with MIS-C and new onset diabetes, and discuss the implication and clinical management of these concomitant conditions.

CASE PRESENTATION

An eight-year-old female presented with hyperglycemia, ketosis and metabolic acidosis consistent with diabetic ketoacidosis (DKA) in the setting of fever, rash, respiratory distress, hemodynamic instability, reduced systolic function with dilation of the left anterior descending artery, and positive SARS-CoV-2 antibodies suggestive of MIS-C.

Time limited eating in adolescents with obesity (time LEAd): Study protocol

BACKGROUND

Time limited eating (TLE) has been shown to be effective for weight loss and improvement of glycemic control in adults with obesity and type 2 diabetes (T2D), but has not been well studied in adolescents. TLE may be a more feasible, flexible and effective dietary intervention for adolescents because it removes the need for intensive counting of calories or macronutrients, and emphasizes eating during a specified time period.

OBJECTIVES

The aim of this study is to assess the feasibility of a TLE approach in adolescents with obesity using a continuous glucose monitor (CGM) to promote adherence to the intervention.

METHODS

We propose a prospective, randomized controlled trial, in 60 adolescents (ages 14-18) with obesity (BMI% ≥ 95th percentile). Youth will be randomized to one of three treatment groups for a 12-week intervention: Group 1) Low sugar and carbohydrate education (LSC, 5% of total daily calories from sugar (<35 g)/day; <90 g carbohydrate (CHO)/day) + blinded CGM (used to monitor adherence and glycemic outcomes without real time feedback), Group 2) LSC + TLE (16-h fast/8-h feed for 5 days per week) + blinded CGM, and Group 3) LSC + TLE+ real time feedback via CGM (to evaluate effect of providing CGM data on intervention efficacy). Outcomes will include change in total body fat (TBF) percentage measured on DEXA scan, BMI status and fasting blood glucose at 12 weeks compared to baseline.

CONCLUSIONS

TLE is a potentially powerful lifestyle intervention that could be readily integrated into pediatric weight management programs to optimize their impact and accelerate healthy changes.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03954223.

SAT-097 Early Adiposity Rebound in Youth with Congenital Adrenal Hyperplasia Predicts Childhood Obesity and Adiposity in Adolescence

Purpose: Youth with classical Congenital Adrenal Hyperplasia (CAH) due to 21-hydroxylase deficiency have an increased prevalence of obesity, abdominal adiposity, and fat mass compared to unaffected youth. As well, CAH youth in the United Kingdom (UK) have been found to have an earlier adiposity rebound (AR; rise in BMI corresponding to increased adipocyte size and number) at 1.7 years old, three years earlier than the general UK population. In unaffected youth, an earlier AR is predictive of obesity in adolescence. Our objective was to further understand the relationships between AR, weight status, and disease factors inherent to CAH in pediatric patients at our United States (US) center. Methods: In 45 youth with classical CAH, weight-for-length (kg/cm; if <2 yr) percentiles or BMI (kg/m²; if ≥2 yr) Z-scores were calculated every 6 months between the ages of 1 and 7 years, and at the patient’s last clinic visit. The cubic polynomial method was used to determine age at AR, located at the nadir before the second rise in the model. BMI-Z at the last clinic visit (12.6±3.8 yr) was used to classify final weight status as lean (Z<2) or obese (Z≥2). AR, and weight-for-length percentile at 1 yr, were analyzed for prediction of BMI-Z at 7 yr. Additionally, in a subset of 21 CAH youth enrolled in prior studies, total body fat and trunk fat (DXA), as well as abdominal subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT; single-slice CT or 3-T MRI at the level of the umbilicus) were cross-sectionally measured. Other CAH factors assessed in all youth included: glucocorticoid dose at AR, 17OHP at newborn diagnosis, and average bone age SD from clinical x-rays. Mann-Whitney U tests and Pearson correlations were used to assess group differences and associations. Simple linear regressions were used to predict childhood obesity and adolescent adiposity. Data are presented as mean±SD. Results: Age at AR for CAH youth was 3.1±1.4 yr, which is earlier than the normative US population (5.5 yr). Stratifying youth by weight status at their last clinic visit, age at AR was earlier in obese (2.5±1 yr, n=23) versus lean (3.7±1.6 yr, n=22; p<0.01) youth. AR strongly predicted BMI-Z at 7 yr (R= -0.65, β= -0.27, p<0.001) whereas weight-for-length percentile did not (R=0.22, p=0.14). AR was negatively correlated with total body fat (R= -0.58, p<0.01), trunk fat (R= -0.60, p<0.01), and abdominal SAT (R= -0.60, p<0.01), but not with VAT (R= -0.24, p=0.3). There were no associations between AR and glucocorticoid dose or newborn 17OHP. However, AR was negatively correlated with bone age SD (R= -0.37, p=0.05). Conclusion: Youth with CAH at our center exhibited an earlier AR by two years compared to the normative US population. This earlier AR was predictive of obesity in childhood, as well as increased total body fat and central adiposity in adolescence. Further study of disease-specific factors such as genotype in CAH are merited.

Kids N Fitness: A Group-based Pediatric Weight Management Curriculum Adapted for a Clinical Care Model

BACKGROUND

The current AAP clinical practice guidelines for the management of pediatric obesity recommend a structured, comprehensive, multi-disciplinary clinical intervention. However, there is a gap in the current literature on standardized curriculums for implementation of such programs. The objective of the present study is to adapt an evidenced-based, family- centered, weekly, weight management curriculum that addresses nutritional, physical activity and behavioral topics for a clinical care model at a tertiary care children's hospital.

METHODS

The curriculum was adapted for use in six individual sessions offered monthly by a multidisciplinary team, including a health educator, physician, dietitian, physical therapist and psychologist. Each provider offered specific feedback and curriculum adaptation based on their specialty. All team members completed training with scheduled treatment fidelity monitoring during implementation. To evaluate the effectiveness of the adapted curriculum, 60 adolescents, ages 14-18 years, with overweight or obesity, and at least one family member, will complete the six month intervention. The primary outcome is mean change in zBMI and %BMIp95 at six month and 18 months. Secondary outcomes include retention, satisfaction, effect on metabolic factors and activity level.

CONCLUSION

There is a paucity of literature on utilizing a standard curriculum in clinical weight management programs. Drawing from evidenced-based curriculum to strengthen clinical care creates an opportunity to improve existing clinical programs and potentially increase access and implementation of the current treatment recommendations for this high risk population.

Early Adiposity Rebound Predicts Obesity and Adiposity in Youth with Congenital Adrenal Hyperplasia

INTRODUCTION

Youth with classical congenital adrenal hyperplasia (CAH) have higher prevalence of cardiometabolic risk factors such as obesity, abdominal adiposity, and hypertension. Patients with CAH also exhibit an earlier adiposity rebound (AR) compared to normative populations. However, the predictive relationship between AR and cardiometabolic risk factors needs to be better understood.

METHODS

We performed a retrospective cohort study at a US tertiary pediatric center in youth with classical CAH due to 21-hydroxylase deficiency. AR was determined by cubic polynomial modeling. A subset of participants had fasting analytes, whole-body dual-energy X-ray absorptiometry, and magnetic resonance imaging as adolescents.

RESULTS

In 42 youth with CAH (45.2% female, 54.8% Hispanic, and 90.5% salt-wasting form), the average age at AR was 3.4 ± 1.3 years. AR differed by BMI-z, with youth with obesity having an earlier AR (2.8 ± 1.0 years) compared to lean youth (4.1 ± 1.3 years, p = 0.001). However, AR did not differ by either CAH form or sex. Earlier AR predicted higher BMI-z at 7 and 12 years of age. In addition, earlier AR predicted increased central obesity (as measured by waist circumference, subcutaneous adipose tissue, and trunk fat) and total body fat in adolescence. AR was negatively correlated with bone age, and its relationships with HDL and hypertension were trending towards significance.

CONCLUSIONS

AR in youth with classical CAH could serve as a useful clinical marker to identify those patients who are at higher risk for developing cardiometabolic risk factors during childhood and adolescence.

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.

An addiction-based mobile health weight loss intervention: protocol of a randomized controlled trial

BACKGROUND

The notion of obesity as an addictive process is controversial. However, studies show that between 5.9 and 30.7% of adolescents with obesity report food or eating addiction. Few weight management interventions have tested techniques based on addiction medicine principles.

METHODS

This multi-center randomized control trial (RCT) is designed to test the effectiveness of a mobile health (mHealth) weight-loss intervention based on addiction principles, such as withdrawal and tolerance, in a sample of 180 adolescents (ages 14-18) recruited from four pediatric weight management clinics in Southern California. Akin to a Multiphase Optimization Strategy (MOST) design evaluating multicomponent behavioral interventions, we will compare the combination of an app + phone coaching (App+Coach) to app alone (App) and in-clinic multi-disciplinary (Clinic) intervention arms. The primary outcome is mean change in zBMI and %BMIp95 over 18 months. We hypothesize that youth who receive App+Coach will have a greater reduction in body weight over the 18-month study period at a lower cost than standard of care models. Secondary outcomes include adherence to treatment regimen, intervention satisfaction, effect of the intervention on metabolic factors and activity level. We will also explore potential moderators of intervention effectiveness such as addictive eating habits, self-regulation and executive functioning.

CONCLUSIONS

New and creative approaches are needed to address pediatric obesity. If successful, this RCT may provide an innovative and cost-effective mHealth approach, based on addiction methods, for weight loss among adolescents with overweight and obesity.

Energy Management for Personalized Weight Reduction (EMPOWER) Program: Three-Year Outcome Data

BACKGROUND

The current consensus guidelines for management of pediatric obesity recommend clinic-based, family-centered, multi-disciplinary interventions. It is well reported that these programs often only lead to modest improvements in BMI status. The individual factors that differentiate which patient's BMI status will improve vs. worsen remains understudied. A retrospective cohort study was conducted to evaluate the outcomes of EMPOWER clinic and identify the participant specific characteristics that predicted BMI status improvement in this population.

METHODS

Youth who completed at least 6 visits in EMPOWER were included. Paired t-test was utilized to evaluate the mean change in zBMI, modified BMIz and %BMI_p95 from baseline to 6^th visit, and multivariate mixed effect models were utilized to analyze effect of baseline characteristics on change in BMI status.

RESULTS

92 participants were included in the analysis, 87% with severe obesity and 66% Hispanic. At the 6^th visit, there was a significant reduction in zBMI (-0.09 SD, p <0.001) and modified BMIz (-0.0003 SD, p = 0.04) with a small reduction in %BMI_p95 (-1.15 %, p = 0.20). Lower BMI status (p < 0.001) and absence of a comorbidity (p < 0.05) at baseline were predictors of BMI status improvement whereas age, gender, ethnicity, family history of obesity and insurance status were not significant predictors.

CONCLUSIONS

Given that implementation of the current guidelines for management of obesity in pediatrics only results in modest BMI status reduction, further investigation is required to understand how the determinants of obesity-related health outcomes can guide development of more innovative, effective interventions for this high risk population.

Improved medical-alert ID ownership and utilization in youth with congenital adrenal hyperplasia following a parent educational intervention

BACKGROUND

Classical congenital adrenal hyperplasia (CAH) is a potentially life-threatening condition, and adrenal crisis is a major cause of morbidity and mortality in affected children. Medical-alert identification (ID) could prevent complications of adrenal crisis by identifying the need for time-sensitive, critical treatment. Our objectives were to evaluate usage of medical-alert IDs by CAH youth, ownership and awareness of IDs amongst their parents, and the effect of an in-clinic educational intervention on ID utilization.

METHODS

Fifty families of youth with classical CAH secondary to 21-hydroxylase deficiency (11.2±5.0 years old, 58% female) were prospectively studied. An in-clinic needs assessment survey was administered at baseline to parents, paired with an educational intervention, and a follow-up needs assessment phone survey 1 month post-intervention. A quality improvement (QI) framework was utilized with plan-do-study-act (PDSA) process-improvement cycles.

RESULTS

At baseline, 20/50 (40%) CAH families owned a medical-alert ID, of which only 10/20 (50%) of ID owners reported usage >3 days per week. Only 26/50 (52%) parents were aware of ID options. Post-intervention, ID ownership doubled to 39/50 (78%; p<0.05), usage amongst ID owners reached 100% (39/39), and awareness increased to 42/50 (84%; p<0.05). A surprising barrier reported by five Spanish-speaking families was the inability to order medical-alert IDs online.

CONCLUSIONS

Only a small percentage of CAH youth frequently wear a medical-alert ID, but utilization can be effectively improved with an in-clinic educational intervention. Further study is merited to assess a potential reduction in morbidity and mortality of adrenal crisis with increased medical-alert ID utilization.

X-linked Hypophosphatemic Rickets, del(2)(q37.1;q37.3) Deletion Syndrome and Mosaic Turner Syndrome, mos 45,X/46,X, del(2)(q37.1;q37.3) in a 3-year-old Female

There are currently no published cases that report concomitant Turner syndrome (TS), 2q37 deletion syndrome and X-linked hypophosphatemic rickets (XLH). Interestingly, since the clinical phenotypes of TS and 2q37 deletion syndrome overlap, the correct diagnosis may be missed without a standardized approach to genetic testing consisting of both karyotype and microarray. Both chromosome anomalies have been associated with short stature and a variety of skeletal abnormalities however to date no reports have associated these syndromes in association with a phosphate regulating endopeptidase homolog, X-linked (PHEX) gene deletion resulting in XLH. We report a 3-year-old female with 3 concurrent genetic disorders including a 9.98 Mb terminal deletion of chromosome 2: del(2)(q37.1;q37.3), XLH secondary to a small microdeletion of part of the PHEX gene, and mosaic TS (mos 45,X[32]/46,X[18]). This is the first case report of a patient with 2q37 deletion syndrome and mosaic TS (mos 45,X[32]/46,X[18]) found to have XLH secondary to an interstitial constitutional PHEX gene deletion. Her severe phenotype and multiple genotypic findings reinforce the importance of thorough genetic testing in the setting of complicated phenotypic presentations.

A novel SLC12A1 gene mutation associated with hyperparathyroidism, hypercalcemia, nephrogenic diabetes insipidus, and nephrocalcinosis in four patients

Solute Carrier Family 12 member 1 (SLC12A1) gene encodes the sodium-potassium-chloride co-transporter (NKCC2) at the apical membrane of the thick ascending loop of Henle (TAL). Bartter's syndrome (BS) type I is a rare, autosomal recessive, renal tubular disorder associated with mutation of the SLC12A1 gene. Presenting features include: hypokalemic metabolic alkalosis, hypercalciuria and nephrocalcinosis. The many allelic variants reported present with a spectrum of phenotypes, biochemical abnormalities and clinical severities. However, to date, only two reports have described hyperparathyroidism and hypercalcemia in patients with SLC12A1 gene mutations. We describe 4 patients with 4 novel mutation variants in the SLC12A1 gene (c.735C>G, c.1137del, c.2498-2499del, and c.1833delT) presenting with variable degrees of hyperparathyroidism, hypercalcemia, hypokalemic metabolic alkalosis, nephrocalcinosis, and nephrogenic diabetes insipidus. The link between calcium and parathyroid hormone abnormalities in patients with SLC12A1 mutations is unclear; the cases described suggest an association between primary hyperparathyroidism and loss of function mutation of SLC12A1, which may result in an aberrant threshold of the calcium sensing receptor at the level of the kidney.