Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years

Developing and Evaluating Behaviour Change Interventions for People with Younger-Onset Type 2 Diabetes: Lessons and Recommendations from Existing Programmes

People with younger-onset type 2 diabetes (YOT2D, diagnosis before 40 years of age) are at higher risk of morbidity and premature mortality compared with their similar-age type 1 diabetes and later-onset type 2 diabetes peers. Despite recommendations for targeted, behavioural, and psychosocial approaches to optimising health outcomes, there are few such interventions for this group. Furthermore, evaluations of health behaviour change interventions targeting this priority population have proven challenging to complete. Despite this, there is little guidance for future behavioural programme developers. The aims of this paper are to synthesise lessons learned and recommendations from published evaluations of YOT2D-focused health behaviour change interventions, and illustrate challenges and solutions using case studies from our own experience. A rapid review of the literature identified 11 trials of behavioural interventions for YOT2D (5 randomised controlled trials, 6 pre/post studies). We sourced related needs assessment and development papers to describe the life course of each programme. We identified two development and two evaluation-related themes impacting successful trial execution. Development recommendations include ensuring appropriate adaptation of existing interventions to the unique challenges and characteristics of the target group, use of theory or theoretical frameworks throughout, and involvement of the priority population and key stakeholders from inception. Evaluation recommendations include planning for meaningful evaluation and development of age-appropriate Core Outcomes Sets. Future programme developers would benefit from closer attention to intervention development guidelines and a focus on supporting those with YOT2D to achieve behaviour change and diabetes self-management goals, ahead of change to biomedical outcomes.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

A look at engagement profiles and behavior change: A profile analysis examining engagement with the Aim2Be lifestyle behavior modification app for teens and their families

Mobile-Health is increasingly used to deliver lifestyle modification interventions; however, little is known about how users engage with these apps. This study aims to profile how teens engage with Aim2Be- a lifestyles behavior modification app), characterize engagement profiles, and examine which engagement profiles support changes in behaviors (diet, physical activity, screen time and sleep) and changes in the mediators targeted by the app. Data were collected from 301 teens (14.8 years, 49% boys, 68% Caucasian) living in Canada, from March to October 2018, who utilized the Aim2Be app for 4.5 months. App-analytics tracked teen engagement with the app features (selecting aims, completing tasks and quick wins, using the knowledge center and social wall, and accessing the virtual coach). Factor mixture modeling identified the following engagement profiles: Uninvolved (32%) did not use most app features; Dabblers (25%) minimally used the app features; Engaged (24%) had moderate-to-high use of app features; and Keeners (19%) had the highest use of all app features. Regression models showed that teens were more engaged with Aim2Be if their parents were involved and if they participated with their mothers and/or an educated parent. Finally, Keeners significantly improved on most mediators of behavior change and increased their fruit and vegetable intake. The findings suggest that parental engagement supported teen engagement of the Aim2Be app and high engagement was needed to support behavior change among teens. Gaining a greater understanding of the features that appeal to teens is necessary to support behavior change.

Trajectory of body mass index and height changes from childhood to adolescence: a nationwide birth cohort in Japan

To investigate the dynamics of body mass index (BMI) and height changes in childhood leading to obesity in adolescents. BMI Z-scores were calculated using the LMS (lambda-mu-sigma) method based on yearly height and weight information (age 1.5-15 years) from a nationwide Japanese birth cohort that started in 2001 (n = 26,711). We delineated the trajectories of BMI and height changes leading to obesity at age 15 years using mixed effect models. Children who became obese at the age of 15 years kept relatively high BMI z-scores through childhood for both genders, and had an increasing trend over time as opposed to the normal weight group, with an increasing slope during puberty. Early adiposity rebound was associated with overweight or obesity at the age of 15 years. Age at peak height velocity (APHV) occurred earlier in the obese/overweight group at age 15 years than in the normal weight group, and occurred later in the underweight group. Obese adolescents experienced early adiposity rebound timing and maintained a serial BMI z-score increase throughout childhood, with a greater slope at puberty. An earlier peak in height gain during puberty may have contributed to the observed patterns of BMI change.

Parent Involvement in Diet or Physical Activity Interventions to Treat or Prevent Childhood Obesity: An Umbrella Review

Parents substantially influence children’s diet and physical activity behaviors, which consequently impact childhood obesity risk. Given this influence of parents, the objective of this umbrella review was to synthesize evidence on effects of parent involvement in diet and physical activity treatment and prevention interventions on obesity risk among children aged 3–12 years old. Ovid/MEDLINE, Elsevier/Embase, Wiley/Cochrane Library, Clarivate/Web of Science, EBSCO/CINAHL, EBSCO/PsycInfo, and Epistemonikos.org were searched from their inception through January 2020. Abstract screening, full-text review, quality assessment, and data extraction were conducted independently by at least two authors. Systematic reviews and meta-analyses of diet and physical activity interventions that described parent involvement, included a comparator/control, and measured child weight/weight status as a primary outcome among children aged 3–12 years old were included. Data were extracted at the level of the systematic review/meta-analysis, and findings were narratively synthesized. Of 4158 references identified, 14 systematic reviews and/or meta-analyses (eight treatment focused and six prevention focused) were included and ranged in quality from very low to very high. Our findings support the inclusion of a parent component in both treatment and prevention interventions to improve child weight/weight status outcomes. Of note, all prevention-focused reviews included a school-based component. Evidence to define optimal parent involvement type and duration and to define the best methods of involving parents across multiple environments (e.g., home, preschool, school) was inadequate and warrants further research. PROSPERO registration: CRD42018095360.

Pediatric Weight Management Through mHealth Compared to Face-to-Face Care: Cost Analysis of a Randomized Control Trial

BACKGROUND

Mobile health (mHealth) may improve pediatric weight management capacity and the geographical reach of services, and overcome barriers to attending physical appointments using ubiquitous devices such as smartphones and tablets. This field remains an emerging research area with some evidence of its effectiveness; however, there is a scarcity of literature describing economic evaluations of mHealth interventions.

OBJECTIVE

We aimed to assess the economic viability of using an mHealth approach as an alternative to standard multidisciplinary care by evaluating the direct costs incurred within treatment arms during a noninferiority randomized controlled trial (RCT).

METHODS

A digitally delivered (via a smartphone app) maintenance phase of a pediatric weight management program was developed iteratively with patients and families using evidence-based approaches. We undertook a microcosting exercise and budget impact analysis to assess the costs of delivery from the perspective of the publicly funded health care system. Resource use was analyzed alongside the RCT, and we estimated the costs associated with the staff time and resources for service delivery per participant.

RESULTS

In total, 109 adolescents participated in the trial, and 84 participants completed the trial (25 withdrew from the trial). We estimated the mean direct cost per adolescent attending usual care at €142 (SD 23.7), whereas the cost per adolescent in the mHealth group was €722 (SD 221.1), with variations depending on the number of weeks of treatment completion. The conversion rate for the reference year 2013 was $1=€0.7525. The costs incurred for those who withdrew from the study ranged from €35 to €681, depending on the point of dropout and study arm. The main driver of the costs in the mHealth arm was the need for health professional monitoring and support for patients on a weekly basis. The budget impact for offering the mHealth intervention to all newly referred patients in a 1-year period was estimated at €59,046 using the assessed approach.

CONCLUSIONS

This mHealth approach was substantially more expensive than usual care, although modifications to the intervention may offer opportunities to reduce the mHealth costs. The need for monitoring and support from health care professionals (HCPs) was not eliminated using this delivery model. Further research is needed to explore the cost-effectiveness and economic impact on families and from a wider societal perspective.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01804855; https://clinicaltrials.gov/ct2/show/NCT01804855.

The effect of heavy prenatal alcohol exposure on adolescent body mass index and waist-to-height ratio at 12-13 years

BACKGROUND

Growing evidence suggests that prenatal alcohol exposure (PAE) has the potential to impact on a wide range of physical outcomes in offspring, including metabolism and body composition, although the evidence to-date is primarily from preclinical studies. The current clinical study examined the association between heavy PAE and indirect measures of adiposity in adolescence.

METHODS

Analyses drew on data from the Longitudinal Study of Australian Children, a national prospective cohort of children and their families from birth to adolescence. Participants included children with heavy PAE (≥70 g/week; n = 46), measured via maternal self-report of alcohol use during pregnancy and a comparison group of children without any PAE (n = 782), frequency matched on sex, ethnicity and socio-economic position. Body mass index (BMI) z-scores, waist-to-height ratios and proportion overweight/obese were calculated from height, weight and waist circumference measured at age 12-13 years. Two (PAE) × two (sex) ANCOVA and logistic regression models were performed, controlling for matching variables, adolescent age, pubertal status and birthweight; maternal age at birth and smoking during pregnancy.

RESULTS

Female adolescents with heavy PAE during late pregnancy had significantly higher BMI z-scores (M = 0.75, SD = 0.69) and proportion overweight/obese (38.5%) than females not exposed to any prenatal alcohol (M = 0.29, SD = 1.07, P = 0.04; 23.8%, P = 0.03, respectively). There was no significant effect of heavy PAE on male adolescent BMI z-scores and proportion overweight/obese or adolescent waist-to-height ratios (all P > 0.05).

CONCLUSIONS

Heavy PAE had a sex-specific effect on measures of adiposity in early adolescence, with girls more likely to have increased BMI and overweight/obesity status. Further longitudinal follow-up of children exposed to PAE is required to confirm if maternal alcohol consumption is a risk factor for later life obesity.

Packaging and Scaling the Stanford Pediatric Weight Control Program: A Family-Based, Group, Behavioral Weight Management Program for Children with Obesity and Their Families: Background, Rationale, and Design of the Stanford CORD 3.0 Project

Efficacious treatments for children with obesity have not been broadly disseminated. The Stanford Pediatric Weight Control Program (SPWCP) is grounded in behavioral theory and prior observations, follows a proven treatment model, and is consistent with the US Preventive Services Task Force (USPSTF) recommendations. It has shown high levels of participation and retention and reductions in BMI and percent of median BMI for age and sex comparable to many studied programs, as well as improvements in physiological risk factors, psychological measures, and diet, activity, and screen time behaviors in children with obesity when delivered as a real-world clinical program with sociodemographically diverse families in multiple clinic and community settings. The Stanford CORD 3.0 Project proposes to use technology, design, behavioral theory, and biomedical business innovation strategies to package and scale the SPWCP to reach low-income children throughout the United States. Efficacy and success of implementation of the new packaged program will be tested in a one-arm pilot implementation study when delivered by community partners.

Examination of the '5-2-1-0' Recommendations in Racially Diverse Young Children Exposed to Tobacco Smoke

PURPOSE

The '5-2-1-0' guidelines recommend that children: eat ≥5 servings of fruits/vegetables ('5'), have ≤2 hours of screen-time ('2'), have ≥1 hour of activity ('1'), and drink 0 sugar-sweetened beverages ('0') daily. The pediatric emergency department (PED) treats children at risk for obesity and tobacco smoke exposure (TSE). We examined body mass index (BMI), overweight, obesity, TSE, and '5-2-1-0' rates in children with TSE in the PED.

DESIGN

Cross-sectional study of PED children.

SETTING

The PED of a children's hospital.

SAMPLE

Children with TSE >6 months-5 years old (N = 401).

MEASURES

Sociodemographics, '5-2-1-0' behaviors, BMI, and cotinine-confirmed TSE.

ANALYSIS

Associations between '5-2-1-0' and sociodemographics were examined with logistic regression.

RESULTS

Mean (SD) age = 2.4 (1.6) years; 53.1% were Black; 65.8% had low-income; and 93.4% had TSE. Of 2-5-year-olds, mean (SD) BMI percentile was 66.2 (30.1), 16.1% were overweight and 20.6% were obese. In total, 10.5% attained '5', 72.6% attained '2', 57.8% of 2-5-year-olds attained '1', and 9.8% attained '0'. Compared to White children, "other" race children were more likely to meet '5' (aOR(95% CI):4.67(1.41, 5.45)); 2-5-years-olds (aOR(95%CI):0.60(0.38, 0.95)) and Black children (aOR(95%CI):0.36(0.21, 0.60)) were at decreased odds to meet '2' compared to younger or White children, respectively. Compared to younger children, 2-5-year-olds were at decreased odds to meet '0' (aOR(95%CI):0.08(0.02, 0.26)).

CONCLUSION

Racially diverse, low-income children with TSE had low '5-2-1-0' attainment. Interventions are needed to improve lifestyle habits in this population.

Contextualising Eating Disorder Concerns for Paediatric Obesity Treatment

PURPOSE OF REVIEW

Eating disorders are complex mental health conditions that share risk factors with obesity. This review outlines the context for concerns that paediatric obesity treatment presents a risk for eating disorder development.

RECENT FINDINGS

Most children and adolescents undergoing professionally supervised obesity treatment will have improvements or no change to eating disorder risk profiles. However, some may subsequently develop a clinical eating disorder, and this is proposed to relate to weight-focussed dietary interventions that are standard in paediatric obesity treatment. Nevertheless, dietary restraint may not be a strong predictor of eating disorder risk in the context of paediatric obesity treatment. Most international guidelines recommend weight maintenance or weight loss as a treatment goal, and weight loss is related to improvements in cardiometabolic health but not eating disorder risk in the short term. The risk of inducing or exacerbating an eating disorder during paediatric weight management is likely to be low; however, the serious consequences combined with increasing scale of obesity treatment, and lack of empirical evidence, are of concern. There is a need for further research to identify long-term predictors of eating disorder development for children and adolescents who seek treatment for their obesity.

[Clinical guidelines «Obesity in children»]

Childhood obesity is an urgent problem of pediatric endocrinology due to the widespread occurrence, the development of metabolic complications and their steady tracking into adulthood. The developed clinical guidelines are the main working tool of the practitioner. They briefly and structurally present the main information about the epidemiology and modern classification of obesity, methods of its diagnosis and treatment based on the principles of evidence-based medicine.

The Families and Schools for Health Project: A Longitudinal Cluster Randomized Controlled Trial Targeting Children with Overweight and Obesity

This cluster randomized controlled trial aimed at overweight and obese children compared three treatments. Two psychoeducation interventions for parents and children were conducted: Family Lifestyle (FL) focused on food and physical activity; Family Dynamics (FD) added parenting and healthy emotion management. A third Peer Group (PG) intervention taught social acceptance to children. Crossing interventions yielded four conditions: FL, FL + PG, FL + FD, and FL + FD + PG-compared with the control. Longitudinal BMI data were collected to determine if family- and peer-based psychosocial components enhanced the Family Lifestyle approach. Participants were 1st graders with BMI%ile >75 (n = 538: 278 boys, 260 girls). Schools were randomly assigned to condition after stratifying for community size and percent American Indian. Anthropometric data were collected pre- and post-intervention in 1st grade and annually through 4th grade. Using a two-level random intercept growth model, intervention status predicted differences in growth in BMI or BMI-M% over three years. Children with obesity who received the FL + FD + PG intervention had lower BMI gains compared to controls for both raw BMI (B = -0.05) and BMI-M% (B = -2.36). Interventions to simultaneously improve parent, child, and peer-group behaviors related to physical and socioemotional health offer promise for long-term positive impact on child obesity.

Decision-Making Processes Related to Perseveration Are Indirectly Associated With Weight Status in Children Through Laboratory-Assessed Energy Intake

Decision-making contributes to what and how much we consume, and deficits in decision-making have been associated with increased weight status in children. Nevertheless, the relationships between cognitive and affective processes underlying decision-making (i.e., decision-making processes) and laboratory food intake are unclear. We used data from a four-session, within-subjects laboratory study to investigate the relationships between decision-making processes, food intake, and weight status in 70 children 7-to-11-years-old. Decision-making was assessed with the Hungry Donkey Task (HDT), a child-friendly task where children make selections with unknown reward outcomes. Food intake was measured with three paradigms: (1) a standard ad libitum meal, (2) an eating in the absence of hunger (EAH) protocol, and (3) a palatable buffet meal. Individual differences related to decision-making processes during the HDT were quantified with a reinforcement learning model. Path analyses were used to test whether decision-making processes that contribute to children's (a) expected value of a choice and (b) tendency to perseverate (i.e., repeatedly make the same choice) were indirectly associated with weight status through their effects on intake (kcal). Results revealed that increases in the tendency to perseverate after a gain outcome were positively associated with intake at all three paradigms and indirectly associated with higher weight status through intake at both the standard and buffet meals. Increases in the tendency to perseverate after a loss outcome were positively associated with EAH, but only in children whose tendency to perseverate persistedacross trials. Results suggest that decision-making processes that shape children's tendencies to repeat a behavior (i.e., perseverate) are related to laboratory energy intake across multiple eating paradigms. Children who are more likely to repeat a choice after a positive outcome have a tendency to eat more at laboratory meals. If this generalizes to contexts outside the laboratory, these children may be susceptible to obesity. By using a reinforcement learning model not previously applied to the study of eating behaviors, this study elucidated potential determinants of excess energy intake in children, which may be useful for the development of childhood obesity interventions.

A systematic review of physical activity and quality of life and well-being

Maintaining or improving quality of life (QoL) and well-being is a universal goal across the lifespan. Being physically active has been suggested as one way to enhance QoL and well-being. In this systematic review, conducted in part for the 2018 U.S. Health and Human Services Physical Activity Guidelines for Americans Scientific Advisory Committee Report, we examined the relationship between physical activity (PA) and QoL and well-being experienced by the general population across the lifespan and by persons with psychiatric and neurologic conditions. Systematic reviews, meta-analyses, and pooled analyses from 2006 to 2018 were used for the evidence base. Strong evidence (predominantly from randomized controlled trials [RCTs]) demonstrated that, for adults aged 18-65 years and older adults (primarily 65 years and older), PA improves QoL and well-being when compared with minimal or no-treatment controls. Moderate evidence indicated that PA improves QoL and well-being in individuals with schizophrenia and Parkinson's disease, and limited evidence indicated that PA improves QoL and well-being for youth and for adults with major clinical depression or bipolar disorder. Insufficient evidence existed for individuals with dementia because of a small number of studies with mixed results. Future high-quality research designs should include RCTs involving longer interventions testing different modes and intensities of PA in diverse populations of healthy people and individuals with cognitive (e.g., dementia) and mental health conditions (e.g., schizophrenia) to precisely characterize the effects of different forms of PA on aspects of QoL and well-being.

Effects and Responsiveness of a Multicomponent Intervention on Body Composition, Physical Fitness, and Leptin in Overweight/Obese Adolescents

Physical exercise reduces the biochemical markers of obesity, but the effects of multicomponent interventions on these markers should be explored. The present study aimed to elucidate how overweight/obese adolescents respond to a multicomponent program approach on body composition, physical fitness, and inflammatory markers, using a quasi-experimental study with 33 overweight/obesity adolescents (control group (CG) = 16; intervention group (IG) = 17). The intervention consisted of 24 weeks with physical exercises and nutritional and psychological guidance. Both groups were evaluated at the pre/post-intervention moments on body mass index (BMI); body fat (%Fat); waist circumference (WC); waist/hip ratio (WHR); waist-to-height ratio (WHtR), cardiorespiratory fitness (CRF); abdominal strength, flexibility; leptin; interleukin 6; interleukin 10; and tumor necrosis factor-alpha. Mixed-analysis of variance and generalized estimation equations were used for statistical analysis. There was an interaction effect between groups and time on %Fat (p = 0.002), WC (p = 0.023), WHR (p < 0.001), WHtR (p = 0.035), CRF (p = 0.050), and leptin (p = 0.026). Adolescents were classified as 82.4% responders for %Fat, 70.6% for WC, 88.2% for WHR, and 70.6% for CRF. Further, there was an association between changes in %Fat (p = 0.033), WC (p = 0.032), and WHR (p = 0.033) between responders and non-responders with CRF in the IG. There was a positive effect on body composition, physical fitness, and leptin. In addition, reductions in body composition parameters were explained by CRF improvements.

School-based interventions for the treatment of childhood obesity: a systematic review, meta-analysis and meta-regression of cluster randomised controlled trials

OBJECTIVE

Schools offer an ideal setting for childhood obesity interventions due to their access to children and adolescents. This review aimed to systematically review the impact of school-based intervention for the treatment of childhood obesity.

DESIGN

Eight databases were searched from inception till 30 May 2020. A revised Cochrane risk-of-bias tool and the Grading of Recommendations, Assessment, Development and Evaluations criteria were used to evaluate the risk of bias and overall evidence. Meta-analysis and meta-regression were performed on Stata software using the random effects model. Overall effect was evaluated using Hedges' g, and heterogeneity was assessed using Cochran's Q and I2.

SETTING

Cluster randomised controlled trials (cluster-RCT) delivered in school.

PARTICIPANTS

Children and adolescents (6-18 years of age) with overweight and obesity.

RESULTS

Twelve cluster-RCT from seven countries with 1755 participants were included in the meta-analysis. School-based interventions for the treatment of childhood obesity reduced BMI and BMI z-scores with a medium effect (g = 0·52). Subgroup analyses showed greater effectiveness of brief school-based interventions and the interventions conducted in lower-middle to upper-middle economies. Meta-regression assessed the heterogeneity and the final model, with covariates of the type of economies and trial duration, accounted for 41·2 % of the variability. The overall quality of evidence was rated low because of the high risk of bias and inconsistency.

CONCLUSIONS

School-based interventions are a possible approach to provide universal healthcare for the treatment of childhood obesity, and further well-designed cluster-RCT with longer follow-up are needed. This study is registered with PROSPERO (CRD42020160735).

The association between adverse childhood experiences and childhood obesity: A systematic review

Adverse childhood experiences (ACEs) are associated with numerous physical and mental health issues in children and adults. The effect of ACEs on development of childhood obesity is less understood. This systematic review was undertaken to synthesize the quantitative research examining the relationship between ACEs and childhood obesity. PubMed, PsycInfo, and Web of Science were searched in July 2020; Rayyan was used to screen studies, and the Newcastle-Ottawa Scale was used to assess risk of bias. The search resulted in 6,966 studies screened at title/abstract and 168 at full-text level. Twenty-four studies met inclusion criteria. Study quality was moderate, with greatest risk of bias due to method of assessment of ACEs or sample attrition. Findings suggest ACEs are associated with childhood obesity. Girls may be more sensitive to obesity-related effects of ACEs than boys, sexual abuse appears to have a greater effect on childhood obesity than other ACEs, and co-occurrence of multiple ACEs may be associated with greater childhood obesity risk. Further, the effect of ACEs on development of childhood obesity may take 2-5 years to manifest. Considered collectively, findings suggest a need for greater attention to ACEs in the prevention and treatment of childhood obesity.

Physiotherapy and related management for childhood obesity: A systematic scoping review

INTRODUCTION

Despite targeted efforts globally to address childhood overweight/obesity, it remains poorly understood and challenging to manage. Physiotherapists have the potential to manage children with obesity as they are experts in movement and physical activity. However, their role remains unclear due to a lack of physiotherapy-specific guidelines. This scoping review aims to explore existing literature, critically appraising and synthesising findings to guide physiotherapists in the evidence-based management of childhood overweight/obesity.

METHOD

A scoping review was conducted, including literature up to May 2020. A review protocol exists on Open Science Framework at https://osf.io/fap8g/. Four databases were accessed including PubMed, Embase, CINAHL, Medline via OVID, with grey literature searched through google via "file:pdf". A descriptive synthesis was undertaken to explore the impact of existing interventions and their efficacy.

RESULTS

From the initial capture of 1871 articles, 263 intervention-based articles were included. Interventions included qualitative focused physical activity, quantitative focused physical activity and multicomponent interventions. Various outcome measures were utilised including health-, performance- and behaviour-related outcomes. The general trend for physiotherapy involvement with children who are obese appears to favour: 1) multicomponent interventions, implementing more than one component with environmental modification and parental involvement and 2) quantitative physical activity interventions, focusing on the quantity of bodily movement. These approaches most consistently demonstrated desirable changes across behavioural and health-related outcome measures for multicomponent and quantitative physical activity interventions respectively.

CONCLUSION

When managing children with obesity, physiotherapists should consider multicomponent approaches and increasing the quantity of physical activity, given consistent improvements in various obesity-related outcomes. Such approaches are well suited to the scope of physiotherapists and their expertise in physical activity prescription for the management of childhood obesity. Future research should examine the effect of motor skill interventions and consider the role of environmental modification/parental involvement as factors contributing to intervention success.

The Effectiveness of School-Based Interventions on Obesity-Related Behaviours in Primary School Children: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

School-based interventions are promising for targeting a change in obesity-related behaviours in children. However, the efficacy of school-based interventions to prevent obesity remains unclear. This review examined the effectiveness of school-based interventions at changing obesity-related behaviours (increased physical activity, decreased sedentary behaviour and improved nutrition behaviour) and/or a change in BMI/BMI z-score. Following PRISMA guidelines, seven databases were systematically searched from 1 January 2009 to 31 December 2020. Two review authors independently screened studies for eligibility, completed data extraction and assessed the risk of bias of each of the included studies. Forty-eight studies met the inclusion criteria and were included in a narrative synthesis. Thirty-seven studies were eligible for inclusion in a meta-analysis. The findings demonstrate that interventions in children when compared to controls resulted in a small positive treatment effect in MVPA in the control group (2.14; 95% CI = 0.77, 3.50). There was no significant effect on sedentary behaviour, energy intake, and fruit and vegetable intake, and BMI kg/m2. A small significant reduction was found between groups in BMI z-score (-0.04; 95% CI = -0.07, -0.01) in favour of the intervention. The findings have important implications for future intervention research in terms of the effectiveness of intervention components and characteristics.

A community-based, multi-level, multi-setting, multi-component intervention to reduce weight gain among low socioeconomic status Latinx children with overweight or obesity: The Stanford GOALS randomised controlled trial

BACKGROUND

There are few long-term studies of interventions to reduce in low socioeconomic status children with overweight or obesity. The Stanford GOALS trial evaluated a 3-year, community-based, multi-level, multi-setting, multi-component (MMM) systems intervention, to reduce weight gain among low socioeconomic status, Latinx children with overweight or obesity.

METHODS

We did a two-arm, parallel group, randomised, open-label, active placebo-controlled trial with masked assessment over 3 years. Families from low-income, primarily Latinx communities in Northern California, CA, USA, with 7-11-year-old children with overweight or obesity were randomly assigned to a MMM intervention or a Health Education (HE) comparison intervention. The MMM intervention included home environment changes and behavioural counselling, community after school team sports, and reports to primary health-care providers. The primary outcome was child BMI trajectory over three years. Secondary outcomes included one- and two-year changes in BMI. This trial is registered with ClinicalTrials.govNCT01642836.

FINDINGS

Between July 13, 2012, and Oct 3, 2013, 241 families were recruited and randomly assigned to MMM (n=120) or HE (n=121). Children's mean age was 9·5 (SD 1·4) years, 134 (56%) were female and 107 (44%) were male, and 236 (98%) were Latinx. 238 (99%) children participated in year 1, 233 (97%) in year 2, and 227 (94%) in year 3 of follow-up assessments. In intention-to-treat analysis, over 3 years, the difference between intervention groups in BMI trajectory was not significant (mean adjusted difference -0·25 [95% CI -0·90 to 0·40] kg/m²; Cohen's d=0.10; p=0·45). Children in the MMM intervention group gained less BMI over 1 year than did children in the HE intervention group (-0·73 [-1·07 to -0·39] kg/m², d=0.55); the same was true over 2 years (-0·63 [-1·13 to -0·14] kg/m²; d =0.33). No differential adverse events were observed.

INTERPRETATION

The MMM intervention did not reduce BMI gain versus HE over 3 years but the effects over 1 and 2 years in this rigorous trial show the promise of this systems intervention approach for reducing weight gain and cardiometabolic risk factors in low socioeconomic status communities.

FUNDING

US National Institutes of Health.

‘I Think It Will Be Like This Forever’: How Family Narratives Affect Participation in a Childhood Weight Management Intervention

The family represents the cause of as well as the solution to childhood overweight in many family-based childhood weight management interventions. Involving the family also entails involving the individual family members’ experiences with, attitudes towards, and understandings of obesity. This study explores how families with life-long experiences of overweight manage and experience a family-based childhood weight management intervention in Northern Zealand in Denmark. The analysis is focused on family narratives and their temporal character. The families’ narratives about overweight and past weight management interventions are crucial to how they understand and manage the present intervention. Additionally, the families expect the focus on weight management to continue to be a constant part of their everyday life. The paper concludes that the understanding of weight management in interventions should take its point of departure in the life-world, which the individual family creates through members’ narratives about overweight.

Testing a multicomponent lifestyle intervention for combatting childhood obesity

BACKGROUND

Childhood obesity is a major global health concern. Weight-management camps involving delivery of a program of physical activity, health education, and healthy eating are an effective treatment, although post-intervention weight-management is less well understood. Our objective was to assess the effectiveness of a weight-management camp followed by a community intervention in supporting weight-management for overweight children and children with obesity.

METHODS

Participants were overweight Qatari schoolchildren or schoolchildren with obesity, ages 8-14 years, (n = 300) recruited over a three-year period across 14 randomly selected schools in the Doha area. They attended a two-week weight management camp, then a 10-week program of weekly lifestyle education and physical activity sessions, which also included behavior change techniques. The programme was cognitive behavioural therapy (CBT)-focused with a strong element of behavioural economics blended in.

RESULTS

Participants saw a significant BMI SDS reduction as a result of the entire intervention (camp + education and activity sessions) both at the individual (p < 0.0001) and cluster/school (p = 0.0002) levels, and weight loss occurred during each intervention stage separately for the camp (p < 0.0001 for both the individual and cluster/school levels) and the lifestyle education and activity phase (p < 0.0001 and p = 0.0220 at the individual and cluster/school levels, respectively).

CONCLUSIONS

Weekly lifestyle education and activity sessions which include behavior change techniques may be useful in promoting continued weight management in the period following intensive, immersive childhood obesity interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02972164 , November 23, 2016.

Effectiveness of dietary interventions on weight outcomes in childhood: a systematic review meta-analysis of randomized controlled trials

BACKGROUND

Rapid growth and elevated weight in childhood are significantly associated with obesity in later life, but evidence regarding dietary interventions and weight outcomes is lacking. This study aimed to determine the effectiveness of dietary interventions on body mass index (BMI) and BMI z-score in childhood.

METHODS

PubMed, EmBase, and the Cochrane library were searched from inception till June 2019. Studies that investigated the effectiveness of dietary interventions on BMI and BMI z-score in childhood were considered eligible in our study. The changes in BMI and BMI z-score between dietary interventions and control were calculated by pooled weighted mean differences (WMDs) and 95% CIs were evaluated using random-effects model.

RESULTS

Twenty-eight randomized controlled trials involving a total of 17,488 children were included. The summary WMDs indicated that children who received dietary interventions had greater reduction in BMI (WMD: -0.12; 95% CI: -0.20 to -0.05; P=0.001) and BMI z-score (WMD: -0.04; 95% CI: -0.06 to -0.02; P=0.001) when compared to the usual controls. Subgroup analyses revealed that the sample size, mean age, duration of interventions, and study quality could affect the effectiveness of dietary interventions in children.

CONCLUSIONS

The findings of this meta-analysis suggested that dietary interventions improved BMI and BMI z-score, whereas these results are limited due to substantial heterogeneity and study quality of the included studies.

Parental Food Choices and Engagement in Raising Children's Awareness of Sustainable Behaviors in Urban Poland

Promoting sustainable food consumption patterns and understanding factors driving environmentally-friendly food choices is one of the challenges of public health nutrition policies in the 2020s and crucial for the future wellbeing of humans, food systems and the planet as a whole. To assess the impact of sustainability issues on the behaviors of parents living with young school-aged children in Poland a CAWI survey of 1035 adults in urban areas was conducted. A clustering procedure revealed that two of the identified clusters (73% of the sample) rated sustainability factors as important when purchasing food for children but only one of these clusters (29% of the sample) was actively engaged in raising their child’s awareness about sustainable behaviors. The third cluster (27% of the sample) had no intentions to teach their children about food sustainability because of lack of time or distrust in these topics. More than 80% of the sample agreed that parents share a responsibility in teaching children about the links between food, health and environment. Principles of healthy and sustainable diets should be incorporated into public health programmes to empower family members to engage in raising their children’s awareness and adopt more healthy and environmentally-friendly food consumption practices.

Evaluation of a school-based multicomponent behavioural intervention in deprived urban areas for children classified as overweight, obese or at risk for overweight

OBJECTIVE

This study evaluated the effect of an after-school group-based medium-intensity multicomponent behavioural intervention programme for children aged 8-12 years classified as overweight, obese or at risk for overweight on body mass index standard deviation score (BMI SDS). In accordance with standardized protocols body weight and height were measured in 195 participants (88 boys, 107 girls) at baseline and at the end of the programme. A total of 166 children derived from a school-based monitoring system served as control group. Multivariate regression analyses examined the effect of the intervention and the independent factors associated with better outcomes in the intervention group.

RESULTS

Analysis of covariance showed a significant intervention effect on BMI SDS in favour of the intervention group (b-coefficient - 0.13 ± 0.03; p < 0.01) compared with the control group. Change in BMI SDS between baseline and follow-up in the intervention group was associated with baseline age (b-coefficient 0.03 ± 0.02; p = 0.04) but was independent from gender, ethnicity, baseline BMI SDS, time between baseline and follow-up, school year and attendance rate.

Relationship between Physical Activity, Oxidative Stress, and Total Plasma Antioxidant Capacity in Spanish Children from the GENOBOX Study

The World Health Organization has recommended performing at least 60 min a day of moderate-to-vigorous physical activity (MVPA) and reducing sedentarism in children and adolescents to offer significant health benefits and mitigate health risks. Physical fitness and sports practice seem to improve oxidative stress (OS) status during childhood. However, to our knowledge, there are no data regarding the influence of objectively-measured physical activity (PA) and sedentarism on OS status in children and adolescents. The present study aimed to evaluate the influence of moderate and vigorous PA and sedentarism on OS and plasma total antioxidant capacity (TAC) in a selected Spanish population of 216 children and adolescents from the GENOBOX study. PA (light, moderate, and vigorous) and sedentarism (i.e., sedentary time (ST)) were measured by accelerometry. A Physical Activity-Sedentarism Score (PASS) was developed integrating moderate and vigorous PA and ST levels. Urinary 8-hydroxy-2′-deoxyguanosine (8-OHdG) and isoprostane F2α (F₂-IsoPs), as markers of OS, were determined by ELISA; and TAC was estimated by colorimetry using an antioxidant kit. A higher PASS was associated with lower plasma TAC and urinary 8-OHdG and F₂-IsoPs, showing a better redox profile. Reduced OS markers (8-OHdG and F₂-IsoPs) in children with higher PASS may diminish the need of maintaining high concentrations of antioxidants in plasma during rest to achieve redox homeostasis.

See How They Grow: Testing the feasibility of a mobile app to support parents' understanding of child growth charts

BACKGROUND

Mobile devices provide new opportunities for the prevention of overweight and obesity in children. We aimed to co-create and test an app that offered comprehensible feedback to parents on their child's growth and delivered a suite of age-specific information about nutrition and activity.

METHODS

A two-phased approach was used to co-create the digital growth tool-See How They Grow-and test its feasibility. Phase one used focus groups (parents and professionals such as paediatricians and midwives) and a national on-line survey to gather requirements and build the app. Phase two involved testing the app over 12-weeks, with parents or carers of children aged ≤ 2-years. All research activities were undertaken exclusively through the app, and participants were recruited using social media and hard copy materials given to patents at a child health visit.

FINDINGS

Four focus groups and 101 responses to the national survey informed the features and functions to include in the final app. Two hundred and twenty-five participants downloaded the app, resulting in 208 eligible participants. Non-Māori/Non-Pacific (78%) and Māori (14%) had the highest downloads. Fifty-four per cent of participants were parents of children under 6-months. These participants were more likely to regularly use the app than those with children older than 6-months (64% vs 36%, P = 0.011). Over half of the participants entered three measures (n = 101, 48%). Of those that completed the follow-up survey (n = 101, 48%), 72 reported that the app helped them better understand how to interpret growth charts.

CONCLUSION

The app was acceptable and with minor modifications, has the potential to be an effective tool to support parents understanding of growth trajectories for their children. A larger trial is needed to evaluate if the app can have a measurable impact on increasing knowledge and behaviour, and therefore on preventing childhood overweight and obesity.

Impact of Lifestyle Intervention Programs for Children and Adolescents with Overweight or Obesity on Body Weight and Selected Cardiometabolic Factors-A Systematic Review

Excessive body mass is a health problem among children and adolescents that contributes to the occurrence of lipid disorders and abnormal blood pressure. Effective treatment of excessive body mass in children is essential for the health of population in the future. The aim of the study was to identify universal components of lifestyle interventions in children and adolescents with overweight or obesity leading to weight loss and improvement of selected cardiometabolic parameters. The review included studies from the PubMed and Google Scholar databases published in 2010–2019, which were analyzed for eligibility criteria including age of the participants, BMI defined as overweight or obese, nutritional intervention and the assessment of BMI and/or BMI z-score and at least one lipid profile parameter. Eighteen studies were included in the review, presenting the results of 23 intervention programs in which a total of 1587 children and adolescents participated. All interventions, except one, were multi-component. Data analysis suggests a relationship between a decrease in BMI and/or BMI z-score with diet and physical activity, the involvement of a dietician/nutrition specialist and physician in the treatment team and a longer duration of intervention. Moreover, it seems that a decrease in BMI is mostly associated with decreases in total cholesterol, triglycerides, low density lipoprotein cholesterol and blood pressure. No change in BMI and/or BMI z-score is associated with no change in blood pressure. Our data can be used by public health authorities to design effective weight loss programs for children and adolescents.

Effectiveness and process evaluation in obesity and type 2 diabetes prevention programs in children: a systematic review and meta-analysis

BACKGROUND

Obesity in children is one of the most severe public health challenges of the current century and Type 2 Diabetes Mellitus (T2DM) frequency is also escalating. More so, the importance of process evaluation (PE) in complex interventions is increasingly recognized. The present review, aims to identify the effectiveness in terms of body composition parameters in a generation of articles to prevent obesity and T2DM in children. We hypothesise that those studies reporting PE applying the latest implementation guidelines suggested by the researchers would potentially show positive changes in body composition compared to those not reporting it. Additionally, we will evaluate the implementation degree of PE in those articles considering it and describe the PE subcomponents. Lastly, we aim to assess the intervention target used and its results.

METHODS

A literature review was performed in parallel by 2 independent reviewers. A final number of 41 studies were selected for inclusion criteria.

RESULTS

Meta-analysis of BMI and zBMI found non-significant effects of the proposed interventions. Sub-group analysis revealed only a significant effect in studies which performed PE. Moreover, PE was reported in 42% effective studies and 57% non-effective studies. Fidelity and satisfaction were the most implemented PE subcomponents, although there was a generally low grade of PE use (7/41). The highest proportion of effectiveness (83%) was shown in interventions of physical activity alone while the intervention most used was 3-arm target (diet, PA and BS).

CONCLUSIONS

Overall, obesity and T2DM prevention studies included in this review are not effective in terms of BMI and zBMI. Those studies performing PE reported to be effective in terms of BMI, while studies not reporting PE did not have positive results in terms of BMI and zBMI. In addition, none of the intervention studies included all PE indicators and most studies, which included PE in their interventions, did not provide full report of the PE components, according to the guidelines used for the present review. PROSPERO registration number: CRD42018093667.

Urban sprawl and childhood obesity

Urban sprawl is thought to be a risk factor for childhood obesity primarily because the physical environment it creates discourages children's physical activity while encouraging their sedentary behavior. However, there has not been any review on the association between urban sprawl and childhood obesity. This study filled this research gap by comprehensively reviewing literature focusing on associations between urban sprawl and weight-related behaviors and outcomes among children and adolescents. Only two longitudinal and three cross-sectional studies conducted in two countries were identified. Sample sizes ranged from 2324 to 129 781. Four studies used weight status, and only one study used both behaviors and weight status as outcome variables. All positive, negative, and non-significant associations were reported. This review could not identify a clear association between urban sprawl and childhood obesity. More longitudinal studies are needed for in-depth analyses on this important topic in more regions, which would be important not only for public health guidelines but also for research, practice, and policies in urban planning.

Weight Loss and Improvement of Metabolic Alterations in Overweight and Obese Children Through the I2AO2 Family Program: A Randomized Controlled Clinical Trial

Childhood obesity is a major public health concern. We wanted to evaluate the effectiveness of a multidisciplinary program based on healthy eating, exercise, cognitive-behavioral therapy, and health education to achieve weight loss and improve metabolic parameters in overweight and obese children. A randomized, controlled clinical trial with long-term follow-up (24 months) was conducted at a community care center in overweight and obese individuals aged 6-12 years. A sample of 108 children was divided into an experimental and a control group receiving a standard care program. The experimental groups received a 12-month interdisciplinary program; the results were evaluated at 4 months, the end of the intervention, and at follow-up 12 months later. Anthropometric and biological marker measurements related to metabolic alterations, dyslipidemia (based on total cholesterol), hyperglycemia, fasting glycaemia, triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol in blood were recorded. The intervention had a significant effect (p < 0.001) in terms of decreased body mass index, skinfolds, and waist and arm circumferences. These changes were accompanied by biochemical changes underlying an improvement in metabolic parameters, such as a significant reduction in total cholesterol, low-density lipoprotein-cholesterol, triglycerides, and hyperglycemia and a significant increase in high-density lipoprotein-cholesterol. These effects were still significant for markers of excess weight or obesity in the experimental group 12 months after the end of the intervention, suggesting that an enduring change in healthy lifestyles had been maintained period. This interdisciplinary, nurse-led program helped to reduce childhood and adolescent excess weight and obesity and had long-lasting effects.

Effects of Three Different Family-Based Interventions in Overweight and Obese Children: The "4 Your Family" Randomized Controlled Trial

Childhood overweight and obesity prevalence has risen dramatically in the past decades, and family-based interventions may be an effective method to improve children's eating behaviors. This study aimed to evaluate the effectiveness of three different family-based interventions: group-based, individual-based, or by website approach. Parents and school aged overweight or obese children, 8-12 years of age, were eligible for the study. A total of 115 children were randomly allocated in one of the three interventions, and 91 completed the study (79% compliance); Group 1 (n = 36) received group-based interventions by various experts; Group 2 (n = 30) had interpersonal family meetings with a dietitian; and Group 3 (n = 25) received training through a specifically developed website. Anthropometric, dietary, physical activity, and screen time outcomes were measured at baseline and at the end of the study. Within-group comparisons indicated significant improvement in body weight, body mass index (BMI)-z-score, physical activity, and screen time from baseline in all three study groups (p < 0.05). Furthermore, total body fat percentage (%TBF) was also decreased in Groups 2 and 3. Between-group differences varied with body weight and %TBF change, being larger in Group 3 compared to Groups 1 and 2, in contrast to BMI-z-score, screen time, and health behaviors, which were significantly larger in Group 2 than the other two groups. In conclusion, personalized family-based interventions are recommended to successfully improve children's lifestyle and body weight status.

Effect of individual- versus collective-based nutritional-lifestyle intervention on the atherogenic index of plasma in children with obesity: a randomized trial

BACKGROUND

The Atherogenic Index of Plasma is a predictive biomarker of atherosclerosis in adults but there is a lack of studies in paediatric population aimed at evaluating the longitudinal changes of the AIP and of the cardiometabolic blood profile related to nutritional interventions. The aim of this study was to compare the effect of individual- versus collective-based nutritional-lifestyle intervention on the Atherogenic Index of Plasma in schoolchildren with obesity.

METHODS

One-hundred sixty-four children aged 6-12 years with Body Mass Index z-score > 2 referred to the Paediatric Obesity Clinic, San Paolo Hospital, Milan, Italy, were consecutively enrolled and randomized to undergo to either an individual- (n = 82) or a collective- (n = 82) based intervention promoting a balanced normo-caloric diet and physical activity. In addition, the individual intervention included a tailored personalized nutritional advice and education based on the revised Coventry, Aberdeen, and London-Refined taxonomy. Both at baseline and after 12 months of intervention, dietary habits and anthropometric measures were assessed, a fasting blood sample were taken for biochemistry analysis.

RESULTS

The participation rate at 12 months was 93.3% (n = 153 patients), 76 children in the individual-intervention and 77 children in the collective intervention. At univariate analysis, mean longitudinal change in Atherogenic Index of Plasma was greater in the individual than collective intervention (- 0.12 vs. - 0.05), as well as change in triglyceride-glucose index (- 0.22 vs. - 0.08) and Body Mass Index z-score (- 0.59 vs. - 0.37). At multiple analysis, only change in Body Mass Index z-score remained independently associated with intervention (odds ratio 3.37).

CONCLUSION

In children with obesity, an individual-based nutritional and lifestyle intervention, including techniques from the CALO-RE taxonomy, could have an additional beneficial effect over a collective-based intervention, although the actual size of the effect remains to be clarified. Trial Registration Clinical Trials NCT03728621.

Digital Tools to Support Family-Based Weight Management for Children: Mixed Methods Pilot and Feasibility Study

BACKGROUND

Family-based behavioral therapy is an efficacious approach to deliver weight management counseling to children and their parents. However, most families do not have access to in-person, evidence-based treatment. We previously developed and tested DRIVE (Developing Relationships that Include Values of Eating and Exercise), a home-based parent training program to maintain body weight among children at risk for obesity, with the intent to eventually disseminate it nationally alongside SafeCare, a parent support program that focuses on parent-child interactions. Currently the DRIVE program has only been tested independently of SafeCare. This study created the "mHealth DRIVE" program by further adapting DRIVE to incorporate digital and mobile health tools, including remotely delivered sessions, a wireless scale that enabled a child-tailored weight graph, and a pedometer. Telehealth delivery via mHealth platforms and other digital tools can improve program cost-effectiveness, deliver long-term care, and directly support both families and care providers.

OBJECTIVE

The objective of this study was to examine preliminary acceptability and effectiveness of the mHealth DRIVE program among children and parents who received it and among SafeCare providers who potentially could deliver it.

METHODS

Study 1 was a 13-week pilot study of a remotely delivered mHealth family-based weight management program. Satisfaction surveys were administered, and height and weight were measured pre- and post-study. Study 2 was a feasibility/acceptability survey administered to SafeCare providers.

RESULTS

Parental and child satisfaction (mean of 4.9/6.0 and 3.8/5.0, respectively) were high, and children's (N=10) BMI z-scores significantly decreased (mean -0.14, SD 0.17; P=.025). Over 90% of SafeCare providers (N=74) indicated that SafeCare families would benefit from learning how to eat healthily and be more active, and 80% of providers reported that they and the families would benefit from digital tools to support child weight management.

CONCLUSIONS

Pediatric mHealth weight management interventions show promise for effectiveness and acceptability by families and providers.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03297541, https://clinicaltrials.gov/ct2/show/NCT03297541.

Psychological health in preschool children with underweight, overweight or obesity: a regional cohort study

OBJECTIVE

To examine if underweight (UW), overweight (OW) or obesity (OB), or body mass index (BMI) expressed as its SD score (BMI SDS), were associated with psychological difficulties in preschool children.

DESIGN

Regional cohort study.

SETTING

Oppland County, Norway.

METHODS

At the routine school entry health assessment at 5-6 years of age, parents were invited to participate by local public health nurses. The parents completed questionnaires on sociodemographic, health and lifestyle factors of the child and the family, and on the child's neurocognitive development. They assessed psychological health with the Strengths and Difficulties Questionnaire (SDQ). Public health nurses measured weight and height on all eligible children and reported age, sex, height and weight anonymously for the children who declined to participate.

PARTICIPANTS

We obtained information on 1088 of 1895 (57%) eligible children. The proportion of UW, OW and OB was slightly higher among the children who declined.

MAIN OUTCOME MEASURES

SDQ subscale and Total Difficulties Scores.

RESULTS

The mean SDQ scores and proportion of scores ≥the 90th percentile had a curvilinear pattern from UW through normal weight (NW), OW and OB with NW as nadir, but the pattern was only significant for the mean Emotional problems, Peer problems and Total SDQ Scales, and for the Total SDQ Score ≥the 90th percentile (TDS90). After adjusting for relevant social, developmental, health and behavioural characteristics, TDS90 was only significantly associated with UW in multiple logistic regression analyses, and only with the lowest quartile of BMI SDS in a linear spline regression analysis.

CONCLUSIONS

The study suggests that UW and low BMI, but not OW, OB or higher BMI, are independent risk factors for having psychological symptoms in preschool children.

Individual Physical Activity Behaviour and Group Composition as Determinants of the Effectiveness of a Childhood Obesity Intervention Program

INTRODUCTION

Up to now, there is limited clarity on factors that determine the effectiveness of childhood obesity interventions.

OBJECTIVE

This study intends to uncover individual- and program-level predictors of BMI-SDS and fitness to achieve significant, sustainable health improvements.

METHODS

Data of 249 children with obesity or overweight who participated in an outpatient multidisciplinary program were analysed and compared to 54 waitlist controls. Linear regression models were used to examine associations between individual- and group-level variables and BMI-SDS and fitness.

RESULTS

Among intervention children, BMI-SDS decreased by 0.19 units and physical fitness increased by 11.5%, versus a BMI-SDS decrease of 0.07 and a 1.8% decrease in fitness in the control group. Participants who reported being physically active before the program start achieved greater improvements in BMI-SDS (β = -0.177, p < 0.05) and physical fitness (β = 0.174, p < 0.05) than inactive peers. BMI-SDS decreased significantly more for members of gender-heterogeneous groups (β = 0.194, p < 0.05) with a narrow age range (β = 0.152, p < 0.05).

CONCLUSIONS

The program under review is effective in counteracting juvenile obesity. The results give reason to believe that forming mixed-gender groups with a small age range and providing increased support for reportedly inactive children may improve program effectiveness.

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

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

Relationship between primary school healthy eating and physical activity promoting environments and children's dietary intake, physical activity and weight status: a longitudinal study in the West Midlands, UK

OBJECTIVE

We aimed to examine the association between food and physical activity environments in primary schools and child anthropometric, healthy eating and physical activity measures.

DESIGN

Observational longitudinal study using data from a childhood obesity prevention trial.

SETTING

State primary schools in the West Midlands region, UK.

PARTICIPANTS

1392 pupils who participated in the WAVES (West Midlands ActiVe lifestyle and healthy Eating in School children) childhood obesity prevention trial (2011-2015).

PRIMARY AND SECONDARY OUTCOME MEASURES

School environment (exposure) was categorised according to questionnaire responses indicating their support for healthy eating and/or physical activity. Child outcome measures, undertaken at three time points (ages 5-6, 7-8 and 8-9 years), included body mass index z-scores, dietary intake (using a 24-hour food ticklist) and physical activity (using an Actiheart monitor over 5 days). Associations between school food and physical activity environment categories and outcomes were explored through multilevel models.

RESULTS

Data were available for 1304 children (94% of the study sample). At age 8-9 years, children in 10 schools with healthy eating and physical activity-supportive environments had a higher physical activity energy expenditure than those in 22 schools with less supportive healthy eating/physical activity environments (mean difference=5.3 kJ/kg body weight/24 hours; p=0.05). Children in schools with supportive physical activity environments (n=8) had a lower body mass index z-score than those in schools with less supportive healthy eating/physical activity environments (n=22; mean difference=-0.17, p=0.02). School food and physical activity promoting environments were not significantly associated with dietary outcomes.

CONCLUSIONS

School environments that support healthy food and physical activity behaviours may positively influence physical activity and childhood obesity.

TRIAL REGISTRATION NUMBER

ISRCTN97000586.

Comparison of different mobile health applications for intervention in children and adolescent with overweight: a protocol for systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

Overweight in children is increasing worldwide. Innovative smartphone health applications (mHealth apps) have either sought to deliver single or multi-component interventions for the management of overweight in children. However, the clinical effects of these apps are poorly explored. The objective of the review will be to compare the benefits and harms of different categories of mHealth apps for intervention of overweight in children.

METHODS AND ANALYSIS

We will include randomised clinical trials irrespective of publication type, year, status or language. Children and adolescents between 0 to 18 years will be referred to as children in the remaining part of the paper. Children with all degrees of overweight included obesity and morbidly obese in the remaining part of the paper will be referred to as overweight. We plan to classify different apps according to type of intervention, measurement device, coaching and reward system. The following databases will be used: Cochrane Library, Excerpta Medica database (Embase), PsycINFO, PubMed, IEEE Explore and Web of Science, CINAHL and LILACS. Primary outcomes will be body mass index z-score, quality of life and serious adverse event. Secondary outcomes will be body weight, self-efficacy, anxiety, depression and adverse event not considered serious. Study inclusion, data extraction and bias risk assessment will be conducted independently by at least two authors. We will assess the risk of bias through eight domains and control risks of random errors with Trial Sequential Analysis. The quality of the evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation Tool (GRADE).

ETHICS AND DISSEMINATION

As the protocol is for a systematic reviews, we have not included any patient data and we do not require ethical approval. This review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019120266.

Contextual Complexities in Implementing a Family-Based Childhood Obesity Intervention: The Perspectives of Enrolled Children and Their Parents

Family interventions to treat childhood obesity are widely used, but knowledge about how family dynamics are affected by these interventions is lacking. The present study aims to understand how a family intervention impacts the context of family dynamics, and how different contexts affect the families’ implementation of the intervention. Based on qualitative interviews, we studied families with a child between 9–12 years enrolled in a family intervention to treat childhood obesity at a pediatric outpatient clinic. We conducted 15 family interviews including 36 family members. We found that the family intervention created a new context for the enrolled children. They had to navigate in different contexts and non-supportive environments and push for change if they needed more supportive environments in their attempt to adhere to healthy habits. We show the complexities experienced by parents and grandparents when trying to comply with siblings’ and/or grandchildren’s different needs. The enrolled children were often indirectly blamed if others had to refrain from unhealthy preferences to create supportive environments. These findings are significant in understanding the important role of contexts in family-obesity interventions. This knowledge is relevant to health professionals, researchers, and policymakers.

Impact of a community-based pilot intervention to tackle childhood obesity: a 'whole-system approach' case study

Background

Go-Golborne was a three-year pilot programme to test an innovative, community-based ‘whole system’ approach to preventing overweight in children in Golborne ward, London. Whilst there is a growing interest in local whole systems approaches to obesity, understandings of what they look like in practice are newly emerging. Go-Golborne was designed, implemented and evaluated within this context.

Methods

The evaluation used a case-study design and theory of change approach to assess the effectiveness of the intervention. Height/weight measurements of children in the six participating primary schools were recorded annually for 4 years. For behavioural outcomes, children aged six-11 completed four annual on-line surveys (total 4331 responses). Parents were surveyed in year one and year four (177 responses). Three focus group discussions were held with children aged 10–11 (N = 21); interviews were conducted with parents (N = 11), and school representatives (N = 4). Stakeholders were surveyed twice (37 responses), and interviews were conducted with key stakeholders (N = 11). An extensive range of programme documents were reviewed and additional process data was collected from the programme team. The RE-AIM framework was used to synthesise findings and examine public health impact.

Results

Go-Golborne reached a diverse range of partners across Golborne. Events were attended by over 3360 local children and families and all six primary schools in the ward actively engaged in activities. The proportion of children in the above healthy weight categories remained stable over time. A number of changes in home, school and neighbourhood environments to support healthy behaviour change were evidenced. There was some qualitative evidence of positive changes in children’s behaviours, though significant or sustained changes were not evidenced by the quantitative data.

Conclusions

Go-Golborne helped stakeholders and parents to develop a shared commitment to improving healthy weight in children, to identify barriers to a healthy lifestyle, and to start to make changes in their services/behaviours. The campaigns and changes made at micro-level appeared to be insufficient, in the face of counteracting forces and personal factors, to achieve significant behaviour change within 3 years. This highlights the need for local initiatives to be reinforced by supporting action at regional, national and global levels.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12889-020-09694-2.

Towards a Functional Approach to the Assessment of Daily Life Physical Activity in Children: Are the PAQ-C and Fitbit Flex-2 Technically Adequate?

Considering the need for functional physical activity (PA) measures in PA settings, this study sought to determine the technical adequacy of the Physical Activity Questionnaire for Older Children (PAQ-C) and the Fitbit Flex-2, two instruments with promising features for wide use, using the Actigraph GT3X+ accelerometer as the criterion reference. A total of 218 Greek children (94 boys, 124 girls; mean age = 10.99 ± 1.52 years) volunteered to join in. Participants wore the PA trackers for seven days and completed the PAQ-C. Moreover, a sub-group (n = 60) recompleted the PAQ-C after a week. Results revealed acceptable internal consistency and excellent test-retest reliability for the PAQ-C. Regarding concurrent validity, weak to moderate correlations with PA parameters recorded by the GT3X+ were revealed for the total PAQ-C and were excellent for the Flex-2, while a Bland-Altman plot indicated good agreement. Finally, in alignment with relevant literature, significant gender, but no age, differences were found in participants' PA records in all the tools applied. The above results support the use of the PAQ-C and the Fitbit Flex-2 in children. Considering that they shed light into different parameters of children's habitual PA, their combined utilisation, providing comprehensive information, is strongly recommended.

Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews

BACKGROUND

Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes.

METHODS

Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised.

RESULTS

Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I2 = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I2 = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions.

CONCLUSION

There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns.

TRIAL REGISTRATION

Registered in PROSPERO ( CRD42019120295 ) on 10th January 2019.

The impact of change in neighborhood poverty on BMI trajectory of 37,544 New York City youth: a longitudinal study

BACKGROUND

Neighborhood poverty may increase childhood obesity risk. However, evidence for the neighborhood poverty-obesity relationship is limited. The purpose of this study was to examine how moving to a higher or lower poverty neighborhood impacts body mass index (BMI) z-score trajectories among youth, with the goal of informing policy change, interventions, and clinical practices to reduce childhood obesity.

METHODS

Methods entailed secondary analysis of existing longitudinal data. The sample included youth attending New York City public schools in grades kindergarten through twelfth from school years 2006/2007 through 2016/2017. Eligibility criteria included moving to a higher or lower poverty neighborhood during the data midpoint [school years 2010/2011 through 2013/2014] of the 12-year data-period; New York City-specific metrics were used to define both neighborhood (Neighborhood Tabulation Area) and relevant neighborhood poverty levels (< 5, 5 to < 10%, 10 to < 20%, 20 to < 30%, 30 to < 40% and ≥ 40% of individuals below Federal Poverty Level). Two-piece latent growth curve models were used to describe BMI z-score trajectories of youth who moved to higher versus lower poverty neighborhoods, with propensity score weighting to account for preexisting differences between the two groups. Primary analyses were stratified by sex and exploratory subgroup analyses were stratified by sex and developmental stage (early childhood, middle childhood, and adolescence) to explore sensitive periods for neighborhood poverty exposure.

RESULTS

Of 532,513 youth with home address data, 18,370 youth moved to a higher poverty neighborhood and 19,174 moved to a lower poverty neighborhood (n = 37,544). Females and males who moved to a higher poverty neighborhood experienced less favorable BMI z-score trajectories for obesity risk, though effects were small. Exploratory subgroup analyses demonstrated that negative effects of neighborhood poverty were most pronounced among young and adolescent females and young males, whereas effects were mixed for other subgroups.

CONCLUSIONS

Youth who moved to higher poverty neighborhoods experienced less favorable BMI z-score trajectories for obesity risk, though effects were small and most consistent for females and younger youth. Additional research is needed to illuminate neighborhood poverty's impact on obesity, in order to inform policy, intervention, clinical, and research efforts to reduce obesity and improve child well-being.

Psychotherapy versus treatment as usual and other control interventions in children and adolescents with overweight and obesity: a protocol for systematic review with meta-analysis and Trial Sequential Analysis

INTRODUCTION

The prevalence of children with overweight and obesity is increasing worldwide. Multicomponent interventions incorporating diet, physical activity and behavioural change have shown limited improvement to body mass index (BMI). However, the impact of psychotherapy is poorly explored. This systematic review aims to assess the effects of psychotherapeutic approaches for children with all degrees of overweight.

METHODS AND ANALYSIS

We will include randomised clinical trials involving children and adolescents between 0 and 18 years with overweight and obesity, irrespective of publication type, year, status or language up to April 2020. Psychotherapy will be compared with no intervention; wait list control; treatment as usual; sham psychotherapy or pharmaceutical placebo. The following databases will be searched: Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE, Embase, PsycINFO, PubMed, Web of Science, CINAHL and LILACS. Primary outcomes will be BMI z-score, quality of life measured by a validated scale and proportion of patients with serious adverse events. Secondary outcomes will be body weight, self-esteem, anxiety, depression and proportion of patients with non-serious adverse events. Exploratory outcomes will be body fat, muscle mass and serious adverse events. Study inclusion, data extraction and bias risk assessments will be conducted independently by at least two authors. We will assess risk of bias according to Cochrane guidelines and the Cochrane Effective Practice and Organisation of Care guidance. We will use meta-analysis and control risks of random errors with Trial Sequential Analysis. The quality of the evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation Tool. The systematic review will be reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane guidelines.

ETHICS AND DISSEMINATION

As individual patient data will not be included, we do not require ethics approval. This review will be published in a peer review journal.

PROSPERO REGISTRATION NUMBER

CRD42018086458.