Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity

Gut microbiome shifts in adolescents after sleeve gastrectomy with increased oral-associated taxa and pro-inflammatory potential

Bariatric surgery is highly effective in achieving weight loss in children and adolescents with severe obesity, however the underlying mechanisms are incompletely understood, and gut microbiome changes are unknown. Here, we show that adolescents exhibit significant gut microbiome and metabolome shifts several months after laparoscopic vertical sleeve gastrectomy (VSG), with increased alpha diversity and notably with enrichment of oral-associated taxa. To assess causality of the microbiome/metabolome changes in phenotype, pre-VSG and post-VSG stool was transplanted into germ-free mice. Post-VSG stool was not associated with any beneficial outcomes such as adiposity reduction compared pre-VSG stool. However, post-VSG stool exhibited a potentially inflammatory phenotype with increased intestinal Th17 and decreased regulatory T cells. Concomitantly, we found elevated fecal calprotectin and an enrichment of proinflammatory pathways in a subset of adolescents post-VSG. We show that in some adolescents, microbiome changes post-VSG may have inflammatory potential, which may be of importance considering the increased incidence of inflammatory bowel disease post-VSG.

Kidney consequences of obesity

Herein, we review the devastating consequences of the worldwide obesity epidemic on kidney health and outcomes. We submit that the obesity epidemic is the most pressing public health crisis facing the nephrology community today. A historical approach has been undertaken, wherein major breakthroughs in the recognition and understanding of obesity-related kidney disease (ORKD) are highlighted. We begin with a description of the worldwide obesity epidemic followed by an account of the discovery and characterization of ORKD. A detailed summary of the pathophysiology of ORKD disease is presented, wherein we set forth the following two propositions: first, ORKD is due to a maladaptive response to caloric surplus; and second, this maladaptive response causes kidney damage via hemodynamic (hyperfiltration), hormonal (adipokine dysregulation), and lipotoxic pathways. Each of these pathways is described, with particular emphasis on the relatively recent discovery that the final stage of cellular injury in ORKD is mitochondrial oxidative damage. The prevention and treatment of ORKD are then discussed, including environmental, behavioral, pharmacologic, and surgical options. Finally, we conclude with suggestions for future research to improve early recognition and treatment of ORKD.

Two-Year Outcomes for the Active and Healthy Families Pediatric Obesity Group Intervention for Families in an Emerging Latinx Community: a Mixed Methods Study

INTRODUCTION

Childhood obesity and its comorbidities disproportionately affect Latinos, but there are not clear interventions to narrow the disparity and have a lasting impact. Our study aims to assess the 2-year outcomes and explore the potential mechanisms of behavior change, along with the barriers to sustaining those behaviors, among participants of a family-based, culturally tailored Spanish-language weight management program.

METHODS

We conducted a mixed methods study comprised of a retrospective secondary data analysis and semi-structured interviews. The intervention, Active and Healthy Families, consisted of eight biweekly group sessions for child-caregiver dyads in an emerging Latinx community. We extracted clinic visit data from child participants and matched controls from 2017 to 2021. We compared normalized BMI measurements (BMIpct95) between the intervention and control arm participants using mixed effects linear regression modeling from the start to 2 years post-intervention. We conducted caregiver interviews from 2020 to 2021 after intervention participation and performed a thematic analysis.

RESULTS

Intervention participation for the 40 AHF child participants was associated with a lower-than-expected average BMIpct95 compared to controls at two years post-intervention. Interview themes included as follows: (1) caregivers felt responsible for their children's health; (2) families acquired new knowledge that they applied; (3) the group format facilitated mutual support and sharing; and (4) the COVID-19 pandemic exposed barriers to maintaining behavior change.

CONCLUSION

The AHF intervention may effectively support long-term pediatric weight loss in an emerging Latinx community. Parents offered insights into key intervention components that may facilitate behavior change and identified opportunities to reduce barriers to sustain those behaviors.

Metabolic outcomes and safety of GLP-1 receptor agonists in children and adolescents with obesity: A systematic review and meta-analysis

BACKGROUND

Glucagon-like peptide 1 receptor agonists have been proven to be effective in adults with obesity. However, robust evidence on their effects on body weight, obesity-related metabolic changes, and safety in children and adolescents with obesity remains limited, making them a subpopulation with scant treatment options. Therefore, this meta-analysis aimed to determine more precise estimates of the efficacy and safety of glucagon-like peptide-1 agonists in pediatric obesity.

METHODS

Three databases were searched (PubMed, Embase, and Cochrane Central Register of Controlled Trials) for trials published until the half of September 2024. The search indexing terms included 3 categories: [1] obesity [2], youth, and [3] glucagon-like peptide-1 receptor agonist (GLP-1 RA). Randomized controlled trials in youth with obesity (age ≤ 18 years) that assessed anthropometric and metabolic parameters were included. A total of 2016 studies were retrieved, and 24 full-text articles were screened. The data were analyzed using both mean differences (MDs) and standardized mean differences (SMDs) with 95% CIs and odds ratios (ORs) with 95% CIs. We applied a random effects model. Our outcomes were body weight (BW), BMI, waist circumference (WC), lipid profile, Hb1Ac, fasting blood glucose (FBG), blood pressure, and side effects.

RESULTS

Eight studies comprised of 715 children and adolescents were included. On average, GLP-1 RA reduced BMI (SMD -0.67; 95% CI -0.8 to -0.41), BW (SMD -0.60; 95% CI -0.89 to -0.44), and WC (SMD -0.40; 95% CI -0.61 to -0.18). Although lipid profiles, HbA1c, and FBG were unaffected, GLP-1 RA was linked to a slight reduction in SBP (SMD -0.20; 95% CI -0.35 to -0.04) and an increase in HR (SMD + 0.26; 95% CI + 0.07 to +0.46), with no significant effect on DBP. Adverse effects, primarily nausea and vomiting, were more common in the intervention group, although trial withdrawal rates remained low.

CONCLUSIONS

Within this specific population, GLP-1 RAs exhibit significant reductions in BW, BMI, WC, and SBP. The analyses of lipid profiles, DBP, HbA1c, and FBG showed no significant changes. Also, the administration of these medications is concurrent with an elevated incidence of side effects, which are predominantly gastrointestinal and tolerable.

TRIAL REGISTRATION

PROSPERO identifier: CRD42024532845.

Obesity Management in Female Adolescents

BACKGROUND

Global childhood obesity continues to rise, particularly in adolescent females. The underlying cause of this change in prevalence is multifactorial with a complex interplay of genetic, socioeconomic and environmental influences. In this review, we aim to emphasize the multiple options available for assisting an adolescent female to improve their overall health and longevity.

DESIGN

Experts from each of their respective fields reviewed the current literature regarding the management of obesity in female adolescents.

RESULTS

Lifestyle changes, including decreases in overall calorie consumption and simple carbohydrates as well as increases in activity/exercise have been the mainstay of obesity therapy due to their effects on decreasing insulin resistance and associated metabolic disease, as well as weight loss. However, the combination of provider encouraged weight loss and societal obesity stigma leads to an increased risk for disordered eating. The high prevalence of mental health and sleep disorders in female youth with obesity are recent findings, as is the importance in treating these conditions for improved quality of life as well as success with lifestyle changes. The American Academy of Pediatrics' 2023 obesity guidelines are the first across the globe to recommend early adjunctive use of weight loss medications for obesity. These recommendations correspond with the development and increasing availability of new combinations of existing mediations as well as the glucagon like peptide-1 receptor agonist class of medications. Youth with a body mass index in excess of 35-40 kg/m2, can now undergo bariatric surgery in many countries, with very encouraging short- and medium-term success.

CONCLUSION

There are now many approaches to consider when treating an adolescent female for obesity or associated metabolic disease, and customized approaches may be needed for optimal success at the individual patient level.

Obesity management in the pediatric patient

PURPOSE

The purpose of this review is to discuss treatment modalities for obesity in children and adolescents, including nonpharmacological, pharmacological, and surgical interventions.

SUMMARY

The prevalence of pediatric obesity has dramatically risen, with rates of 20.7% and 22.2% among children and adolescents, respectively. Obesity is a complex medical condition with multifactorial risk factors, including diet and exercise, social determinants of health, and environmental and genetic factors. The management approach among children and adolescents with obesity includes nutrition counseling, increased physical activity, and readiness for behavioral change. Pharmacotherapy may be recommended, yet the literature has not elucidated the most appropriate first-line treatment. Metformin and orlistat have been studied and may be considered in pediatric patients with comorbid complications, including type 2 diabetes and nonalcoholic fatty liver disease. Phentermine and topiramate in combination, as well as glucagon-like peptide-1 receptor agonists, have provided modest benefits in weight reduction among youth. Setmelanotide has a unique mechanism of action and may be considered for those with obesity due to genetic disorders. Bariatric surgery should be reserved for adolescents meeting criteria for severe obesity.

CONCLUSION

Treatment for obesity in children and adolescents includes a comprehensive approach with structured lifestyle programs, mental health support, and mitigation of social determinants of health. Pharmacotherapy may also be considered, yet no medication is recommended over another, giving flexibility for shared decision-making with the patient and family regarding comorbidities and potential drug interactions. Adolescents with severe obesity who meet specified criteria may also be referred for surgical evaluation.

Emerging cardiovascular risk factors in childhood and adolescence: a narrative review

It is widely recognized that four key health behaviors-regular physical activity, maintaining a normal BMI, eating a healthy diet, and avoiding smoking-offer significant protection against cardiovascular disease in children and adolescents. However, changes in the lifestyle of families have contributed to the emergence of new behaviors that may impact the health of children and adolescents. This narrative review aims to identify existing evidence on the effect of these arising habits on the cardiovascular health of children and adolescents, mainly on blood pressure and endothelial function. A thorough search was conducted across various databases, including PubMed/MEDLINE, the Cochrane Library, Science Direct and EBSCO.

CONCLUSION

 Some of the behaviors most frequently identified in the pediatrician's office are childhood stress and behavioral disorders, new forms of nicotine consumption, the impact of the use of screens and digital devices, changes in sleep patterns, and, finally, the generalization of energy drinks and supplements to promote muscle development, mainly in adolescents. The effect on cardiovascular health, mainly on blood pressure, does not seem negligible. Early identification of these unhealthy behaviors might allow the pediatrician to intervene and prevent the progression of cardiovascular disease.

WHAT IS KNOWN

• Traditional cardiovascular risks (poor diet, inactivity, smoking, obesity) contribute to hypertension and endothelial dysfunction in youth. • Western family lifestyles have shifted dramatically over two decades, altering pediatric environments.

WHAT IS NEW

• Emerging risks include psychosocial stressors, novel nicotine products, screen time-induced HTN, sleep deprivation, and energy drink/supplement use. • These factors correlate with blood pressure elevation, endothelial damage, and chronic inflammation, urging pediatricians to address non-traditional factors in holistic care.

Childhood obesity: The threatening apprentice of the adiposity empire

Childhood obesity is a global health problem, with its prevalence having tripled since 1975. The increase in its prevalence has been predominantly in developing countries, but also in those with high economic status. Nowadays, there are multiple obesity definitions, however, one of the most accurate is the one which defines obesity as the accumulation of excessive body adiposity and not as an body weight excess. Nevertheless, the body mass index (BMI) is the most frequently used tool for its classification, according to the cut-off points established by the Center for Disease Control and World Health Organization tables. In children and adolescents an adiposity excess is related to the appearance of cardiovascular disease in adulthood and with many comorbidities such as metabolic syndrome, insulin resistance, type 2 diabetes, hypertension and metabolic dysfunction-associated steatotic liver disease, among others. Currently, there is still controversy about which is the ideal indicator for measuring overweight and obesity. BMI is still used as a standardized measure but may miss cases in which body composition is pathological despite a BMI within the normal-weight category. An adequate knowledge of the impact on health of dysfunctional adiposity as well as its accurate diagnosis will allow health professionals to address this condition in a more precise and comprehensive manner, and substantially improve the associated cardiometabolic risk and prognosis.

The Moderating Effect of Coping on Stress and Childhood Obesity-Related Health Behaviors among Non-Hispanic Black Caregivers

Child health behaviors and weight status may be affected by caregivers' perception and experience of stress. However, little is known about the influence of caregiver coping strategies on childhood overweight and obesity, particularly among non-Hispanic Black caregivers. This study examined associations among specific caregiver stress types (i.e., general, parenting, race-related), child weight status, and health-related behaviors (i.e., intake of fruits and vegetables, consumption of fast food, engagement in physical activity) as well as the moderating effect of caregiver coping strategies. In addition to general coping, the study examined the role of religious coping. This cross-sectional study included 157 non-Hispanic Black caregiver and child (aged 3-7 years) dyads; all caregivers identified as Christian Protestant. Logistic regression models were fit to explore the associations among caregiver stress and child outcomes and to investigate moderation effects of caregiver coping. Models were adjusted for sociodemographic covariates. Association between parenting stress and child weight status was significantly moderated by acceptance coping while the relationship between general stress and child sugary drink intake was moderated by emotional coping. The combination of three stress types was significantly associated with increased child fast food intake. Future research should examine specific coping strategies to address varying levels and types of stress experienced by caregivers from minoritized backgrounds.

Childhood Obesity as a Pediatric Vital Sign: A Population Health Initiative

The high prevalence of obesity; the disparities in the risk of obesity based on race, ethnicity, and socioeconomic status; and the serious short- and long-term effects of childhood obesity led to the selection of obesity as a Pediatric Vital Signs (PVS) indicator. This report describes the approach (multisector collaborations, guidance form the enhanced chronic model), interventions (multisector interventions to involve clinicians, community organizations, data systems, policy advocates, children and families), and measures (proportion of children with overweight and obesity seen in a health system, change in provider knowledge and behavior, uptake of educational/resource programs, engagement of coalitions) adopted for the PVS population health child obesity initiative, challenges with implementation (data measures, finances, reach), and potential solutions (building multisector collaborations, inclusion of the lived experience) for sustainability.

Efficacy of myo-inositol and zinc on insulin resistance in a paediatric population with obesity

AIM

To assess the efficacy of the combined administration of myo-inositol and zinc, a mineral involved in the insulin pathway, in paediatric obesity with insulin resistance on HOMA-IR, glucose-insulin metabolism, and lipid profile.

MATERIALS AND METHODS

Double-blind, randomized, placebo-controlled study conducted in North Italy. Fifty-six patients (10-18 years, Tanner stage ≥3) with obesity and insulin resistance were randomized to myo-inositol (2000 mg), zinc gluconate (5 mg), and galactooligosaccharides (GOS) from plant-based origin (1000 mg) (TRT) or placebo (PLC) containing only GOS from plant-based origin (1000 mg). All patients received an isocaloric diet following the Mediterranean diet style. Data were collected at baseline (V0) and after 3 months (V1). The primary outcome was the insulin resistance index (HOMA-IR).

RESULTS

Fifty out of 56 recruited subjects completed the study. TRT improved HDL cholesterol level compared to PLC (p = 0.05) but not insulin resistance. A stratified post hoc analysis was performed by sex, BMI, and subgroups of adherence to the Mediterranean diet. Subjects were divided for obesity grade, fasting insulin (p = 0.0137) and HOMA-IR (p = 0.0273) were lower in TRT than in PLC patients, with a greater effect on severe obesity. No adverse events were detected.

CONCLUSION

Three months of supplementation with myo-inositol and zinc were beneficial on lipid profile and in managing obesity complications at least in subjects with severe phenotype. Thus, myo-inositol and zinc could be used as non-pharmacological agents. This work suggests a long-term study with a larger sample size to enrich the findings.

Evaluating and treating pediatric obesity: A practice update

ABSTRACT

The American Academy of Pediatrics (AAP) in 2023 released a guideline for evaluating and treating children and adolescents with overweight and obesity. The AAP advocated for a patient-centered, comprehensive ("whole child") approach to evaluation and a treatment regimen that includes a foundation of both motivational interviewing and intensive health behavior and lifestyle therapy, along with adjunctive pharmacotherapy and referral of adolescents with severe obesity to bariatric surgery. This article reviews the diagnosis of pediatric obesity and provides an update on the latest evidence and expert recommendations for evaluation and treatment of this condition.

The change of alanine aminotransferase distributions among US youths, NHANES 1988-2020

OBJECTIVES

The trend of alanine aminotransferase (ALT), a biomarker of metabolic dysfunction-associated steatotic liver disease (MASLD, formerly known as nonalcoholic fatty liver disease), remains poorly described for the pediatric population because no widely accepted cutoffs are available to categorize ALT value. We described the nuanced changes in the distribution of ALT continuous values.

STUDY DESIGN

We analyzed the data from 15,702 adolescents aged 12-19 who participated in the National Health and Nutrition Examination Surveys between 1988 and 2020. The ALT distributions were standardized for age and sex. The prevalence of elevated ALT was also assessed.

RESULTS

The ALT geometric mean increased from 11.82 U/L in 1988-1994 to 17.24 U/L in 1999-2004, stayed above 17 U/L for a decade, and then decreased to 14.04 U/L in 2017-2020 (p for the quadratic trend <0.001). However, the 95th percentile of the ALT distribution remained above 35 U/L by the end of the study period after jumping from 26.02 U/L in 1988-1994 to 33.83 U/L in 1999-2004. The prevalence of elevated ALT (>42 U/L in boys and 30 U/L in girls), doubled from 1.53% (0.87%-2.19%) in 1988-1994 to 3.49% (2.73%-4.25%) in 1999-2004, and lingered around 4% through 2020.

CONCLUSIONS

The ALT mean decreased in recent years, but the prevalence of elevated ALT remained persistently high. Population-wide reductions in fructose consumption may have contributed to the decrease in ALT mean. The stagnant right end of the distribution, manifesting as the high prevalence of elevated ALT, calls for intensified clinical prevention.

Quality of Evidence and Strength of Recommendations in American Academy of Pediatrics' Guidelines

OBJECTIVE

Summarize the quality of the evidence and the strength of recommendations in the American Academy of Pediatrics' (AAP) current clinical practice guidelines.

METHODS

We identified the AAP's current clinical practice guidelines from its website. Three independent reviewers abstracted each recommendation, the quality of evidence supporting it, and its strength from every guideline. We resolved discrepancies by consensus and analyzed results using descriptive statistics.

RESULTS

We identified 14 current clinical practice guidelines. Individual guidelines make between 1 and 39 recommendations (mean 16.9, median 15), and the guidelines make a total of 236 recommendations. Twenty-five (10.6%) recommendations are based on Level A evidence (well-designed and -conducted trials, meta-analyses), 112 (47.5%) Level B (trials with minor limitations; consistent findings from multiple observational studies), 64 (27.1%) Level C (single or few observational studies or multiples studies with inconsistent findings or major limitations), 15 (6.4%) Level D (expert opinion, case reports, reasoning from first principles), and 20 (8.5%) Level X (exceptional situations in which validating studies cannot be performed and there is a clear preponderance of benefit or harm). Eighty-two (34.7%) recommendations are Strong, 117 (49.6%) Moderate, and 37 (15.7%) Weak. Fifty of the 117 (42.7%) Moderate Recommendations are based on Level C evidence, and 10 of the 80 (13%) Strong Recommendations are based on Level X evidence.

CONCLUSION

A minority of recommendations in the AAP's current clinical practice guidelines (10.6%) are based on the highest-quality evidence. Additional research is needed to improve the quality of evidence supporting pediatric clinical practice guidelines.

Parent and carer experiences of health care professionals' communications about a child's higher weight: a qualitative systematic review

OBJECTIVE

The objective of this systematic review was to identify, critically appraise, and synthesize the best available qualitative evidence on parent and carer experiences of communications from health care professionals concerning their child's higher weight.

INTRODUCTION

Public discourse on obesity has shifted in recent years and created pressure to change the way that weight is discussed in health care. A child's higher weight can be a sensitive issue to discuss in health care, but successful communication with parents can increase parental compliance with treatment and improve overall family welfare. It is, therefore, important to explore how parents and carers experience the communication about children's higher weight to ensure effective, up-to-date, and ethical counseling on childhood obesity.

INCLUSION CRITERIA

This qualitative review included studies that focused on the experiences of parents or carers of children (birth to 12 years) with a higher weight who received verbal or written communication from health care professionals about their child's weight.

METHODS

The following databases were systematically searched from 2010 onward: MEDLINE (EBSCOhost), CINAHL (EBSCOhost), PsycINFO (Ovid), Scopus, LILACS, and the Finnish health sciences database MEDIC. ProQuest Dissertations and Theses (ProQuest) was searched for unpublished articles. The search was conducted in July 2022 and updated in October 2023. No country or language limits were applied. A manual search was used to supplement the database searches. Study selection including title and abstract screening, full-text screening, critical appraisal, and data extraction were performed by 2 reviewers. The research findings were categorized and aggregated into synthesized findings. The synthesized findings were assigned confidence scores, and categories and finalized synthesized findings were agreed upon by all reviewers.

RESULTS

The 33 included studies varied in qualitative study design and methodological quality. There were over 900 eligible participants (parents and carers) and 147 unequivocal and credible research findings. The research findings yielded 8 categories and 3 synthesized findings with low confidence scores. The synthesized findings were as follows: i) Parents receiving communication on a child's higher weight experience strong feelings that can affect their parenting; ii) A health care professional's active and individual communication, with the sensitive use of words, creates a good communication experience for parents; and iii) Parents want to receive information about the child's higher weight that is useful to them and is based on an acceptable weight estimation.

CONCLUSION

Although confidence in the synthesized findings is low, this review indicates that communication from a health care professional on a child's higher weight should meet the parents' expectations and the family's situation and needs. Having the skills to deal with heightened emotions, using expertise and empathy as a professional, and providing appropriate information create a good communication experience for parents. In addition, parents' desire to protect their child and the strengthening of the parenting experience should be acknowledged to conduct safe communication.

SUPPLEMENTAL DIGITAL CONTENT

A Finnish-language version of the abstract of this review is available at: http://links.lww.com/SRX/A92 .

Next Steps in Efforts to Address the Obesity Epidemic

Obesity prevalence continues to rise globally at alarming rates, with adverse health and economic implications. In this state-of-the-art review, we provide an analysis of selected evidence about the current knowledge in the obesity literature, including a synthesis of current challenges in obesity and its determinants. In addition, we review past and current efforts to combat the obesity epidemic, highlighting both successful efforts and areas for further development. Last, we offer insights into the next steps to address the obesity epidemic and advance the field of obesity through both research and practice by (a) adopting a systems perspective, (b) fostering cross-sector and community collaborations, (c) advancing health equity, (d) narrowing the research-to-practice and research-to-policy gaps with multidisciplinary approaches, and (e) embracing complementary approaches for concurrent obesity prevention and treatment.

Virtual Reality as a Dietary Education Adjunct for Pediatric Patients With Obesity: A Pragmatic, Randomised Pilot Study

BACKGROUND

Pediatric obesity is associated with increased morbidity. One common therapy within multicomponent treatment for obesity is nutrition counselling and dietary education led by a Registered Dietitian (RD). Virtual reality (VR) improves engagement when used as an educational adjunct.

METHODS

The primary aim investigated immediate dietary choices when pediatric patients with obesity engaged in traditional RD nutrition counselling compared to VR-supplemented nutrition counselling. Secondary aims explored food likability, knowledge, and satisfaction. Patients, 6-20 years old, presenting for obesity counselling were recruited. The primary aim was measured by after-visit food choice. Secondary aims were measured with the Pediatric Adapted Liking Scale, an assessment of nutritional facts, and a VR satisfaction survey. Statistical analysis included Chi-square, Wilcoxon and t-tests.

RESULTS

Forty participants were enroled and divided into two groups described above. There were no differences in food choice (p = 0.90). Regarding likability, the VR group liked vegetables more than those in the standard of care group (p = 0.045).

CONCLUSION

There were no differences in nutritional knowledge (p = 0.574). Participants in the VR group reported high satisfaction.

GLP-1 Receptor Agonists in Pediatric and Adolescent Obesity

Obesity remains highly prevalent among children in the United States and is associated with an ever-increasing burden of obesity-related diseases. Effective pediatric obesity prevention and treatment will require both societal interventions and health care system innovation. One recent advancement is the approval of glucagon-like peptide-1 receptor agonists (GLP-1RAs) for use in adolescents. GLP-1RAs are notable for their effectiveness in weight management and in their ability to ameliorate obesity-related diseases. GLP-1RAs can be an important part of a comprehensive treatment plan for pediatric patients seeking obesity care, and we will review the pediatric clinician's considerations for their effective use. We discuss the history of obesity pharmacology and development of GLP-1RAs. We review the indications for use and common adverse reactions. We highlight the importance of mental health care for obesity treatment, with a focus on disordered eating behaviors and their intersection with obesity and pharmacologic treatment of obesity. Nutrition remains an important issue for obesity prevention and management, and we highlight nutritional concerns during GLP-1RA therapy. Finally, we discuss health inequities in obesity, the dangers of perpetuating these inequities if GLP-1RA access remains biased, and the opportunities for improvement.

Topiramate treatment of pediatric metabolic dysfunction-associated steatotic liver disease: A descriptive cohort study

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a common disease in children. Lifestyle modification is the primary treatment but difficult to achieve and maintain. Topiramate is a component of an approved weight loss medication (topiramate-phentermine) in children aged 12 years and older but is more commonly used as a single agent, off-label, for pediatric obesity. Our aim is to describe change in anthropometrics and laboratory values while providing topiramate treatment of pediatric MASLD.

METHODS

Descriptive cohort study including patients aged <18 years with MASLD and body mass index (BMI) >95th percentile treated with topiramate for weight loss for ≥3 months from January 1, 2010, to December 30, 2023. The primary outcome was change in serum alanine aminotransferase (ALT) levels from baseline to 3-6 months. Secondary outcomes were changes in BMI z score, glycated hemoglobin, and lipid profile.

RESULTS

Of 43 patients prescribed topiramate, 11 were excluded for nonadherence, leaving 32 (56% boys, 72% non-Hispanic) for further analyses. With topiramate, ALT levels improved (76 vs 50 U/L, p = 0.001). Further, 43% of patients had either ALT normalization or reduction by >50% from baseline. BMI z score decreased by 0.1 from baseline to 3-6 months. There were no improvements in glycated hemoglobin or lipids. Eight patients (25%) reported mild side effects.

CONCLUSION

Topiramate, as an adjunct to lifestyle intervention, may be considered in the treatment of pediatric MASLD, specifically in the context of failed lifestyle modification and inability to tolerate or qualify for other obesity pharmacotherapy.

Navigating challenges in pediatric trial conduct: integrating bayesian sequential design with semiparametric elicitation for handling primary and secondary endpoints

BACKGROUND

This study presents a Bayesian Adaptive Semiparametric approach designed to address the challenges of pediatric randomized controlled trials (RCTs). The study focuses on efficiently handling primary and secondary endpoints, a critical aspect often overlooked in pediatric trials. This methodology is particularly pertinent in scenarios where sparse or conflicting prior data are present, a common occurrence in pediatric research, particularly for rare diseases or conditions.

METHOD

Our approach considers Bayesian adaptive design, enhanced with B-Spline Semiparametric priors, allowing for the dynamic updating of priors with ongoing data. This improves the efficiency and accuracy of the treatment effect estimation. The Semiparametric prior inherent flexibility makes it suitable for pediatric populations, where responses to treatment can be highly variable. The design operative characteristics were assessed through a simulation study, motivated by the real-world case of the REnal SCarring Urinary infEction Trial (RESCUE).

RESULT

We demonstrate that Semiparametric prior parametrization exhibits an improved tendency to correctly declare the treatment effect at the study conclusion, even if recruitment challenges, uncertainty, and prior-data conflict arise. Moreover, the Semiparametric prior design demonstrates an improved ability in truly stopping for futility, with this tendency varying with the sample size and discontinuation rates. Approaches based on Parametric priors are more effective in detecting treatment efficacy during interim assessments, particularly with larger sample sizes.

CONCLUSION

Our findings indicate that these methods are especially effective in managing the complexities of pediatric trials, where prior data may be limited or contradictory. The flexibility of Semiparametric prior design in incorporating new evidence proves advantageous in addressing recruitment challenges and making informed decisions with restricted data.

Metabolic improvement after exercise training in children with obesity: Possible role of the six-minute walking test

The aims of this study are to evaluate the effectiveness of an online supervised training program in modulating lipid and glucose metabolism in children with obesity and to investigate the possible role of the 6-minute walking test (6MWT) as a predictor of metabolic improvement. A total of 35 Caucasian children with obesity (aged 8-13) were enrolled in the study and tested before (T0) and after (T1) a 12-week online supervised exercise training protocol: cardiovascular fitness (by means of 6MWT), metabolic biochemical profile, lifestyle (with ad hoc questionnaires focusing on physical activity, nutrition, sedentariness, sleep hours and quality, health perception) and Cardiac Autonomic Regulation (CAR) were assessed. Spearman correlations between the variations in the studied outcomes were explored. After intervention, the distance covered during 6MWT significantly increased (p < 0.001), and nutrition quality improved slightly but significantly (p = 0.03). The improvement in the 6MWT performance was shown to be significantly correlatee with the reduction of insulin levels (r = -0.455; p = 0.02), HOMA-IR Index (r = -0.452; p = 0.02), total cholesterol values (r = -0.549; p = 0.004) and Atherogenic Index of Plasma (AIP) (r = 0.422; p = 0.04). Moreover, there was a significant correlation between the improvement in 6MWT and health perception (r = 0.578; p = 0.002). We observed that the improvement in the 6MWT performance correlates with better metabolic profile after exercise training in children with obesity suggesting the goodness of this simple test on unveil changes in pathogenetic processes underlying obesity.

Overweight and obesity in early childhood and obesity at 10 years of age: a comparison of World Health Organization definitions

The World Health Organization recommends using + 2 SD of body mass index z-score (zBMI) to define overweight/obesity (OWO) in children ages 2 to 5 years whereas + 1 SD is used as cut-point from 5 years onwards. Empirical evidence for using different cut-points across childhood is lacking. Our objective was to compare the ability of OWO in early childhood defined using zBMI cut-points at + 2 SD and + 1 SD to predict obesity at 10 years. Data from a prospective birth cohort (QLSCD) were analyzed. At ages 2.5, 3.5, and 4.5 years, children were classified as OWO based on + 2 SD and + 1 SD zBMI cut-points. At 10 years, obesity was assessed (zBMI and waist circumference). Associations between OWO (vs non-OWO) and later obesity were estimated using multivariable linear regressions. Outcome predictions for each cut-point were compared using partial eta-squared values. The sample included 1092 children (53% female). OWO in early childhood was 2-3 times more prevalent when using + 1 SD vs + 2 SD cut-points. In relation to later obesity, partial eta-squared values for both cut-points of OWO were in the small to medium effect size range (ranging from 3 to 15%), suggesting that OWO regardless of cut-point contributed only modestly to obesity measured at 10 years. However, across all time points, eta-squared values were slightly higher for OWO defined at + 1 SD vs + 2 SD, indicating a higher proportion of variance in outcomes being accounted for at zBMI + 1 SD. Conclusion: In children 2 to 5 years old, both definitions of OWO had small to modest effect sizes in relation to obesity in childhood albeit with a marginally superior predictive ability of the + 1 SD over the + 2 SD cut-point across early childhood. From a clinical perspective, using a single cut-point from early childhood onwards may be more practical to monitor growth and weight gain over time and identify children at risk of persistent obesity. What is Known: • The World Health Organization recommends using zBMI cut-points at + 2 SD for children ages 2-5 years, and + 1 SD from 5 years onwards to define overweight/obesity • Research is needed to determine which zBMI cut-point (+ 2 SD or + 1 SD) in children under 5 years best predicts subsequent obesity What is New: • Both definitions of overweight/obesity in early childhood contributed modestly to obesity at 10 years, with + 1 SD being marginally more effective than + 2 SD • Using a single cut-point at + 1 SD across childhood may be more practical for monitoring growth, weight gain, and identifying children at risk of persistent obesity.

Cardiovascular Health in the Transition From Adolescence to Emerging Adulthood: A Scientific Statement From the American Heart Association

Cardiovascular disease remains a leading cause of death in the United States, with an alarming rise in the proportion of young adults experiencing cardiovascular events. Many adolescents enter adulthood with significant cardiovascular disease risk factors. This scientific statement addresses the critical need for cardiovascular health promotion during emerging adulthood, a transitional stage between the ages of 18 and 25 or 29 years of age. We discuss the significance of social determinants of health and the interplay between individual-level risk factors and developmental changes, including shifts in substance use, social connections, and emotional well-being. We conclude by outlining strategies for optimizing cardiovascular health promotion and disease prevention, underscoring the importance of primordial prevention, early intervention, and tailored approaches to address the unique needs of emerging adults. Addressing these multifaceted factors is crucial for mitigating the burden of cardiovascular disease risk factors among emerging adults and promoting long-term cardiovascular well-being.

Changes in Youth Cholesterol Screening Rates in an Academic Center During the COVID-19 Pandemic

Screening youth for hypercholesterolemia allows for detection of familial hypercholesterolemia that can predispose to premature heart disease, however guidelines provide conflicting recommendations regarding universal cholesterol screening. The COVID-19 pandemic and the perception of conflicting guideline recommendations (2011 National Heart, Lung, and Blood Institute guidelines and United States Preventive Services Task Force recommendations in 2016 and 2023) may have adversely affected youth cholesterol screening rates. This study examines screening rates during and after the COVID-19 pandemic and the most recent guideline update. Electronic health record data from a single academic institution was used to calculate Order Placement Rates (OPRs) for subjects aged 8 years 9 months-21 years from 3/18/2019 to 12/31/2023. Demographic data included subject sex, age, zip code, and primary provider's specialty. Zip codes were categorized as rural/urban and underserved/middle/advantaged. The study period was divided into five stages (pre-pandemic, mid-pandemic, late-pandemic, post-pandemic, and post-guideline). Relative to baseline OPR prior to 3/18/2019, study period OPRs decreased slightly in pre-pandemic (73.3%), mid-pandemic (70.9%), and late-pandemic (65.4%) stages, with sharper declines during post-pandemic (47.6%) and post-guideline stages (35.2%). OPR decreased more significantly for youth 9-11 years than 17-21 years (post-guideline OPR: 35.1% versus 46.9%). Urban underserved and urban advantaged had higher OPRs. OPRs for family medicine and pediatrics declined (p < 0.01), more significantly in pediatrics (post-guideline versus pre-pandemic OPR adjusted odds ratio [95% CI] = 0.03 [0.02-0.04] for pediatrics, 0.35 [0.30-0.40] for family medicine). Our institution showed decreases in cholesterol screening OPRs after both the COVID-19 pandemic and guideline update. OPRs dropped most significantly among youth aged 9-11 years and among pediatric providers. Urban youth were more likely to be screened than rural youth. Discrepancies persist among access to youth cholesterol screening.

A recent update on childhood obesity: aetiology, treatment and complications

Obesity is a complex, chronic condition characterised by excess adiposity. Rates of obesity in childhood and adolescence are increasing worldwide, with a corresponding increase in adulthood. The aetiology of obesity is multifactorial and results from a combination of endocrine, genetic, environmental and societal factors. Population level approaches to reduce the prevalence of childhood obesity worldwide are urgently needed. There are wide-ranging complications from excess weight affecting every system in the body, which lead to significant morbidity and reduced life expectancy. Treatment of obesity and its complications requires a multi-faceted, biopsychosocial approach incorporating dietary, exercise and psychological treatments. Pharmacological treatments for treating childhood obesity have recently become available, and there is further development of new anti-obesity medications in the pipeline. In addition, bariatric surgery is being increasingly recognised as a treatment option for obesity in adolescence providing the potential to reverse complications related to excess weight. In this review, we present an update on the prevalence, aetiology, complications and treatment of childhood obesity.

Long-term results of a digital treatment tool as an add-on to pediatric obesity lifestyle treatment: a 3-year pragmatic clinical trial

BACKGROUND

The integration of mobile health technology with physical visits shows promising one-year treatment outcomes, but long-term evidence is lacking.

OBJECTIVES

To assess three-year treatment outcomes for patients utilizing the digital treatment tool Evira in combination with physical visits, compared with standard obesity care.

METHODS

In a pragmatic trial, children with obesity aged 4.0-17.9 years receiving digi-physical treatment with Evira (n = 107) were compared with a group receiving standard treatment (n = 321). Evira comprises a digitless body scale for home-weighing, a mobile application, and a web-based clinic interface, enabling easy family-clinic communication and continuous visual treatment feedback.

RESULTS

At the three-year follow-up, the adjusted average change in body mass index Z-score was -0.29 [95% confidence interval: -0.40, -0.18] units in the digi-physical treatment group vs. -0.12 [-0.21, -0.03] in the standard treatment group, p = 0.02, and 31.8% vs. 18.7% obtained obesity remission respectively, p = 0.0046.

CONCLUSION

Over a three-year period, the digi-physical treatment generated superior treatment effect and higher obesity remission rate than standard treatment.

Metabolic Signatures in Adipose Tissue Linking Lipophilic Persistent Organic Pollutant Mixtures to Blood Pressure Five Years After Bariatric Surgery Among Adolescents

Persistent organic pollutants (POPs) are lipophilic environmental contaminants accumulated in the adipose tissue. Weight loss interventions, such as bariatric surgery, can mobilize POPs from adipose tissue into the bloodstream. We hypothesized that this mobilization could contribute to increases in blood pressure among 57 adolescents with severe obesity undergoing bariatric surgery. POPs and metabolic features were measured from visceral adipose tissue collected during surgery using gas and liquid chromatography, coupled with high-resolution mass spectrometry. Blood pressure was assessed at baseline, 6 months, and 5 years post-surgery. We used quantile g-computation to estimate associations of POP mixtures with blood pressure changes. With one quartile increase in POP mixtures, systolic blood pressure (SBP) increased by 6.4% five years after bariatric surgery compared to baseline SBP [95% confidence interval (CI): 0.4%, 12.4%]. The meet-in-the-middle approach identified overlapping metabolic features and pathways linking POP mixtures to SBP changes, highlighting the role of prostaglandin formation via arachidonic acid metabolism. POP mixtures were negatively associated with indole-3-acetate (-0.729, 95% CI: -1.234, -0.223), which was negatively associated with SBP changes at five years (-3.49%, 95% CI: -6.51%, -0.48%). Our findings suggested that lipophilic POP mixtures attenuated the beneficial effect of bariatric surgery on improved blood pressure among adolescents via alterations in lipid metabolism.

Long-Term Effects of a Responsive Parenting Intervention on Child Weight Outcomes Through Age 9 Years: The INSIGHT Randomized Clinical Trial

Importance

Behavioral interventions to treat childhood obesity have had limited success. Primary prevention is desirable, but whether intervention effectiveness can be sustained is unknown.

Objective

To examine the effect of an intervention designed for the primary prevention of obesity and delivered through age 2 years on weight outcomes through age 9 years.

Design, Setting, and Participants

A longitudinal observation of a single-center randomized clinical trial comparing a responsive parenting intervention vs a home safety intervention (control) among primiparous mother-child dyads who completed the assessment at age 3 years with follow-up to age 9 years. All data were analyzed from January 21 to November 15, 2024.

Interventions

Research nurses conducted 4 home visits during infancy and research center visits at ages 1 and 2 years totaling less than 10 contact hours. The responsive parenting curriculum focused on feeding, sleep, interactive play, and emotion regulation.

Main Outcomes and Measures

The primary outcome is body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) across 4 assessments from age 3 through 9 years, with the assessment of study group differences using repeated-measures analysis. A test for an interaction between sex and study group was planned. Secondary outcomes include BMI z scores and prevalence of overweight (BMI ≥85th to <95th percentile) and obesity (BMI ≥95th percentile) at 5, 6, and 9 years.

Results

Of the 232 primiparous mother-child dyads (116 per group) (7 Asian [3%], 11 Black [5%], 1 Native Hawaiian or Other Pacific Islander [0.4%], 207 White [89%], and 6 children with other race and ethnicity [including Asian, Indian, Hispanic, Dominican, and other race; 2.5%]; 121 male children [52%]), 177 (76%) had anthropometric data at age 9 years. From ages 3 to 9 years, children in the responsive parenting group had a lower mean (SD) BMI than controls (16.64 [0.21] vs 17.07 [0.20]; absolute difference, -0.43; P = .049). Sex moderated this effect; female participants in the responsive parenting group had a lower mean (SD) BMI than female participants in the control group (16.32 [0.26] vs 17.32 [0.26]; absolute difference, -1.00; P = .007), with no group differences among male participants. Cross-sectional analyses revealed no differences in BMI z scores or prevalence of overweight or obesity at ages 5, 6, and 9 years between the responsive parenting group and the control group.

Conclusions and Relevance

An early-life responsive parenting intervention resulted in lower BMI from age 3 to 9 years compared with a control intervention. This group difference was driven by effects on female participants, with differences appearing to dissipate over time. A life-course approach may be required to sustain the benefits of early-life responsive parenting interventions for obesity prevention.

Trial Registration

ClinicalTrials.gov Identifier: NCT03555331.

Key Gaps in the Prevention and Treatment of Obesity in Children and Adolescents: A Critical Appraisal of Clinical Guidelines

BACKGROUND

The worldwide increase in the prevalence of childhood obesity necessitates effective prevention and treatment strategies. Clinical practice guidelines (CPGs) offer guidance, but significant heterogeneity or lack of practical application exists in their recommendations. The purpose of the present study is to provide an expert, comprehensive, and comparative analysis of gaps in current CPGs for the prevention and treatment of obesity in children and adolescents.

RESULTS

A total of 14 CPGs were identified, focusing on childhood obesity prevention (n = 11), treatment (n = 9), or both (n = 6). Prevention CPGs generally recommend body mass index (BMI) assessment, but specific measurement frequency is often absent. While some provide age-specific dietary recommendations, graphical tools are lacking. Recommendations for increased physical activity and reduced screen time are common, but age-stratified guidance is deficient. Furthermore, recommendations regarding mental health and sleep are notably absent. Treatment CPGs utilize BMI for obesity diagnosis, but inconsistencies in cut-off points persist. Comorbidity assessment is generally recommended, yet age-specific guidance remains lacking. Dietary recommendations are present in most CPGs, but many lack detailed specifications (e.g., meal frequency, portion sizes, macronutrient distribution, age-appropriate examples). Most CPGs advocate for 60 min of daily physical activity and limit screen time to 2 h per day. Recommendations concerning sleep are consistently absent. While parental involvement is acknowledged, specific guidance for active participation in prevention and treatment is deficient. Pharmacological treatment options are frequently outdated, and surgical intervention is reserved for exceptional cases of severe obesity.

CONCLUSIONS

Standardizing BMI cut-off points and defining age groups across CPGs would improve consistency and comparability in the diagnosis, prevention, and treatment of childhood obesity. Tailoring recommendations for diet, physical activity, sedentary behavior, and sleep to specific age groups would ensure developmentally appropriate interventions. A stronger emphasis on early prevention strategies is needed to address the root causes of obesity. Clear guidance for parents and families would facilitate their active engagement in prevention and treatment. Up-to-date information regarding pharmacological and surgical treatments is imperative.

Lifestyle and Biochemical Parameters That May Hamper Immune Responses in Pediatric Patients After Immunization with the BNT162b2 mRNA COVID-19 Vaccine

BACKGROUND

The aim of this study was to evaluate whether increased body mass index (BMI) and biochemical and lifestyle parameters linked to obesity and smoke exposure disrupt immune responses of children and adolescents following vaccination with the mRNA BNT162b2 vaccine.

METHODS

A prospective, single-center, cohort study was conducted. Participants were assigned to receive two doses of the mRNA vaccine. Anti-SARS-CoV-2 IgG and neutralizing antibodies (AB) were measured before vaccination (T0) and 14 days after the second dose (T1). BMI and biochemical parameters were evaluated at T0. A questionnaire on lifestyle characteristics was filled in.

RESULTS

IgG optical density (OD) ratio at T1 was lower in the overweight-obese group regardless of COVID-19 disease positive history [p = 0.028 for the seronegative group, p = 0.032 for the seropositive group]. Neutralizing AB were lower in overweight-obese participants in the seronegative group at T1 [p = 0.008]. HDL, fasting glucose/insulin ratio (FGIR), C-reactive protein (CRP), HBA1c, uric acid, and smoke exposure were significantly correlated with BMI [p = 0.006, p < 0.001, p < 0.001, p = 0.006, p = 0.009, p < 0.001, respectively]. The main biochemical parameters that were inversely correlated with IgG and neutralizing AB titers at T1 were uric acid [p = 0.018, p = 0.002], FGIR [p = 0.001, p = 0.008] and HBA1C [p = 0.027, p = 0.038], while smoke exposure negatively affected the humoral immune responses at T0 in the convalescent group [p = 0.004, p = 0.005].

CONCLUSIONS

Current data suggests that uric acid, insulin resistance (IR), and smoke exposure could adversely affect the immune responses in overweight-obese vaccinated children, highlighting the need for actions to enhance the protection of this particular subgroup.

Cross-Sectional and Longitudinal Associations Among Weight Stigma, Psychological Distress, and Eating Behaviors in Youth with Obesity: A Clinical Sample

Background and Objectives: Obesity in youth is a growing public health concern, placing them at higher risk for adverse physical and psychological outcomes. Understanding the predictors that affect weight management, particularly the role of internalized weight stigma, psychosocial factors, and eating behaviors, is essential for developing an effective intervention at longitudinal follow-up. Materials and Methods: We enrolled 102 youths with obesity aged 10 to 18 years old from clinical settings. Baseline demographic data, psychosocial measures, including the Weight Self-Stigma Questionnaire (WSSQ) and Hospital Anxiety and Depression Scale (HADS), and eating behavior scales, such as the Three-Factor Eating Questionnaire (TFEQ-R21) and eating disorder as Sick, Control, One, Fat, Food questionnaire (SCOFF), were collected in the first visit. We conducted a study with both cross-sectional and longitudinal components. Correlational bivariate analysis was conducted to explore relationships between key variables. The factors affecting BMI changes were investigated using generalized estimating equations (GEEs) as part of a longitudinal analysis. Results: The mean age of participants was 13.22 years and 63.7% were male. Bivariate correlation analysis revealed positive relationships between initial BMI Z-scores and WSSQ scores (r = 0.196, p < 0.05). In bivariate analysis, a negative correlation was found between the difference in BMI Z-scores and visit number (r = -0.428, p < 0.01). GEE analysis demonstrated that initial BMI Z-scores (coefficient = 1.342, p < 0.001) and anxiety (coefficient = 0.050, p < 0.001) were significant positive predictors of BMI Z-scores, while depression was negatively associated (coefficient = -0.081, p < 0.001). Excluding the TFEQ subscales, SCOFF improved the model's QIC and highlighted WSSQ as a significant, albeit weak, predictor (p = 0.615 in the full model versus p < 0.05 in the reduced model). Conclusions: Psychosocial factors, particularly anxiety and weight stigma, are associated with elevated BMI Z-scores in youth affected by obesity in this study. The baseline age, BMI Z-score, internalized weight stigma, and psychological stress influenced the body weight trajectory over time. Frequent clinical follow-ups contribute to improved BMI outcomes. Future research may examine the efficacy of weight management by reducing weight stigma and psychological distress along with the outpatient care of obesity.

Metabolic dysfunction-associated steatotic liver disease in children

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as non-alcoholic fatty liver disease, is the most common cause of chronic liver disease in children. MASLD encompasses a spectrum of liver disease and can be severe, with 10% of affected children presenting with advanced fibrosis. While biopsy remains the most accurate method for diagnosing and staging the disease, MRI proton density fat fraction and magnetic resonance elastography are the most reliable non-invasive measures for assessing steatosis and fibrosis, respectively. MASLD is associated with multiple comorbidities including type 2 diabetes, hypertension, dyslipidaemia, decreased bone mineral density, obstructive sleep apnoea, anxiety and depression. Currently, there are no pharmacological treatments available for children, highlighting the urgent need for paediatric clinical trials. A diet low in free sugars is promising for reducing steatosis and decreasing alanine aminotransferase, a surrogate marker for hepatic inflammation. Emerging data indicate that steatosis can be present in children under 6 years of age, which was previously considered rare. The intricate interplay of genetics may inform future therapeutics and prognostication, with the PNPLA3 gene showing the most evidence for association with the risk and severity of steatotic liver disease and steatohepatitis. MASLD is a complex disease affecting one in ten children and is associated with increased early mortality risk. More dedicated studies are needed in children to advance our understanding of this disease and find effective treatments.

Parenting Practices to Prevent Childhood Obesity Among Hispanic Families: A Systematic Literature Review

Background: Childhood obesity disproportionately affects Hispanic families and remains an unresolved public health concern. Interventions to enhance health-related parenting practices may be a promising strategy to lower the risk for childhood obesity. However, there are scarce data on which parenting practices would be culturally relevant and contribute to lower the risk for childhood obesity among Hispanic families in the United States. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. An electronic database search of records was carried out in PubMed, CINAHL, PsycINFO, and Scopus to synthesize studies assessing associations or intervention effects of parenting practices on child BMI or other anthropometric measure among Hispanic parent-child dyads aged ≥18 and 2-12 years, respectively. Results: Of 1055 unique records identified, 17 studies were included. Most of these studies used a cross-sectional design (n = 10) and child BMI z-scores or BMI-for-age-sex percentiles as the outcome variable. Parenting practices to lower the risk for child overweight/obesity among Hispanic families included setting limits and providing routines (e.g., limited screentime), supporting a healthy lifestyle and physical activity (e.g., providing transportation to places for children's physical activities), and parenting feeding or diet-related practices (e.g., control the foods that children eat). Conclusion: Parenting practices that support healthy behaviors may be components of interventions to lower the risk for childhood obesity among Hispanic families.

Multi-Prong Formative Evaluation of a Pediatric Clinical-Community Food Access and Nutrition Education Intervention

PURPOSE

To understand pediatricians', community partners', and food insecure parent/caregivers' perspectives on addressing food access and nutrition education in clinical settings, and to conduct a formative evaluation of a clinical-community food access and nutrition education intervention.

DESIGN

A mixed-methods evaluation.

SETTING

Data was collected from pediatricians and parents/caregivers recruited from one urban pediatric primary care clinic, and from community partners involved in food access.

PARTICIPANTS

Pediatricians (n = 14), parents at risk of food insecurity (n = 7), and community partner staff (n = 8) participated in qualitative interviews.

METHOD

A cross-sectional survey among pediatricians assessing demographics, nutrition training, and knowledge of food access programs was administered. Semi-structured virtual interviews were conducted to understand experiences with food insecurity and food access programs, and to identify content and delivery preferences for a clinical-community intervention. Descriptive statistics were used to characterize the pediatrician and parent demographics and pediatrician nutrition knowledge. A hybrid deductive-inductive thematic analysis was used to identify emerging themes from qualitative interviews.

RESULTS

Few pediatricians (n = 3, 11%) reported receiving previous nutrition training, and knowledge-based food access program questions revealed significant gaps in pediatricians' understanding of program eligibility. Thematic analyses underscore challenges in addressing food insecurity in the clinical setting, gaps in clinical-community partnerships, and barriers to participating in food access programs.

CONCLUSION

Findings provide recommendations for the development of clinical-community food access and nutrition education interventions.

Metabolic and Anthropometric Effects of a Randomized Freely Chosen Exercise Prescription Program vs a Video-Based Training Program in Patients With Childhood Obesity: A Randomized Clinical Trial

Objectives When dealing with children and adolescents living with obesity, it is vital to be aware that exercise provides benefits in the prevention and control of non-communicable diseases and general well-being. The growing prevalence of childhood obesity makes it necessary to develop strategies aimed at controlling the barriers that limit the performance of exercise, which is why we designed a plan of exercise prescription through videos that could be accessible, free, and designed for exercise at home, as a complement to a multidisciplinary intervention program for lifestyle change. This study aimed to compare the effects of a video-based exercise prescription program (EPV) versus free-choice exercise (FCE) on anthropometric and metabolic indicators. Methods We conducted an open-label, randomized, controlled clinical trial. Patients aged eight to 16 years with obesity from the Child Unit of the General Hospital of Mexico were included. Forty-two participants finished the follow-up; 20 were boys, and 22 were girls. All patients were included in a multi-component program of healthy lifestyle changes and randomized to receive EPV (n=22) or FCE (n=20) for six months. Results The primary outcomes in both groups were a decrease in body mass index (BMI) (p < 0.001), a reduction in body fat mass (p < 0.001), and an increase in lean body mass (p = 0.003). Other outcomes observed were: in EPV, there was a decrease in low density lipid (LDL) (p=0.04); alanine aminotransferase (ALT) (p=0.002), aspartate aminotransferase (AST) (p=0.001) and uric acid (p=0.003) and an increase in high density lipid (HDL) (p=0. 002), while in FCE there was a decrease in Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) (p=0.006), insulin (p=0.006), LDL (p=0.02), ALT (p=0.002), AST (p=0.004) and gamma-glutamyl transferase (GGT) (p=0.025). Conclusion Both EPV and FCE exercise prescription programs, as part of a multidisciplinary intervention for childhood obesity, had favorable effects on body composition and metabolic parameters.

Parental Perspectives on Their Child's Body Image

Poor body image is a prominent issue affecting youth. In this nationally representative online survey, we explored parents' concerns about their child's appearance, as well as their perceptions of their child's body image concerns and related behaviors and interactions with others. Among the 1653 respondents, weight was parents' most cited body image concern, while more parents perceived that their child was self-conscious about their weight than there were parents concerned about their child's weight. Parental perceptions related to their child's body image can inform providers' efforts to address poor body image, such as around weight, and improve the health and self-esteem of their pediatric patients.

A family-based behavioral group obesity randomized control feasibility trial across a clinical trials network: a focus on contact hours

OBJECTIVE

This ancillary study's purpose is to describe the relationship between dose of treatment and body mass index (BMI) outcomes in a tele-behavioral health program delivered in the IDeA States Pediatric Clinical Trials Network to children and their families living in rural communities.

METHODS

Participants randomized to the intervention were able to receive 26 contact hours (15 hr of group sessions and 11 hr of individual sessions) of material focused on nutrition, physical activity, and behavioral caregiver training delivered via interactive televideo. Dose of the intervention received by child/caregiver dyads (n = 52) from rural areas was measured as contact hours. The total doses of group, individual, and total contact hours were analyzed, and generalized linear mixed models were utilized to determine how dose received impacted BMI outcomes.

RESULTS

The majority (64.4%) of participants received the target of at least 80% (20.8 hr) of the total intervention dose. Older children (9-11 years) achieved significantly less intervention dose than targeted (M = 19.7; p = .031); as did males (M = 17.2; p < .001), children who identified as Black (M = 17.8; p < .001), and children from Site 3 (M = 18.0; p < .001). Dose was not significantly related to BMI outcomes in children or caregivers.

CONCLUSIONS

As this study is underpowered and took place during the early stages of the COVID-19 pandemic, results should be interpreted with caution, but contact hours did not predict health outcomes for families living in rural communities.

Effectiveness of behavioural and psychological interventions for managing obesity in children and adolescents: A systematic review and meta-analysis framed using minimal important difference estimates based on GRADE guidance to inform a clinical practice guideline

OBJECTIVE

Conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) of behavioural and psychological interventions for managing paediatric obesity.

METHODS

Eligible studies, published between 1985 and 2022, included 0 to 18 year olds with outcomes reported ≥3 months post-baseline, including patient-reported outcome measures (PROMs), cardiometabolic and anthropometric outcomes, and adverse events (AEs). We pooled data using a random effects model and assessed certainty of evidence (CoE) related to minimally important difference estimates for outcomes using GRADE.

RESULTS

We included 73 unique RCTs (n = 6305 participants, 53% female). Intervention types included physical activity (n = 1437), nutrition (n = 447), psychological (n = 1336), technology-based (n = 901) or multicomponent (≥2 intervention types, n = 2184). Physical activity had a small effect on health-related quality of life (HRQoL), varying effects ranging from moderate to very large on blood pressure, lipids and insulin resistance, and a small effect on BMIz. Nutrition had a small effect on lipids, insulin resistance and BMIz. Psychological interventions showed a small effect on HRQoL and triglycerides and moderate benefits on depressive symptoms, while technology interventions showed small benefits on blood pressure and BMIz. Multicomponent interventions had a large benefit on anxiety, small benefit on depressive symptoms, with large to very large benefits on lipids, and small benefits for diastolic blood pressure, insulin resistance and BMIz. AEs were reported infrequently, and when reported, were described as mild.

CONCLUSION

Physical activity and multicomponent interventions showed improvements in PROMs, cardiometabolic and anthropometric outcomes. Future trials should consistently measure PROMs, evaluate outcomes beyond the intervention period, and study children <6 years of age.

Current and future state of pharmacological management of pediatric obesity

Pediatric obesity is a highly prevalent chronic disease, which has traditionally been treated with lifestyle therapy alone. Yet for many youth, lifestyle intervention as a monotherapy is often insufficient for achieving clinically significant and durable BMI reduction. While metabolic/bariatric surgery achieves robust and long-lasting outcomes, it is neither widely accessible nor wanted by most pediatric patients and families. In the past 3 years, this treatment gap between lifestyle therapy and metabolic/bariatric surgery has been filled with a number of landmark clinical trials examining the safety and efficacy of anti-obesity medication (AOM) for use in children and adolescents. These trials include studies of liraglutide, phentermine/topiramate ER, semaglutide, and setmelanotide, all of which have led to FDA and/or EMA approval. Concurrent with this developing evidence base, in 2023, the American Academy of Pediatrics published their first Clinical Practice Guideline on the assessment and management of childhood obesity. The Guideline includes the recommendation that pediatric health care providers should offer AOM to youth ages ≥12 years with obesity. Recognizing that AOM use in the pediatric population will likely become the standard of care and to provide perspective on the recently generated data regarding new AOM, this narrative review summarizes the published randomized controlled trials (RCTs) from the past 10 years that examine AOM for the pediatric population. This report additionally includes RCTs examining AOM for special populations of pediatric obesity including monogenic obesity, Bardet Biedl syndrome, Prader Willi syndrome, and hypothalamic obesity. Finally, the clinical application of AOM for children and adolescents, as well as future directions and challenges are discussed.

Mental distress or psychiatric condition? Exploring the gray area of categorizing psychological suffering among adolescents with obesity: a mixed methods study

Introduction Obesity in adolescents is associated with increased mental distress and psychiatric disorders, both of which are under-diagnosed in clinical practice. Methods We designed a mixed methods study, to explore the practical challenges of this screening and its consequences. The qualitative part interviewed 20 physicians: non psychiatrist physicians and child and adolescent psychiatrists - practicing in various specialized settings. The quantitative part examined self-assessment questionnaires and psychiatric clinical diagnoses in 242 patients admitted for inpatient appraisal of obesity. Results 7.9% reported severe depressive symptoms and 71.9% severe anxiety symptoms. Among this cohort, 28.5% were diagnosed with anxiety disorder and 16.9% with depression disorder. Both qualitative and quantitative data show that a large share of adolescents with obesity experience mental health distress, often intense. However, in most of these adolescents, this distress is not diagnosed as a mental health condition, thus creating a discrepancy which we named a "gray area" of psychological suffering. Conclusions Screening adolescents with obesity for both mental health distress and disease should be systematic. Frontline professionals need improved training and referral pathways and resources.

Cardiological Findings in Children and Adolescents Before and After Guanfacine Treatment for Attention Deficit and Hyperactivity Disorder

Objective: This study evaluates the short-term cardiovascular effects of guanfacine treatment in children and adolescents with attention deficit/hyperactivity disorder (ADHD). The treatment's impact on novel electrocardiographic parameters was also investigated. Methods: In a retrospective study conducted between January 2023 and June 2024, 37 patients aged 6-18 years with ADHD underwent baseline and follow-up cardiac evaluations including electrocardiography (ECG) and blood pressure measurements. Novel ECG markers (QRS-T angle, QT dispersion, QTc dispersion, Tp-e interval, Tp-e dispersion, Tp-e/QT ratio, and Tp-e/QTc ratio) were analyzed alongside standard parameters such as heart rate, QT, and corrected QT (QTc) intervals. Guanfacine was initiated at 1 mg and titrated weekly until an optimal clinical response was achieved. Results: Guanfacine treatment led to a significant reduction in heart rate (-12.3 bpm; p < 0.001) and P wave axis (-12.3°; p = 0.038) and an increase in QT interval (+16.8 ms; p = 0.014). However, no significant changes were observed in blood pressure, QTc duration, or the novel ECG parameters. Importantly, the absence of any changes in these advanced markers supports the cardiovascular safety of guanfacine. Two patients experienced side effects (bradycardia and hypotension), leading to treatment discontinuation. ANCOVA analysis indicated that the duration between ECG evaluations significantly influenced the QT interval changes, emphasizing the importance of timing when monitoring cardiovascular effects. Conclusions: Guanfacine demonstrated minor, statistically significant effects on the selected cardiac parameters without clinically meaningful changes to or adverse impacts on the novel ECG markers investigated. As extended-release guanfacine has only been available in Türkiye for the management of ADHD for approximately two years, studies evaluating its clinical efficacy and side effects are critical for clinicians working in this field.

The Use of Complementary and Alternative Treatments in Adolescent Obesity: A Narrative Review

Adolescent obesity is a growing global health problem all around the world. We reviewed the use of complementary and alternative medicine (CAM) for adolescent obesity, examining improvements in BMI or any metabolic indices of obesity. We performed a PubMed and Scopus search for articles on CAM treatments in adolescents aged 12-17 years, and included all studies with subjects in that age range. Out of 226 PubMed articles and 14 Scopus articles, 28 articles from PubMed and 1 article from Scopus fit our criteria. Most CAM studies that showed some improvement in BMI were acupuncture- or yoga-based. Yoga-based interventions showed a BMI reduction of 1-2 points, which is similar to results achieved in studies based on physical activity and Orlistat, a weak anti-obesity medication; meanwhile, acupuncture-based studies showed a slightly higher BMI reduction of 2-4 points, similar to that achieved with Liraglutide, a GLP-1 agonist that is a good anti-obesity medication. Herbs and supplements showed improvement in metabolic markers of obesity. Stress interventions in mind-body interventions, music skip-rope exercise, and creative drama in physical activity-based interventions also showed improvement in BMI. Although many of the studies reviewed were RCTs, the small sample size of those RCTs is a limiting factor. There may be a role for investigating this topic in larger populations to generate more effective conclusions.

Using Parks and Recreation Providers to Enhance Obesity Treatment: A Randomized Controlled Trial

OBJECTIVE

Intensive health behavior and lifestyle treatment (IHBLT) is recommended for children aged 6-18 years with obesity. The objective was to evaluate the effectiveness of Fit Together, a health care and parks and recreation partnership to deliver IHBLT.

METHODS

A randomized controlled trial was conducted from 2018 to 2021. Youths (aged 5-17 years) with obesity were recruited from primary care clinics and randomized to a waitlist control or Fit Together (ie, clinical obesity care plus group-based lifestyle sessions at a local recreation center). Primary outcomes, child body mass index relative to the 95th percentile (BMIp95) and submaximal heart rate, were collected at baseline and 6 months. Generalized estimating equation models were used to assess changes in primary outcomes for those affected and not affected by COVID-19 study disruptions.

RESULTS

Participants (n = 255) had a mean (SD) age of 10.0 (3.0) years, were 39% Hispanic, and were 38% non-Hispanic Black. Intervention youths not affected by COVID-19 disruptions experienced a significant decrease in BMIp95 (β = -3.05; 95% confidence interval [CI], -5.08 to -1.01) compared with controls. There was no difference in BMIp95 between intervention and control youths affected by COVID-19 disruptions (β = -3.25; 95% CI, -7.98 to 1.48). For the entire cohort, intervention youths had a significant decrease in BMIp95 compared with control youths (β = -3.32; 95% CI, -5.69 to -0.96). Submaximal heart rate was only available for the nondisrupted group, but there was no difference between intervention and control youths (β = -7.18; 95% CI, -16.12 to 1.76).

CONCLUSION

Effective child obesity treatment can be implemented in local communities through a partnership between clinical practices and parks and recreation providers. Future research will explore this model in combination with newer, more effective obesity treatments.

Fructose Intake and Unhealthy Eating Habits Are Associated with MASLD in Pediatric Obesity: A Cross-Sectional Pilot Study

Background/Objectives: Fructose consumption in children is increasing, as is the prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD). Despite evidence linking added sugars to metabolic syndrome, fructose's impact on liver disease in youth remains unclear, especially in pediatrics. Our study aimed to evaluate the role of fructose intake in metabolic and liver dysfunction in a cohort of pre-school children and adolescents with obesity. Methods: We recruited 41 children and adolescents with obesity (age range: 2.5-16 years, BMI SDS 2.6 ± 0.5 kg/m2). Clinical and biochemical parameters were assessed. Through ultrasound (US), MASLD, hepatorenal index (HRI), subcutaneous adipose tissue (scAT), and visceral adipose tissue (vAT) were assessed. Dietary intake was evaluated using the IDEFICS FFQ and a fructose-specific questionnaire. Results: Pubertal subjects had more scAT and vAT, higher insulin resistance, and higher liver fibrosis parameters than those prepubertal. MASLD was detected in 12 subjects, associated with higher scAT and vAT. Pubertal subjects had lower weekly fructose intake than prepubertal subjects (p < 0.02). However, they consumed less fructose from fruits (p < 0.04) and more from other sugars (p < 0.04) than younger children. Patients with MASLD reported higher fructose intake (p < 0.01), primarily from fruits (p < 0.003), likely due to misreporting, alongside higher consumption of unhealthy food, mainly rich in saturated fats. Conclusions: Fructose intake and unhealthy dietary habits were associated with MASLD in pre-school and adolescents with obesity. Advice to pay attention to fructose intake and foods rich in saturated fats is mandatory to decrease both obesity and MASLD. Further high-powered studies in any pediatric age and different geographical areas are needed to better evaluate the MASLD history.

Is Reducing the Obesity Epidemic in Children and Adolescents Really a Mission Impossible?

The prevalence of pediatric excess weight has reached such levels that there are fears of a sharp increase in associated noncommunicable diseases when today's children become adults [...].

Harnessing Artificial Intelligence in Obesity Research and Management: A Comprehensive Review

Purpose: This review aims to explore the clinical and research applications of artificial intelligence (AI), particularly machine learning (ML) and deep learning (DL), in understanding, predicting, and managing obesity. It assesses the use of AI tools to identify obesity-related risk factors, predict outcomes, personalize treatments, and improve healthcare interventions for obesity. Methods: A comprehensive literature search was conducted using PubMed and Google Scholar, with keywords including "artificial intelligence", "machine learning", "deep learning", "obesity", "obesity management", and related terms. Studies focusing on AI's role in obesity research, management, and therapeutic interventions were reviewed, including observational studies, systematic reviews, and clinical applications. Results: This review identifies numerous AI-driven models, such as ML and DL, used in obesity prediction, patient stratification, and personalized management strategies. Applications of AI in obesity research include risk prediction, early detection, and individualization of treatment plans. AI has facilitated the development of predictive models utilizing various data sources, such as genetic, epigenetic, and clinical data. However, AI models vary in effectiveness, influenced by dataset type, research goals, and model interpretability. Performance metrics such as accuracy, precision, recall, and F1-score were evaluated to optimize model selection. Conclusions: AI offers promising advancements in obesity management, enabling more personalized and efficient care. While technology presents considerable potential, challenges such as data quality, ethical considerations, and technical requirements remain. Addressing these will be essential to fully harness AI's potential in obesity research and treatment, supporting a shift toward precision healthcare.

Liraglutide for Children 6 to <12 Years of Age with Obesity - A Randomized Trial

BACKGROUND

No medications are currently approved for the treatment of nonmonogenic, nonsyndromic obesity in children younger than 12 years of age. Although the use of liraglutide has been shown to induce weight loss in adults and adolescents with obesity, its safety and efficacy have not been established in children.

METHODS

In this phase 3a trial, which consisted of a 56-week treatment period and a 26-week follow-up period, we randomly assigned children (6 to <12 years of age) with obesity, in a 2:1 ratio, to receive either once-daily subcutaneous liraglutide at a dose of 3.0 mg (or the maximum tolerated dose) or placebo, plus lifestyle interventions. The primary end point was the percentage change in the body-mass index (BMI; the weight in kilograms divided by the square of the height in meters). The confirmatory secondary end points were the percentage change in body weight and a reduction in BMI of at least 5%.

RESULTS

A total of 82 participants underwent randomization; 56 were assigned to the liraglutide group and 26 to the placebo group. At week 56, the mean percentage change from baseline in BMI was -5.8% with liraglutide and 1.6% with placebo, representing an estimated difference of -7.4 percentage points (95% confidence interval [CI], -11.6 to -3.2; P<0.001). The mean percentage change in body weight was 1.6% with liraglutide and 10.0% with placebo, representing an estimated difference of -8.4 percentage points (95% CI, -13.4 to -3.3; P = 0.001), and a reduction in BMI of at least 5% occurred in 46% of participants in the liraglutide group and in 9% of participants in the placebo group (adjusted odds ratio, 6.3 [95% CI, 1.4 to 28.8]; P = 0.02). Adverse events occurred in 89% and 88% of participants in the liraglutide and placebo groups, respectively. Gastrointestinal adverse events were more common in the liraglutide group (80% vs. 54%); serious adverse events were reported in 12% and 8% of participants in the liraglutide and placebo groups, respectively.

CONCLUSIONS

Among children (6 to <12 years of age) with obesity, treatment with liraglutide for 56 weeks plus lifestyle interventions resulted in a greater reduction in BMI than placebo plus lifestyle interventions. (Funded by Novo Nordisk; SCALE Kids ClinicalTrials.gov number, NCT04775082.).