Dietetic management of obesity and severe obesity in children and adolescents: A scoping review of guidelines

Treatment of childhood obesity based on the reduction of ultra-processed foods plus energy restriction: A randomised controlled trial based on the Brazilian guidelines

Reducing ultra-processed foods (UPF) improves diet quality and may curb energy consumption. This study aimed to compare an intervention based on the reduction of UPF, according to the Dietary Guideline for the Brazilian Population (DGBP), with and without advice on energy intake. A parallel and randomised controlled trial was carried out with children with obesity from 7 to 12 years old. Both control (CG) and intervention groups (IG) participated monthly in 6 standardised educational activities based on the 10 steps of the DGBP. An individualised food plan was also provided to the IG. The rate of change for body mass index (BMI), waist circumference, body weight, and UPF consumption were investigated based on mixed-effect models. At the end of the study, the BMI declined in the IG (Δ = -0.27 kg/m2) compared to the CG (Δ = + 0.53 kg/m2) (p = .0002). Both groups showed a decline in grams of UPF until the fourth month and a gradual increase in the following months. Combining the qualitative approach of the DGBP with counselling on energy restriction through the diet plan proved to be effective in reducing childhood obesity. Clinical Trial Registration: This trial is registered at the Brazilian Registry of Clinical Trials (REBEC), under the RBR-3st5sn registry, available at http://www.ensaiosclinicos.gov.br/rg/RBR-3st5sn/. The datasets generated by the current study are not publicly available but are available from the corresponding author on reasonable request.

What adolescents see on Instagram: Content analysis of #intermittentfasting, #keto, and #lowcarb

AIM

To describe popular diet content visible on #intermittentfasting, #keto, and #lowcarb on adolescent social media accounts.

METHODS

An adolescent Instagram profile captured 200 'top' images from three popular diet hashtags (#intermittentfasting, #keto, and #lowcarb) across two timepoints. Images were coded using a pre-determined ontology as food (core or discretionary; common foods/food groups), people (group, individual, before/after), or informative. Descriptive statistics were used to summarise these categories across hashtags.

RESULTS

At the time of first data collection, there were 3.8 million #intermittentfasting, 19 million #keto, and 22 million #lowcarb posts on Instagram. At the second timepoint there were 4.3 million #intermittentfasting, 21.5 million #keto, and 24.3 million #lowcarb posts. Images tagged #intermittentfasting were categorised as 44% food, 39% people, 10% information; #keto were 64% food, 28% people, 5% information; and #lowcarb were 69% food, 14% people, 16% information. Food images mostly depicted animal proteins (58.6% of #intermittentfasting; 62.9% of #keto; and 40.1% of #lowcarb). Images of people were individual (44%) or before/after (39%); mostly female (77%), of white (53%) ethnicity. Across all posts, 12.5% were linked to a commercial product/program, and 2.3% provided nutrition information.

CONCLUSION

Diet-related images visible when adolescents search #intermittentfasting, #keto, and #lowcarb on Instagram promote animal-based foods with or without vegetables. These diet hashtags on Instagram do not provide nutrition information and are not helpful for young people searching for diet information online.

Eating Disorders In weight-related Therapy (EDIT) Collaboration: rationale and study design

The cornerstone of obesity treatment is behavioural weight management, resulting in significant improvements in cardio-metabolic and psychosocial health. However, there is ongoing concern that dietary interventions used for weight management may precipitate the development of eating disorders. Systematic reviews demonstrate that, while for most participants medically supervised obesity treatment improves risk scores related to eating disorders, a subset of people who undergo obesity treatment may have poor outcomes for eating disorders. This review summarises the background and rationale for the formation of the Eating Disorders In weight-related Therapy (EDIT) Collaboration. The EDIT Collaboration will explore the complex risk factor interactions that precede changes to eating disorder risk following weight management. In this review, we also outline the programme of work and design of studies for the EDIT Collaboration, including expected knowledge gains. The EDIT studies explore risk factors and the interactions between them using individual-level data from international weight management trials. Combining all available data on eating disorder risk from weight management trials will allow sufficient sample size to interrogate our hypothesis: that individuals undertaking weight management interventions will vary in their eating disorder risk profile, on the basis of personal characteristics and intervention strategies available to them. The collaboration includes the integration of health consumers in project development and translation. An important knowledge gain from this project is a comprehensive understanding of the impact of weight management interventions on eating disorder risk.

Clinical practice guidelines for the management of overweight and obesity published internationally: A scoping review

With the increasing prevalence of obesity placing additional demands on healthcare systems, many jurisdictions and professional bodies have developed clinical practice guidelines to support practitioners in the management of people with overweight and obesity. This scoping review aimed to identify key features of contemporary guidelines for the clinical management of overweight and obesity. Searches of MEDLINE, Guidelines International Network's international guidelines library, and other grey literature sources identified 38 guidelines of 18 countries and one region published since 2010. Guidelines were developed by committees (n = 36, 95%) that comprised knowledgeable experts (n = 36, 95%) and were multidisciplinary (n = 33, 87%), with limited consumer representation (n = 11, 29%). Guideline documentation incorporated review questions (n = 23, 61%), systematic reviews (n = 25, 66%), evidence grading systems (n = 33, 87%), processes for reaching consensus (n = 19, 50%), and guideline review details (n = 28, 74%). Treatment approaches included in most guidelines were nutrition and physical activity (n = 38, 100%), psychology (n = 37, 97%), pharmacotherapy (n = 32, 84%), and bariatric surgery (n = 31, 82%). Most guidelines targeted populations based on age (n = 30, 79%). Guidelines contained recommendations for pregnancy (n = 12, 32%), older adults (n = 9, 24%), and people with eating disorders (n = 8, 21%). Future guidelines would benefit from involvement of consumers including groups known to be at increased risk of overweight and obesity, targeted guidance for at risk groups, and consideration of weight bias and stigma.

Nutrient Deficiency After Bariatric Surgery in Adolescents: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis study aimed to estimate changes in blood nutrient concentrations and nutrient deficiencies in adolescents following bariatric surgery.

METHODS

We searched PubMed, Scopus, and the Web of Science to find studies published between January 2000 and August 2023. Observational studies reporting the mean blood concentration of nutrients before and after bariatric surgery or the proportion of nutrient deficiencies after the surgery in healthy adolescents were selected.

RESULTS

Fifteen studies were included. Gastric bypass and sleeve gastrostomy were the most common types of surgery. Vitamin D, iron, or ferritin, vitamin B12, calcium, and folic acid were the most studied nutrients, respectively. Other nutrients examined in the studies included zinc, phosphorus, and albumin. The serum ferritin increased by 21 mcg/L (95% CI = 10.0, 32.0 mcg/L) after the surgery, but there were no significant alterations in other nutrients. The postoperative prevalence of low albumin, ferritin, vitamin D, and vitamin B12 levels was 10%, 49%, 41%, and 20%, respectively. Also, 23% had an iron deficiency, and 10% had a calcium deficiency after bariatric surgery.

CONCLUSIONS

The serum ferritin level increased following bariatric surgery in adolescents. Vitamin D and ferritin deficiencies were estimated to be present in more than one-third of adolescents after the surgery.

Intermittent dietary carbohydrate restriction versus calorie restriction and cardiometabolic profiles: A randomized trial

OBJECTIVE

The aim of this study was to investigate the effectiveness of an intermittent low-carbohydrate diet (ILCD) versus calorie restriction (ICR) in young populations and potential mechanisms.

METHODS

Thirty-four participants aged 9 to 30 years with cardiometabolic risk were randomized to receive a self-administered 2-week ILCD (carbohydrate intake ≤ 50 g/d on seven nonconsecutive days) or ICR (500-600 kcal/d for two consecutive days per week). Differences in changes in obesity measures, glycemic and lipid profiles, gut microbiota composition, and three serum biomarkers were compared.

RESULTS

The ILCD and ICR similarly reduced body weight, waist circumference, fasting glucose, insulin, postprandial glucose variation, monocyte chemoattractant protein-1, free fatty acid, and fibroblast growth factor 21, whereas ILCD produced significantly different alterations in the following outcomes compared with ICR: greater increases in low-density lipoprotein cholesterol and total cholesterol (-0.36 mmol/L, 95% CI: -0.68 to -0.04; -0.40 mmol/L, 95% CI: -0.73 to -0.06) and greater decrease in triglyceride (0.20 mmol/L, 95% CI: 0.04 to 0.37). Actinobacteria and Bifidobacterium reduced after ILCD but not ICR; and the reductions strongly correlated with changes in fasting glucose (both r = 0.84) and low-density lipoprotein cholesterol (r = -0.81 and -0.72).

CONCLUSIONS

This study found no evidence of differences in changes from baseline in obesity measures, glucose regulation, and inflammation between ILCD and ICR, despite trends in reduction in those parameters. However, there seemed to be some differences in responses in lipids and gut microbiota.

Effect of the Nutritional Intervention Program on Body Weight and Selected Cardiometabolic Factors in Children and Adolescents with Excess Body Weight and Dyslipidemia: Study Protocol and Baseline Data

Excess body weight and associated dyslipidemia in children and adolescents are the main risk factors for cardiovascular diseases in young adults. There is a reasonable need to develop an effective lifestyle modification program that includes various dietary therapies. A low-glycemic index (GI) diet may be recommended in the treatment of obesity. Its use is also recognized as reasonable in cardiovascular diseases, including dyslipidemia. The aim of the presented nutritional intervention program was to evaluate the effectiveness of an energy-balanced diet based on the principal recommendation on Cardiovascular Health Integrated Lifestyle Diet-2 (CHILD-2) and low-GI products (LGI diet) in children and adolescents with excess body weight and dyslipidemia. The study involved 64 children and adolescents (44 boys and 20 girls) aged 8-16 with overweight or obesity and dyslipidemia. For 8 weeks, the participants followed a dietary treatment using two types of diets: one based on products with a low GI, and one standard therapy diet. During this time, they participated in three visits with a dietitian, during which the assessment of their current and habitual food intake was made, and anthropometric measurements and blood pressure were taken. Patients were under the care of a pediatrician who qualified them for the study and ordered lipid profile tests. This article presents the design, protocol of the nutritional intervention program, and baseline data. The collected results will be used to develop practical nutritional recommendations for children and adolescents with excess body weight and dyslipidemia.

The treatment of obesity in children and adolescents: consensus position statement of the Italian society of pediatric endocrinology and diabetology, Italian Society of Pediatrics and Italian Society of Pediatric Surgery

This Position Statement updates the different components of the therapy of obesity (lifestyle intervention, drugs, and surgery) in children and adolescents, previously reported in the consensus position statement on pediatric obesity of the Italian Society of Pediatric Endocrinology and Diabetology and the Italian Society of Pediatrics. Lifestyle intervention is the first step of treatment. In children older than 12 years, pharmacotherapy is the second step, and bariatric surgery is the third one, in selected cases. Novelties are available in the field of the medical treatment of obesity. In particular, new drugs demonstrated their efficacy and safety and have been approved in adolescents. Moreover, several randomized control trials with other drugs are in process and it is likely that some of them will become available in the future. The increase of the portfolio of treatment options for obesity in children and adolescents is promising for a more effective treatment of this disorder.

Child and adolescent obesity

The prevalence of child and adolescent obesity has plateaued at high levels in most high-income countries and is increasing in many low-income and middle-income countries. Obesity arises when a mix of genetic and epigenetic factors, behavioural risk patterns and broader environmental and sociocultural influences affect the two body weight regulation systems: energy homeostasis, including leptin and gastrointestinal tract signals, operating predominantly at an unconscious level, and cognitive-emotional control that is regulated by higher brain centres, operating at a conscious level. Health-related quality of life is reduced in those with obesity. Comorbidities of obesity, including type 2 diabetes mellitus, fatty liver disease and depression, are more likely in adolescents and in those with severe obesity. Treatment incorporates a respectful, stigma-free and family-based approach involving multiple components, and addresses dietary, physical activity, sedentary and sleep behaviours. In adolescents in particular, adjunctive therapies can be valuable, such as more intensive dietary therapies, pharmacotherapy and bariatric surgery. Prevention of obesity requires a whole-system approach and joined-up policy initiatives across government departments. Development and implementation of interventions to prevent paediatric obesity in children should focus on interventions that are feasible, effective and likely to reduce gaps in health inequalities.

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.

Considerations of eating disorder risk during obesity treatment in Australia: Current practice, attitudes and barriers

INTRODUCTION

People with obesity are vulnerable to eating disorders. It has been suggested that screening for eating disorder risk be part of obesity care. However, it is unclear what current practice entails.

OBJECTIVE

To explore considerations of eating disorder risk during treatment of obesity, including assessment and intervention strategies used in clinical practice.

MATERIALS AND METHODS

An online (REDCap) cross-sectional survey was distributed to health professionals working with individuals with obesity in Australia through professional societies and social media. The survey had three sections: 1. Characteristics of Clinician/Practice, 2. Current Practice, 3. Attitudes. Data were summarised using descriptive statistics and free-text comments were independently coded in duplicate to identify themes.

RESULTS

59 health professionals completed the survey. Most were dietitians (n = 29), identified as women (n = 45) and worked within a public hospital (n = 30) and/or private practice (n = 29). Overall, 50 respondents reported assessing for eating disorder risk. Most reported that having a history of, or risk factors of eating disorders should not preclude obesity care but emphasised the importance of treatment modification including using a patient-centred approach involving a multidisciplinary team and promoting healthy eating behaviours, with less emphasis on calorie restriction or bariatric surgery. Management approaches did not differ for those with eating disorder risk factors or a diagnosed eating disorder. Clinicians identified the need for additional training and clear referral pathways.

CONCLUSION

Individualised care, balancing models of care for eating disorders and obesity and further access to training and services will be important in improving care of patients with obesity.

Chronic Stress and Steatosis of Muscles, Bones, Liver, and Pancreas: A Review

BACKGROUND

Chronic stress is a recognized risk factor for poor health, body composition disequilibrium, impaired mental health, and deterioration of quality of life. Chronic stress-related cortisol oversecretion and circadian dysregulation and associated systemic low grade, injurious inflammation ("para-inflammation") contribute to steatosis in various metabolically active solid organs, affecting both their structure and function. The aim of this review was to summarize current knowledge on the impact of chronic stress and associated para-inflammation on skeletal muscle, bone, liver, and pancreas, leading to their steatosis. Current management of these maladaptive conditions is also included and underscored in this review.

SUMMARY

Steatosis of metabolically active solid organs is involved in various metabolic processes and considered a risk factor for chronic noncommunicable diseases, yet its role in chronic stress physiology and pathophysiology has been overlooked.

KEY MESSAGES

Chronic stress-associated steatosis of several solid organs is generally disregarded in current clinical practice. Physicians should be alert for these steatoses and should address them adequately so as to provide appropriate medical care. New guidelines generated by learned societies are needed, along with large observational studies, to offer novel solutions to this old problem.

Weight-neutral interventions in young people with high body mass index: A systematic review

AIM

This systematic review explored the feasibility, acceptability and effect on health outcomes of weight-neutral interventions in health improvement-seeking young people with overweight/obesity.

METHODS

Six databases were searched to March 2021 for health, but not weight, focused interventions (PROSPERO, CRD42020152671). Eligible studies recruited young people (10-24 years) with overweight/obesity. The studies were described using narrative synthesis, with numerical results summarised. The quality of included studies was assessed using the Joanna Briggs Institute critical appraisal tools.

RESULTS

Six articles were included, representing three pilot studies. Study 1 (n = 37, 14-17 years) compared a 6-week mindful eating program with single-session lifestyle education; Study 2 (n = 35, 14-17 years) compared 12-week weight-neutral lifestyle education focused on intuitive eating and carbohydrate quality, with/without guided imagery; and Study 3 (n = 33, 12-17 years) compared a 6-week mindfulness intervention with cognitive behavioural therapy in adolescents with depressive symptoms at risk of type 2 diabetes. All interventions explored feasibility (intervention group retention 57%-88%, attendance >80%) and reported interventions were acceptable. Studies 1 and 3 reported no change in mindfulness. Study 2 reported an increase (p < 0.05) in intuitive eating following weight-neutral plus guided imagery (0.32 ± 0.36, Hawks' Scale, score 1-4), compared with weight-neutral alone (0.15 ± 0.29). Study 1 reported decreased body mass index (p < 0.001) following mindful eating (-1.1 kg/m² ), compared with single-session lifestyle education (+0.7 kg/m² ); Studies 2 and 3 found no change in body mass index or body mass index z-score.

CONCLUSIONS

Weight-neutral interventions may be feasible and acceptable in adolescents with overweight/obesity in the short term (≤12 weeks), but data are limited.

Dietary Patterns in Adolescent Obesity as Predictors of Long-Term Success Following an Intensive Inpatient Lifestyle Programme

(1) Background: Lifestyle interventions for adolescents with obesity show minor long-term effects on anthropometric parameters. The persistence of dietary changes after obesity inpatient rehabilitation has not been sufficiently investigated. (2) Objectives: To analyse dietary patterns in German adolescents with obesity as predictors of long-term success following an intensive inpatient lifestyle programme regarding food choices as well as body weight and comorbidities. (3) Methods: Food consumption data of 137 German adolescents with obesity aged 10-17 years were collected by a nutrition interview. Cluster analysis was used to group the participants according to their food consumption. Dietary patterns, changes in body weight and insulin resistance were compared over a 2-year-period. (4) Results: Three dietary patterns were identified. Big Eaters (n = 32) consume high amounts of total sugar and meat, Moderate Eaters (n = 66) have a diet comparable to the national average, and Snackers (n = 39) have a particularly high consumption of total sugar. Big Eaters and Snackers significantly reduced the consumption of total sugar. Among Moderate Eaters, no persistent changes were observed. (5) Conclusion: Weight reduction interventions can induce long-lasting changes in the diet of adolescents with obesity. Therefore, the success of a weight reduction intervention should not be determined by weight reduction only.

Gut microbiota in obesity and related comorbidities in children and adolescents: the role of biotics in treatment

INTRODUCTION

Obesity is a complex pathology, globally spread, with a multifactorial pathogenesis, strictly linked with lifestyle, hormones, genetic and epigenetic factors. Evidence supports that obesity, and its comorbidities, are related to changes in gut microbiota, partially responsible of the modulation of energy metabolism.

EVIDENCE ACQUISITION

Pediatric obesity has been associated with lower bacterial diversity and differences in composition of the gut microbiota, also varying according to the metabolic status of obese subjects. Indeed, differences in distributions and activity of microorganisms in the gut of metabolically healthy and unhealthy obese children have been highlighted.

EVIDENCE SYNTHESIS

Based on human studies, this review aims to discuss gut microbiota alterations in obese children and adolescents and its role in obese-related complications. Moreover, the role of biotics (probiotics, prebiotics, synbiotics and -marginally- postbiotics) has been analyzed as modulator of obesity-related dysbiosis.

CONCLUSIONS

As a conclusion, a deeper knowledge about biotic mechanisms of action would be of great interest to implement the clinical care of children and adolescents with obesity and related comorbidities.

Infant age at egg introduction and malnutrition‐related child growth in the United States

To evaluate the relationship between infant age of egg introduction and malnutrition‐related growth outcomes in the United States, we analysed secondary data of 1716 mother–child dyads in the Infant Feeding Practices Study II and its Year 6 Follow‐Up Study. Malnutrition‐related growth outcomes included body mass index z‐score (BMIZ), obesity (weight‐for‐height z‐score [WHZ] ≥3 or BMIZ ≥ 2), WHZ, wasting (WHZ < −2), height‐for‐age z‐score (HAZ), and stunting (HAZ < –2). Infant age at egg introduction was analysed as a continuous variable. We used generalised estimating equations to estimate the mean difference in continuous outcomes and relative risk [RR]) for binary outcomes, adjusting for related maternal and child confounders. We also explored interactions with child sex, maternal race/ethnicity, maternal educational level, ever breastfeeding, and formula feeding. In the total sample, a later infant age at egg introduction was associated with a lower mean difference in HAZ (confounder‐adjusted mean difference = −0.08, 95% confidence interval [CI]: −0.12 to −0.03 per month) and a higher risk of stunting (confounder‐adjusted RR = 1.17, 95% CI: 1.03–1.33 per month) at 6 years. The associations between infant age at egg introduction and 12‐month growth outcomes differed by child sex. Among females but not among males, later introduction of eggs was associated with a lower mean WHZ (−0.06 [−0.12 to 0.00] per month) at 12 months. Later egg introduction during infancy was associated with a lower mean HAZ and a higher risk of stunting in 6‐year‐old children. Besides this, it was associated with a lower WHZ among females at 12 months.

This secondary data analysis evaluated the relationship between infant age at egg introduction and malnutrition‐related growth outcomes among young US children within the Infant Feeding Practices Study II and its Year 6 Follow‐up Study.

In the total sample, a later infant age at egg introduction was associated with a lower mean 6‐year height‐for‐age z‐score and a higher risk of stunting at 6 years.

The associations between infant age at egg introduction and 12‐month growth outcomes differed by child sex. Later introduction of eggs was associated with a lower mean weight‐for‐height z‐score among females. However, this association was not observed among males.

Clinical practice guidelines for the prevention of childhood obesity: A systematic review of quality and content

Obesity in childhood is a significant global issue, and prevention is key to reducing prevalence. Healthcare providers can play an important role in the prevention of obesity. The aim of this systematic review was to identify and evaluate clinical practice guidelines (CPGs) for preventing childhood obesity with a focus on the role of medical doctors. Peer-reviewed literature and gray literature sources were searched for CPGs published from 2010 to 2021. Eleven CPGs were identified. Quality was evaluated using the Appraisal of Guidelines for Research and Evaluation Collaboration (AGREE II) instrument; seven CPGs were higher quality and four lower quality. Recommendations within the CPGs covered three main areas: growth monitoring, maintaining a healthy weight, and managing overweight. The importance of involving the whole family and healthy lifestyle behaviors was emphasized. The majority of the CPGs rated poorly in guideline applicability highlighting the need for practical implementation tools. Although our review identified a number of CPGs relevant to the prevention of obesity for doctors working with children and their families, more research is needed to produce high-quality meaningful and applicable CPGs to maximize uptake, implementation, and ultimately, benefit to children and their families.

Nutritional and Oral Hygiene Knowledge versus Reported Behavior of Children and Adolescents-A Cross-Sectional Interview-Based Study

Despite the fact that healthy, sugar-reduced nutrition has been propagated by the media and in schools for years, dental caries in children remains a major health problem worldwide, caused primarily by an unhealthy diet. The objective of this study is to compare statements on nutrition and hygienic knowledge with those on children's actual dietary and hygienic behavior. A random sample of 554 children and adolescents aged 3-19 years was enrolled. Designed as a cross-sectional interview-based community survey, this study was conducted consecutively during three one-day public science-promoting events at the Saarland University's Medical Faculty. Participants' oral hygiene and nutritional knowledge was profound; however, the reported translation into practice showed deficiencies. Boys and younger children (3-10 years) often showed better oral hygiene knowledge than girls and older children (over 11 years) but had problems implementing it into their daily life practice. In contrast, girls and older children often showed less oral hygiene knowledge but reported more favorable behavior. Finally, children up to the mixed dentition phase preferred drinking sweets more often than older children, posing a risk to the developing permanent dentition. Intensifying well-known controlled motivation training approaches to encourage children and adolescents is recommended to put their knowledge into practice.

Family-based treatment of children with severe obesity in a public healthcare setting: Results from a randomized controlled trial

To compare the effectiveness of family-based behavioural social facilitation treatment (FBSFT) versus treatment as usual (TAU) in children with severe obesity. Parallel-design, nonblinded, randomized controlled trial conducted at a Norwegian obesity outpatient clinic. Children aged 6-18 years referred to the clinic between 2014 and 2018 were invited to participate. Participants were randomly allocated using sequentially numbered, opaqued, sealed envelopes. FBSFT (n = 59) entailed 17 sessions of structured cognitive behavioural treatment, TAU (n = 55) entailed standard lifestyle counselling sessions every third month for 1 year. Primary outcomes included changes in body mass index standard deviation score (BMI SDS) and percentage above the International Obesity Task Force cut-off for overweight (%IOTF-25). Secondary outcomes included changes in sleep, physical activity, and eating behaviour. From pre- to posttreatment there was a statistically significant difference in change in both BMI SDS (0.19 units, 95% confidence interval [CI]: 0.10-0.28, p < .001) and %IOTF-25 (5.48%, 95%CI: 2.74-8.22, p < .001) between FBSFT and TAU groups. FBSFT participants achieved significant reductions in mean BMI SDS (0.16 units, (95%CI: -0.22 to -0.10, p < .001) and %IOTF-25 (6.53%, 95% CI: -8.45 to -4.60, p < .001), whereas in TAU nonsignificant changes were observed in BMI SDS (0.03 units, 95% CI: -0.03 to 0.09, p = .30) and %IOTF-25 (-1.04%, 95% CI: -2.99 to -0.90, p = .29). More FBSFT participants (31.5%) had clinically meaningful BMI SDS reductions of ≥0.25 from pre- to posttreatment than in TAU (13.0%, p = .021). Regarding secondary outcomes, only changes in sleep timing differed significantly between groups. FBSFT improved weight-related outcomes compared to TAU.

Obesity in children and adolescents: epidemiology, causes, assessment, and management

This Review describes current knowledge on the epidemiology and causes of child and adolescent obesity, considerations for assessment, and current management approaches. Before the COVID-19 pandemic, obesity prevalence in children and adolescents had plateaued in many high-income countries despite levels of severe obesity having increased. However, in low-income and middle-income countries, obesity prevalence had risen. During the pandemic, weight gain among children and adolescents has increased in several jurisdictions. Obesity is associated with cardiometabolic and psychosocial comorbidity as well as premature adult mortality. The development and perpetuation of obesity is largely explained by a bio-socioecological framework, whereby biological predisposition, socioeconomic, and environmental factors interact together to promote deposition and proliferation of adipose tissue. First-line treatment approaches include family-based behavioural obesity interventions addressing diet, physical activity, sedentary behaviours, and sleep quality, underpinned by behaviour change strategies. Evidence for intensive dietary approaches, pharmacotherapy, and metabolic and bariatric surgery as supplemental therapies are emerging; however, access to these therapies is scarce in most jurisdictions. Research is still needed to inform the personalisation of treatment approaches of obesity in children and adolescents and their translation to clinical practice.

Weight Bias and Stigma: Impact on Health

Weight bias and stigma exist in a variety of realms in our society (media, education, employment, and health care), and unfortunately many view it as a socially acceptable form of discrimination. Patients with obesity often avoid scheduling appointments for health promotion visits and routine care due to perceived weight bias and stigma from their health care provider. Within the health care setting, it is important that health care providers strategically focus on reducing obesity bias and provide high-quality obesity management. People-first language should be used and waiting rooms and examination rooms should be accommodating to people of all sizes.

Ketogenic diet as an advanced option for the management of pediatric obesity

PURPOSE OF REVIEW

The Duke Healthy Lifestyles Program (HL), established in 2006, has treated over 15,000 pediatric patients with obesity. A subset of patients with obesity do not respond to dietary and lifestyle changes. Development of the Staged Transitional Eating Plan (STEP) in 2012 provided a ketogenic advanced dietary option for these specific patients.

RECENT FINDINGS

The goal of STEP is to facilitate weight loss, while assuring adequacy and the promotion of health through the abundant inclusion of vegetables, fatty fish, nuts, olive oil, and other foods consistent with the Mediterranean Diet. STEP is a three-phase eating plan, each with a defined carbohydrate limit. STEP is ideal for patients eager to try a low carbohydrate diet, those with good vegetable acceptance, and those with families who are able to participate in the same eating plan as them.

SUMMARY

STEP, the HL version of low carbohydrate high fat eating, is a safe dietary intervention for a carefully selected subset of pediatric patients with obesity who are trying to lose weight.

The role of structure in dietary approaches for the treatment of pediatric overweight and obesity: A critical review

A multicomponent approach for the treatment of pediatric overweight/obesity, which includes behavioral strategies to alter diet and physical activity/sedentary behavior, has graded recommendations for its use. Dietary interventions to be used within this approach do not. In adults, research indicates that strongly graded dietary interventions providing greater structure (or more control over the types/amount of food consumed) produce better weight outcomes. For this critical review, dietary interventions recommended by the Expert Committee for the treatment of pediatric overweight/obesity were categorized according to their potential degree of dietary structure, and their impact on weight outcomes was described. Four levels of dietary structure were reviewed, operationalized as alterations to the following: food groups, such as fruits and vegetables (low structure); daily eating occasions, such as meals (moderate structure); large nutrients, such as energy (high structure); and energy plus additional dietary alterations (very high structure). In total, 24 interventions (four low, three moderate, five high, and 12 very high structure structure) were identified and reviewed. Reductions in standardized body mass index increased with increasing structure, and interventions ≥6 months had better outcomes than interventions <6 months. Future research should empirically test dietary intervention structure to determine its impact on weight status during pediatric overweight/obesity treatment.

Novel dietary interventions for adolescents with obesity: A narrative review

Adolescent obesity is increasing and a range of treatment approaches are needed. Provision of tailored treatment options accounting for individual and family needs, preferences, and capacity may encourage adolescents with obesity to seek treatment, and/or improve treatment outcomes. Delivered by trained health care professionals, novel dietary interventions may have utility for adolescents not responding to conventional diets, adolescents with comorbidities or severe obesity, and/or when rapid or substantial weight loss is required. This review describes current evidence and clinical considerations relating to the use of very low energy diets, low carbohydrate diets, and intermittent energy restriction in the treatment of adolescent obesity. Emerging evidence on the use of these novel dietary interventions demonstrates short-term weight-related and cardiometabolic improvements. While the evidence is encouraging, and no serious adverse effects have been reported, monitoring of intervention safety is essential. Considerations for health care professionals providing care to adolescents include nutritional adequacy, psychosocial health and social relationships during the intervention. Furthermore, long-term weight-related, cardiometabolic and psychological health outcomes of these dietary interventions are not well understood. Large randomised controlled trials are warranted to inform clinical practice and future guidelines for the use of novel dietary interventions in adolescents with obesity.

Contextualising Eating Disorder Concerns for Paediatric Obesity Treatment

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Metabolic Derangement in Pediatric Patient with Obesity: The Role of Ketogenic Diet as Therapeutic Tool

Obesity is defined as a condition characterized by an excessive fat accumulation that has negative health consequences. Pediatric obesity is associated with an increased risk for many diseases, including impaired glycemic and lipidic control that may lead to the development of chronic, and potentially disabling, pathologies, such as type 2 diabetes mellitus (T2DM) and cardiovascular events, in adult life. The therapeutic strategy initially starts with interventions that are aimed at changing lifestyle and eating behavior, to prevent, manage, and potentially reverse metabolic disorders. Recently, the ketogenic diet (KD) has been proposed as a promising dietary intervention for the treatment of metabolic and cardiovascular risk factors related to obesity in adults, and a possible beneficial role has also been proposed in children. KD is very low in carbohydrate, high in fat, and moderate to high in protein that may have the potential to promote weight loss and improve lipidic derangement, glycemic control, and insulin sensitivity. In this review, we present metabolic disorders on glycemic and lipidic control in children and adolescents with obesity and indication of KD in pediatrics, discussing the role of KD as a therapeutic tool for metabolic derangement. The results of this review may suggest the validity of KD and the need to further research its potential to address metabolic risk factors in pediatric obesity.

Novel Metabolic Regulation of Bile Acid Responses to Low Cholesterol in Whole-Grain-Diet-Fed Mice

Hypercholesterolemia is a major risk factor for chronic metabolic diseases. Nevertheless, a whole-grain diet could ameliorate this issue in a number of ways, including by regulating bile acid metabolism. However, the potential mechanism is unclear. The aim of the current study is to explore the effects of whole-grain diets (brown rice diet and whole wheat diet) on bile acid homeostasis. After intervention for 8 weeks in mouse model, whole-grain diets showed reduced feed conversion ratio, and the lipid levels (total cholesterol (TC) and triglycerides (TG)) were also meliorated in the serum and liver of mice. Moreover, whole-grain diets reduced the expression of 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) (cholesterol synthesis) in the liver of mice. Interestingly, whole-grain diets not only promoted the mRNA expressions of low-density lipoprotein receptor (LDLR), ATP binding cassette transporter G1 (ABCG1), and scavenger receptor class B type I (SR-BI) (reverse cholesterol transport) but also facilitated the expressions of cytochrome P450, family 7, subfamily a, polypeptide 1 (CYP7a1) and cytochrome P450, family 27, subfamily a, polypeptide 1 (CYP27a1) (bile acid synthesis). Further study found that whole-grain diets promoted intestinal bile acid reabsorption and reduced bile acid excretion. Our study provided a novel metabolic regulation of bile acids in response to reduced cholesterol levels induced by whole-grain diets.

Vaccinium bracteatum Thunb. fruit extract reduces high-fat diet-induced obesity with modulation of the gut microbiota in obese mice

Vaccinium bracteatum Thunb. fruits have been used as traditional food. This study investigated the effects of a polyphenol-rich Vaccinium bracteatum Thunb. fruit extract (VBTE) on obesity and obesity-related diseases in mice, and the potential role of the gut microbiota in the bioactivity of VBTE was also determined. Chemical constituents of the VBTE were analyzed by liquid chromatography-electrospray ionization-mass spectrometry (LC-ESI-MS/MS). C57BL/6J mice (weighing 17.8-21.6 g) were fed a low-fat diet (LFD) or high-fat diet (HFD) with or without VBTE treatment for 14 weeks. The gut microbial changes were determined using 16S rRNA sequencing. Our results showed that VBTE mainly contains 36 kinds of polyphenols. VBTE reduced HFD-induced body weight gain by 33.42% (p < .05), steatosis scores by 56.25% (p < .05), and insulin resistance index by 51.49% (p < .05). Moreover, VBTE altered the composition of the gut microbiota. The correlation analysis indicated that Akkermansia, Alistipes, Bacteroides, Alloprevotella, Ruminiclostridium, Ruminiclostridium_9, and Rikenellaceae_RC9_gut_group were negatively correlated with serum lipids, glucose, and insulin, while Escherichia-Shigella was positively associated with these clinical indicators. In conclusion, VBTE supplement could reduce obesity and be a treatment option for obesity-related diseases by influencing the gut microbiota in mice. PRACTICAL APPLICATIONS: Plant extracts are widely used to treat obesity and related metabolic disorders. Polyphenols, the well-known natural antioxidants present in fruits, are consumed as a dietary supplement to prevent many diseases. Recent pharmacological studies have reported that Vaccinium bracteatum Thunb. fruits have many physiological functions, such as anti-proliferative, anti-inflammatory, and antidepressant-like effects. Despite these properties of Vaccinium bracteatum Thunb. fruits, their anti-obesity effect has not been studied to date. The findings of this study will support VBTE could be used as an important therapeutic application for preventing obesity and related metabolic diseases by modulating the gut microbiota.

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

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