Food Insecurity and Pediatric Obesity: a Double Whammy in the Era of COVID-19

Investigating the controversial link between pediatric obesity and graft survival in kidney transplantation

BACKGROUND

Childhood obesity is a significant public health concern, particularly amongst children with chronic kidney disease requiring kidney transplant (KT). Obesity, defined as a body mass index (BMI) of 30 kg/m² or greater, is prevalent in this population and is associated with disease progression. While BMI influences adult KT eligibility, its impact on pediatric transplant outcomes remains unclear. This study investigates the effect of BMI on graft survival and patient outcomes, addressing gaps in the literature and examining disparities across BMI classifications.

AIM

To assess the impact of BMI classifications on graft and patient survival following KT.

METHODS

A retrospective cohort study analyzed 23081 pediatric transplant recipients from the Standard Transplant Analysis and Research database (1987-2022). Patients were grouped into six BMI categories: Underweight, healthy weight, overweight, and Class 1, 2, and 3 obesity. Data were analyzed using one-way way analysis of variance, Kruskal-Wallis tests, Chi-squared tests, Kaplan-Meier survival analysis with log-rank tests, and Cox proportional hazard regressions. Statistical significance was set at P < 0.05.

RESULTS

Class 3 obese recipients had lower 1-year graft survival (88.7%) compared to healthy-weight recipients (93.1%, P = 0.012). Underweight recipients had lower 10-year patient survival (81.3%, P < 0.05) than healthy-weight recipients. Class 2 and 3 obese recipients had the lowest 5-year graft survival (67.8% and 68.3%, P = 0.013) and Class 2 obesity had the lowest 10-year graft survival (40.7%). Cox regression identified increases in BMI category as an independent predictor of graft failure [hazard ratio (HR) = 1.091, P < 0.001] and mortality (HR = 1.079, P = 0.008). Obese patients experienced longer cold ischemia times (11.6 and 13.1 hours vs 10.2 hours, P < 0.001). Class 3 obesity had the highest proportion of Black recipients (26.2% vs 17.9%, P < 0.001).

CONCLUSION

Severe obesity and underweight status are associated with poorer long-term outcomes in pediatric KT recipients, emphasizing the need for nuanced transplant eligibility criteria addressing obesity-related risks and socioeconomic disparities.

Association Between Social Determinants of Health and Choice of Urinary Reconstruction in Children

OBJECTIVES

To examine if social determinants of health (SDH) are associated with the type of urological reconstruction performed in patients with neurogenic bladder secondary to myelomeningocele and anorectal malformations.

METHODS

A single-institution retrospective review was performed in children with incontinent urinary reconstruction (IUR) or continent urinary reconstruction (CUR) and a diagnosis of myelomeningocele, anorectal malformation, or spinal cord pathology from years 2014-2021. Demographic, clinical, and SDH data were collected and compared to reconstruction type. Categorical variables were analyzed via Fisher's Exact Test. Ordinal variables were analyzed using Cochran-Armitage Test for Trend.

RESULTS

From 2014 to 2021, 208 patients underwent urological reconstruction. Patients had a diagnosis of anorectal malformation (32.2%), myelomeningocele (30.8%), spinal cord pathology (18.8%), other diagnosis (18.3%), or cloacal exstrophy (4.8%). Of the cohort, 154 (74%) had a CUR, and 54 (26%) underwent IUR. Median age at reconstruction was higher in those who underwent CUR (6.7 years [IQR 5.3, 9.8]) than for IUR (5.6 [IQR 1.5, 10.5]) (p=0.01). There was no difference between insurance type for IUR vs. CUR (p=0.11). There was no association between Child Opportunity Index (COI) and reconstruction type (p=0.5). Patients who underwent IUR were more likely to have experienced food insecurity (p=0.02), missed at least one appointment (p=0.02), or have unmarried parents (p=0.03). Those who lived out of state more often pursued CUR (p=0.01).

CONCLUSIONS

There was an association between SDH and type of urologic reconstruction performed in pediatric patients. Social factors must be considered in preoperative planning for urinary reconstruction.

Screening for Food Insecurity: US Preventive Services Task Force Recommendation Statement

Importance

According to survey data, 12.8% of households experienced food insecurity in 2022, with 7.7% of households experiencing low food security and 5.1% experiencing very low food security. Nearly one-third of households with incomes below the federal poverty threshold are food insecure. Food insecurity is one among a multitude of medical, psychological, and social conditions common among economically disadvantaged households.

Objective

The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the evidence on the benefits and harms of screening for food insecurity in the health care setting.

Population

Children, adolescents, and adults.

Evidence Assessment

The USPSTF concludes that the evidence is insufficient and the balance of benefits and harms for screening for food insecurity on health outcomes in the primary care setting cannot be determined.

Recommendation

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for food insecurity on health outcomes in the primary care setting. (I statement).

Food for Thought: The Impact of a Nutritional Toolkit on Well-being in Children

PURPOSE

This study investigated whether attendance by a cohort of pediatric patients at an educational/interventional nutritional program could impact dietary habits, physical health and mental well-being.

METHODS

A 16-week program was offered to 235 children with food insecurity which focused on fresh produce and nutritional education, recipes, as well as physical and mental wellness. Underlying diagnoses were obesity in 41.7 % (n = 98), cancer in 22.1 % (n = 52), mental health issues in 5.5 % (n = 12) or other in 30.7 % (n = 72). Health assessment surveys included changes in food choices, physical activity, mental wellness, memory, sleep, creativity, and BMI at enrollment, end of study, and at three-month follow-up. Results were compared by two-way student-t test and Pearson chi-square analysis.

RESULTS

The median age was 9.9 years (range 1-21 years). Significant improvements were found at the end of study in vegetable consumption (p = 0.002), physical activity (p = 0.001), mental wellness (p = 0.015), focus (p = 0.052), memory (p = 0.004), sleep (p = 0.003), creativity (p = 0.004) and BMI for obese patients (p = 0.025). Food choice improvements were seen in carbohydrates which decreased from 53.0 to 38.7 % (p = 0.013) and vegetable consumption which increased from 32.5 to 39.5 % (p = 0.014). Protein intake did not change significantly. At three-month follow-up there was no decline in interest, produce intake, physical activity, mental wellness, focus, sleep or creativity.

CONCLUSIONS

A diet intervention program where children and their parents are educated on healthy food choices had a significant influence on children's diet and well-being. For pediatric surgery patients with obesity and cancer, these changes could have a significant impact on long term outcomes and warrant further study.

LEVEL OF EVIDENCE

III.

Grocery intervention and DNA-based assessment to improve diet quality in pediatric obesity: a pilot randomized controlled study

OBJECTIVE

We assessed the impact of a food-provisioning intervention on diet quality in children with obesity.

METHODS

Participants (n = 33, aged 6-11 years) were randomly assigned to either usual care (intensive health behavior and lifestyle treatment) or intervention (usual care + food provisioning; high-fiber, low-dairy diet) for 4 weeks. The primary outcome was a change in child diet quality at Week 4. Secondary outcomes were changes in weight, food insecurity, gut microbiome composition (16S ribosomal RNA), and dietary intake, measured via an objective DNA-based biomarker (i.e., FoodSeq). Genomic dietary data were analyzed against a larger pediatric adolescent obesity cohort (n = 195, aged 10-18 years) from similar households.

RESULTS

Intervention demonstrated changes across all assessed diet components and was more effective than usual care in increasing whole grain (β = 0.20, 95% CI: 0.05 to 0.34; p = 0.013) and fiber (β = 2.52, 95% CI: 1.28 to 3.76; p < 0.001) and decreasing dairy (β = -1.31, 95% CI: -2.02 to -0.60; p = 0.001). FoodSeq results, highly concordant with grocery orders (adjusted R2 = 0.65; p < 0.001), indicated a dietary shift toward low-energy-density plant taxa in the intervention relative to a prior survey of diet in a related cohort (β = 8.64, 95% CI: 5.18 to 12.14; p < 0.001). No significant changes were observed in microbiome, weight, or food insecurity.

CONCLUSIONS

Our study supports the potential of dietitian-guided food provisioning for improving diet quality in children with obesity and demonstrates an objective genomic approach for evaluating dietary shifts.

Parental education and neighbourhood socioeconomic status in the prediction of childhood overweight: A multilevel analysis

OBJECTIVE

This study examined cross-level interaction between parental education and neighbourhood SES in predicting overweight including obesity among school-aged children.

METHODS

This analysis used data from 19 984 children aged 5-6 years participating in the school-entry examination of the years 2015 to 2019 in the Aachen city region in Germany. We employed multilevel logistic regression models to predict overweight based on parental education and neighbourhood SES, along with their cross-level interaction, while controlling for several characteristics of the child.

RESULTS

Children from families with intermediate (OR: 1.99; 95% CI, 1.65-2.40) and low parental education (OR: 2.55; 95% CI, 1.92-3.39) and from neighbourhoods with intermediate (OR: 1.25; 95% CI, 1.02-1.53) and low SES (OR: 1.61; 95% CI, 1.29-2.02) were at significantly higher odds for overweight. There was an indication of a cross-level interaction effect (p-value <0.10) to the disadvantage of children with higher parental education, suggesting that inequalities in overweight decrease in more deprived neighbourhoods. The predicted probability of overweight for children with high parental education increased from 6.4% in high SES neighbourhoods to 7.8% in intermediate and 9.9% in low SES neighbourhoods. Sensitivity analyses for obesity and a higher context level of spatial SES confirmed the results.

CONCLUSIONS

The results highlight the crucial role of both individual and contextual socioeconomic conditions in predicting childhood overweight. They also suggest that the impact of neighbourhood socioeconomic status on childhood overweight varies by parental education, particularly disadvantaging children with higher parental education, indicating a social contagion of overweight through spatial disadvantage.

Impact of COVID-19 pandemic on adolescents undergoing metabolic bariatric surgery

BACKGROUND

While the lasting effect of the COVID-19 pandemic continues to unfold, the impact on adolescents undergoing bariatric surgery remains unseen.

OBJECTIVE

We examined the impact of the pandemic on adolescents undergoing metabolic bariatric surgery.

SETTING

Academic hospital, New York, NY.

METHODS

A single-institution review of prospectively collected data evaluated adolescents who underwent laparoscopic sleeve gastrectomy between 2010 and 2023, forming two cohorts: pre-COVID (before March 1, 2019) and COVID (after March 1, 2020). Absolute and percent weight loss and body mass index (BMI) change at 6 and 12 months postsurgery were compared between cohorts. Multivariable linear regression models were constructed to estimate the association between weight loss, adjusting for age, gender, ethnicity, and BMI.

RESULTS

A total of 358 patients were included: 245 in the pre-COVID cohort and 113 in the COVID cohort. There were no significant differences in baseline characteristics. There were no significant differences between cohorts at 6 months in weight loss (21.6 kg vs. 22.5 kg, P = .43), percent weight loss (18% vs. 18%, P = .63), and BMI change (8.0 vs. 8.4, P = .39) which was maintained at 12 months. In multivariate models, after adjusting for age, gender, ethnicity, and baseline BMI, undergoing surgery during the pandemic was not associated with a difference in weight loss or BMI change at 6 and 12 months postoperatively.

CONCLUSION

Despite the severe societal impact of the COVID-19 pandemic, laparoscopic sleeve gastrectomy remained a durable intervention for adolescent obesity, with no observed differences in weight loss in patients undergoing surgery during the pandemic compared to prepandemic.

Neighborhood Food Access in Early Life and Trajectories of Child Body Mass Index and Obesity

Importance

Limited access to healthy foods, resulting from residence in neighborhoods with low food access, is a public health concern. The contribution of this exposure in early life to child obesity remains uncertain.

Objective

To examine associations of neighborhood food access during pregnancy or early childhood with child body mass index (BMI) and obesity risk.

Design, Setting, and Participants

Data from cohorts participating in the US nationwide Environmental Influences on Child Health Outcomes consortium between January 1, 1994, and March 31, 2023, were used. Participant inclusion required a geocoded residential address in pregnancy (mean 32.4 gestational weeks) or early childhood (mean 4.3 years) and information on child BMI.

Exposures

Residence in low-income, low-food access neighborhoods, defined as low-income neighborhoods where the nearest supermarket is more than 0.5 miles for urban areas or more than 10 miles for rural areas.

Main Outcomes and Measures

BMI z score, obesity (age- and sex-specific BMI ≥95th percentile), and severe obesity (age- and sex-specific BMI ≥120% of the 95th percentile) from age 0 to 15 years.

Results

Of 28 359 children (55 cohorts; 14 657 [51.7%] male and 13 702 [48.3%] female; 590 [2.2%] American Indian, Alaska Native, Native Hawaiian, or Other Pacific Islander; 1430 [5.4%] Asian; 4034 [15.3%] Black; 17 730 [67.2%] White; and 2592 [9.8%] other [unspecified] or more than 1 race; 5754 [20.9%] Hispanic and 21 838 [79.1%] non-Hispanic) with neighborhood food access data, 23.2% resided in low-income, low-food access neighborhoods in pregnancy and 24.4% in early childhood. After adjusting for individual sociodemographic characteristics, residence in low-income, low-food access (vs non-low-income, low-food access) neighborhoods in pregnancy was associated with higher BMI z scores at ages 5 years (β, 0.07; 95% CI, 0.03-0.11), 10 years (β, 0.11; 95% CI, 0.06-0.17), and 15 years (β, 0.16; 95% CI, 0.07-0.24); higher obesity risk at 5 years (risk ratio [RR], 1.37; 95% CI, 1.21-1.55), 10 years (RR, 1.71; 95% CI, 1.37-2.12), and 15 years (RR, 2.08; 95% CI, 1.53-2.83); and higher severe obesity risk at 5 years (RR, 1.21; 95% CI, 0.95-1.53), 10 years (RR, 1.54; 95% CI, 1.20-1.99), and 15 years (RR, 1.92; 95% CI, 1.32-2.80). Findings were similar for residence in low-income, low-food access neighborhoods in early childhood. These associations were robust to alternative definitions of low income and low food access and additional adjustment for prenatal characteristics associated with child obesity.

Conclusions

Residence in low-income, low-food access neighborhoods in early life was associated with higher subsequent child BMI and higher risk of obesity and severe obesity. We encourage future studies to examine whether investments in neighborhood resources to improve food access in early life would prevent child obesity.

Food insecurity amongst asylum seekers and people without status in Israel

BACKGROUND

The COVID-19 pandemic caused massive disruptions globally, with food insecurity a primary concern amongst vulnerable communities. As one of the most marginalized and vulnerable groups in Israeli society asylum seekers and undocumented populations were amongst the first to be affected by the pandemic and the economic crisis that followed. The objective of the study was to evaluate the severity and causes of food insecurity among asylum seekers and other undocumented communities because of COVID-19.

METHODS

A multi method approach was used. The quantitative component included an online questionnaire regarding access to food, aid and choices, and the 6 item Household Food Security Survey Module (HFSSM) The qualitative component included 4 focus groups and thematic analysis. The study was conducted in November 2020, by the Ministry of Health's Nutrition Division and the Tel Aviv Municipality's foreign community assistance and information center (Mesila). The convenience sample was drawn from the low-income neighborhood population of South Tel Aviv. Logistic regression, multivariate analysis and content analysis, were performed.

RESULTS

Four hundred eighty-five people completed the quantitative survey, with average age 33.2 ± 5.4 years and 349 (72.0%) experienced food insecurity. In the multivariate analysis, being older (p = 0.04, Odds Ratio OR 1.1, Confidence Interval CI 1.05-1.15) and being single (unmarried) (p = 0.03, OR 2.1, CI 1.2, 3.5) predicted food insecurity. Qualitative findings identified three main themes: children preferring Israeli/ Western foods to traditional foods; financial stresses were compounded; a preference for receiving assistance with purchasing food (vouchers), rather than food handouts.

CONCLUSION

In conclusion, vulnerable populations (asylum seekers and other undocumented communities) were severely affected and are in danger of food insecurity. Culturally relevant and contextualized solutions are needed to address the acute hunger within the community. These include establishment of a cross-ministerial forum, a social grocery store, increased liaison with food rescue bodies, complete nutritional support for children in educational settings and increased guidance regarding food choices and budgeting.

Examining Patient- and Community-Level Factors Associated with Pediatric Mental Healthcare Access Within a Patient Navigation Program

In 2021, national leaders in the United States declared a "national youth mental health crisis." Still, only 1-in-4 children receive adequate mental healthcare access. Patient Navigator Programs (PNPs) can improve children's referral-to-connection to mental health services. We examined patient- and community-level factors associated with pediatric mental healthcare access. Pediatric Support Services (PSS) is a PNP that triages mental and behavioral health referrals within a large health system in a southeastern state. This study analyzes PSS data from September 2017-March 2023 and Child Opportunity Index 2.0 state-normed zip-code level data to assess social drivers of health estimates. Structural equation modeling was conducted between patient- and community-level factors and connection to mental health services. Overall, 62.7% of children connected to mental health services since PSS' inception. Regardless of SDOH, as children get older, they are more likely to connect with mental health services (β = .053, SE = .010, p < .001). Children with greater number of referral needs are more likely to connect with mental health services (β = .034, SE = .011, p = .002). Further, children who live in communities with higher opportunity levels are more likely to connect with mental health services (β = .016, SE = .008, p = .040), suggesting that children who live in low-income communities experience more barriers to mental healthcare. Social drivers may inform referral practices and tiered navigation support for optimal mental healthcare access among children. Further research should demonstrate the effectiveness of PNPs integrated within healthcare and community-based settings.

Comparing Family Health Before and After a Family-Focused Nutrition Program during the Pandemic

INTRODUCTION

The COVID-19 pandemic affected child health behaviors, leading to worse physical health. Given the importance of good family health in improved child health outcomes, this secondary cohort analysis tested the hypothesis that family health would improve from baseline to 12-week follow-up after participation in a novel family nutrition program.

METHODS

Diverse parent-child dyads participated in a home-based virtual Teaching Kitchen Outreach (vTKO) program (11 weekly healthy, low-cost recipes, cooking videos, and associated groceries delivered). The primary outcome was the Family Healthy Lifestyle Subscale (FHLS). Secondary outcomes were parent and child nutrition, and food insecurity. Statistical testing and modeling were used to evaluate pre-post outcomes.

RESULTS

Of 123 enrolled dyads, 114 (93%) had sufficient data for analysis. Participants were 11% Hispanic, 54% Black, and 28% White; 31% completed high school or less; and 30% indicated food insecurity. Cohort mean pre-post FHLS scores significantly increased (25.5 vs. 27.3; p < 0.001). There were significant improvements in parent nutrition (p < 0.001) and child nutrition (p = 0.02 to < 0.001), but not in food security. After adjusting for baseline covariates, tobit regression found statistically significant pre-post FHLS differences (2.3; 95% CI=[1.4, 3.3]; p < 0.001).

DISCUSSION

Participants in the novel home-based vTKO program reported improved family health over 12 weeks.

Barriers to Care for Pediatric Patients with Obesity

This review article emphasizes the challenges pediatric patients face during obesity treatment. Prior research has been compartmentalized, acknowledging that stigma, the ability to implement lifestyle changes, social health determinants, and healthcare accessibility are considerable impediments for obese children. These issues emerge at various levels, including the individual or family, the community and school, and even national policy. This suggests the need for a more comprehensive, team-based approach to tackle pediatric obesity. Understanding these barriers is the first step toward creating effective strategies and solutions to overcome these challenges.

Urban-Rural Disparities in Food Insecurity and Weight Status among Children in the United States

Place of residence (urban versus rural) is a contextual determinant of health that has received less attention in the food insecurity literature. The purpose of this study was to assess the urban-rural disparity in the prevalence of food insecurity and weight status among US children. Using data from the National Health and Nutrition Examination Survey (NHANES) 2013-2016 with three age groups of children (2-5, 6-11, and 12-17 years old), the associations of weight status and child and household food security status by urban-rural residence were examined using Rao-Scott Chi-square tests. Statistical significance was set at p < 0.05. Children living in urban areas were significantly more likely to experience household food insecurity (29.15%) compared to their rural counterparts (19.10%), among those aged 6-11 years. The associations between children's weight status and child and household food security status were significant for children living in urban areas overall and different age groups but not for children living in rural areas. These trends were more pronounced in older age groups. Given the link between food insecurity and higher obesity rates, particularly among urban children, this study highlights the importance of incorporating food security interventions into future obesity prevention programs.

Childhood Obesity and Early Body Mass Index Gains Associated with COVID-19 in a Large Rural Health System

OBJECTIVE

To evaluate body mass index (BMI) change among a population of children with a high proportion residing in rural areas across two pandemic time periods.

METHODS

Electronic health records were evaluated in a rural health system.

INCLUSION CRITERIA

2-17 years at initial BMI; >2 BMIs during pre-pandemic (January 1, 2018-February 29, 2020); >1 BMI in early pandemic (June 1, 2020-December 31, 2020); and >1 BMI in later pandemic (January 1, 2021-December 31, 2021). Mixed effects linear regression models were used to estimate average monthly rate of change in BMI slope (∆BMI) from pre-pandemic to pandemic and test for effect modification of sex, race/ethnicity, age, BMI, public insurance, and rural address.

RESULTS

Among the 40,627 participants, 50.2% were female, 84.6% were non-Hispanic white, 34.9% used public insurance, and 42.5% resided in rural areas. The pre-pandemic proportion of children with overweight, obesity, and severe obesity was 15.6%, 12.8%, and 6.3%, respectively. The ∆BMI nearly doubled during the early pandemic period compared with the pre-pandemic period (0.102 vs 0.055 kg/m2), however, ∆BMI in the later pandemic was lower (0.040 vs 0.055 kg/m2). ∆BMI remained higher in the later pandemic for all race categories compared to Non-Hispanic white. Children with public insurance had higher ∆BMI compared to those with private insurance that remained higher in the later pandemic (0.051 vs 0.035 kg/m2). There was no significant difference between ∆BMI for rural and urban children during pandemic periods.

CONCLUSIONS

Despite the decreased ∆BMI among children in the later pandemic, prevalence of obesity and severe obesity remain high. Efforts must continue to be made to limit excess weight gain during childhood and to assess the impact of forces like structural and social factors in both etiology and prevention.

Telehealth Use in a National Pediatric Weight Management Sample During the COVID-19 Pandemic

Background: This study aimed to assess the implementation and access to telehealth-delivered pediatric weight management (PWM) during the initial phase of the COVID-19 pandemic at six US PWM programs (PWMP) using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Methods: The COVID-19 period (COVID) was defined in this retrospective, multisite study as the time when each site closed in-person care during 2020. The Pre-COVID period (Pre-COVID) was an equivalent time frame in 2019. Patients were stratified by visit completion status. Patient characteristics for COVID and Pre-COVID were compared to examine potential changes/disparities in access to care. Results: There were 3297 unique patients included across the six sites. On average, telehealth was initiated 4 days after in-person clinic closure. Compared with Pre-COVID, COVID (mean duration: 9 weeks) yielded fewer total completed visits (1300 vs. 2157) and decreased revenue (mean proportion of nonreimbursed visits 33.30% vs. 16.67%). Among the completed visits, COVID included a lower proportion of new visits and fewer patients who were male, non-English speaking, Hispanic, or Asian and more patients who were Black or lived ≥20 miles from the program site (p < 0.05 for all). Among no-show/canceled visits, COVID included more patients who had private insurance, older age, or a longer time since the last follow-up. Conclusion: Rapid implementation of telehealth during COVID facilitated continuity of PWM care. Clinic volume and reimbursement were lower during COVID and differences in the patient population reached by telehealth emerged. Further characterization of barriers to telehealth for PWM is needed.

Changes in food sufficiency among Korean adults in urban and rural areas during the COVID-19 pandemic: an analysis of the 7th and 8th Korea National Health and Nutrition Examination Survey

OBJECTIVES

Understanding changes in food sufficiency within various demographic groups during emergency situations, such as the global coronavirus disease 2019 (COVID-19) pandemic, is crucial in formulating public health policies for future preparedness. This study investigated potential differences between urban and rural residents in food sufficiency trends during the COVID-19 pandemic and examined how these changes varied according to socio-demographic factors.

METHODS

This cross-sectional study analyzed data from 19,724 adults aged 20 years and older, utilizing information from the 7th-8th Korea National Health and Nutrition Examination Survey (2018-2021).

RESULTS

In urban areas, across all subpopulations, food sufficiency improved significantly during the COVID-19 period relative to pre-pandemic levels (p<0.001). However, in rural regions, a significant increase in food sufficiency during the COVID-19 era was observed only among female, with an odds ratio of 1.42 (95% confidence interval, 1.06 to 1.89). Nevertheless, no significant interaction terms were found between region and various socio-demographic factors regarding changes in food sufficiency during the COVID-19 period.

CONCLUSIONS

During the COVID-19 pandemic, food sufficiency among urban residents improved compared to the pre-pandemic era, whereas their rural counterparts saw no such improvement. Additionally, no significant interaction was detected between urban versus rural areas and changes in food sufficiency during the COVID-19 period. These findings indicate the need for targeted food policies to prepare for potential future pandemics, particularly in rural areas, where food sufficiency did not improve.

Infant Obesity Prevention Programs for Underrepresented Mothers in a Home Visiting Program: A Qualitative and Community-Engaged Needs Assessment

A qualitative, community-engaged assessment was conducted to identify needs and priorities for infant obesity prevention programs among mothers participating in home visiting programs. Thirty-two stakeholders (i.e., community partners, mothers, home visitors) affiliated with a home visiting program serving low-income families during the prenatal to age three period participated in group level assessment sessions or individual qualitative interviews. Results indicated families face many challenges to obesity prevention particularly in terms of healthy eating. An obesity prevention program can address these challenges by offering realistic feeding options and non-judgmental peer support, improving access to resources, and tailoring program content to individual family needs and preferences. Informational needs, family factors in healthy eating outcomes, and the importance of access and awareness of programs were also noted. To ensure the cultural- and contextual-relevance of infant obesity prevention programs for underserved populations, needs and preferences among community stakeholders and the focal population should be used as a roadmap for intervention development.

Racial and ethnic demographics in malnutrition related deaths

BACKGROUND AND AIMS

Currently, 40 million Americans are food insecure. They are forced to skip meals and buy non-nutritious food, leading to health disparities for those of low socioeconomic status. This study aims to investigate relationships between malnutrition deaths and sociodemographic groups.

METHODS

This cross-sectional study from 2009 to 2018 used aggregate data from the CDC Wide-ranging Online Data for Epidemiologic Research (CDC Wonder). Patients with known race, gender, and Hispanic origin age ≥18 who died from malnutrition (E40-E46) were included. Place of death was grouped into home, inpatient medical facility, hospice facility, nursing facility/long-term care, other (including outpatient, ED, and DOA), and unknown. Crude rates of malnutrition deaths per 100,000 persons for race, gender, and Hispanic origin were calculated using US census estimates. Gross proportions of total deaths were calculated for each place of death.

RESULTS

Between 2009 and 2018, there were 46,517 malnutrition deaths in the US. Death rates for Black (1.8) and White Americans (2) were twice as high compared to Native Americans (1.1) and Asians or Pacific Islanders (0.7). Death rates among females (2.3) were higher than males (1.5). Death rates among non-Hispanics (2.1) were twice as high compared to Hispanics (0.7). Most people who died of malnutrition died in hospitals (37 %).

CONCLUSION

Malnutrition deaths occur at greater rates among White, Black, non-Hispanic Americans, and females. Despite reported disparities in food access, Black and White Americans have similar malnutrition mortality rates, raising concerns that malnutrition is under-diagnosed among Black patients. Given the existing nutrition literature, this finding requires further investigation.

Caregiver perceptions of a pediatric produce prescription program during the COVID-19 pandemic

Introduction

Produce prescription programs are rapidly expanding as a type of Food is Medicine intervention with prospects for mitigating food insecurity and reducing diet-related health disparities. Gaining insight into participant perspectives on program logistics and perceived impacts is crucial to program success and improvements.

Methods

Between May and June 2021, we conducted individual and small group interviews with 23 caregivers with children aged 1-5 years who participated in a produce prescription program from 2020 to 2021 in Texas, U.S. They were provided with a gift card to a major national grocery retailer to purchase fresh produce. The card was reloaded $60 monthly for 8 months with automatic roll-over of unused funds to the next month. Participants also received nutrition education in the form of two videos. A deductive analysis approach was employed, and NVivo qualitative data analysis software was used to perform coding and to assist with subsequent analyses.

Results

All 23 participants were female, with an average age of 37.5 years, and the majority identified as Hispanic/Latino (83%). About 43% of the families had three or more children. Six themes were generated from interviews. Three of these themes were related to program logistics: (1) ease of program use; (2) participant satisfaction with the incentive; and (3) desire for additional store options. The remaining main themes pertained to program impact: (1) the enhanced ability to purchase produce; (2) the usefulness of the nutrition education; and (3) persistent challenges encountered when preparing the produce for picky eaters and young children.

Conclusion

A pediatric produce prescription program was perceived as logistically easy and a helpful source of financial support for accessing fresh produce. Program features such as card-based incentive system and partnership with major grocery retailer were favored by participants. For future program design, it may be beneficial to consider collaborating with multiple grocery outlets and enhancing the intensity and targeting of nutrition education.

South-to-South parental migration patterns and excess weight among children: Insights from a national cross-sectional study in Colombia

BACKGROUND

Evidence from Latin America suggests that children embedded in South-to-North migrant networks (i.e. relatives who live abroad, typically in the United States) are at increased risk of excess weight. It is unclear if the same findings apply to children embedded in Latin American intraregional migration or South-to-South migration networks.

OBJECTIVE

To compare excess weight among Colombian children embedded in South-to-South migration networks (n = 334) to children with non-migrant parents (n = 4272) using Colombia's 2015 National Survey of the Nutritional Situation.

METHODS

Prevalence ratios (PRs) for excess weight (BMI z-score ≥1) by parent migration history were estimated using weighted multivariable logistic regression adjusting for demographics, child behaviours, community and household indicators, including household food insecurity.

RESULTS

Most migrant parents returned to Colombia from Venezuela (84%) and reported higher household food insecurity rates than non-migrant parents (59% versus 32%). Models excluding household food insecurity showed that excess weight among children with migrant parents was 51% lower (PR = 0.49; 95% CI 0.25, 0.98) than among children with non-migrant parents. After adjustment for household food insecurity, no statistically significant differences were found.

CONCLUSION

Colombian children with return migrant parents from Venezuela experienced less excess weight than children with non-migrant parents, but higher rates of food insecurity in migrant households might partially explain this difference. This study calls attention to two serious public health concerns for Colombian children-those who have excess weight and those who lack sufficient food, particularly among migrant returnees (a situation that may have worsened since the COVID-19 pandemic).

Lifestyle Behaviors of Bronx Middle-School Students Enrolled in an Afterschool Program: Lessons Learned from the COVID-19 Shutdown

Background: A minority of American youth meet CDC lifestyle behavior recommendations. Children in the Bronx face barriers to healthy behaviors amplified by COVID-19. This research evaluated baseline behavior among distinct cohorts attending afterschool programming before and after the COVID-19 shutdown. Methods: Three Bronx public schools collected demographic and behavior data at the start of the 2021-2022 school year. This was compared to baseline data from students during the 2016-2017 and 2017-2018 school years at 1 school. Results: During the 2016-2017 and 2017-2018 school years, 76 students completed lifestyle behaviors questionnaires. During the 2021-2022 school year 89 students completed questionnaires. Participants surveyed after the COVID-19 shutdown drank more sweetened beverages (Median (IQR) = 3 (2-5) cups/day vs 2 (1-4) cups/day, P = .029) than those surveyed before the pandemic. Changes to the distribution of sleep (8 (7.5-9) hours/day vs 8 (6-9) hours/day, P = .005) and fast food consumption (1 (0 to 2-3) times/week vs 1 (1 to 2-3) times/week), P = .004) without changes in medians were also observed. PA hours completed weekly trended toward significant decline (4 (2-5) hours/week vs 3 (2-5) hours/week, P = .09). Conclusions: Changes in behaviors including sleep, physical activity, and sweetened beverage and fast food consumption observed after the COVID-19 shutdown highlight the importance of robust programming to promote healthy lifestyle behaviors in youth.

The Ongoing Impact of COVID-19 on Pediatric Obesity

In the developed world, pediatric obesity (PO) has been a major health concern since the last century, and this condition may lead to detrimental life-long physical and mental comorbidities. Currently, its prevalence has increased in low- and middle-income countries and in many high-income countries. Thus, the provision of effective and tailored care for children and their families has become vital. The social consequences of the COVID-19 pandemic are known everywhere, and among these, it has been argued that the COVID-19 pandemic has had a major impact on PO. Overall, the growth of PO over the last decade has been enhanced by the pandemic. During the COVID-19 pandemic, children, adolescents and young adults gained weight as the pediatric population dealt with sedentary lifestyles and changes in food habits. In this review, we want to highlight the impact that the COVID-19 pandemic had on PO.

Food Insecurity and Pediatric Nonalcoholic Fatty Liver Disease Severity

OBJECTIVE

To determine the association between food insecurity and pediatric nonalcoholic fatty liver disease (NAFLD).

METHODS

Cross-sectional study of patients < 21 years of age with histologically confirmed NAFLD. The Household Food Security Survey Module was administered to determine food insecurity status. Skin lipidomics were performed to explore pathophysiologic mechanisms.

RESULTS

Seventy-three patients with histologically confirmed NAFLD completed the Household Food Security Survey Module. Of these, the majority were male (81%) and non-Hispanic (53%), with a mean age at biopsy of 13 ± 3 years. Food insecurity was seen in 42% (n = 31). Comparison of features between food insecure and food secure subgroups revealed no differences in sex, ethnicity, BMI z-score, aminotransferases, or histologic severity. However, children experiencing food insecurity presented on average 2 years before their food secure counterparts (12.3 ± 3.0 vs 14.4 ± 3.6 years, P = .015). A subset of 31 patients provided skin samples. Skin lipidomics revealed that food insecurity was associated with down-regulated features from the lipoamino acid class of lipids, previously linked to inflammation and adipocyte differentiation.

CONCLUSIONS

Food insecurity is highly prevalent in children with NAFLD and is associated with earlier presentation. Lipidomic analyses suggest a possible pathophysiologic link that warrants further exploration.

Family-based pediatric weight management interventions in US primary care settings targeting children ages 6-12 years old: A systematic review guided by the RE-AIM framework

Obesity is a pandemic that disproportionately affects children from vulnerable populations in the USA. Current treatment approaches in primary care settings in the USA have been reported to be insufficient at managing pediatric obesity, primarily due to implementation challenges for healthcare systems and barriers for families. While the literature has examined the efficacy of pediatric obesity interventions focused on internal validity, it lacks sufficient reporting and analysis of external validity necessary for successful translation to primary care settings. We conducted a systematic review of the primary-care-setting literature from January 2007 to March 2020 on family-based pediatric weight management interventions in both English and/or Spanish for children ages 6-12 years in the USA using the Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. A literature search, using PRISMA guidelines, was conducted in January 2022 using the following electronic databases: Medline Ovid, Embase, and Cochrane Library. 22 270 records were screened, and 376 articles were reviewed in full. 184 studies were included. The most commonly reported dimensions of the RE-AIM framework were Reach (65%), Efficacy/Effectiveness (64%), and Adoption (64%), while Implementation (47%) and Maintenance (42%) were less often reported. The prevalence of reporting RE-AIM construct indicators ranged greatly, from 1% to 100%. This systematic review underscores the need for more focus on external validity to guide the development, implementation, and dissemination of future pediatric obesity interventions based in primary care settings. It also suggests conducting additional research on sustainable financing for pediatric obesity interventions.

Cross-sectional analysis reveals COVID-19 pandemic community lockdown was linked to dysregulated cortisol and salivary alpha amylase in children

The COVID-19 pandemic altered everyday life starting in March 2020. These alterations extended to the lives of children as their normal routines were disrupted by community lockdowns, online learning, limited in-person social contact, increased screen time, and reduced physical activity. Considerable research has investigated the physical health impact of COVID-19 infection, but far fewer studies have investigated the physiological impact of stressful pandemic-related changes to daily life, especially in children. The purpose of this study was to leverage an ongoing clinical trial to investigate physiological consequences associated with chronic stress of pandemic community lockdown on children. As a part of the clinical trial, children provided saliva samples. Saliva samples were analyzed for cortisol and salivary alpha amylase (sAA) content. This secondary cross-sectional analysis included 94 preadolescent children located within the Greater Boston, Massachusetts community. Children participated in the study either before, during, or following the pandemic community lockdown to form three groups for comparison. In response to chronic stress caused by the pandemic community lockdown, participants demonstrated dysregulation of fast-acting catecholamine response of the locus-coeruleus-norepinephrine system and slower-acting glucocorticoid response, resulting in an asymmetrical relationship of hypocortisolism (M = 0.78 ± 0.19 μg/mL, p < 0.001) paired with higher sAA (M = 12.73 ± 4.06 U/mL, p = 0.01). Results suggest that the abrupt COVID-19 disruption to daily life, including the stressful experience of community lockdown, had physiological effects on typically developing children. Further research is required to investigate mental health outcomes of children following the chronic stress of the pandemic community lockdown.

A co-designed, community-based intensive health behavior intervention promotes participation and engagement in youth with risk factors for type 2 diabetes

Background

Obesity among youth (children and adolescents) is associated with increased risk for youth-onset type 2 diabetes. Lifestyle change can delay or prevent the development of type 2 diabetes, yet real-world implementation of health behavior recommendations is challenging. We previously engaged youth with risk factors for type 2 diabetes, their caregivers, and professionals in a human-centered design study to co-design a lifestyle change program. Here we report the outcomes for this 16-week co-designed lifestyle change program for youth at risk for T2D and their caregivers.

Research design and methods

This single-arm family-based cohort study included youth aged 7-18 years, with BMI ≥85th percentile (overweight or obese) and at least one additional risk factor for type 2 diabetes, and their caregivers. Clinical (BMI, HbA1c), self-reported physical activity, and quality of life outcomes were evaluated at baseline (B), post-intervention (M4), and 1 year (M12) following the intervention.

Results

Seventy-eight youth (mean age 12.4 ± 2.7y, 67% female, 37.8% white) and 65 caregivers were included in the data analysis. Youth baseline BMI z-scores (2.26 ± 0.47) and HbA1c (5.3 ± 0.3) were unchanged at follow up time points [BMI z-scores M4 (2.25 ± 0.52), M12 (2.16 ± 0.58), p-value 0.46], [HbA1c M4 (5.3 ± 0.3), M12 (5.2 ± 0.3), p-value (0.04)]. Youth reported increased physical activity at M4 (p = 0.004), but not at M12. Youth quality of life scores increased at M12 (p=0.01). Families who attended at least one session (n=41) attended an average of 9 out of 16 sessions, and 37 percent of families attended 13 or more sessions.

Conclusion

A co-designed, community-based lifestyle intervention promotes increased physical activity, improved quality of life, maintenance of BMI z-scores and HbA1c, and engagement in youth with risk factors for T2D.

Patterns of participation in summer programming among United States' elementary children from low-income urban households: Results from the project SWEAT study

Food insecurity increases among marginalized children during the summer when school is out of session. Summer programming that offers access to healthy meals and snacks may reduce the risk. There is a national call in the US for more research to assure equitable access to summer programming. The objective of this prospective observational study was to characterize patterns of participation in summer programming among elementary children from low-income urban neighborhoods of metropolitan[Blinded]. Summer programming was broadly defined (e.g., church, school, recreation center, community center). Caregivers(n = 100) received weekly text messages via TextIt during the summer (Jun-Aug 2017). They were asked: "How many days this week did [ChildName] attend a summer program? Please respond with a number from 0 to 5, where 0 - no days, 2 - 2 days, etc." Weekly counts were summed. Stepwise logistic and linear regression models were conducted to examine differences in patterns of attendance according to key sociodemographic characteristics. Mean age was 7.03 ± 0.23. 52 % identified as female, 70 % were low-income, and 80.0 % identified as Black. 51 % attended summer programming at least once; 49 % never attended. Those who attended at least once vs. not at all were more likely to be male(p < 0.01); 62.75 % males vs. 37.25 % females attended summer programming at least once, whereas 67.35 % females compared to 32.65 % males never attended. Overall mean attendance was 10.40 ± 1.43 days(out of 50). Mean + SE attendance was lower for females (7.52 + 1.76) vs. males (13.52 + 2.21)(p < 0.05), and non-Black (4.30 + 1.97) vs. Black (11.93 + 1.67)(p = 0.01) children. Future research is needed to understand barriers to participation in summer programming.

COVID-19 and children's behavioral health: An overview

The paper reviews the impact of the COVID-19 pandemic on children's and adolescents' well-being. A trauma-informed framework is employed to discuss the emerging evidence of notable changes in youth's psychological, developmental, academic, and social well-being since the start of the COVID-19 pandemic. Children and adolescents have been uniquely affected based on their age at the start of the pandemic. Despite multiple resiliency factors, COVID-19 and its ramifications have had an adverse effect on youth in general and have exacerbated preexisting racial and socioeconomic disparities. This review concludes with recommendations for child health clinicians.

Adolescent Independent Eating Occasions, Dietary Intake, and Parenting Practices During the COVID-19 Pandemic: A Qualitative Study of Parents and Adolescents From Households With Low Income

OBJECTIVE

Examine how experiencing the coronavirus disease 2019 (COVID-19) pandemic influenced adolescent independent eating occasions (iEOs) and iEO-related parenting practices from the perspective of parents and adolescents METHODS: Cross-sectional remote interviews were conducted for this basic qualitative research study. Participants were a purposive sample of multiracial/ethnic adolescents aged 11-14 years and their parents from households with low income (n = 12 dyads) representing 9 US states. The main outcome measures were iEOs and iEO-related parenting practices. Data were analyzed using directed content analysis.

RESULTS

About half of the parents indicated that their adolescents had more iEOs during the COVID-19 pandemic and that there were changes in the types of foods consumed during iEOs. In contrast, most adolescents indicated their iEOs had not changed remarkably in frequency or foods consumed since the onset of the pandemic. Most parents reported no change in how they taught their adolescents about healthy food, the rules for foods/beverages permitted during iEOs, or how they monitored what their adolescents ate during iEOs; adolescent reports were in general agreement. Most parents indicated that family members were home together more often during the pandemic, which increased cooking frequency.

CONCLUSIONS AND IMPLICATIONS

The effect of the COVID-19 pandemic on adolescents' iEOs varied, and the parenting practices used to influence iEOs remained stable during the pandemic. Families experienced having more time together and cooking at home more often.

The Health and Nutritional Status of Children (10-18 years) Belonging to Food Insecure Households: The Korea National Health and Nutrition Examination Survey (2012-2019)

To research the health and nutritional status in Korean children and adolescents belonging to food insecure households (FI), the preregistered secondary data of 18 items from the Food Security Evaluation in the Korea National Health and Nutrition Examination Survey (KNHANES; 2012-2019) were used. Comparative analyses (food security group [FS], (n = 3150) vs. FI, (n = 405) of household characteristics, health status (anthropometrics, clinics, mentality), and nutritional status (nutrient intake, diet-quality, and pattern) were performed in children (boys: 1871, girls: 1684) aged 10-18 years. The FI comprised higher proportions of participants from low-income families, basic livelihood-security recipients, and vulnerability (characteristics: female household heads, aged ≥50, single, unemployed, with low education and unmet healthcare needs). Compared to FS, boys had higher abdominal obesity and alcohol use, whereas girls had lower high-density-lipoprotein cholesterol (HDLc) and mental vulnerability (self-perceived obesity despite FS-similar anthropometry) in FI. Inadequate protein intake among boys and girls, and high carbohydrate and inadequate fat intake among girls were especially found in the FI status. From the results of a nutrition quality test, Vit-A in boys, and protein, niacin, and iron intakes in girls were insufficient, respectively. Health-nutritional policies to improve children's lifestyles should reinforce FI-based intake of deficient nutrients.

Epidemiology of pediatric trauma and fractures during and beyond the COVID-19 pandemic

Purpose

Previous literature has shown decreases in pediatric trauma during the COVID-19 outbreak, but few have analyzed beyond the peak of the pandemic. This study assesses the epidemiology of pediatric trauma cases in a high-volume teaching hospital in New York City before, during, and after the height of the COVID-19 pandemic.

Methods

Institutional data on pediatric trauma orthopedic cases from January 1, 2018 to November 30, 2021 were extracted. The following time frames were studied: (1) April 1-June 22 in 2018 and 2019 (pre-pandemic), (2) April 1-June 22, 2020 (peak pandemic), and (3) April 1-June 22, 2021 (post-peak pandemic). Inferential statistics were used to compare patient and trauma characteristics.

Results

Compared to the pre-pandemic cohort (n = 6770), the peak pandemic cohort (n = 828) had a greater proportion of fractures (p < 0.01) and had a significantly decreased overall traumas per week rate (p < 0.01) and fractures per week rate (p < 0.01). These decreased trauma (p < 0.01) and fracture rates (p < 0.01) persisted for the post-peak pandemic cohort (n = 2509). Spatial analysis identified zip code clusters throughout New York City with higher rates of emergency department presentation during the peak pandemic compared to pre-pandemic, and these areas aligned with lower-income neighborhoods.

Conclusion

During the peak of the pandemic, overall trauma and fracture volumes decreased, the types of prevalent injuries changed, and neighborhoods of different economic resources were variably impacted. These trends have mostly persisted for 12 months post-peak pandemic. This longitudinal analysis helps inform and improve long-term critical care and public health resource allocation for the future.

Level of evidence

Level III.

A systematic appraisal of the information, engagement, aesthetic and functional quality of nutrition-related smartphone apps for children and adolescents

OBJECTIVE

Nutrition-related smartphone applications (apps) could improve children's nutrition knowledge and skills. However, little is known about the quality of nutrition-related apps for children. This study aimed to identify and evaluate the quality of nutrition-related smartphone apps designed for children ages 4-17.

DESIGN

This systematic appraisal is guided by the Protocol for App Store Systematic Reviews.

SETTING

Using Google's Advanced Search, we identified 1814 apps/1184 additional apps in an updated search on iOS, of which twenty-four were eligible. The apps' objective and subjective quality were evaluated using the twenty-three-item, five-point Mobile App Rating Scale. The objective quality scale consists of four subscales: engagement, functionality, aesthetics and information.

RESULTS

Most of the apps (75 %) focussed solely on promoting nutrition skills, such as making food dishes, rather than nutrition knowledge. Of the twenty-four apps, 83 % targeted children 4-8 years old. The app objective quality mean score was 3·60 ± 0·41. The subscale mean scores were 3·20 ± 0·41 for engagement, 4·24 ± 0·47 for functionality, 4·03 ± 0·51 for aesthetics and 2·94 ± 0·62 for information. The app subjective quality mean score was 2·10 ± 0·90.

CONCLUSIONS

More robust approaches to app development leveraging co-design approaches, including involving a multidisciplinary team of experts to provide evidence-based nutrition information, are warranted.

Impact of the COVID-19 kindergarten closure on overweight and obesity among 3- to 7-year-old children

BACKGROUND

Knowledge on the impact of the temporary kindergarten closure policy under COVID-19 in 2020 on childhood overweight and obesity is inadequate. We aimed to examine differences in rates of overweight and obesity from 2018 to 2021 among kindergarten children aged 3-7 years.

METHODS

Overweight was defined as body mass index (BMI) > 1 standard deviation (SD) for age and sex, and obesity was defined as BMI > 2 SD for age and sex. Generalized linear mixed modeling was used for analysis.

RESULTS

A total of 44,884 children and 71,216 growth data points from all 57 public kindergartens in Jiading District, Shanghai, China were analyzed. The rates of obesity from 2018 to 2021 were 6.9%, 6.6%, 9.5%, and 7.3% in boys and 2.8%, 2.8%, 4.5%, and 3.1% in girls, respectively. The rates of overweight from 2018 to 2021 were 14.3%, 14.3%, 18.2%, and 15.3% in boys and 10.6%, 10.9%, 13.9%, and 11.6% in girls. The rates of obesity and overweight among kindergarten children in 2020 were significantly higher than those in 2018, 2019, and 2021. Compared to 2020, the odds ratios of the obesity rate in 2018, 2019, and 2021 were 0.67 [95% confidence interval (CI) = 0.58-0.77, P < 0.001], 0.72 (95% CI = 0.64-0.80, P < 0.001) and 0.81 (95% CI = 0.72-0.92, P = 0.001), respectively. The odds ratios of the overweight rate in 2018, 2019, and 2021 were 0.75 (95% CI = 0.69-0.82, P < 0.001), 0.78 (95% CI = 0.72-0.84, P < 0.001), and 0.89 (95% CI = 0.81-0.97, P = 0.008), respectively, compared to 2020.

CONCLUSIONS

The rates of overweight and obesity significantly increased among kindergarten children in 2020 after the 5-month kindergarten closure. It was critical to provide guidance to caregivers on fostering a healthy lifestyle for children at home under public health emergencies.

Food Insecurity, the Food Environment, and COVID-19 in Rural South Carolina

In this study, we explored the relationship between the food environment and food security among rural adults during the COVID-19 pandemic. Researchers, with assistance from community partners, conducted a cross-sectional survey assessing the impact of COVID-19 on food access, food security, and physical activity in 9 rural South Carolina (SC) counties. This survey was administered to a purposive sample (N = 587) from August 2020 to March 2021. The dependent variable was a binary indicator of food insecurity (past 3 months), in accordance with the USDA Household Food Security Survey Module. Independent variables were sociodemographic characteristics, food environment factors (eg, shopping at grocery stores, partial markets, and farmers' markets), and shopping behaviors during the pandemic. Overall, 31% of respondents were food insecure. Food security status differed by income and household composition. Results indicate that the odds of food insecurity were higher for respondents who shopped frequently at partial markets (adjusted odds ratio [AOR] = 1.61, 95% confidence interval [CI]: 1.01-2.56) and shopped more for food before the pandemic than during the pandemic (AOR = 1.68, 95% CI: 1.07-2.64). Findings underscore the importance of examining the relationship between the food environment and food insecurity during COVID-19 in rural settings.

Trends in health behavior at an afterschool program: the impact of COVID-19 on students' behavior

Background

A minority of American youth meet CDC physical activity (PA) recommendations; children in the Bronx face additional structural barriers to engaging in PA. The B'N Fit Power expansion draws on pilot programming to increase the proportion of middle school students who engage in one hour of daily PA. The COVID-19 pandemic presented additional obstacles, including increased food insecurity and suspension of organized PA programming. This research aimed to evaluate differences in baseline target behavior attainment before and after the start of the COVID-19 pandemic to inform future programming to help children reduce their risk of obesity.

Methods

Afterschool program leaders at three Bronx public schools collected demographic and target behavior data at baseline and attendance data throughout the school year.

Results

During the 2016-2017 and 2017-2018 school years, 76 students enrolled and completed one year of programming, which was administered at a single site (61 % Hispanic, 46% female). Of these, 76 (100%) completed a baseline target behaviors questionnaire. During the 2021-2022 school year, 417 students enrolled and completed one year of programming at one of the three sites (70% Hispanic, 48% female). 89 (21%) completed a baseline target behaviors questionnaire. Participants surveyed after the start of the COVID-19 pandemic reported drinking more sugar-sweetened beverages (Median=3 daily, IQR 2-5), sleeping less (Median=8 hours daily, IQR 6-9 hours), and consuming fast food more frequently (Median=1 time weekly, IQR 0 times weekly-2 to 3 times weekly) than those surveyed prior to the start of the pandemic. The number of PA hours completed each week trended toward significant decline (Median=3, IQR 2-5, p=0.09) in students tracked after the start of the pandemic.

Conclusions

The attainment of several target behaviors among school children linked to the reduction of childhood obesity declined during the COVID-19 pandemic. These findings can be applied to enhancing existing real-world afterschool PA programming.

Social Challenges as a Consequence of the COVID-19 Pandemic among South Florida Preschool Children with Disability and Obesity

The COVID-19 pandemic has negatively impacted the childcare industry over the past two years. This study examined how pandemic-related challenges impacted preschool-aged children by disability and obesity status. Participants were 216 children (80% Hispanic, 14% non-Hispanic Black) aged 2 to 5 years in 10 South Florida childcare centers. In November/December 2021, parents completed a COVID-19 Risk and Resiliency Questionnaire, and body mass index percentile (BMI) was collected. Multivariable logistic regression models examined the association of COVID-19 pandemic-related social challenges (transportation, employment) and child BMI and disability status. As compared to normal-weight children, those families with a child who was obese were more likely to report pandemic-related transportation (OR: 2.51, 95% CI: 1.03-6.28) challenges and food insecurity (OR: 2.56, 95% CI: 1.05-6.43). Parents of children with disabilities were less likely to report that food did not last (OR: 0.19, 95% CI: 0.07-0.48) and that they could not afford balanced meals (OR: 0.33, 95% CI: 0.13-0.85). Spanish-speaking caregivers were more likely to have a child who was obese (OR: 3.04, 95% CI: 1.19-8.52). The results suggest that COVID-19 impacts obese preschool children from Hispanic backgrounds, while disability was a protective factor.

Socioeconomic inequality in overweight/obesity among US children: NHANES 2001 to 2018

Background

Previous research has found that the prevalence of childhood overweight/obesity varies depending on household income, ethnicity, and sex. The goal of our research is to examine changes over time in socioeconomic inequality and the prevalence of overweight/obesity among American children under five by sex and ethnicity.

Methods

This cross-sectional analysis used data from the National Health and Nutrition Examination Surveys (NHANES) collected from 2001-02 to 2017-18. Overweight/obesity in children under five [Body Mass Index (BMI)-for-age z-score >2 standard deviations] was defined according to the World Health Organization (WHO) growth reference standard. The slope inequality index (SII) and the concentration index (CIX) were used to measure the socioeconomic inequality in overweight/obesity.

Results

Between 2001-02 and 2011-12, childhood overweight/obesity in the United States decreased from 7.3% to 6.3%, and had increased to 8.1% by 2017-18. However, this pattern varied widely by ethnicity and sex. For both the 2015-16 and 2017-18 surveys, overweight/obesity was more concentrated in the poorest household quintile for overall Caucasian children ((SII = -11.83, IC 95% = -23.17, -0.49 and CIX = -7.368, IC 95% = -13.92, -0.82) and (SII = -11.52, IC 95% = -22.13, -0.91 and CIX = -7.24, IC 95% = -13.27, -1.21), respectively) and for males of other ethnicities [(SII = -13.93, IC 95% = -26.95, -0.92) and CIX = -8.55, IC 95% = -0.86, -16.25] and (SII = -21.19, IC 95% = -40.65, -1.74) and CIX = -13.11, IC 95% = -1.42, -24.80), respectively). In the last three surveys, overweight/obesity was also more concentrated in the poorest household quintile for the overall children of other ethnicities. With the exception of African American females in the 2013-14 survey, for whom overweight/obesity was significantly concentrated in a quintile of the richest households (SII = 12.60, 95% CI = 0.24, 24.97 and CIX = 7.86, 95% CI = 15.59, 0.12); overweight/obesity was found to be concentrated in the richest household quintile for overall African American children, but not significantly so.

Conclusions

Our findings give an update and reinforce the notion that overweight/obesity in children under the age of five has increased and that related wealth inequalities are a public health problem in the United States.

Usability Testing an mHealth Program with Tailored Motivational Messages for Early Adolescents

Obesity among children is a rising concern throughout the world. In the U.S., rates of childhood obesity are the highest among children from diverse and economically disadvantaged households. Obesity in adolescence increases the risk of negative physical and psychological health consequences. Mobile-app-based health interventions have been found to be an effective tool to encourage children to adopt a healthier living style. A novel mobile app prototype was developed for early adolescents to communicate with and engage them interactively about healthy eating and active living. To test the app's usability, students from a U.S. middle school, with a majority of children from low-income families, were recruited to use the app and report their feedback. The usability testing results confirmed that the app was equally well received by participants of different genders, normal weight versus overweight/obesity, and amounts of screen time. Study participants also provided overwhelming positive feedback for the embedded and tailored motivational messages that encourage healthy eating and active living. The conceptualization of the app prototype was guided by the self-determination theory, social cognitive theory, and priming theory, in addition to incorporating evidence-based obesity prevention principles. This prototype, hence, provides a valid platform for building theory-based behavioral interventions.

Interlinkages between Climate Change and Food Systems: The Impact on Child Malnutrition-Narrative Review

The pandemics of obesity, undernutrition, and climate change represent severe threats to child health. They co-occur; interact with each other to produce sequelae at biological, psychological, or social levels; and share common underlying drivers. In this paper, we review the key issues concerning child diet and nutritional status, focusing on the interactions with climate and food systems. Inadequate infant and young child feeding practices, food insecurity, poverty, and limited access to health services are the leading causes of malnutrition across generations. Food system industrialization and globalization lead to a double burden of malnutrition, whereby undernutrition (i.e., stunting, wasting, and deficiencies in micronutrients) coexists with overweight and obesity, as well as to harmful effects on climate. Climate change and the COVID-19 pandemic are worsening child malnutrition, impacting the main underlying causes (i.e., household food security, dietary diversity, nutrient quality, and access to maternal and child health), as well as the social, economic, and political factors determining food security and nutrition (livelihoods, income, infrastructure resources, and political context). Existing interventions have the potential to be further scaled-up to concurrently address undernutrition, overnutrition, and climate change by cross-cutting education, agriculture, food systems, and social safety nets. Several stakeholders must work co-operatively to improve global sustainable nutrition.

Temporal Changes in Energy-Balance Behaviors and Home Factors in Adolescents with Normal Weight and Those with Overweight or Obesity

This study aimed to examine the temporal changes in energy-balance behaviors and home factors in adolescents with normal weight and those with overweight or obesity (OWOB). Adolescents or parent proxies completed survey assessments two to four years before (T0; n = 82 ), ≤ six months before (T1; n = 68 ), and ≤ three months after the COVID-19 pandemic outbreak (T2; n = 82 ), to capture energy-balance behaviors (i.e., physical activity [PA], screen time, sleep) and home factors (i.e., food environment, food worry, parent support for PA). At T0 and T1 (before pandemic), participants visited our laboratory for anthropometric measurements. At T2, parent proxies also completed a survey to report the COVID-19 pandemic exposure and impact. The participating families experienced moderate levels of pandemic exposure and impact, although exposure was higher in the OWOB group F 1,78 = 5.50 , p < . 05 . Repeated-measure multivariate analyses of covariance (RM-MACOVAs) did not show significant time by weight status interaction effects (p > 0.05 ; adjusted for race and sex). However, the models detected significant time (T0 vs. T2) by race (White vs. non-White) interaction effect λ 7,66 = 0.81 , p < 0.05 , with greater increase in food worry F 1,72 = 4.36 , p < . 05 but less increase in screen time F 1,72 = 4.54 , p < . 05 among the non-White group. Graphical visualization depicted some favorable change patterns in adolescents with normal weight (vs. those with OWOB) for certain behaviors and home factors (e.g., number of days per week ≥ 60 mins PA, food worry). These findings suggest that the COVID-19 pandemic exerted greater adverse effects on adolescents with OWOB and specifically on screen time and food worry among non-White adolescents.

"The obesity pandemic" in the COVID-19 pandemic - new treatment for an old problem

Obesity is a worldwide problem, and the fact that it increasingly affects children and adolescents is worrying. The COVID-19 pandemic and the restrictions introduced affected the physical activity of children and adolescents, and changed their lifestyle and the amount of time spent in front of screens, which are significant factors correlated with weight gain. Due to the scale of the problem of obesity and overweight, much attention is currently paid to seeking effective forms of therapy in these different, difficult circumstances. Interventions promoting a healthy lifestyle among obese children after the COVID-19 pandemic are particularly important and necessary. This article provides a review of the literature on the recent worsening of obesity in the paediatric population, with particular emphasis on the importance of the COVID-19 pandemic. New methods of fighting obesity with the use of telemedicine and current methods of pharmacotherapy, including new drugs, are presented.

The Effects of Financial Stress and Household Socio-Economic Deprivation on the Malnutrition Statuses of Children under Five during the COVID-19 Lockdown in a Marginalized Region of South Punjab, Pakistan

The lockdown after the COVID-19 pandemic not only caused public health crises and income stress but also put millions at risk of food insecurity and malnutrition across the globe, especially in low and middle-income countries [LMICs]. This study evaluated the effects of financial stress and household socio-economic deprivation on the nutritional status of 1551 children under the age of five during COVID-19 in Pakistan. A self-administered questionnaire was used between November 2020 and April 2021 to collect information on age, height, children's weight, and socio-economic status from 1152 rural households from underdeveloped regions in Punjab, Pakistan. With the help of the proportionate simple random sampling method, this study employed a model (binary logistic regression) to calculate the likelihood of malnourishment. The findings showed that the stunting, underweight, and wasting prevalence rates during COVID-19 were 58.86%, 41.89%, and 8.11%, respectively, in the Bahawalpur region. According to the binary logistic regression analysis, among the household deprivation status (HDS) categories, the risks of childhood malnutrition were lesser in HDS-2 (OR = 0.05, 95% CI: 0. 005-0.879) and HDS-3 (OR = 0.04, 95% CI: 0.008-0.193). Similar to this, within the financial stress index (FSI) categories, the children in homes with medium financial stress had reduced odds of malnutrition (OR = 0.10, 95% CI: 0.018-0.567), and the children in households with low financial stress had reduced risks of malnutrition (OR = 0.006, 95% CI: 0.005-0.061). The proposed research found that stunting and underweight increased by 17.26% and 12.29% during the COVID-19 lockdown in the Bahawalpur region. Additionally, financial stress and socio-economic deprivation strongly affected children's nutritional statuses during the COVID-19 lockdown in the Bahawalpur region of Southern Punjab.

Food insecurity in households of children receiving care at a paediatric obesity management clinic in Montreal: Overall prevalence and changes associated with the COVID-19 pandemic

Objectives

Food insecurity and paediatric obesity are two major public health issues in Canada that may have been exacerbated by the COVID-19 pandemic. We assessed food insecurity and its correlates among households of children receiving care at a paediatric obesity management clinic in Montreal. We also assessed whether the prevalence of food insecurity among households of children who received care during the COVID-19 pandemic differed from those who received care before it.

Methods

This is a retrospective, cross-sectional analysis of medical records of children (2 to 17 years) who received care at a paediatric obesity management clinic in Montreal (Maison de santé prévention - Approche 180 [MSP-180]). Children's household food security status was assessed using Health Canada's Household Food Security Survey Module.

Results

Among the 253 children included in the study, 102 (40.3%) lived in households with moderate (n=89; 35.2%) or severe food insecurity (n=13; 5.1%). Food insecurity was more prevalent in households of children who were first- or second-generation immigrants compared with those who were third generation or more (48.3% versus 30.1%; P=0.03). Prevalence of food insecurity among households of children who received care during the COVID-19 pandemic was 5.5% higher than among those who received care before the pandemic, but the difference was not statistically significant (39.6% versus 45.1%; P=0.65).

Conclusions

Forty per cent of children treated at this paediatric obesity clinic lived in a food insecure household. This prevalence may have increased during the first year of the COVID-19 pandemic, but statistical power was insufficient to confirm it.

Sociodemographic Comparison of Children With High-risk Medical Conditions Referred vs Identified Through Screening Plus Outreach for COVID-19 Therapeutics

Importance

Minoritized groups are less likely to receive COVID-19 therapeutics, but few studies have identified potential methods to reduce disparities.

Objective

To determine whether screening plus outreach, when compared with referral alone, increases identification of vulnerable pediatric patients at high risk for severe disease eligible for COVID-19 therapeutics from low-resourced communities.

Design, Setting, and Participants

A retrospective cohort study of COVID-19 medication allocation between January 1, 2022, and February 15, 2022, at Lurie Children's Hospital, a quaternary care children's hospital, in Chicago, Illinois. The cohorts were pediatric patients referred for COVID-19 therapeutics or with a positive SARS-CoV-2 polymerase chain reaction within the hospital system followed by outreach. Screening involved daily review of positive cases of SARS-CoV-2, followed by medical record review for high-risk conditions, and communication with clinicians and/or patients and families to offer therapy.

Exposures

Diagnosis of COVID-19.

Main Outcomes and Measures

The primary measure was difference in child opportunity index (COI) scores between the 2 cohorts. Secondary measures included presence and duration of symptoms at diagnosis, medication uptake, race and ethnicity, insurance type, qualifying medical condition, sex, primary language, and age.

Results

Of 145 total patients, the median (IQR) age was 15 (13-17) years, and most were male (87 participants [60.0%]), enrolled in public insurance (83 participants [57.2%]), and members of minoritized racial and ethnic groups (103 participants [71.0%]). The most common qualifying conditions were asthma and/or obesity (71 participants [49.0%]). From 9869 SARS-CoV-2 tests performed, 94 eligible patients were identified via screening for COVID-19 therapeutics. Fifty-one patients were identified via referral. Thirty-two patients received medication, of whom 8 (25%) were identified by screening plus outreach alone. Compared with referred patients, patients in the screening plus outreach group were more likely to have moderate, low, or very low COI composite scores (70 patients [74.5%] vs 27 patients [52.9%]); public insurance (65 patients [69.1%] vs 18 patients [35.3%]); and asthma or obesity (60 patients [63.8%] vs 11 patients [21.6%]). Patients in the referral group were more likely to be non-Hispanic White (23 patients [45.1%] vs 19 patients [20.2%]) and receive medication (24 patients [47.1%] vs 8 patients [8.5%]).

Conclusions and Relevance

Compared with referral patients, screening plus outreach patients for COVID-19 medications were more socially vulnerable, with lower COI scores, and more likely to have asthma or obesity. Future studies should investigate communication strategies to improve uptake of these medications after outreach.

The COVID-19 pandemic and changes in eating habits of Brazilian adolescents

Introduction

The social distancing imposed by the COVID-19 pandemic influenced lifestyle and modified dietary patterns. Our objective was to evaluate the consumption of fruits and vegetables (FV), and ultra-processed foods (UPF), before and after the COVID-19 pandemic, as well as to identify the sociodemographic factors associated.

Methods

This study used data from the "Convid Adolescents", a survey on health behaviors that were collected through an online questionnaire self-completed by 9.470 adolescents between 12 and 17 years of age during the pandemic in Brazil in 2020. Individuals were invited to participate through a chain-sampling procedure called "virtual snowballing". Information about FV, and UPF consumption before and during the pandemic period were reported. The independent variables used were sex, age group, race/color of skin, kind of school, education level of the mother, region of Brazil, financial difficulties during the pandemic, food insecurity, and social restrictions. Logistic regression models were used.

Results

There was a reduction in the low consumption of FV (83.5% to 80.3%) and there was no significant difference in the high consumption of UPF (38.9% to 38.1%) before and during the pandemic. The incidence of low consumption of FV and high consumption of UPF during the pandemic was 20% and 13.8%, respectively. Girls, private school adolescents, who reported having food insecurity and financial difficulties during the pandemic were the most affected subgroups.

Conclusions

Despite little change in the prevalence of FV and UPF consumption before and during the pandemic, the incidence of high consumption of UPF and low FV consumption was high, and it identified in specific population subgroups.

COVID-19 Lockdown: Impact on Oral Health-Related Behaviors and Practices of Portuguese and Spanish Children

This study aimed to assess and compare the impact of COVID-19 pandemic lockdowns on the oral health attitudes, dietary habits and access to dental care of Portuguese and Spanish children. A cross-sectional observational study involving caregivers of 3−17-year-old children who had cohabited during a COVID-19 pandemic lockdown in Spain and Portugal was conducted. Caregivers completed an online anonymous questionnaire. Aiming groups comparison, chi-square test was used for qualitative variables. 770 surveys were obtained. Significant changes in the children’s routine were higher in Portugal (p < 0.001). Both countries showed a large percentage of children who had between 2−3 snacks between meals (p < 0.001) and a higher consumption of snacks was particularly noticed among Spanish children with untreated dental caries during the lockdown (p = 0.003). Most caregivers reported children’s oral hygiene habits did not suffer noteworthy alterations (p = 0.417), although parental supervision of toothbrushing was associated with dental attendance during the lockdown. The majority of the sample had no dental attendance during confinement. Confinement appears to have not markedly affected the oral health status and habits of the majority of these children, although an important impact of some demographic and behavioral factors upon dietary and oral care/habits was detected.

Navajo Nation Stores Show Resilience During COVID-19 Pandemic

On April 8, 2020, the Navajo Nation issued an administrative order limiting business operations. Facing high coronavirus disease 2019 (COVID-19) rates and limited food infrastructure, a survey was conducted among Navajo Nation store managers to assess: (1) COVID-19 adaptations; (2) challenges; (3) changes in customer volume and purchasing; and (4) suggestions for additional support. Purposive sampling identified 29 stores in Navajo communities. Representatives from 20 stores (19 store managers/owners, 1 other; 7 grocery, and 13 convenience/other stores) were interviewed by phone or in-person to reach saturation (new information threshold < 5%). Responses were coded using frequencies and inductive thematic analysis. All 20 stores implemented COVID-19 guidelines (Centers for Disease Control and Prevention [CDC]/Navajo Nation) and most received orientation/support from local chapters, community organizations, or health centers. Stores implemented staff policies (50%, handwashing, vaccinations, protective personal equipment (PPE), sick leave, temperature checks), environmental changes (50%, hand sanitizer, checkout dividers), customer protocols (40%, limit customers, mask requirements, closed restrooms), and deep cleaning (40%). Most stores (65%) reported challenges including stress/anxiety, changing guidelines, supply chain and customer compliance; 30% reported infection or loss of staff. Weekday customer volume was slightly higher vs. pre-COVID, but weekend lower. Stores reported consistent or more healthy food purchases (50%), more nonfood essentials (20%), or shelf-stable foods (10%). Desired support included further orientation (30%), leadership support (20%), overtime/time to learn guidelines (20%), and signage/handouts (15%). Despite a high COVID-19 burden and limited food store infrastructure, Navajo Nation stores adapted by implementing staff, environmental and customer policies. Local support, staffing, and small store offerings were key factors in healthy food access.