Massive obesity in adolescents: dietary interventions and behaviours associated with weight regain at 2 y follow-up

Sustainability Requires Many Faces of Support

Purpose: This study focused on the sustainability of a school-wide health behavior intervention in rural schools in the Southwestern US. Informed by the seven premises of Theories of Action with Merit, the purpose of this study was to investigate which portion(s) of a five-year, school-wide health behavior intervention were still in practice (i.e. sustainable), and why they were maintained following the removal of funding and resources for the program. Method: Teachers (N = 41) participated in individual, semi-structured interviews during which they shared what aspects of the original intervention were retained as part of personal classroom practices or of the school culture. Teachers reflected on facilitators and barriers to the sustainability of these practices. Data also included field notes from campus visits. To establish trustworthiness, data triangulation (interview transcripts, survey results, and field notes) provided multiple angles of analysis, and two researchers negotiated all themes. Results: Using the premises of the Theories of Action with Merit, teachers' comments often circulated around themes of administrative support and personal investment/interest in healthy behaviors. Additional themes of sustainability included feeling capable and physical activity being the "norm" at their school. Conclusions: Teachers' personal beliefs and self-efficacy in physical literacy held the highest importance in sustaining classroom healthy behavior practices as opposed to the district or state expectations for healthy behaviors. Administrator support was key to whole-school integration and sustainability of practices, however, teachers described evidence of support differently suggesting administrators need awareness of how messages of support are being translated.

Prevalence of Overweight and Obesity and Association with Risk Factors in Secondary School Children in Croatia

BACKGROUND

Childhood and adolescent overweight and obesity represent significant global health concerns. The primary objective of this study was to assess the prevalence and associations of some potential risk factors with overweight and obesity among Croatian adolescents aged 15 to 18.

METHODS

This cross-sectional study included 344 secondary school students from Croatia's Mediterranean region, with data collected through an anonymous questionnaire. The questionnaire gathered sociodemographic information, adherence to the Mediterranean diet of both children and their parents, and the children's dietary habits and physical activity levels.

RESULTS

Weight status data revealed that 2.6% of participants were underweight, 82% had normal weight, 11% were overweight, and 4.4% were classified as obese. The results indicated that boys (p < 0.001), children who skip breakfast (p = 0.031), those with less active lifestyles compared to their peers (p = 0.001), children whose mothers have a higher BMI (p < 0.001), and children from smaller families (p = 0.034) are at greater risk of being overweight or obese.

CONCLUSIONS

This study provides valuable insights into the risk factors associated with overweight and obesity in this age group, which can support the development of targeted strategies for this population.

Macronutrients modified dietary intervention in the management of overweight/obese children and adolescents: a systematic review

The prevalence of obesity in adults and children is rapidly increasing worldwide. Obesity is among the main causes of chronic diseases and various problems, including economic consequences and they can also be affected by genetic, environmental, psychological, and socioeconomic factors. Dietary modification is a well-known and important factor in weight control, in particular, dietary macronutrient composition, food selection, dietary patterns, and energy restriction can affect weight reduction. Therefore, this systematic review aims to provide basic evidence for identifying the optimal macronutrient composition for managing obesity in Korean children and adolescents. We searched literature through an international database, studies were selected using our eligibility criteria and quality was assessed via a risk of bias tool. In our results, several studies have demonstrated that dietary macronutrient modifications affect body composition and metabolic markers in children and adolescents. In contrast, hypocaloric diets, regardless of macronutrient composition, are reportedly effective for weight loss in obese children. However, these findings were based on intervention studies that examined the association between dietary macronutrient composition and obesity in non-Korean children and adolescents. Therefore, in the future, more intervention studies are needed to elucidate this relationship and evidence between macronutrients and obesity in Korean children and adolescents.

The effect of breakfast on childhood obesity: a systematic review and meta-analysis

Objective

Previous cohort trials have shown that skipping breakfast increases the risk of obesity or overweight in children. However, this finding remains controversial. Through a meta-analysis, this study systematically evaluated the effect of skipping breakfast on the prevalence of obesity or overweight in children.

Methods

We performed a literature search for studies published until March 19, 2023. using the Cochrane, PubMed, and Embase databases. Based on the inclusion and exclusion criteria, observational studies on the relationship between skipping breakfast and overweight/obesity in children and adolescents were analyzed. Three investigators independently screened the relevant literature, extracted the data, and assessed the risk of bias. The quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS). A random-effects model was used. The odds ratio (OR) with its 95% confidence interval (CI) was used to indicate the effect size.

Results

A total of 40 retrospective studies with 323,244 children ranging in age from 2 to 20 years were included in this study. The results of this meta-analysis showed that children and adolescents who skipped breakfast had a significantly higher prevalence of obesity or overweight than those who ate breakfast (OR, 1.59; 95% CI, 1.33-1.90; P < 0.001). Skipping breakfast was positively associated with overweight in children and adolescents (OR, 1.37; 95% CI, 1.23-1.54; P < 0.001). Similarly, skipping breakfast was positively associated with obesity in children and adolescents (OR, 1.51; 95% CI, 1.30-1.76; P < 0.001). The effect was also different by sex, with girls being the most affected (OR, 1.47; 95% CI, 1.23-1.76; P < 0.001). There was also a correlation between skipping breakfast and abdominal obesity in children (OR, 0.65; 95% CI, 0.55-0.77; P < 0.001).

Conclusion

This meta-analysis suggested that skipping breakfast is associated with an increased risk of overweight/obesity in children and adolescents. The findings provide support for a possible protective role of breakfast against excessive weight gain in children and adolescents. However, more rigorous study designs with validated and standardized measures of relevant variables are needed.

Targeted dietary approaches for the management of obesity and severe obesity in children and adolescents: A systematic review and meta-analysis

There is a need for a detailed understanding of effective dietary interventions for children with obesity. This systematic review examined the effectiveness of diets of varying energy content as a component of weight treatment in children and adolescents with obesity, severe obesity and obesity-related comorbidity. A systematic search of six databases, from 2000 to 2021, for intervention studies of targeted dietary treatment for obesity in children aged 2-18 years identified 125 studies. Dietary interventions were grouped according to diet type and energy target. Risk of bias was assessed using the Effective Public Healthcare Panacea Project assessment tool. Meta-analysis examined change in body mass index (BMI) at intervention end. A broad array of diet types were effective at reducing BMI in children with obesity. When dietary types were considered by energy target, a gradient effect was observed. Very-low energy diets were most effective with a - 4.40 kg/m² (n = 3; 95% CI -7.01 to -1.79). While dietary interventions with no specified energy target were ineffective, resulting in a BMI gain of +0.17 kg/m² (n = 22; 95% CI 0.05 to 0.40). Practical definitions of dietary energy target in the management of obesity and severe obesity are urgently required to ensure treatment seeking children have timely access to efficacious interventions.

Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions

The objective of this technical report is to provide clinicians with evidence-based, actionable information upon which to make assessment and treatment decisions for children and adolescents with obesity. In addition, this report will provide an evidence base to inform clinical practice guidelines for the management and treatment of overweight and obesity in children and adolescents. To this end, the goal of this report was to identify all relevant studies to answer 2 overarching key questions: (KQ1) "What are clinically based, effective treatments for obesity?" and (KQ2) "What is the risk of comorbidities among children with obesity?" See Appendix 1 for the conceptual framework and a priori key questions.

Pediatric quality of life multidimensional fatigue scale (PedsQL-MFS) detects the effects of a 3-week Inpatient body weight reduction program for children and adolescents with obesity

BACKGROUND

Fatigue is a frequent complaint amongst children and adolescents with obesity, and it interferes with adherence to dietary and exercise regimes that could reduce obesity. The present study evaluated the effect of an inpatient 3-week body weight reduction program on body weight and fatigue.

METHOD

One hundred children and adolescents with obesity (64% female; aged 11-18 years) undertook an inpatient program of personalized diet, daily exercise, education, and counselling.

RESULTS

The sample evidenced a mean reduction in body mass (females: ΔM = 4.3 (sd = 2.1) kg, p < .001), males: ΔM = 6.2 (sd = 2.6) kg, p < .001), BMI standard deviation score (females: ΔM = 0.17 (sd = 0.07), males: ΔM = 0.24 (sd = 0.08), p < .001) and fatigue (females: ΔM = 7.8 (sd = 9.7), males: ΔM = 5.0 (sd = 6.9), p < .001) as measured by the Pediatric Quality of Life Multidimensional Fatigue Scale (PedsQL-MFS) and improvements on the Attention problems subscale of the Youth Self Report (total sample: ΔM = 0.89 (sd = 2.44), p < .001). Reliable change analyses revealed fatigue changes were achieved by up to 34% females and 17% males, but the majority did not achieve reliable change and changes in fatigue were not correlated with changes in body mass.

CONCLUSIONS

The program achieved clinically significant improvements in some children and adolescents. Future studies should explore predictors of treatment responsiveness. Trial registration Observational study. Not registered.

Development and Implementation of a Pilot Integrative Day Hospital Program for Youth with Severe Obesity and Mental Health Issues

Background: Adolescents with severe obesity and comorbid mental health issues are the most resistant to traditional weight management approaches and have poor treatment outcomes. Our objective was to implement and evaluate a pilot day hospital treatment program for adolescents with severe obesity, or risk for severe obesity, and significant mental health comorbidities. Methods: This was a prospective cohort study of adolescents 12-18 years of age with severe obesity (BMI >99th percentile), or at risk for severe obesity, and comorbid mental health issues. The intervention, focused on healthy lifestyle and mental health support, was implemented within an existing psychiatric day hospital at a pediatric quaternary care hospital. Anthropometric and mental health measures were analyzed pre- and postintervention. Results: Thirty-two adolescents with a mean age of 14.9 years [standard deviation (SD) 1.6] participated in the pilot integrative day hospital program for a mean duration of 5.2 months (SD 2.3). Eleven participants had primary severe obesity and comorbid mental health conditions (obesity subgroup) and 21 participants had primary mental illness and were at risk for obesity (psychiatry subgroup). We did not observe a significant difference between BMI pre- and postprogram among adolescents in both subgroups. In other words, adolescents in both subgroups achieved weight maintenance. Fear in losing control of overeating and/or being seen by others when eating decreased significantly in the obesity subgroup [mean difference (MD) 0.99; 95% confidence interval (CI): 0.27 to 1.71]. There was a significant decrease in participant-reported depression symptom severity, both overall and within program subgroups. Quality-of-life scores of study participants improved significantly within the obesity subgroup (MD -12.31; 95% CI: -21.69 to -2.93), but not within the psychiatry subgroup (MD -6.35; 95% CI: -13.37 to 0.67). Conclusions and Implications: A day hospital model of care may result in weight maintenance, decreased eating concerns, and improved mental health in adolescents with severe obesity or risk for severe obesity, and significant mental health comorbidities.

Effect of a high protein/low glycaemic index diet on insulin resistance in adolescents with overweight/obesity-A PREVIEW randomized clinical trial

BACKGROUND

Pubertal insulin resistance (IR) is associated with increased risk of type 2 diabetes mellitus development in adolescents with overweight/obesity.

OBJECTIVES

The PREVIEW study was a randomized parallel trial assessing the change in IR, analyzed by Homeostatic Model Assessment of IR (HOMA-IR), at 2 years after randomization to a high protein vs a moderate protein diet in adolescents with overweight/obesity. It was hypothesized that a high protein/low glycaemic index diet would be superior in reducing IR compared to a medium protein/medium GI diet, in insulin resistant adolescents with overweight or obesity.

METHODS

Adolescents with overweight/obesity and IR from the Netherlands, United Kingdom and Spain were randomized into a moderate protein/moderate GI (15/55/30En% protein/carbohydrate/fat, GI ≥ 56) or high protein/low GI (25/45/30En% protein/carbohydrate/fat, GI < 50) diet. Anthropometric and cardiometabolic parameters, puberty, dietary intake and physical activity (PA) were measured and effects on HOMA-IR were analyzed.

RESULTS

126 adolescents were included in this study (13.6 ± 2.2 years, BMI z-score 3.04 ± 0.66, HOMA-IR 3.48 ± 2.28, HP n = 68, MP n = 58). At 2 years, changes in protein intake were not significantly different between timepoints or intervention groups and no effects of the intervention on IR were observed. The retention rate was 39%, while no compliance to the diets was observed.

CONCLUSIONS

The PREVIEW study observed no effect of a high protein/low GI diet on IR in adolescents with overweight/obesity and IR because of lack of feasibility, due to insufficient retention and dietary compliance after 2 years.

Impacts of Dietary Macronutrient Pattern on Adolescent Body Composition and Metabolic Risk: Current and Future Health Status-A Narrative Review

Obesity, particularly in childhood and adolescence, is one of the serious public health problems worldwide. According to the World Health Organization, 10% of young people aged 5-17 years are obese, which is rapidly increasing around the world. Furthermore, approximately 80% of adolescents who become obese develop bodyweight-related health problems in adulthood. Eating habits and lifestyles play important roles in forming body composition and metabolic status. Changes in body composition in adolescence, the period in which secondary sex characteristics begin to develop, can alter hormonal and metabolic status, can consequently affect health status and the risk of developing chronic diseases in adulthood, and moreover may have an impact on probable body composition and metabolic status in the next generation. Here, we reviewed cross-sectional and interventional studies to analyze the role of dietary patterns focusing on macronutrient intake in growth, body composition, and metabolic changes in adolescents. These findings provide insights into optimal dietary guidelines for healthy growth with accretion of adequate body composition in adolescence, and provide an effective strategy for preventing and managing the risk of obesity-related metabolic disease in adulthood, with the additional benefit of providing potential benefits for the next generation's health.

Association between protein-rich dietary patterns and anthropometric measurements among children aged 6 years

AIM

The associations between types of dietary protein intake and child anthropometric measurements have not been fully studied. Therefore, we examined dietary protein pattern in relation to anthropometric indicators among 6-year-old children.

METHODS

We carried out a cross-sectional study of 788 randomly selected children from health centres in Tehran, Iran. Dietary intake was assessed using a food frequency questionnaire completed by the mothers. Anthropometric measurements were based on standard protocols. Principle component analysis was performed to identify different dietary protein patterns. We used multivariate logistic regression to evaluate how these patterns were associated with child anthropometry.

RESULTS

Three dietary protein patterns were identified: pattern 1 (rich in red and processed meats, dairy products and eggs), pattern 2 (rich in fish and poultry) and pattern 3 (rich in soy and legumes). After adjusting for potential confounders (energy intake, socioeconomic status and physical activity), being in the third compared to the first tertiles of pattern 2 was associated with increased (OR = 1.57; 95% CI: 1.09-2.27; P = .01) and decreased (OR = 0.54; 95% CI: 0.32-0.92; P = .02) risk of overweight/obesity and underweight/wasting, respectively. There was no association between other dietary patterns and risk of overweight/obesity or underweight/wasting.

CONCLUSIONS

The present study showed inverse association between the fish/white meat pattern and underweight/wasting and also a positive association between higher fish/white meat protein intake and higher risk of overweight/obesity. Further studies are needed to confirm these results.

What change in body mass index is associated with improvement in percentage body fat in childhood obesity? A meta-regression

OBJECTIVE

Using meta-regression this paper sets out the minimum change in body mass index-SD score (BMI-SDS) required to improve adiposity as percentage body fat for children and adolescents with obesity.

DESIGN

Meta-regression.

SETTING

Studies were identified as part of a large-scale systematic review of the following electronic databases: AMED, Embase, MEDLINE via OVID, Web of Science and CENTRAL via Cochrane library.

PARTICIPANTS

Individuals aged 4-19 years with a diagnosis of obesity according to defined BMI thresholds.

INTERVENTIONS

Studies of lifestyle treatment interventions that included dietary, physical activity and/or behavioural components with the objective of reducing obesity were included. Interventions of <2 weeks duration and those that involved surgical and/or pharmacological components (eg, bariatric surgery, drug therapy) were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

To be included in the review, studies had to report baseline and post-intervention BMI-SDS or change measurements (primary outcome measures) plus one or more of the following markers of metabolic health (secondary outcome measures): adiposity measures other than BMI; blood pressure; glucose; inflammation; insulin sensitivity/resistance; lipid profile; liver function. This paper focuses on adiposity measures only. Further papers in this series will report on other outcome measures.

RESULTS

This paper explores the potential impact of BMI-SDS reduction in terms of change in percentage body fat. Thirty-nine studies reporting change in mean percentage body fat were analysed. Meta-regression demonstrated that reduction of at least 0.6 in mean BMI-SDS ensured a mean reduction of percentage body fat mass, in the sense that the associated 95% prediction interval for change in mean percentage body fat was wholly negative.

CONCLUSIONS

Interventions demonstrating reductions of 0.6 BMI-SDS might be termed successful in reducing adiposity, a key purpose of weight management interventions.

TRIAL REGISTRATION NUMBER

CRD42016025317.

WITHDRAWN: Interventions for treating obesity in children

BACKGROUND

Child and adolescent obesity is increasingly prevalent, and can be associated with significant short- and long-term health consequences.

OBJECTIVES

To assess the efficacy of lifestyle, drug and surgical interventions for treating obesity in childhood.

SEARCH METHODS

We searched CENTRAL on The Cochrane Library Issue 2 2008, MEDLINE, EMBASE, CINAHL, PsycINFO, ISI Web of Science, DARE and NHS EED. Searches were undertaken from 1985 to May 2008. References were checked. No language restrictions were applied.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of lifestyle (i.e. dietary, physical activity and/or behavioural therapy), drug and surgical interventions for treating obesity in children (mean age under 18 years) with or without the support of family members, with a minimum of six months follow up (three months for actual drug therapy). Interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data following the Cochrane Handbook. Where necessary authors were contacted for additional information.

MAIN RESULTS

We included 64 RCTs (5230 participants). Lifestyle interventions focused on physical activity and sedentary behaviour in 12 studies, diet in 6 studies, and 36 concentrated on behaviorally orientated treatment programs. Three types of drug interventions (metformin, orlistat and sibutramine) were found in 10 studies. No surgical intervention was eligible for inclusion. The studies included varied greatly in intervention design, outcome measurements and methodological quality.Meta-analyses indicated a reduction in overweight at 6 and 12 months follow up in: i) lifestyle interventions involving children; and ii) lifestyle interventions in adolescents with or without the addition of orlistat or sibutramine. A range of adverse effects was noted in drug RCTs.

AUTHORS' CONCLUSIONS

While there is limited quality data to recommend one treatment program to be favoured over another, this review shows that combined behavioural lifestyle interventions compared to standard care or self-help can produce a significant and clinically meaningful reduction in overweight in children and adolescents. In obese adolescents, consideration should be given to the use of either orlistat or sibutramine, as an adjunct to lifestyle interventions, although this approach needs to be carefully weighed up against the potential for adverse effects. Furthermore, high quality research that considers psychosocial determinants for behaviour change, strategies to improve clinician-family interaction, and cost-effective programs for primary and community care is required.

Percent Body Fat Measurement in the Medical Management of Children with Obesity

Sustaining weight loss can be challenging, as physiological responses to weight loss, including metabolic and hormonal adaptations and decreased energy expenditure, promote weight regain. Paired with sustained dietary changes, physical activity can promote weight maintenance after successful weight loss, as physical activity can help maintain fat-free mass. We present several illustrative cases to highlight the potential use of body composition measurement using a bioelectrical impedance analysis (BIA) scale to augment obesity management counseling in a tertiary care pediatric weight-management clinic. BIA does require some interpretation, as it can be affected by hydration status and time of day, as well as patient age, sex, and body mass index. Nonetheless, BIA can be a helpful aid to obesity counseling. More research is needed to better understand how to use change in percent body fat over time as a motivational tool for management of children with obesity. [Pediatr Ann. 2018;47(12):e487-e493.].

Effects of a high-protein intake on metabolic targets for weight loss in children with obesity: a randomized trial

OBJECTIVE

The objective of this research is to study effects of a 4-week high-protein (HP) diet on energy intake, resting energy expenditure (REE), protein turnover and body composition in children with obesity.

METHODS

In this randomized placebo-controlled single-blind crossover study, children with obesity (n = 14; mean age: 10.1 years ± 1.2 standard deviation; body mass index-standard deviation score [BMI-SDS]: 2.8 ± 0.5) received an ad libitum HP (+50 g protein per day) or normal-protein (NP) diet for 4 weeks with a washout period of ≥2 weeks. Energy intake, REE, protein turnover, weight, BMI-SDS and body composition were measured.

RESULTS

No differences were found in energy intake or REE between HP and NP. There was an increased urea production and phenylalanine hydroxylation after HP compared with NP (p < 0.05). There was an increased rise in fat-free mass after HP compared with NP (∆HP: 0.8 ± 0.8 kg vs. ∆NP: 0.1 ± 0.6 kg, p < 0.05). BMI and BMI-SDS increased during the study (BMI-SDS start: 2.8 ± 0.5, end: 2.9 ± 0.5, p < 0.05) without a difference between groups.

CONCLUSIONS

A 4-week HP diet with ad libitum food intake did not affect energy intake and energy expenditure in children with obesity. BMI increased, although that could be partly explained by an increase in fat-free mass.

Effects of multidisciplinary interventions on weight loss and health outcomes in children and adolescents with morbid obesity

OBJECTIVE

Morbid obesity is the fastest growing subcategory of childhood obesity, associated with an increased health risk that persists into adulthood. There is an urgent need to develop multifaceted interventions that target initial and long-term lifestyle changes. This review investigates the effects of multidisciplinary interventions on weight loss and health outcomes in children and adolescents with morbid obesity. The influence of age, gender and family participation on health outcomes and intensive treatment alternatives are explored.

METHODS

The review includes 16 studies conducted between 1995 and 2017. Studies examined youth with morbid obesity, 4-18 years old, undergoing multidisciplinary treatment.

RESULTS

All studies found a reduction in body mass index (BMI or z-score) and if measured, cardiovascular risk factors. Physical activity, nutrition education, behavioural modification and family involvement are commonly included treatment components and have improved weight loss and health-related outcomes. However, initial weight loss was often not sustainable, despite the favourable interventional effect on cardiometabolic risk markers. Weight loss was prolonged in younger children and among the male sex.

CONCLUSIONS

There is not a 'one-size-fits-all' treatment approach, and matched care to personal needs is preferable. The integration of a chronic care approach is critical for the successful adaption of sustainable health behaviours.

Treatment of Pediatric Obesity: An Umbrella Systematic Review

OBJECTIVE

Multiple interventions are available to reduce excess body weight in children. We appraised the quality of evidence supporting each intervention and assessed the effectiveness on different obesity-related outcomes.

METHODS

We conducted a systematic search for systematic reviews of randomized controlled trials evaluating pediatric obesity interventions applied for ≥6 months. We assessed the quality of evidence for each intervention using GRADE (Grading of Recommendation, Assessment, Development, and Evaluation) approach.

RESULTS

From 16 systematic reviews, we identified 133 eligible randomized controlled trials. Physical activity interventions reduced systolic blood pressure and fasting glucose (low to moderate quality of evidence). Dietary interventions with low-carbohydrate diets had a similar effect to low-fat diets in terms of body mass index (BMI) reduction (moderate quality of evidence). Educational interventions reduced waist circumference, BMI, and diastolic blood pressure (low quality of evidence). Pharmacological interventions reduced BMI (metformin, sibutramine, orlistat) and waist circumference (sibutramine, orlistat) and increased high-density lipoprotein cholesterol (sibutramine) but also raised systolic and diastolic blood pressure (sibutramine). Surgical interventions (laparoscopic adjustable gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy) resulted in the largest BMI reduction (moderate quality of evidence). Combined interventions consisting of dietary modification, physical activity, behavioral therapy, and education significantly reduced systolic and diastolic blood pressure, BMI, and triglycerides. Combined parent-child interventions and parent-only interventions had similar effects on BMI (low quality of evidence).

CONCLUSIONS

Several childhood obesity interventions are effective in improving metabolic and anthropometric measures. A comprehensive multicomponent intervention, however, appears to have the best overall outcomes.

Economic Evaluation of Intensive Inpatient Treatments for Severely Obese Children and Adolescents

BACKGROUND

Considering the large economic consequences of severe childhood obesity for the society, we aimed to conduct an economic evaluation comparing two intensive 1-year lifestyle treatments with varying inpatient periods for severely obese children and adolescents with regard to standard deviation score BMI (SDS-BMI) and quality-adjusted life years (QALYs).

METHODS

An economic evaluation from a societal perspective accompanying a randomized controlled trial with a 24-month follow-up. 80 participants (8-19 years) with severe obesity were included. Participants received an intensive 1-year lifestyle treatment with an inpatient period of 2 months (short-stay group) or 6 months (long-stay group). Data were collected at baseline, 6, 12 ,and 24 months and included SDS-BMI and QALYs.

RESULTS

SDS-BMI decreased in the first 6 months of treatment, stabilized in the second 6 months, and increased during the 2nd year in both groups. After 24 months, SDS-BMI was similar in both groups, but remained lower than baseline values (mean difference -0.24, 95% CI -0.42; -0.06). There was no difference in QALYs between the groups after 24 months. For SDS-BMI, the probability of the short-stay treatment being cost-effective in comparison with the long-stay treatment was 1 at a willingness-to-pay of 0 EUR/unit of effect, which slowly decreased to 0.54 for larger willingness-to-pay values.

CONCLUSIONS

Based on the results of this study, the short-stay treatment is considered to be more cost-effective from the societal perspective in comparison with the long-stay treatment. Future research should provide insight in whether the short-stay treatment is cost-effective in comparison with usual care.

Prenatal caprine milk oligosaccharide consumption affects the development of mice offspring

SCOPE

The composition of the gastrointestinal (GIT) microbiota, particularly in early life, influences the development of metabolic diseases later in life. The maternal microbiota is the main source of bacteria colonising the infant GIT and can be modified by dietary prebiotics. Our objective was to determine the effects of prenatal consumption of prebiotic caprine milk oligosaccharides (CMO) on the large intestine of female mice, milk composition, and offspring's development.

METHODS AND RESULTS

C57BL/6 mice were fed either a control diet, CMO diet, or galacto-oligosaccharide diet from mating to weaning. From weaning, some pups nursed by CMO, GOS, and control-dams were fed the control diet for 30 days. CMO or GOS-fed dams had increased colon length and milk protein concentration compared to control-fed dams. At weaning, pups from CMO-fed dams had increased body weight and colon length and increased proportions of colonic Bifidobacterium spp compared to the pups from control-fed dams. Thirty days after weaning, pups from CMO-fed dams had increased visceral fat weight compared to pups from control-fed dams.

CONCLUSION

Consumption of CMO by the dams during gestation and lactation improved the development of the pups, and the relative abundance of bifidobacteria and butyric acid in the colon, at weaning.

Sport-based physical activity intervention on body weight in children and adolescents: a meta-analysis

Controversial results reported in past research pertaining to the effectiveness of sport-based physical activity interventions on weight loss. The purpose of this study was to assess the impact of sport-based physical activity intervention on body weight in children and adolescents using a meta-analysis. Academic Search Complete, Education Source, ERIC, Medline, ProQuest, PsycINFO and SportDiscus databases were searched from January 2000 to April 2015. Eighteen studies met following inclusion criteria: sport-based intervention studies; subjects aged 6-18 years; reported body weight; published in peer-reviewed journals written in English. The mean intervention duration was 17.72 weeks. The overall effect size (ES) was 0.52 (Cohen's d (ES) = 0.52, 95% CI = 0.08, 0.95, P = 0.021), using a random effects model. Moderator analyses results showed that the Q statistic for the sport type (individual sport or team sport, Qbetween (Q_b) = 14.52, df = 1, P = 0.001) and diet control (Qbetween (Q_b) = 8.85, df = 1, P = 0.001), explained the heterogeneity of ESs. Our study showed that there was a moderate overall effect of sport-based physical activity intervention on body weight reduction. The team sport type (ES = 1.05, 95% CI = 0.44, 1.66) and diet control group (ES = 0.84, 95% CI = 0.26, 1.41) appeared to be more effective in reducing body weight.

Cardiometabolic and Fitness Improvements in Obese Girls Who Either Gained or Lost Weight during Treatment

OBJECTIVE

To evaluate the quality of weight change (change in fat mass vs fat-free mass [FFM]), changes in cardiorespiratory fitness (CRF), and frequencies of metabolic risk factors in adolescent females with obesity who either lost or gained weight following lifestyle treatment.

STUDY DESIGN

Fifty-eight girls (mean age = 13.0 ± 1.6 years; 77% black; mean body mass index = 36.5 ± 4.5 kg/m(2)) completed a 6-month lifestyle intervention combining dietary and behavioral counseling with aerobic and resistance exercise training. We examined baseline to 6-month differences in weight (kg), body composition, CRF, and frequencies of metabolic risk factors between weight loss and weight gain groups.

RESULTS

In the weight loss group, body weight (-4.50 ± 3.53 kg, P < .001), fat mass (-4.50 ± 2.20 kg, P < .001), and body fat percentage (-2.97% ± 1.45%, P < .001) decreased, and FFM was unchanged at 6 months. In the weight gain group, body weight (4.50 ± 2.20 kg, P < .001), fat mass (1.52 ± 3.16 kg, P < .024), and FFM (2.99 ± 2.45 kg, P < .001) increased, and body fat percentage was unchanged. Both groups improved CRF (P < .05). Frequencies of metabolic risk factors were reduced across all participants after the 6-month treatment.

CONCLUSIONS

Participation in a weight management program might elicit health improvements in obese adolescent females who increase weight and fat mass, provided that FFM gains are sufficient to negate increases in body fat percentage.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00167830.

Dietary animal and plant protein intakes and their associations with obesity and cardio-metabolic indicators in European adolescents: the HELENA cross-sectional study

Background

Previous studies suggest that dietary protein might play a beneficial role in combating obesity and its related chronic diseases. Total, animal and plant protein intakes and their associations with anthropometry and serum biomarkers in European adolescents using one standardised methodology across European countries are not well documented.

Objectives

To evaluate total, animal and plant protein intakes in European adolescents stratified by gender and age, and to investigate their associations with cardio-metabolic indicators (anthropometry and biomarkers).

Methods

The current analysis included 1804 randomly selected adolescents participating in the HELENA study (conducted in 2006–2007) aged 12.5-17.5 y (47% males) who completed two non-consecutive computerised 24-h dietary recalls. Associations between animal and plant protein intakes, and anthropometry and serum biomarkers were examined with General linear Model multivariate analysis.

Results

Average total protein intake exceeded the recommendations of World Health Organization and European Food Safety Authority. Mean total protein intake was 96 g/d (59% derived from animal protein). Total, animal and plant protein intakes (g/d) were significantly lower in females than in males and total and plant protein intakes were lower in younger participants (12.5-14.9 y). Protein intake was significantly lower in underweight subjects and higher in obese ones; the direction of the relationship was reversed after adjustments for body weight (g/(kg.d)). The inverse association of plant protein intakes was stronger with BMI z-score and body fat percentage (BF%) compared to animal protein intakes. Additionally, BMI and BF% were positively associated with energy percentage of animal protein.

Conclusions

This sample of European adolescents appeared to have adequate total protein intake. Our findings suggest that plant protein intakes may play a role in preventing obesity among European adolescents. Further longitudinal studies are needed to investigate the potential beneficial effects observed in this study in the prevention of obesity and related chronic diseases.

Adipose tissue dysregulation and metabolic consequences in childhood and adolescent obesity: potential impact of dietary fat quality

Evidence suggests that at a population level, childhood and adolescent obesity increase the long-term risk of chronic diseases such as type 2 diabetes and CVD. At an individual level, however, the metabolic consequences of obesity in youth vary immensely. Despite comparable BMI, some adolescents develop impaired glucose tolerance while others maintain normal glucose homeostasis. It has been proposed that the variation in the capacity to store lipid in the subcutaneous adipose tissue (SAT) may partially discriminate metabolically healthy from unhealthy obesity. In positive energy balance, a decreased capacity to expand SAT may drive lipid accumulation to visceral adipose tissue, liver and skeletal muscle. This state of lipotoxicity is associated with chronic low-grade inflammation, insulin resistance and dyslipidaemia. The present review examines the differential adipose tissue development and function in children and adolescents who exhibit metabolic dysregulation compared with those who are protected. Additionally, the role of manipulating dietary fat quality to potentially prevent and treat metabolic dysfunction in obesity will be discussed. The findings of the present review highlight the need for further randomised controlled trials to establish the effect of dietary n-3 PUFA on the metabolic phenotype of obese children and adolescents. Furthermore, using a personalised nutrition approach to target interventions to those at risk of, or those with established metabolic dysregulation may optimise the efficacy of modifying dietary fat quality.

Improved insulin sensitivity and body composition, irrespective of macronutrient intake, after a 12 month intervention in adolescents with pre-diabetes; RESIST a randomised control trial

Background

A higher protein to carbohydrate ratio in the diet may potentiate weight loss, improve body composition and cardiometabolic risk, including glucose homeostasis in adults. The aim of this randomised control trial was to determine the efficacy of two structured lifestyle interventions, differing in dietary macronutrient content, on insulin sensitivity and body composition in adolescents. We hypothesised that a moderate-carbohydrate (40-45% of energy), increased-protein (25-30%) diet would be more effective than a high-carbohydrate diet (55-60%), moderate-protein (15%) diet in improving outcomes in obese, insulin resistant adolescents.

Methods

Obese 10–17 year olds with either pre-diabetes and/or clinical features of insulin resistance were recruited at two hospitals in Sydney, Australia. At baseline adolescents were prescribed metformin and randomised to one of two energy restricted diets. The intervention included regular contact with the dietician and a supervised physical activity program. Outcomes included insulin sensitivity index measured by an oral glucose tolerance test and body composition measured by dual-energy x-ray absorptiometry at 12 months.

Results

Of the 111 adolescents recruited, 85 (77%) completed the intervention. BMI expressed as a percentage of the 95th percentile decreased by 6.8% [95% CI: −8.8 to −4.9], ISI increased by 0.2 [95% CI: 0.06 to 0.39] and percent body fat decreased by 2.4% [95% CI: −3.4 to −1.3]. There were no significant differences in outcomes between diet groups at any time.

Conclusion

When treated with metformin and an exercise program, a structured, reduced energy diet, which is either high-carbohydrate or moderate-carbohydrate with increased-protein, can achieve clinically significant improvements in obese adolescents at risk of type 2 diabetes.

Trial registration

Australian New Zealand Clinical Trail Registry ACTRN12608000416392. Registered 25 August 2008.

Impact of dietary macronutrient distribution on BMI and cardiometabolic outcomes in overweight and obese children and adolescents: a systematic review

The present systematic review examined the effectiveness of weight management interventions comparing diets with varying macronutrient distributions on BMI and cardiometabolic risk factors in overweight or obese children and adolescents. A systematic search of seven databases for the period 1975-2013 identified 14 eligible randomized or quasi-randomized controlled trials conducted with 6-18-year-old subjects. Seven trials compared a low-fat (≤ 33% energy or < 40 g/day) to an isocaloric (n = 2) or ad libitum (n = 5) low-carbohydrate diet (< 20% energy or < 60 g/day). Meta-analysis indicated a greater reduction in BMI in the low-carbohydrate group immediately after dietary intervention; however, the quality of the studies was limited and cardiometabolic benefits were inconsistent. Six trials compared increased-protein diets (19-30% energy) to isocaloric standard-protein diets (15-20% energy) and one compared an increased-fat diet (40% energy) to an isocaloric standard-fat diet (27% energy); there were no differences in outcomes in these studies. Current evidence suggests that improved weight status can be achieved in overweight or obese children and adolescents irrespective of the macronutrient distribution of a reduced-energy diet. Tailoring the macronutrient content to target specific cardiometabolic risk factors, such as a low-carbohydrate diet to treat insulin resistance, may be possible, but further research is needed before specific recommendations can be made.

Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: a scientific statement from the American Heart Association

Severe obesity afflicts between 4% and 6% of all youth in the United States, and the prevalence is increasing. Despite the serious immediate and long-term cardiovascular, metabolic, and other health consequences of severe pediatric obesity, current treatments are limited in effectiveness and lack widespread availability. Lifestyle modification/behavior-based treatment interventions in youth with severe obesity have demonstrated modest improvement in body mass index status, but participants have generally remained severely obese and often regained weight after the conclusion of the treatment programs. The role of medical management is minimal, because only 1 medication is currently approved for the treatment of obesity in adolescents. Bariatric surgery has generally been effective in reducing body mass index and improving cardiovascular and metabolic risk factors; however, reports of long-term outcomes are few, many youth with severe obesity do not qualify for surgery, and access is limited by lack of insurance coverage. To begin to address these challenges, the purposes of this scientific statement are to (1) provide justification for and recommend a standardized definition of severe obesity in children and adolescents; (2) raise awareness of this serious and growing problem by summarizing the current literature in this area in terms of the epidemiology and trends, associated health risks (immediate and long-term), and challenges and shortcomings of currently available treatment options; and (3) highlight areas in need of future research. Innovative behavior-based treatment, minimally invasive procedures, and medications currently under development all need to be evaluated for their efficacy and safety in this group of patients with high medical and psychosocial risks.

Evaluation of a community-based weight management program for predominantly severely obese, difficult-to-reach, inner-city minority adolescents

BACKGROUND

Few interventions targeting severely obese minority youth have been implemented in community-based settings. We evaluate a 9-month multicomponent, community-based program for obese, inner-city adolescents.

METHODS

Of 5250 estimated eligible adolescents, 349 were recruited; they had a mean age of 15 ± 2 years, mean BMI %ile 98.9 ± 1.5, and comprised 52% African American and 44% Hispanic. Longitudinal trends of anthropometric measures were compared 1 year before enrollment (T-12), at baseline (T0) and after program completion (T9). Dietary and physical activity behaviors were compared at T0 and T9. Anthropometric changes were compared at T9 and 18 months (T18) in completers and noncompleters.

RESULTS

A majority of participants were severely obese (67%) and expressed low readiness to change behaviors (82%). For intervals T-12 to T0 versus T0 to T9, there were significant decreases in rates of gain in BMI (0.13 vs. 0.04, p < 0.01), BMI percentile (0.0002 vs. -0.0001, p < 0.01), percent overweight (0.001 vs. -0.001, p < 0.01), and BMI z-score (0.003 vs. -0.003, p < 0.01). Significant increases in vegetable and fruit consumption and in vigorous physical activity participation were observed. From T9 to T18, except for a significant increase in BMI (38.3 ± 7.4 vs. 39.0 ± 7.5, p < 0.01) in completers, all other anthropometric measures remained unchanged in completers and noncompleters.

CONCLUSIONS

We demonstrate modest clinical improvements and increased healthy lifestyle behaviors in predominantly severely obese, difficult-to-reach, ethnic minority adolescents attending a community-based weight management program. The loss of clinical improvements 9 months after program completion implies that extending the duration of such a program may prevent long-term weight regain in severely obese adolescents.

Tratamento multiprofissional da obesidade e sua cessação em adolescentes: efeitos no perfil hemodinâmico

Avaliar os efeitos de um Programa Multiprofissional de Tratamento da Obesidade (PMTO) e de sua cessação sobre o perfil hemodinâmico de adolescentes. Foram avaliados 19 adolescentes com excesso de peso de 10 a 18 anos. Medidas antropométricas, pressão arterial e frequência cardíaca de repouso foram incluídas na análise. Os adolescentes completaram 16 semanas do PMTO com uma equipe multiprofissional focada em promover mudanças no estilo de vida dos adolescentes. Os mesmos retornaram para avaliação após oito semanas de cessação das atividades. Após o PMTO, foi observada redução na frequência cardíaca de repouso nas meninas sem diferença significativa para o momento de cessação. Os meninos apresentaram melhora para as variáveis: circunferência abdominal, IMC, gordura relativa e massa magra após o PMTO. Após o período cessação houve aumento significativo apenas no peso. Os resultados evidenciam o impacto positivo de um PMTO demonstrando efeitos diferentes de acordo com o gênero.

Does regular breakfast cereal consumption help children and adolescents stay slimmer? A systematic review and meta-analysis

OBJECTIVE

To review systematically the evidence on breakfast cereal consumption and obesity in children and adolescents and assess whether the regular consumption of breakfast cereals could help to prevent excessive weight gain.

METHODS

A systematic review and meta-analysis of studies relating breakfast cereal consumption to BMI, BMI z-scores and prevalence of obesity as the outcomes.

RESULTS

14 papers met the inclusion criteria. The computed effect size for mean BMI between high consumers and low or non-consumers over all 25 study subgroups was -1.13 kg/m2 (95% CI -0.81, -1.46, p < 0.0001) in the random effects model, which is equivalent to a standardised mean difference of 0.24. Adjustment for age and publication bias attenuated the effect sizes somewhat but they remained statistically significant. The prevalence and risk of overweight was lower in children and adolescents who consume breakfast cereals regularly compared to those who consume them infrequently. Energy intakes tended to be higher in regular breakfast cereal consumers.

CONCLUSION

Overall, the evidence reviewed is suggestive that regular consumption of breakfast cereals results in a lower BMI and a reduced likelihood of being overweight in children and adolescents. However, more evidence from long-term trials and investigations into mechanisms is needed to eliminate possible confounding factors and determine causality.

The quality of dietary intake methodology and reporting in child and adolescent obesity intervention trials: a systematic review

Assessing dietary intake is important in evaluating childhood obesity intervention effectiveness. The purpose of this review was to evaluate the dietary intake methods and reporting in intervention studies that included a dietary component to treat overweight or obese children. A systematic review of studies published in the English language, between 1985 and August 2010 in health databases. The search identified 2,295 papers, of which 335 were retrieved and 31 met the inclusion criteria. Twenty-three studies reported energy intake as an outcome measure, 20 reported macronutrient intakes and 10 studies reported food intake outcomes. The most common dietary method employed was the food diary (n = 13), followed by 24-h recall (n = 5), food frequency questionnaire (FFQ) (n = 4) and dietary questionnaire (n = 4). The quality of the dietary intake methods reporting was rated as 'poor' in 15 studies (52%) and only 3 were rated as 'excellent'. The reporting quality of FFQs tended to be higher than food diaries/recalls. Deficiencies in the quality of dietary intake methods reporting in child obesity studies were identified. Use of a dietary intake methods reporting checklist is recommended. This will enable the quality of dietary intake results to be evaluated, and an increased ability to replicate study methodology by other researchers.

[Dietary interventions and social care for treating obesity in children]

The prevalence of obesity and associated comorbidities among children and adolescents has risen worldwide throughout the past 3 decades. To break this trend, population-based activities in health promotion/prevention and health care are necessary. Studies showed that long-term eating behavior improvement with the cooperation of the patient's family together with child-friendly organization support both individual therapeutic improvements as well as a relevant reduction of obesity prevalence. A significant BMI reduction can be achieved with a normal varied diet, whose energetic value is 300-400 kcal/day below the patient's daily energetic needs, due to the lower consumption of fat and sugar. This requires, however, that the entire family be willing to change their unhealthy eating behaviors (e.g., soft drinks and fast food) and to introduce regular meals into their daily routine. Sensibly, most therapies combine diet therapy with increased physical activity and parental training. Controlled media consumption, active leisure-time behavior, and a structured daily routine are further conditions for successful weight reduction. The high-risk groups for pediatric obesity, i.e., families with migration background and/or low socioeconomic status, have been poorly reached by established programs.

Long-term results of an obesity program in an ethnically diverse pediatric population

OBJECTIVE

To determine if beneficial effects of a weight-management program could be sustained for up to 24 months in a randomized trial in an ethnically diverse obese population.

PATIENTS AND METHODS

There were 209 obese children (BMI > 95th percentile), ages 8 to 16 of mixed ethnic backgrounds randomly assigned to the intensive lifestyle intervention or clinic control group. The control group received counseling every 6 months, and the intervention group received a family-based program, which included exercise, nutrition, and behavior modification. Lifestyle intervention sessions occurred twice weekly for the first 6 months, then twice monthly for the second 6 months; for the last 12 months there was no active intervention. There were 174 children who completed the 12 months of the randomized trial. Follow-up data were available for 76 of these children at 24 months. There were no statistical differences in dropout rates among ethnic groups or in any other aspects.

RESULTS

Treatment effect was sustained at 24 months in the intervention versus control group for BMI z score (-0.16 [95% confidence interval: -0.23 to -0.09]), BMI (-2.8 kg/m(2) [95% confidence interval: -4.0-1.6 kg/m(2)]), percent body fat (-4.2% [95% confidence interval: -6.4% to -2.0%]), total body fat mass (-5.8 kg [95% confidence interval: -9.1 kg to -2.6 kg]), total cholesterol (-13.0 mg/dL [95% confidence interval: -21.7 mg/dL to -4.2 mg/dL]), low-density lipoprotein cholesterol (-10.4 mg/dL [95% confidence interval: -18.3 mg/dL to -2.4 mg/dL]), and homeostasis model assessment of insulin resistance (-2.05 [95% confidence interval: -2.48 to -1.75]).

CONCLUSIONS

This study, unprecedented because of the high degree of obesity and ethnically diverse backgrounds of children, reveals that benefits of an intensive lifestyle program can be sustained 12 months after completing the active intervention phase.

Changes in depressive symptoms among adolescent bariatric candidates from preoperative psychological evaluation to immediately before surgery

BACKGROUND

The preoperative psychological evaluation (including the assessment of depressive symptoms) is an important component in determining adolescent bariatric candidacy. The adult bariatric data have suggested that candidates can engage in "impression management" and underreport depressive symptoms during their preoperative evaluation. The present study examined whether adolescent depressive symptoms among bariatric candidates change during preoperative preparation compared with adolescents with extreme obesity who were not seeking surgery.

METHODS

Adolescent candidates for bariatric surgery (n = 30; 60% female; mean age 16.5 ± 1.4 years) completed the Beck Depression Inventory-II (BDI-II) at initial consultation (time 1, mean body mass index [BMI] 64.5 ± 11.5 kg/m(2)) and again immediately preoperatively (time 2, mean interval 4.7 ± 2.9 months; mean BMI 64.4 ± 10.4 kg/m(2)). Comparators (n = 25; 64% female; mean age 16.2 ± 1.2 years; mean BMI 46.5 ± 4.8 kg/m(2)) were studied at enrollment in a research protocol and again 6 months later (mean interval 6.2 ± 0.4 months; mean BMI 46.8 ± 5.0 kg/m(2)). The height and weight were also taken.

RESULTS

We found a small, but statistically significant, difference in the BDI-II scores at time 1, with bariatric candidates reporting greater depressive symptoms (mean 16.6 ± 12.9) than the comparators (mean 10.6 ± 9.0; P < .05). No difference was seen in the BDI-II scores between the bariatric candidates (mean 14.4 ± 12.1) and the comparators (mean 10.4 ± 8.2) at time 2 (P = .17). The change in BDI-II scores for the bariatric candidates showed a trend toward significance (P = .09).

CONCLUSION

These results reinforce the position that the adult bariatric literature does not necessarily generalize to the adolescent bariatric population. They further suggest that impression management might not be a significant concern in the assessment of adolescent bariatric candidates. Future research should examine whether preoperative changes in psychological functioning predict the postoperative outcomes.

Immersion treatment of childhood and adolescent obesity: the first review of a promising intervention

Obese children have attended weight loss camps and residential programmes for more than 40 years. This paper provides the first systematic review of the effects of those programmes. Twenty-two studies met inclusion criteria (targeted and assessed change in weight status, minimal stay of 10 days and nights). Similar components across programmes included controlled diet, activities, nutrition education, and therapy and/or education regarding behaviour change. Participants lost substantial amounts of weight in all 22 studies, as measured by reductions in per cent-overweight during intervention. Eleven programmes included long-term follow-up evaluations. Compared with results highlighted in a recent meta-analysis of out-patient treatments, these immersion programmes produced an average of 191% greater reductions in per cent-overweight at post-treatment and 130% greater reduction at follow-up. Furthermore, mean attrition rates were much lower when compared with standard out-patient treatment. Inclusion of a cognitive-behavioural therapy (CBT) component seemed especially promising; follow-up evaluations showed decreased per cent-overweight at follow-up by an average of 30% for CBT immersion programmes vs. 9% for programmes without CBT. Explanations for the potentially greater impact of immersion relative to out-patient treatments are presented, including possibly differential effects on self-efficacy for both children and their parents.

The effect of protein and glycemic index on children's body composition: the DiOGenes randomized study

OBJECTIVE

To investigate the effect of protein and glycemic index (GI) on body composition among European children in the randomized, 6-month dietary intervention DiOGenes (diet, obesity, and genes) family-based study.

PATIENTS AND METHODS

In the study, 827 children (381 boys and 446 girls), aged 5 to 18 years, completed baseline examinations. Families with parents who lost ≥ 8% of their weight during an 8-week run-in low-calorie diet period were randomly assigned to 1 of 5 ad libitum diets: low protein (LP)/low glycemic index (LGI); LP/high GI (HGI); high protein (HP)/LGI; HP/HGI; and control diet. The target difference was 15 GI U between the LGI/HGI groups and 13 protein percentage points between the LP/HP groups. There were 658 children examined after 4 weeks. Advice on food-choice modification was provided at 6 visits during this period. No advice on weight loss was provided because the focus of the study was the ability of the diets to affect outcomes through appetite regulation. Anthropometric measurements and body composition were assessed at baseline, week 4, and week 26.

RESULTS

In the study, 465 children (58.1%) completed all assessments. The achieved differences between the GI and protein groups were 2.3 GI U and 4.9 protein percentage points, respectively. The LP/HGI group increased body fat percentage significantly more than the other groups (P = .040; partial η(2) = 0.039), and the percentage of overweight/obese children in the HP/LGI group decreased significantly during the intervention (P = .031).

CONCLUSIONS

Neither GI nor protein had an isolated effect on body composition. However, the LP/HGI combination increased body fat, whereas the HP/LGI combination was protective against obesity in this sample of children.

Association between eating frequency, weight, and health

There is speculation amongst health professionals, the media, and the public regarding eating frequency (EF) and its impact on weight and health. Nutritional weight-loss and -maintenance interventions of longer than 1 week's duration were reviewed for associations between EF and weight and health. Of the 176 studies identified, 25 relevant studies matched the criteria and only 10 of these were weight-loss interventions. Generally, sample sizes were small, interventions were short-term, and a wide array of definitions was used to define an eating occasion. Several key outcomes such as physical activity, adherence to assigned EF, and hunger were often not measured. The limited evidence available suggests there is no association between EF and weight or health in either weight-loss or -maintenance interventions, with a possible inverse association between EF and lipids in weight-maintenance interventions. Longer term, larger studies that include important weight and health outcomes are needed.

Prevalence and trends of severe obesity among US children and adolescents

OBJECTIVE

To determine the extent to which the 2007 definitions for severe obesity (body mass index [BMI] > or = 99th percentile for age and gender) and morbid obesity (BMI > or = 40kg/m(2)) affects different groups of American children and adolescents and has increased over time.

METHODS

Analysis of nationally representative data from the National Health and Nutrition Examination Survey (NHANES) II, III, and 1999-2004; 12 384 US children and adolescents ages 2 to 19 years were included in the analysis. Outcome measures were the proportion of subjects with severe and morbid obesity, with age, gender, race, and poverty-income ratio (PIR) as key variables.

RESULTS

In 1999-2004, 3.8% of children 2 to 19 years old had a BMI in the > or = 99th percentile, with higher prevalence among boys than girls (4.6% vs 2.9%; P < .001). Prevalence was highest among blacks, 5.7% and Mexican Americans, 5.2%, compared with whites, 3.1% (P < .001). The prevalence differed by the PIR category as well (4.3% for those with PIR < or = 3 vs 2.5% for those with PIR>3; P=.002). BMI > or = 40kg/m(2) was found in 1.3% of adolescents ages 12 to 19 years, with similar associations with race and poverty. The overall prevalence of BMI > or = 99th percentile has increased by more than 300% since NHANES II (1976), and over 70% since NHANES III (1994) in children 2 to 19 years of age.

CONCLUSIONS

Rates of severe childhood obesity have tripled in the last 25 years, with significant differences by race, gender, and poverty. This places demands on health care and community services, especially because the highest rates are among children who are frequently underserved by the health care system.