Exploring the association between individual, family, and program characteristics and change in health outcomes 12 months after enrollment into the CANadian Pediatric Weight management Registry (CANPWR).

OBJECTIVES: To examine individual, family, and program characteristics associated with changes in anthropometric and cardiometabolic health indicators in children with overweight or obesity after participating in multidisciplinary obesity management for 12 months. METHODS: Participants included children 2-17 years old with overweight or obesity enrolled in the CANadian Pediatric Weight Management Registry (CANPWR). Multiple linear regression analyses were conducted to investigate the associations between individual, family, and program characteristics and changes in anthropometry (WHO BMI z-score) and cardiometabolic health indicators (systolic and diastolic blood pressure; fasting and 2-h glucose post-oral glucose tolerance test (OGTT); high density lipoprotein- (HDL) and non-HDL cholesterol and fasting triglycerides). RESULTS: BMI z-score data were available from 1065/1286 (82.8%) at 6-months post-baseline and 893/1286 (69.4%) at 12-months post-baseline. At 6-months, BMI z-score decreased relative to baseline (mean difference (MD) [95% confidence interval (CI)] = -0.08 [-0.10 to -0.06]; p < 0.001). BMI z-score (MD [95% CI] = -0.08 [-0.13 to -0.04); p = 0.001) and fasting triglycerides (MD [95% CI] = -0.07 [-0.13 to -0.02); p = 0.011) decreased at 12 months from baseline. Older age at baseline (estimated ß = 0.025; 95% CI [0.006, 0.042], p = 0.007) and female sex (estimated ß = 0.241; 95% CI [0.108, 0.329], p < 0.001) were associated with a worsened Δ BMI z-score at 12 months, while total hours with mental health provider (estimated ß = -0.015; 95% CI [-0.030, -0.001], p = 0.049) was associated with an improved Δ BMI z-score at 12 months. Hours with an exercise counselor (estimated ß = 0.023; 95% CI [0.008, 0.039], p = 0.003) were associated with improved HDL, while hours with a registered dietitian (estimated ß = -0.026; 95% CI [-0.051, -0.001], p = 0.044) were associated with improved non-HDL cholesterol. CONCLUSIONS: Male sex and hours spent with a mental health provider, exercise counselor, and registered dietitian were related to significant improvements in several anthropometric and cardiometabolic health indicators at 12 months post-baseline.

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

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

Efficacy of the Aim2Be Intervention in Changing Lifestyle Behaviors Among Adolescents With Overweight and Obesity: Randomized Controlled Trial.

BACKGROUND: Aim2Be is a gamified lifestyle app designed to promote lifestyle behavior changes among Canadian adolescents and their families. OBJECTIVE: The primary aim was to test the efficacy of the Aim2Be app with support from a live coach to reduce weight outcomes (BMI Z score [zBMI]) and improve lifestyle behaviors among adolescents with overweight and obesity and their parents versus a waitlist control group over 3 months. The secondary aim was to compare health trajectories among waitlist control participants over 6 months (before and after receiving access to the app), assess whether support from a live coach enhanced intervention impact, and evaluate whether the app use influenced changes among intervention participants. METHODS: A 2-arm parallel randomized controlled trial was conducted from November 2018 to June 2020. Adolescents aged 10 to 17 years with overweight or obesity and their parents were randomized into an intervention group (Aim2Be with a live coach for 6 months) or a waitlist control group (Aim2Be with no live coach; accessed after 3 months). Adolescents' assessments at baseline and at 3 and 6 months included measured height and weight, 24-hour dietary recalls, and daily step counts measured with a Fitbit. Data on self-reported physical activity, screen time, fruit and vegetable intake, and sugary beverage intake of adolescents and parents were also collected. RESULTS: A total of 214 parent-child participants were randomized. In our primary analyses, there were no significant differences in zBMI or any of the health behaviors between the intervention and control groups at 3 months. In our secondary analyses, among waitlist control participants, zBMI (P=.02), discretionary calories (P=.03), and physical activity outside of school (P=.001) declined, whereas daily screen time increased (P<.001) after receiving access to the app compared with before receiving app access. Adolescents randomized to Aim2Be with live coaching reported more time being active outside of school compared with adolescents who used Aim2Be with no coaching over 3 months (P=.001). App use did not modify any changes in outcomes among adolescents in the intervention group. CONCLUSIONS: The Aim2Be intervention did not improve zBMI and lifestyle behaviors in adolescents with overweight and obesity compared with the waitlist control group over 3 months. Future studies should explore the potential mediators of changes in zBMI and lifestyle behaviors as well as predictors of engagement. TRIAL REGISTRATION: ClinicalTrials.gov NCT03651284; https://clinicaltrials.gov/ct2/show/study/NCT03651284. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-020-4080-2.

Priority topics for child and family health research in community-based paediatric health care according to caregivers and health care professionals.

Background: Patient-oriented research (POR) aligns research with stakeholders' priorities to improve health services and outcomes. Community-based health care settings offer an opportunity to engage stakeholders to determine the most important research topics to them. Our objectives were to identify unanswered questions that stakeholders had regarding any aspect of child and family health and prioritize their 'top 10' questions. Methods: We followed the James Lind Alliance (JLA) priority setting methodology in partnership with stakeholders from the Northeast Community Health Centre (NECHC; Edmonton, Canada). We partnered with stakeholders (five caregivers, five health care professionals [HCPs]) to create a steering committee. Stakeholders were surveyed in two rounds (n = 125 per survey) to gather and rank-order unanswered questions regarding child and family health. A final priority setting workshop was held to finalize the 'top 10' list. Results: Our initial survey generated 1,265 submissions from 100 caregivers and 25 HCPs. Out of scope submissions were removed and similar questions were combined to create a master list of questions (n = 389). Only unanswered questions advanced (n = 108) and were rank-ordered through a second survey by 100 caregivers and 25 HCPs. Stakeholders (n = 12) gathered for the final workshop to discuss and finalize the 'top 10' list. Priority questions included a range of topics, including mental health, screen time, COVID-19, and behaviour. Conclusion: Our stakeholders prioritized diverse questions within our 'top 10' list; questions regarding mental health were the most common. Future patient-oriented research at this site will be guided by priorities that were most important to caregivers and HCPs.

Severe obesity and global developmental delay in preschool children: Findings from a Canadian Paediatric Surveillance Program study.

Background: The co-presentation of severe obesity (SO) and global developmental delay (GDD) in Canadian preschool children has not been examined. However, SO and GDD may require syndromic diagnoses and unique management considerations. Objectives: To determine (1) minimum incidence; (2) age of onset and risk factors; and (3) health care utilization for co-presenting SO and GDD. Methods: Through the Canadian Paediatric Surveillance Program (CPSP), a monthly form was distributed to participants from February 2018 to January 2020 asking for reports of new cases of SO and GDD among children ≤5 years of age. We performed descriptive statistics for quantitative questions and qualitative content analysis for open-ended questions. Results: Forty-seven cases (64% male; 51% white; mean age: 3.5 ± 1.2 years) were included. Age of first weight concern was 2.5 ± 1.3 years and age of GDD diagnosis was 2.7 ± 1.4 years. Minimum incidence of SO and GDD was 3.3 cases per 100,000 for ≤5 years of age per year. Identified problems included school and/or behavioural problems (n = 17; 36%), snoring (n = 14; 30%), and asthma/recurrent wheeze (n = 10; 21%). Mothers of 32% of cases (n = 15) had obesity and 21% of cases (n = 10) received neonatal intensive care. Microarray was ordered for 57% (n = 27) of children. A variety of clinicians and services were accessed. As reported by CPSP participants, challenges faced by families and health service access were barriers to care. Conclusion: Children with SO and GDD have multiple comorbidities, and require early identification and referral to appropriate services. These cases may also benefit from additional testing to rule out known genetic obesity syndromes.

Associations between family functioning during early to mid-childhood and weight status in childhood and adolescence: findings from a Quebec birth cohort.

BACKGROUND: Impaired family functioning has been associated with obesity in children and adolescents, but few longitudinal studies exist. We examined whether family functioning from early to mid-childhood is associated with overweight and obesity in later childhood and adolescence. METHODS: We examined data from the Quebec Longitudinal Study of Child Development (QLSCD), a birth cohort (N = 2120), collected between 1998 and 2011. Parent-reported family functioning was assessed at 4 time points between ages 0.5 and 8 years using the McMaster Family Assessment Device with established cut-offs for impaired family functioning. Participants were classified as having experienced: 1) early-childhood impaired functioning, 2) mid-childhood impaired functioning, 3) both early and mid-childhood impaired functioning, or 4) always healthy family functioning. Overweight and obesity were determined at 10- and 13-years using WHO criteria. Covariate adjusted multinomial logistic regressions were fitted to the data to examine associations between longitudinal family functioning groups (using the always healthy functioning as reference category) and the likelihood of having overweight and obesity (vs normal weight) at ages 10 (n = 1251) and 13 years (n = 1226). RESULTS: In the 10- and 13-year sub-samples, respectively 10.2% and 12.5% of participants had experienced both early and mid-childhood impaired family functioning. Participants in this group had an increased likelihood of having obesity (vs normal weight) at age 10 years [OR = 2.63 (95% CI: 1.36; 5.08)] and at age 13 years [OR = 1.94 (95% CI: 0.99; 3.80] compared to those in the always healthy functioning group. No associations were found for other family functioning categories or for overweight status. CONCLUSION: Approximately one in ten children experienced impaired family functioning throughout early and mid-childhood. Findings suggest a link between impaired functioning across childhood and the development of obesity at 10 years of age and possibly at 13 years of age.

Individual and family characteristics associated with health indicators at entry into multidisciplinary pediatric weight management: findings from the CANadian Pediatric Weight management Registry (CANPWR).

OBJECTIVES: (1) To explore individual and family characteristics related to anthropometric and cardiometabolic health indicators and (2) examine whether characteristics that correlate with cardiometabolic health indicators differ across severity of obesity at time of entry to Canadian pediatric weight management clinics. METHODS: We conducted a cross-sectional analysis of 2-17 year olds with overweight or obesity who registered in the CANadian Pediatric Weight Management Registry (CANPWR) between May 2013 and October 2017 prior to their first clinic visit. Individual modifiable health behaviors included dietary intake, physical activity, screen time, and sleep. Family characteristics included parental BMI, family medical history, socioeconomic status and family structure. Linear mixed effects stepwise regression analysis was performed to determine which characteristics were related to each health indicator: BMI z-score; waist circumference; waist to height ratio; blood pressure; glycemia; HDL cholesterol; non-HDL cholesterol; triglycerides. RESULTS: This study included 1296 children (mean age ± standard deviation: 12.1 ± 3.5 years; BMI z-score: 3.55 ± 1.29; 95.3% with obesity). Hours spent sleeping (estimated ß = -0.10; 95% CI [-0.15, -0.05], p = 0.0001), hours per week of organized physical activity (estimated ß = -0.32; 95% CI [-0.53, -0.11], p = 0.0026), daily sugared drink intake (estimated ß = 0.06; 95% CI [0.01, 0.10], p = 0.0136) and maternal BMI (estimated ß = 0.03; 95% CI [0.02, 0.04], p < 0.0001) were associated with BMI z-score (adj. R2 = 0.2084), independent of other individual and family characteristics. Physical activity, total sugared drink intake and sleep duration were associated with glycemia and non-HDL cholesterol, independent of child BMI z-score. However, irrespective of obesity severity, little of the variance (0.86-11.1%) in cardiometabolic health indicators was explained by individual modifiable health behaviors. CONCLUSIONS: Physical activity, total sugared drink intake and hours spent sleeping were related to anthropometric and some cardiometabolic health indicators in children entering pediatric weight management programs. This highlights the importance of these modifiable health behaviors on multiple health indicators in children with obesity.

Re-referring Children for Multidisciplinary Obesity Management.

OBJECTIVES: To examine characteristics of children referred for obesity management based on referral frequency, child- and referrer-related variables associated with re-referral, and determine whether re-referral increased treatment initiation. STUDY DESIGN: This population-level, retrospective analysis included all 2- to 17-year-olds referred for obesity management to 1 of 3 multidisciplinary clinics in Alberta, Canada between April 2013 and December 2017. Children were dichotomized based on referral frequency, specifically once only or more than once (re-referred). Data were retrieved from standardized referral forms and patient registries. Analyses included logistic regression and generalized estimating equations models. RESULT: We analyzed data from 2745 children (47.2% female; mean age: 11.4 years; mean body mass index z score: 3.03) and 2705 physicians (60.2% female; 65.6% pediatricians). Overall, 300 (10.2%) children were re-referred with most (n = 276; 92.0%) being referred twice. Children were less likely to be re-referred if they were referred by a family physician (vs pediatrician) (aOR 0.62; 95% CI 0.46-0.84; P = .0018) or scheduled a clinic appointment following their index referral (aOR: 0.29; 95% CI 0.21-0.4; P < .001). Treatment initiation was higher in children who were referred once only (42.1%) vs their re-referred peers (18.0%; P < .0001); however, for children who were re-referred, they were more likely to initiate treatment following their second referral (aOR 2.3; 95% CI 1.22-4.31; P = .01). This improvement was not sustained on subsequent referrals (aOR 0.44; 95% CI 0.17-1.12; P = .08). CONCLUSIONS: Few children were re-referred for pediatric obesity management; however, for those children who were re-referred, being re-referred once only increased the likelihood of treatment initiation.

Behavioural change as a theme that integrates behavioural sciences in dental education.

The behavioural sciences curriculum in dental education is often fragmented and its clinical relevance is not always apparent to learners. Curriculum integration is vital to understand behavioural subjects that are interrelated but frequently delivered as separate issues in dental programmes. In this commentary, we discuss behavioural change as a curricular theme that can integrate behavioural sciences in dental programmes. Specifically, we discuss behavioural change in the context of dental education guidelines and describe four general phases of behavioural change (defining the target behaviour, identifying the behavioural determinants, applying appropriate behavioural change techniques and evaluating the behavioural intervention) to make the case for content that can be covered within this curricular theme, including its sequencing. This commentary is part of ongoing efforts to improve the behavioural sciences curriculum in dental education in order to ensure that dental students develop the behavioural competencies required for entry-level general dentists.

Physician-related predictors of referral for multidisciplinary paediatric obesity management: a population-based study.

BACKGROUND: It is recommended that primary care-based physicians refer children with overweight and obesity to multidisciplinary paediatric obesity management, which can help to improve weight and health. OBJECTIVE: To determine predictors of referral to multidisciplinary paediatric obesity management. METHODS: This retrospective, population-level study included physicians who could refer 2-17 years old with a body mass index ≥85th percentile to one of three multidisciplinary paediatric obesity management clinics in Alberta, Canada. Physician demographic and procedural data were obtained from Practitioner Claims and Provider Registry maintained by Alberta Health from January 2014 to December 2017. Physician characteristics were compared based on whether they did or did not refer children for obesity management. Univariable and multivariable logistic regression models analysed associations between physician characteristics and referral making. RESULTS: Of the 3863 physicians (3468 family physicians, 395 paediatricians; 56% male; 49.3 ± 12.2 years old; 22.3 ± 12.6 years since graduation) practicing during the study period, 1358 (35.2%) referred at least one child for multidisciplinary paediatric obesity management. Multivariable regression revealed that female physicians (versus males) [odds ratio (OR): 1.68, 95% confidence interval (CI): 1.46-1.93; P < 0.0001], paediatricians (versus family physicians) (OR: 4.89, 95% CI: 3.85-6.21; P < 0.0001) and urban-based physicians (versus non-urban-based physicians) (OR: 2.17, 95% CI: 1.79-2.65; P < 0.0001) were more likely to refer children for multidisciplinary paediatric obesity management. CONCLUSIONS: Approximately one-third of family physicians and paediatricians referred children for multidisciplinary paediatric obesity management. Strategies are needed to improve referral practices for managing paediatric obesity, especially among male physicians, family physicians and non-urban-based physicians as they were less likely to refer children.

Paediatric overweight and obesity impact one-third of children in Canada and the USA. It is recommended that physicians refer children with overweight and obesity to paediatric obesity management, which can help to improve their weight and health. While referral practices of US physicians have been well characterized, Canadian evidence remains limited. To address this gap, we examined predictors of referral making for paediatric obesity management. Our study included physicians (family physicians and paediatricians) who could refer 2­17 years old with overweight and obesity to three paediatric weight management clinics in Alberta, Canada between January 2014 and December 2017. Descriptive analyses and regression models were performed. Of the 3863 physicians practicing during the study period, 1358 (35.2%) referred at least one child for paediatric obesity management. Referring physicians were more likely to be female, paediatricians and practicing in urban-based clinics. Additional research is needed to explore physicians' decisions to refer children for obesity management, which can inform interventions to enhance referral, and ultimately, improve the health and well-being of children with obesity.

Recommendations from parents, administrative staff and clinicians to improve paediatric ambulatory appointment scheduling.

BACKGROUND: Stakeholders can provide valuable input to improve scheduling paediatric ambulatory clinic appointments, a complex process that requires effective planning and communication between parents, administrative staff and clinicians. The purpose of our study was to characterize recommendations from parents, administrative staff and clinicians to improve paediatric ambulatory appointment scheduling. METHODS: Conducted between February 2018 and January 2019, this qualitative study was guided by qualitative description. Data collection was completed using focus groups with three stakeholder groups: parents, administrative staff and clinicians. Participants provided recommendations to optimize paediatric ambulatory appointment scheduling at the Stollery Children's Hospital in Edmonton, Alberta, Canada. Focus group data were transcribed verbatim and analysed using manifest inductive content analysis. RESULTS: Forty-six participants (mean age: 42.7; 87% female) participated in 12 focus groups. Parents (n = 11), administrative staff (n = 22) and clinicians (n = 13) made recommendations that were organized into two categories: appointment triaging and arranging. Triaging recommendations were related to appointment availability (e.g. providing alternatives to cancelling clinics with short notice) and waitlist management (e.g. developing clear and consistent policies regarding information flow and communication between clinics and administrative staff). Appointment arranging recommendations referred to booking (e.g. directly involving parents in the booking process), reminders (e.g. using text message reminders) and attendance (e.g. providing parents with a single point of contact who can provide the correct information about late and cancellation policies). Recommendations were similar across stakeholder groups. CONCLUSION: Our findings showed congruent recommendations across stakeholder groups to address challenges with scheduling ambulatory appointments, many of which have the potential to be modified. Experimental research and quality improvement initiatives are needed to determine the feasibility, acceptability and effectiveness of stakeholder recommendations to improve triaging and scheduling paediatric ambulatory appointments.

Effectiveness and safety of interventions to manage childhood overweight and obesity: An Overview of Cochrane systematic reviews.

BACKGROUND: Childhood overweight and obesity are associated with adverse physical, social, and psychological outcomes. OBJECTIVES: We conducted an overview of Cochrane systematic reviews on the effectiveness and risks of interventions to treat overweight and obesity in children and adolescents. METHODS: In June 2019, we searched the Cochrane Database of Systematic Reviews for eligible reviews. The primary outcomes were change in adiposity (body mass and body mass index [BMI] z-score) and adverse events. Two reviewers screened studies and one reviewer extracted and another verified data. Two reviewers assessed methodological quality and reached consensus. Data were synthesized narratively. RESULTS: We included seven Cochrane reviews published between 2011 and 2017 containing evidence from 167 randomized controlled trials with 21,050 participants. Lifestyle and behavioural interventions more effectively reduced weight compared with no intervention, usual care, or another behavioural treatment (three reviews, low-to-moderate certainty). Parent-child lifestyle and behavioural interventions more effectively reduced BMI z-score compared with no intervention (one review, low certainty). Decision support tools for healthcare providers more effectively limited increases in BMI z-score compared with usual care (one review, moderate certainty). Pharmacologic treatments combined with behavioural modification more effectively reduced adiposity compared with placebo or usual care (one review, low certainty), but the risk of adverse events was greater than non-pharmacologic therapy. Surgical interventions (e.g., LAP-BAND) combined with behavioural modification more effectively reduced adiposity compared with behavioural modification alone (one review, low certainty). Those who underwent surgery reported a higher number of adverse events compared with those treated with lifestyle modification. CONCLUSIONS: There is low-certainty evidence that lifestyle and behavioural interventions, pharmacologic interventions, and surgical interventions are effective in weight management for children with overweight and obesity. Safety data remain lacking across all intervention modalities. Future research should focus on implementation strategies. Further, a focus on overall well-being may be more beneficial than weight management specifically.

No additional long-term effect of group vs individual family intervention in the treatment of childhood obesity-A randomised trial.

AIM: Long-term evaluations of childhood obesity treatments are needed. We examined changes in weight and cardiometabolic risk 1 year after children completed individual family or group-based weight management interventions. METHODS: In 2009-2010, 6- to 12-year-old children with overweight or obesity from Finnmark and Troms (Norway) were recruited after media coverage and randomised to 24 months of individual family (n = 49) or group intervention (n = 48). Individual family intervention included counselling by a paediatric hospital team and a public health nurse in the local community. Group intervention included meetings with other families and a multidisciplinary hospital team, weekly physical activity sessions and a family camp. The primary outcome body mass index (BMI) and cardiometabolic risk factors were analysed 12 months after intervention. RESULTS: From baseline to 36 months, children's BMI increased 3.0 kg/m2 in individual family and 2.1 kg/m2 in group intervention (between-group -0.9kg/m2 , P = 0.096). Data were available from 62 children (64%). Between-group differences in C peptide (P = 0.01) were detected in favour of group intervention. Pooled data from both treatment groups showed continued decrease in BMI standard deviation score (P < 0.001). CONCLUSION: No between-group difference in BMI was observed 12 months after intervention. Both groups combined showed sustained decrease in BMI standard deviation score.

Helping children and families to enrol in weight management: What can stakeholders do?

Many children and their families do not benefit from multidisciplinary clinical care (MCC) for paediatric weight management because they do not enrol in (initiate) treatment. The purpose of this report was to highlight practical recommendations to enhance the enrolment of Canadian children in MCC, which were drawn from multisite Canadian studies (quantitative and qualitative) that we completed recently. Recommendations to stakeholders, including primary care providers, MCC providers and decisions makers, were organized according to opportunities, motivation and barriers to enrol. Findings from our research suggested that enrolment in MCC can be improved by increasing opportunities and motivation to enrol as well as reducing the impact of enrolment barriers.

Parent Recommendations to Enhance Enrollment in Multidisciplinary Clinical Care for Pediatric Weight Management.

OBJECTIVE: To explore parents' recommendations to enhance enrollment in multidisciplinary clinical care for managing pediatric obesity. STUDY DESIGN: Data for this interpretative description study were collected through individual, semistructured interviews that were audiorecorded, transcribed verbatim, and analyzed thematically. Parents (n = 79) were recruited from 4 multidisciplinary weight management clinics in Canada located in Edmonton, Hamilton, Montreal, and Vancouver. RESULTS: Most interviewed parents had children with obesity (body mass index ≥95th percentile; 84.2%), were female (87.3%), had postsecondary education (69.6%), and were white (75.9%). Parents' recommendations referred to enrollment opportunities, information about obesity services, motivation for treatment, and accessibility to obesity services. Specifically, parents recommended to increase referral options and follow-up contacts with families during the enrollment process, inform referring physicians and families about the availability and characteristics of obesity services, enhance families' motivation for treatment, prevent families from getting discouraged, make services more appealing to families, and address accessibility issues (eg, offering multiple options for appointment times, providing support for transportation). CONCLUSIONS: Parents' recommendations support the need for family-centered approaches to enhance enrollment; however, their feasibility, acceptability, and effectiveness remain to be tested empirically.

Predicting Enrollment in Multidisciplinary Clinical Care for Pediatric Weight Management.

OBJECTIVES: To characterize the children who were referred, determine the proportion of referred children who enrolled, and examine factors associated with enrollment in multidisciplinary clinical care for pediatric weight management. STUDY DESIGN: This cross-sectional study included the population of children (2-17 years of age; body mass index of ≥85th percentile) referred to 1 of 3 hospital-based multidisciplinary weight management clinics in Alberta, Canada, from April 2013 to April 2016. Referral and enrollment data were obtained from Alberta Health Services databases. Bivariate and multivariable logistic regression models were used to determine the independent and combined effects of predictors of enrollment. RESULTS: Of the 2014 children (51.8% male; mean body mass index z-score: 3.42 ± 0.03) referred to multidisciplinary clinical care, 757 (37.6%) enrolled in care. Most referred children had severe obesity and were referred by physicians. Several factors independently predicted enrollment; however, in our most parsimonious multivariable model, only the time gap (OR, 0.94; 95% CI, 0.88-0.99; P = .03) between the attendance date of the orientation session and the booking date of initial appointment predicted enrollment for all children. Body mass index z-score (OR, 0.81; 95% CI, 0.67-0.98; P = .03) and time gap (OR, 0.92; 95% CI, 0.85-0.99; P = .02) predicted enrollment in children with severe obesity exclusively. CONCLUSIONS: Fewer than 40% of referred children enrolled in multidisciplinary clinical care. Reducing the duration of enrollment and providing additional support for treatment initiation to children with severe obesity may enhance treatment uptake for pediatric weight management.

The CANadian Pediatric Weight management Registry (CANPWR): lessons learned from developing and initiating a national, multi-centre study embedded in pediatric clinical practice.

BACKGROUND: There is increasing recognition of the value of "real-world evidence" in evaluating health care services. Registry-based, observational studies conducted in clinical settings represent a relevant model to achieve this directive. Starting in 2010, we undertook a longitudinal, observational study (the CANadian Pediatric Weight management Registry [CANPWR]), which is embedded in 10 multidisciplinary, pediatric weight management clinics across Canada. The objective of this paper was to share the lessons our team learned from this multi-centre project. METHODS: Data sources included a retrospective review of minutes from 120 teleconferences with research staff and investigators, notes taken during clinical site visits made by project leaders, information from quality control processes to ensure data accuracy and completeness, and a study-specific survey that was sent to all sites to solicit feedback from research team members (n = 9). Through an iterative process, the writing group identified key themes that surfaced during review of these information sources and final lessons learned were developed. RESULTS: Several key lessons emerged from our research, including the (1) value of pilot studies and central research coordination, (2) need for effective and regular communication, (3) importance of consensus on determining outcome measures, (4) challenge of embedding research within clinical practice, and (5) difficulty in recruiting and retaining participants. The sites were, in spite of these challenges, enthusiastic about the benefits of participating in multi-centre collaborative studies. CONCLUSION: Despite some challenges, multi-centre observational studies embedded in pediatric weight management clinics are feasible and can contribute important, practical insights into the effectiveness of health services for managing pediatric obesity in real-world settings.

Families' perceived benefits of home visits for managing paediatric obesity outweigh the potential costs and barriers.

AIM: Home visits have successfully been used to deliver various health services, but what role could they play in paediatric weight management? Low treatment initiation and high attrition prompted our multidisciplinary paediatric weight management clinic to investigate how families perceived the benefits and barriers of home visits. METHODS: We focused on children with obesity aged 2-17 who were enrolled in our tertiary-level clinic in Alberta, Canada. None had received a home visit. The families were interviewed face-to-face from October 2015 to October 2016, and we used a qualitative description methodological framework and manifest content analysis. The parents were the main interviewees. RESULTS: Of the 56 families, 89% were interested in a home visit, 82% wanted support from a dietician and 54% from an exercise specialist. The perceived benefits of home visits included comprehensive assessment (95%), convenience (86%), tailored care (29%) and family involvement (13%), while the costs and barriers included clinicians' potential judgmental attitudes (30%), loss of privacy (19%) and distractions (10%). Some thought clinicians would find home visits inconvenient (25%), with bureaucratic challenges (14%) and sustainability issues (5%). CONCLUSION: Families felt home visits were a convenient option for managing paediatric obesity and identified important benefits and barriers that could guide such interventions.

Weight up? Changes in children's anthropometry from time of referral to baseline assessment for paediatric weight management.

OBJECTIVES: To examine children's wait time to access a multidisciplinary, tertiary-level weight management clinic and assess anthropometric changes from time of referral to baseline assessment. METHOD: A retrospective medical record review was completed of children (5 to 17 years) enrolled in a multidisciplinary, tertiary-level paediatric weight management clinic from 2006 to 2015. Children's demographic and anthropometric data from their referral to and baseline assessment at the clinic were retrieved from medical records. Based on changes in body mass index (BMI) z-score from the time of referral to baseline assessment, children were categorized as decreasers (>0.05 unit decrease), increasers (>0.05 unit increase) or stabilizers (-0.05 to 0.05 unit change). The proportion of children with a ≥0.25 unit BMI z-score reduction was calculated. Analysis of variance and chi-squared tests were performed. RESULTS: Children (n=400) were 11.7 ± 2.9 years old at the time of referral, 52.8% (n=211) female, and had an average wait time of 4.5 ± 3.9 months. By 3 and 6 months postreferral, 44.0% (n=176) and 80.8% (n=323), respectively, had attended baseline assessments. Based on BMI z-score change, children were classified as decreasers (n=183; 45.8%), increasers (n=118; 29.5%) or stabilizers (n=99; 24.8%). One-fifth of children (n=86; 21.5%) experienced a BMI z-score reduction ≥0.25 units, a subgroup that was younger, had a higher BMI z-score at referral, and had a longer wait time between referral and baseline assessment (all P<0.05). CONCLUSIONS: Most children who enrolled in paediatric weight management initiated treatment within six months and experienced a modest decrease or stabilization in BMI z-score during their wait time.

The readiness and motivation interview for families (RMI-Family) managing pediatric obesity: study protocol.

BACKGROUND: Experts recommend that clinicians assess motivational factors before initiating care for pediatric obesity. Currently, there are no well-established clinical tools available for assessing motivation in youth with obesity or their families. This represents an important gap in knowledge since motivation-related information may shed light on which patients might fail to complete treatment programs. Our study was designed to evaluate the measurement properties and utility of the Readiness and Motivational Interview for Families (RMI-Family), a structured interview that utilizes a motivational interviewing approach to (i) assess motivational factors in youth and their parents, and (ii) examine the degree to which motivation and motivation-related concordance between youth and parents are related to making changes to lifestyle habits for managing obesity in youth. METHODS: From 2016 to 2020, this prospective study will include youth with obesity (body mass index [BMI] ≥97th percentile; 13-17 years old; n = 250) and their parents (n = 250). The study will be conducted at two primary-level, multidisciplinary obesity management clinics based at children's hospitals in Alberta, Canada. Participants will be recruited and enrolled after referral to these clinics, but prior to initiating clinical care. Each youth and their parent will complete the RMI-Family (~1.5 h) at baseline, and 6- and 12-months post-baseline. Individual (i.e., youth or parent) and family-level (i.e., across youth and parent) responses to interview questions will be scored, as will aspects of interview administration (e.g., fidelity to motivational interviewing tenets). The RMI-Family will also be examined for test-retest reliability. Youth data collected at each time point will include demography, anthropometry, lifestyle habits, psychosocial functioning, and health services utilization. Cross-sectional and longitudinal associations between individual and family-level interview scores on the RMI-Family and these clinical measures will be examined. DISCUSSION: As a measurement tool drawing on family-centered care and motivational interviewing, the RMI-Family was designed to increase understanding of the role of motivational factors in pediatric obesity management, allowing healthcare providers and policymakers to manage pediatric obesity more effectively and efficiently. Findings will help to create an innovative, tailored model of health care delivery that uses resources judiciously and is designed to best meet families' needs.