A Longitudinal Comparison of Alternatives to Body Mass Index Z-Scores for Children with Very High Body Mass Indexes

A randomized controlled trial examining general parenting training and family-based behavioral treatment for childhood obesity: The ReFRESH study design

Family-based behavioral treatment (FBT) is one of the most effective treatments for childhood obesity. These programs include behavior change strategies and basic parenting training to help parents make healthy diet and physical activity changes for their children. While effective, not all families respond to this program. Additional training on how to effectively deliver these behavior change strategies may improve outcomes. The authoritative parenting style is associated with many positive academic and socio-emotional outcomes in children, and is characterized by displays of warmth and support while also being consistent with setting limits and boundaries. This parenting style has also been associated with normal weight status. Furthermore, parenting training programs that promote this parenting style for children with behavioral issues have shown unintended effects on decreasing child weight status. Therefore, our goal was to examine the effect of adding more intensive parenting training to FBT on child weight status. We randomized 140 children and their parent to either FBT or FBT + Parenting Training (FBT + PT). Assessments were conducted at baseline, mid-treatment (month 3), post-treatment (month 6), 6-month follow-up (month 12), and 12-month follow-up (month 18). Primary outcome was change in child weight status. Secondary outcomes were rates of drop-out, treatment adherence, and acceptability. If effective, this program may provide another alternative for families to help improve outcomes in childhood obesity management.

Real-world use of glucagon-like peptide-1 receptor agonists in youth with type 2 diabetes is associated with short-term improvements in HbA1c

AIM

To assess the short-term, real-world use and effectiveness of glucagon-like peptide-1 receptor agonist (GLP-1RA) medications in the management of type 2 diabetes (T2D) in a diverse cohort of youth.

METHODS

This multicentre retrospective study analysed youth prescribed a GLP-1RA for the management of T2D at two academic paediatric diabetes centres prior to June 2022. Change in HbA1c and insulin use from baseline to first (median 91 days) and second (median 190 days) follow-up were evaluated for those taking a GLP-1RA. Multivariable linear mixed effects models adjusting for baseline sex, age, race/ethnicity, insurance, insulin regimen, metformin regimen, GLP-1RA dosing frequency and the body mass index Z-score (BMI-Z) examined the change in HbA1c for participants for up to 6 months after baseline.

RESULTS

A total of 136 patients with T2D (median age 16.1 [interquartile range 13.9-18.0] years, 54% female, 56% non-Hispanic Black, 24% Hispanic, 77% with public insurance) were prescribed GLP-1RAs and taking them at first or second follow-up. Median HbA1c decreased from 7.9% to 7.6% (P < .001) at a median follow-up of 91 days (n = 109) and, among those with HbA1c available at baseline and second follow-up (n = 83), from 8.4% to 7.4%. The proportion of patients prescribed insulin decreased from baseline to the first follow-up visit (basal 69% to 60% [P = .008], prandial 46% to 38% [P = .03]). In multivariable analysis, there was a mean decrease in HbA1c by 0.09 percentage points per month (P = .005, 95% confidence interval -0.15, -0.03).

CONCLUSIONS

Real-world use of GLP-1RAs in youth with T2D is associated with decreased HbA1c levels, despite challenges with access and adherence. GLP-1RA treatment may reduce insulin doses for youth with T2D.

Pregnancy health in a multi-state U.S. population of systemically underserved patients and their children: PROMISE cohort design and baseline characteristics

BACKGROUND

Gestational weight gain (GWG) is a routinely monitored aspect of pregnancy health, yet critical gaps remain about optimal GWG in pregnant people from socially marginalized groups, or with pre-pregnancy body mass index (BMI) in the lower or upper extremes. The PROMISE study aims to determine overall and trimester-specific GWG associated with the lowest risk of adverse birth outcomes and detrimental infant and child growth in these underrepresented subgroups. This paper presents methods used to construct the PROMISE cohort using electronic health record data from a network of community-based healthcare organizations and characterize the cohort with respect to baseline characteristics, longitudinal data availability, and GWG.

METHODS

We developed an algorithm to identify and date pregnancies based on outpatient clinical data for patients 15 years or older. The cohort included pregnancies delivered in 2005-2020 with gestational age between 20 weeks, 0 days and 42 weeks, 6 days; and with known height and adequate weight measures needed to examine GWG patterns. We linked offspring data from birth records and clinical records. We defined study variables with attention to timing relative to pregnancy and clinical data collection processes. Descriptive analyses characterize the sociodemographic, baseline, and longitudinal data characteristics of the cohort, overall and within BMI categories.

RESULTS

The cohort includes 77,599 pregnancies: 53% had incomes below the federal poverty level, 82% had public insurance, and the largest race and ethnicity groups were Hispanic (56%), non-Hispanic White (23%) and non-Hispanic Black (12%). Pre-pregnancy BMI groups included 2% underweight, 34% normal weight, 31% overweight, and 19%, 8%, and 5% Class I, II, and III obesity. Longitudinal data enable the calculation of trimester-specific GWG; e.g., a median of 2, 4, and 6 valid weight measures were available in the first, second, and third trimesters, respectively. Weekly rate of GWG was 0.00, 0.46, and 0.51 kg per week in the first, second, and third trimesters; differences in GWG between BMI groups were greatest in the second trimester.

CONCLUSIONS

The PROMISE cohort enables characterization of GWG patterns and estimation of effects on child growth in underrepresented subgroups, ultimately improving the representativeness of GWG evidence and corresponding guidelines.

Body Mass Index Trajectories among the Healthy Communities Study Children: Racial/Ethnic and Socioeconomic Disparities in Childhood Obesity

The purpose of this study is to identify statistically distinguishable trajectories of childhood body mass index (BMI), an important indicator of developmental status of children, and to provide a summary description of demographic characteristics of children based on these distinctive trajectories. Using data from the Healthy Communities Study (HCS), a large longitudinal dataset with oversamples of Hispanic and Black children across 130 communities in the USA, a group-based trajectory analysis approach was used to estimate trajectories of children based on their BMI-z scores. The three most distinguishable BMI trajectory groups identified for the HCS children show no marked increase or decrease in standardized BMI over an age range of 2 to 11. Approximately 28.5% of children were in a trajectory group with consistently obese BMI-z scores for their sex and age. The patterns of BMI trajectory groups identified for boys and girls are similar, but BMI-z scores for boys tend to be slightly higher than those for girls. These BMI trajectories are characterized by racial/ethnic and socioeconomic status disparities. Hispanic and Black children were more likely to be in the obese trajectory group than White children. Children with parents having less education, or children from low family income level, were more likely to be in the obese trajectory group than counterpart children. The findings suggest that BMI disparities exist from the early years of childhood and persist across childhood, with higher BMI associated with Black and Hispanic children as well as those from low socioeconomic status backgrounds.

Beneficial effects of automated insulin delivery over one-year follow-up in real life for youths and adults with type 1 diabetes irrespective of patient characteristics

AIM

To investigate glycaemic outcomes in youths and adults with type 1 diabetes with either MiniMed™ 780G or Tandem t:slim X2™ control-IQ automated insulin delivery (AID) systems and to evaluate clinical factors that migrate, mitigate the achievement of therapeutic goals.

MATERIALS AND METHODS

This retrospective, real-world, observational study was conducted in a specialized university type 1 diabetes centre with patients observed for 3-12 months post-initiation of an AID system. Primary outcomes were the percentage time in the target glucose range [TIR70-180 mg/dl (3.9-10 mmol/L)] as measured by continuous glucose monitoring, mean glucose management indicator (GMI) and glycated haemoglobin (HbA1c) levels.

RESULTS

Our study cohort consisted of 48 adolescents and 183 adults (55% females) aged 10-77 years. The mean (95% confidence interval) TIR70-180 mg/dl after 30 days was higher than baseline and by 14% points after 360 days with 71.33% (69.4-73.2) (n = 123, p < .001). HbA1c levels decreased by 0.7% and GMI by 0.6% after 360 days. The proportion of time spent <70 mg/dl (3.9 mmol/L) was not significantly different from baseline. During follow-up, 780G users had better continuous glucose monitoring results than control-IQ users but similar HbA1c levels, and an increased risk of weight gain. Age at onset influenced TIR70-180 mg/dl in univariate analysis but there was no significant relationship after adjusting on explanatory variables. Baseline body mass index did not influence the performance of AID systems.

CONCLUSIONS

This analysis showed the beneficial effects of two AID systems for people with type 1 diabetes across a broad spectrum of participant characteristics. Only half of the participants achieved international recommendations for glucose control with TIR70-180 mg/dl >70%, HbA1c levels or GMI <7%, which outlines the need to maintain strong educational and individual strategies.

Change in Weight Status Among Children Who Do and Do Not Participate in Intensive Health Behavior and Lifestyle Treatment for Obesity

Background: Primary care providers (PCPs) are expected to provide weight management counseling despite having low confidence in their ability to be effective. This analysis examined change in weight status between children who received usual care from their PCP and those who received one of two structured weight management programs in a randomized control trial. Methods: Data from parent-child dyads who were referred to the Guided Self-Help Obesity Treatment in the Doctor's Office study, but did not participate, were examined to determine change in weight status compared with those who participated in the trial. Families were divided into four groups: Group 1, structured treatment with high attendance; Group 2, structured treatment with low attendance; Group 3, PCP/usual care with some weight management counseling; and Group 4, PCP/usual care with no counseling. Anthropometric data and PCP delivery of weight management counseling were abstracted from the electronic health record. Main outcomes were changes in child BMI z-scores, BMI as a percentage relative to the 95th percentile, and BMI as a difference relative to the 95th percentile at the end of treatment and 6-month follow-up for each group. Results: Groups 1 and 2 showed significant decreases in weight status over time, with Group 1 showing the greatest decrease. Groups 3 and 4 remained relatively stable. Changes in weight status in Groups 2, 3, and 4 were significantly different from Group 1 at post-treatment. Conclusions: While structured weight management programs have a significant impact on weight status, those who received some counseling by their PCP did not show significant increases in weight status and were relatively weight stable. Efforts should be broadened to support PCPs as they provide weight management counseling in the office.

The Effects of Adenotonsillectomy for Obstructive Sleep Apnea on Growth Trajectory in Children With Obesity

OBJECTIVE

To analyze the growth trajectory of children with obesity before and after adenotonsillectomy (T&A). We hypothesize that T&A will not affect the growth trajectory but children in a multidisciplinary weight management program (MWMP) will have a healthier growth trajectory.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary Children's Hospital.

METHODS

Body mass index (BMI) trajectories of nonsyndromic children with obesity and obstructive sleep apnea (OSA) who underwent T&A were analyzed. A linear mixed effects model was fit to the BMI expressed as a percentage of the 95th percentile (%BMIp95 ) data. Covariates included demographic variables, pre- and postoperative participation in an MWMP, baseline obesity class, and time. We explored clinically meaningful interactions. BMI slope estimates before and after surgery were calculated and compared for baseline obesity classification and postoperative MWMP visits.

RESULTS

A total of 177 patients, 58% male with a mean age of 9.7 years at the time of surgery, were studied. Higher baseline obesity class (II and III), time, the interaction between obesity class III and elapsed time relative to surgical date, and the interaction between obesity class III and the postsurgical period were all significantly associated with the outcome of %BMIp95 (P < .05). There was a significantly higher %BMIp95 trajectory following surgery in patients with baseline obesity class III who did not have any postoperative MWMP visits (P < .001). Preoperative obesity visits, however, were not significantly associated with postoperative growth.

CONCLUSION

The association between T&A and weight trajectory depends upon obesity class and participation in a MWMP. Coordinated care of children with obesity between otolaryngologists and an MWMP may improve OSA and obesity outcomes.

LEVEL OF EVIDENCE

The level of evidence: 3.

A long-term follow-up of treatment for young children with obesity: a randomized controlled trial

BACKGROUND

Early childhood obesity interventions supporting parents have the largest effects on child weight status. However, long-term follow-ups are lacking.

OBJECTIVE

To examine weight status 48 months after obesity treatment initiation for 4- to 6-year-olds.

METHODS

177 families were recruited to the More and Less study, a 12-month randomized controlled trial (RCT) conducted in Sweden (2012-2017); 6 children were excluded due to medical diagnoses. Thus, 171 families (non-Swedish origin 59%, university degree 40%) were eligible for this 48-month follow-up with modified intention-to-treat (n = 114 had 48-month data, n = 34 dropped out, n = 23 lost to follow-up). The RCT compared 3 treatment approaches: a 10-week parent support program (1.5 h/w) with follow-up booster sessions (PGB) or without (PGNB), and standard outpatient treatment (ST). Treatment effects on primary outcome (BMI-SDS) and secondary outcomes (BMI, %IOTF25 i.e., the distance, in percent, above the cut-off for overweight) were assessed. Clinically significant reduction of BMI-SDS (≥0.5) was assessed with risk ratio. Sociodemographic factors and attendance were examined by three-way interactions.

RESULTS

After 48 months (mean 50 months, range 38-67 months) mean (95% CI) BMI-SDS was reduced in all groups: PGB -0.45 (-0.18 to -0.73, p < 0.001), PGNB -0.34 (-0.13 to -0.55, p < 0.001), ST -0.25 (-0.10 to -0.40, p < 0.001), no significant difference between groups. A clinically significant reduction of BMI-SDS ≥ 0.5 was obtained in 53.7% of PGB which was twice as likely compared to ST, 33.0%, RR 2.03 (1.27 to 3.27, p = 0.003), with no difference to PGNB, 46.6% (p = 0.113). %IOTF25 was unchanged from baseline for PGB 4.50 (-1.64 to 10.63), and significantly lower compared to ST 11.92 (8.40 to 15.44) (p = 0.043). Sociodemographics or attendance had no effect.

CONCLUSION

The intensive parent-support early childhood obesity intervention led to better weight status outcomes over time, though BMI-SDS alone did not reflect this. Further research should investigate how to assess weight changes in growing children.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT01792531 .

The association of food insecurity on body mass index change in a pediatric weight management intervention

BACKGROUND

Childhood obesity is a critical public health concern. One potential determinant to obesity that is less understood is food insecurity.

OBJECTIVE

To examine the association of food security status on body mass index (BMI) change in a Pediatric Weight Management Intervention (PWMI) consistent with national treatment recommendations.

METHODS

This analysis included 201 participants from the Healthy Weight Clinic (HWC). Using linear mixed models, we compared BMI and %BMIp95 change per year between the food insecure group and food secure group, adjusting for baseline BMI, age and sex, and SNAP enrolment.

RESULTS

In fully adjusted models, children in households with food insecurity had a 0.50 (0.26-0.74) kg/m2 BMI increase per year and a 2.10 (1.02-3.19) %BMIp95 increase per year compared to households that were food secure.

CONCLUSIONS

When comparing the BMI effect of the HWC between the food insecure group and food secure group, those experiencing food insecurity in the HWC had an increase in BMI compared to those with food security. These findings suggest that food insecurity may reduce the effectiveness of PWMIs consistent with national recommendations; however, more studies should be conducted to better understand this relationship.

Modeling BMI z score lability during childhood as a function of child temperament and genetic risk for obesity

OBJECTIVE

This study aimed to examine whether child genetic risk for obesity and temperament (i.e., negative affectivity, effortful control) accounted for stability versus lability in children's weight status (BMI z score) over time.

METHODS

A total of 561 adopted children (42% female; 56% Caucasian, 13% African American, 11% Latino, and 20% other) and their birth and adoptive parents were followed from birth to age 9 years. The multilevel location-scale model was used to examine whether child genetic risk for obesity and temperament were related to differences in level and lability in child BMI z scores over time.

RESULTS

For the full sample, higher levels of child negative affectivity were associated with greater BMI z score lability, whereas higher levels of effortful control and children's mean-level BMI z scores were related to less lability across childhood. Additional analyses examined associations within groups of children with healthy versus overweight/obesity weight statuses. Within the healthy weight status group only, better effortful control was associated with more stable BMI z scores, whereas genetic risk for higher BMI was associated with more labile BMI z scores.

CONCLUSIONS

These findings provide insights into factors that can be harnessed to redirect unhealthy trajectories as well as factors that may challenge redirection or maintain a healthy trajectory.

Weight trajectories and obesity remission among school-aged children

BACKGROUND

Many studies examining weight trajectories have used adiposity measures shown to be problematic for trajectory analysis in children with obesity, and remission of obesity remains poorly understood.

OBJECTIVES

To describe weight trajectories for school-aged children, the rate of obesity remission and factors associated.

METHODS

Children between 6 and 11 years of age with ≥3 valid height and weight measurements from an Oregon hospital-system over a minimum six-month period were included. Percent distance from the median body mass index (BMI) was used for modeling. Latent class analysis and linear mixed models were used to classify children based on their weight trajectory.

RESULTS

We included 11,247 subjects with a median of 2.1 years of follow-up, with 1,614 (14.4%) classified as overweight and 1,794 (16.0%) classified as obese. Of subjects with obesity, 1% experienced remission during follow-up, whereas 23% of those with overweight moved to within a healthy weight range. Latent class analysis identified three classes within each weight-based stratum over time. The majority of children with overweight or obesity had a flat trajectory over time. Lower socioeconomic status was associated with a worsening trajectory. Latent class models using alternate measures (BMI, BMI z-scores, tri-ponderal mass index (TMI)) differed substantially from each other.

CONCLUSIONS

Obesity remission was uncommon using the adiposity metric of distance from the median though transition from overweight to healthy weight was more common. Children with low socioeconomic status have worse trajectories overall. The choice of adiposity metric may have a substantial effect on the outcomes.

Measuring severe obesity in pediatrics using body mass index-derived metrics from the Centers for Disease Control and Prevention and World Health Organization: a secondary analysis of CANadian Pediatric Weight management Registry (CANPWR) data

To examine the (i) relationships between various body mass index (BMI)-derived metrics for measuring severe obesity (SO) over time based the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) references and (ii) ability of these metrics to discriminate children and adolescents based on the presence of cardiometabolic risk factors. In this cohort study completed from 2013 to 2021, we examined data from 3- to 18-year-olds enrolled in the CANadian Pediatric Weight management Registry. Anthropometric data were used to create nine BMI-derived metrics based on the CDC and WHO references. Cardiometabolic risk factors were examined, including dysglycemia, dyslipidemia, and elevated blood pressure. Analyses included Pearson correlations, intraclass correlation coefficients (ICC), and receiver operator characteristic area-under-the-curve (ROC AUC). Our sample included 1,288 participants (n = 666 [52%] girls; n = 874 [68%] white). The prevalence of SO varied from 60-67%, depending on the definition. Most BMI-derived metrics were positively and significantly related to one another (r = 0.45-1.00); ICCs revealed high tracking (0.90-0.94). ROC AUC analyses showed CDC and WHO metrics had a modest ability to discriminate the presence of cardiometabolic risk factors, which improved slightly with increasing numbers of risk factors. Overall, most BMI-derived metrics rated poorly in identifying presence of cardiometabolic risk factors.    Conclusion: CDC BMI percent of the 95th percentile and WHO BMIz performed similarly as measures of SO, although neither showed particularly impressive discrimination. They appear to be interchangeable in clinical care and research in pediatrics, but there is a need for a universal standard. WHO BMIz may be useful for clinicians and researchers from countries that recommend using the WHO growth reference. What is Known: • Severe obesity in pediatrics is a global health issue. • Few reports have evaluated body mass index (BMI)-derived metrics based on the World Health Organization growth reference. What is New: • Our analyses showed that the Centers for Disease Control and Prevention BMI percent of the 95th percentile and World Health Organization (WHO) BMI z-score (BMIz) performed similarly as measures of severe obesity in pediatrics. • WHO BMIz should be a useful metric to measure severe obesity for clinicians and researchers from countries that recommend using the WHO growth reference.

Evaluation of a cluster-randomized controlled trial: Communities for Healthy Living, family-centered obesity prevention program for Head Start parents and children

BACKGROUND

This study reports the outcomes of Communities for Healthy Living (CHL), a cluster randomized obesity prevention trial implemented in partnership with Head Start, a federally-funded preschool program for low-income families.

METHODS

Using a stepped wedge design, Head Start programs (n = 16; Boston, MA, USA) were randomly assigned to one of three intervention start times. CHL involved a media campaign and enhanced nutrition support. Parents were invited to join Parents Connect for Healthy Living (PConnect), a 10-week wellness program. At the beginning and end of each school year (2017-2019), data were collected on the primary outcome of child Body Mass Index z-score (BMIz) and modified BMIz, and secondary outcomes of child weight-related behaviors (diet, physical activity, sleep, media use) and parents' weight-related parenting practices and empowerment. Data from 2 years, rather than three, were utilized to evaluate CHL due to the COVID-19 pandemic. We used mixed effects linear regression to compare relative differences during intervention vs. control periods (n = 1274 vs. 2476 children) in (1) mean change in child BMIz and modified BMIz, (2) the odds of meeting child health behavior recommendations, (3) mean change in parenting practices, and (4) mean change in parent empowerment. We also compared outcomes among parents who chose post-randomization to participate in PConnect vs. not (n = 55 vs. 443).

RESULTS

During intervention periods (vs. control), children experienced greater increases in BMIz and modified BMIz (b = 0.06, 95% CI = 0.02,0.10; b = 0.07, 95% CI = 0.03, 0.12), yet were more likely to meet recommendations related to three of eight measured behaviors: sugar-sweetened beverage consumption (i.e., rarely consume; Odds Ratio (OR) = 1.5, 95% CI = 1.2,2.3), water consumption (i.e., multiple times per day; OR = 1.6, 95% CI = 1.2,2.3), and screen time (i.e., ≤1 hour/day; OR = 1.4, 95% CI = 1.0,1.8). No statistically significant differences for intervention (vs. control) periods were observed in parent empowerment or parenting practices. However, parents who enrolled in PConnect (vs. not) demonstrated greater increases in empowerment (b = 0.17, 95% CI = 0.04,0.31).

CONCLUSIONS

Interventions that emphasize parent engagement may increase parental empowerment. Intervention exposure was associated with statistically, but not clinically, significant increases in BMIz and increased odds of meeting recommendations for three child behaviors; premature trial suspension may explain mixed results.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03334669 , Registered October 2017.

Real-world effectiveness of the Bright Bodies healthy lifestyle intervention for childhood obesity

OBJECTIVE

This study aimed to examine the extent to which Bright Bodies, a high-intensity, family-based pediatric weight management intervention, improved BMI for participants since publication of the randomized controlled trial establishing efficacy in 2007 and to describe adaptations to the program.

METHODS

For participants enrolled from 2008 to 2018, linear mixed-effects models were used to estimate monthly change in BMI expressed as percentage of the 95th percentile (%BMIp95) during participants' first beginner-level program.

RESULTS

The sample included 396 youth individuals (mean age: 11.7  [SD 2.8] years, 61.6% female, 37.1% non-Hispanic Black, 26.3% Hispanic or Latino, 53.8% with public insurance, 80.1% with severe obesity). Across the 11 years, participants' %BMIp95 reduced on average by 1.63% (95% CI: 1.44%-1.82%) per month during their first program (mean duration: 10 weeks) after adjusting for age, sex, season and year, starting %BMIp95, race and ethnicity, and insurance category. Greater reduction in %BMIp95 was associated with male versus female sex, spring/fall versus winter seasons, enrollment in 2008 to 2018 versus 2015 to 2018, and higher starting %BMIp95 (p value for all <0.001). Adaptations since 2007 included pragmatic changes to increase engagement and address funding shortages.

CONCLUSIONS

These results suggest sustained clinical effectiveness of Bright Bodies in the context of real-world adaptations.

A Multidisciplinary Approach to Pediatric Obesity Shows Improvement Postintervention

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Guided Self-Help for Pediatric Obesity in Primary Care: A Randomized Clinical Trial

OBJECTIVES

Our aim was to compare the effect of 2 treatment models on attendance and child weight status: a less intense guided self-help (GSH) program delivered in the primary care setting versus traditional family-based behavioral treatment (FBT) delivered in an academic center.

METHODS

We conducted a randomized clinical trial among 164 children between 5 and 13 years old with a BMI ≥85th percentile and their parents. The intervention group (GSH) received 14 individual sessions over 6 months, with 5.3 hours of treatment. The control group (FBT) received 20 group-based sessions over 6 months, with 20 hours of treatment. Main outcomes included proportion of sessions families attended and change in child BMI z-score (BMIz), percentage from the 95th BMI percentile, difference from the 95th BMI percentile at the end of treatment, and 6-month follow-up.

RESULTS

Mean age of children was 9.6 years, BMI z-score 2.1, 49% female, and >90% Latino. The odds of attending GSH compared to FBT was 2.2 (P < 0.01). Those assigned to GSH had a 67% reduced risk of attrition (hazard ratio = 0.33, 95% confidence interval 0.22-0.50, P < .001). Intent-to-treat analysis showed no between-group differences in change in BMIz and percentage from the 95th BMI percentile over time. Combined, there was a significant reduction in BMIz from baseline to posttreatment (β = -0.07 (0.01), P < .01, d: 0.60) and a slight increase from posttreatment to follow-up (β = 0.007 (0.13), P = .56).

CONCLUSIONS

This study provides support for a novel, less intense GSH model of obesity treatment, which can be implemented in the primary care setting. Future studies should examine effective approaches to dissemination and implementation of GSH in different settings to increase access to treatment.

Measuring BMI change among children and adolescents

BACKGROUND

Weight control programs for children monitor BMI changes using BMI z-scores that adjust BMI for the sex and age of the child. It is, however, uncertain if BMIz is the best metric for assessing BMI change.

OBJECTIVE

To identify which of 6 BMI metrics is optimal for assessing change. We considered a metric to be optimal if its short-term variability was consistent across the entire BMI distribution.

SUBJECTS

285 643 2- to 17-year-olds with BMI measured 3 times over a 10- to 14-month period.

METHODS

We summarized each metric's variability using the within-child standard deviation.

RESULTS

Most metrics' initial or mean value correlated with short-term variability (|r| ~ 0.3 to 0.5). The metric for which the within-child variability was largely independent (r = 0.13) of the metric's initial or mean value was the percentage of the 50th expressed on a log scale. However, changes in this metric between the first and last visits were highly (r ≥ 0.97) correlated with changes in %95th and %50th.

CONCLUSIONS

Log %50 was the metric for which the short-term variability was largely independent of a child's BMI. Changes in log %50th, %95th, and %50th are strongly correlated.

Neonatal Anthropometrics and Obesity Treatment Response in Children and Adolescents

OBJECTIVE

To investigate the relationship between in utero growth conditions, as indicated by neonatal anthropometric measures, and childhood obesity treatment response, to examine the potential usefulness of neonatal anthropometrics as a potential childhood obesity treatment stratification tool.

STUDY DESIGN

The study included 2474 children and adolescents with obesity (mean age, 11.2 years; range, 5.0-18.9 years) treated at the Children's Obesity Clinic in Holbæk, Denmark. Treatment response was registered prospectively, and neonatal data were collected from national electronic registers.

RESULTS

Birth weight, birth length, birth weight for gestational age, and large for gestational age status were positively associated with the degree of obesity at treatment initiation. After a mean (SD) of 1.27 (0.69) years of enrollment in obesity treatment, the children exhibited a mean reduction of -0.32 (0.50) in body mass index SD score. No significant associations between neonatal anthropometric measures and childhood obesity treatment response were detected.

CONCLUSIONS

Neonatal anthropometric measures were positively associated with the degree of obesity at treatment initiation but not with response to multidisciplinary treatment of childhood obesity. Individualization of obesity treatment based on neonatal anthropometry does not seem warranted.

A Type III Hybrid Effectiveness-Implementation Pilot Trial Testing Dissemination and Implementation Strategies for a Pediatric Weight Management Intervention: The Nebraska Childhood Obesity Research Demonstration Project

Background: Several family-based efficacious pediatric weight management interventions (PWMIs) have been developed to reduce child weight status. These programs are typically based in larger cities delivered by an interdisciplinary team in a hospital or medical center. The degree to which these efficacious PWMIs have been translated to, and are feasible in, rural or micropolitan areas is unclear. This study protocol describes a pilot Type III hybrid effectiveness-implementation (T3HEI) trial testing a multilevel strategy that focuses on the adoption, implementation, and sustainability of a PWMI online training program and resource package designed for implementation in micropolitan and rural areas. Methods: The trial design employed the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate outcomes and the Promoting Action on Research Implementation in Health Services framework to specify potential mechanisms of adoption, implementation, and sustainability. The study will test the feasibility of a fund and contract dissemination strategy in the adoption of a PWMI in four to eight rural communities, compare a learning collaborative implementation strategy including embedded training and sustainability action planning with communities who receive the PWMI online program and resources alone, and determine whether the PWMI reach, effectiveness, and maintenance are of magnitude similar to previous effectiveness trials. The dissemination and implementation process focused on an integrated research-practice partnership process model that includes a systems-based approach with multiple sectors and vertical decision-making representation. Conclusions: Our pilot T3HEI study has the potential to inform how best to move and sustain evidence-based PWMIs into practice. The findings will inform larger scale dissemination, implementation, and sustainability efforts in medically underserved areas across the country. Trial registration: This protocol is registered with clinicaltrials.gov (NCT04719442).