Differences in areal bone mineral density between metabolically healthy and unhealthy overweight/obese children: the role of physical activity and cardiorespiratory fitness.

OBJECTIVES: To examine whether areal bone mineral density (aBMD) differs between metabolically healthy (MHO) and unhealthy (MUO) overweight/obese children and to examine the role of moderate-to-vigorous physical activity (MVPA) and cardiorespiratory fitness (CRF) in this association. METHODS: A cross-sectional study was developed in 188 overweight/obese children (10.4 ± 1.2 years) from the ActiveBrains and EFIGRO studies. Participants were classified as MHO or MUO based on Jolliffe and Janssen's metabolic syndrome cut-off points for triglycerides, glucose, high-density cholesterol and blood pressure. MVPA and CRF were assessed by accelerometry and the 20-m shuttle run test, respectively. Body composition was measured by dual-energy X-ray absorptiometry. RESULTS: In model 1 (adjusted for sex, years from peak high velocity, stature and lean mass), MHO children had significantly higher aBMD in total body less head (Cohen's d effect size, ES = 0.34), trunk (ES = 0.43) and pelvis (ES = 0.33) than MUO children. These differences were attenuated once MVPA was added to model 1 (model 2), and most of them disappeared once CRF was added to the model 1 (model 3). CONCLUSIONS: This novel research shows that MHO children have greater aBMD than their MUO peers. Furthermore, both MVPA and more importantly CRF seem to partially explain these findings.

Associations of physical activity and fitness with hepatic steatosis, liver enzymes, and insulin resistance in children with overweight/obesity.

BACKGROUND: Non-alcoholic fatty liver disease is the most common liver disease in childhood and is related to insulin resistance and cardiometabolic risk factors. Evidence supporting the association of fitness and physical activity with hepatic fat, liver enzymes, or triglyceride-to-high-density lipoprotein ratio is scarce in children. OBJECTIVE: To analyze the associations of physical fitness and physical activity (PA) with percentage hepatic fat, liver enzymes, insulin resistance, and cardiometabolic risk in children with overweight/obesity. SUBJECTS: A total of 115 children (10.6 ± 1.1 years; 54% girls) with overweight/obesity of the EFIGRO study (ClinicalTrials.gov: NCT02258126) were included in the analyses. METHODS: Cardiorespiratory fitness (CRF), musculoskeletal fitness and speed-agility were measured by the Alpha-fitness tests, and PA by wGT3X-BT accelerometers. Percentage hepatic fat was assessed by magnetic resonance imaging. Alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT), aspartate aminotransferase (AST), insulin, glucose, triglycerides (TG), and high-density lipoprotein (HDL) levels were obtained from fasting blood samples. The homeostasis model assessment insulin resistance (HOMA-IR) and AST/ALT and TG/HDL ratios were calculated. RESULTS: Higher CRF was associated with lower percentage hepatic fat (ß = -0.266, P = .01) and GGT (ß = -0.315, P < .01), and higher AST/ALT ratio (ß = 0.306, P < .01). CRF-fit children have lower GGT levels (15 ± 1 vs 17 ± 1 U/L, CRF-fit vs CRF-unfit children, P = .02), HOMA-IR (2.2 ± 0.1 vs 2.9 ± 0.1, P < .01) and TG/HDL ratio (1.4 ± 0.1 vs 1.9 ± 0.1, P = .01) and higher AST/ALT ratio (1.3 ± 0.0 vs 1.2 ± 0.0, P = .03), than CRF-unfit children. CONCLUSIONS: These findings emphasize the importance of considering the improvement of CRF as a target of programs for preventing hepatic steatosis, type 2 diabetes and cardiovascular diseases in children with overweight.

Prevalence of responders for hepatic fat, adiposity and liver enzyme levels in response to a lifestyle intervention in children with overweight/obesity: EFIGRO randomized controlled trial.

BACKGROUND/OBJECTIVE: Exercise and lifestyle interventions have been shown to reduce hepatic fat (HF) and adiposity in youth. However, the interindividual response in HF after a lifestyle intervention with or without exercise in children is unknown. The aim of the present study was to compare interindividual variability for HF, adiposity, gamma-glutamyl transferase (GGT), and the aspartate aminotransferase to alanine aminotransferase ratio (AST/ALT) in children with overweight/obesity participating in a 22-week lifestyle intervention with (intensive intervention) or without exercise (control intervention). METHODS: Data from 102 children (9-12 years, 55% girls) with overweight/obesity participating in the EFIGRO randomized controlled trial were analyzed. Percentage HF (magnetic resonance imaging), weight, body and fat mass index (BMI and FMI), GGT, AST/ALT, cardiorespiratory fitness (CRF, 20 meters shuttle run test) were assessed before and after the intervention by the same trained researchers. The control intervention consisted in 11 sessions of a family-based lifestyle and psycho-educational program. The intensive intervention included the control intervention plus supervised exercise (3 sessions/week). RESULTS: The prevalence of responders for HF (54% vs. 34%), weight (27% vs. 11%), BMI (71% vs. 47%), FMI (90% vs. 60%), and GGT (69% vs. 39%) was higher in the intensive than in the control group (Ps < 0.05). Responders for weight (16 ± 3 vs. 6 ± 2 laps) and BMI (11 ± 2 vs. 3 ± 4 laps) improved more CRF levels than non-responders (Ps < 0.05). CONCLUSIONS: The addition of exercise to a lifestyle intervention may increase the responder rates for HF, adiposity, and GGT in children with overweight/obesity. Improvements in CRF may explain differences between weight and BMI responders and non-responders. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02258126.

Dietary determinants of hepatic fat content and insulin resistance in overweight/obese children: a cross-sectional analysis of the Prevention of Diabetes in Kids (PREDIKID) study.

Paediatric non-alcoholic fatty liver disease has increased in parallel with childhood obesity. Dietary habits, particularly products rich in sugars, may influence both hepatic fat and insulin resistance (homeostatic model assessment for insulin resistance (HOMA-IR)). The aim of the study was to examine the association of the consumption of foods and food components, dairy desserts and substitutes (DDS), sugar-sweetened beverages (SSB), as well as total and added sugars, with hepatic fat and HOMA-IR. Dietary intake (two non-consecutive 24 h-recalls), hepatic fat (MRI) and HOMA-IR were assessed in 110 overweight/obese children (10·6 (sd 1·1) years old). Linear regression analyses were used to examine the association of dietary intake with hepatic fat and HOMA-IR adjusted for potential confounders (sex, age, energy intake, maternal educational level, total and abdominal adiposity and sugar intake). The results showed that there was a negative association between cereal intake and hepatic fat (ß=-0·197, P<0·05). In contrast, both SSB consumption (ß=0·217; P=0·028) and sugar in SSB (ß=0·210, P=0·035), but not DDS or sugar in DDS or other dietary components, were positively associated with hepatic fat regardless of potential confounders including total sugar intake. In conclusion, cereal intake might decrease hepatic fat, whereas SSB consumption and its sugar content may increase the likelihood of having hepatic steatosis. Although these observations need to be confirmed using experimental evidence, these results suggest that healthy lifestyle intervention programs are needed to improve dietary habits as well as to increase the awareness of the detrimental effects of SSB consumption early in life.

Associations of dietary energy density with body composition and cardiometabolic risk in children with overweight and obesity: role of energy density calculations, under-reporting energy intake and physical activity.

This study examined (1) the association of dietary energy density from solid (EDS) and solid plus liquids (EDSL) with adiposity and cardiometabolic risk factors (CRF) in children with overweight and obesity, (2) the effect of under-reporting on the mentioned associations and (3) whether the association between ED and body composition and CRF is influenced by levels of physical activity. In a cross-sectional design, 208 overweight and obese children (8-12-year-old; 111 boys) completed two non-consecutive 24 h recalls. ED was calculated using two different approaches: EDS and EDSL. Under-reporters were determined with the Goldberg method. Body composition, anthropometry and fasting blood sample measurements were performed. Moderate to vigorous physical activity (MVPA) was registered with accelerometers (7-d-register). Linear regressions were performed to evaluate the association of ED with the previously mentioned variables. Neither EDS nor EDSL were associated with body composition or CRF. However, when under-reporters were excluded, EDS was positively associated with BMI (P=0·019), body fat percentage (P=0·005), abdominal fat (P=0·008) and fat mass index (P=0·018), while EDSL was positively associated with body fat percentage (P=0·008) and fat mass index (P=0·026). When stratifying the group according to physical activity recommendations, the aforementioned associations were only maintained for non-compliers. Cluster analysis showed that the low-ED and high-MVPA group presented the healthiest profile for all adiposity and CRF. These findings could partly explain inconsistencies in literature, as we found that different ED calculations entail distinct results. Physical activity levels and excluding under-reporters greatly influence the associations between ED and adiposity in children with overweight and obesity.

Adherence to the Mediterranean diet in metabolically healthy and unhealthy overweight and obese European adolescents: the HELENA study.

PURPOSE: To examine the adherence to the Mediterranean dietary pattern (MDP) in metabolically healthy overweight or obese (MHO) and metabolically unhealthy obese (MUO) European adolescents. METHODS: In this cross-sectional study, 137 overweight/obese adolescents aged 12-17 years old from the HELENA study were included. Height, weight, waist circumference and skinfold thickness were measured and body mass index and body fat percent were calculated. Systolic and diastolic blood pressure, glucose, HDL cholesterol, triglycerides and cardiorespiratory fitness (20 m shuttle run test) were measured. MHO and MUO phenotypes were categorized following the Jolliffe and Janssen criteria. Two non-consecutive 24 h recalls were used for dietary intake assessment and the adherence to the MDP was calculated using the Mediterranean dietary pattern score (MDP score) (range 0-9). RESULTS: A total of 45 (22 girls) adolescents (32.8%) were categorized as MHO. The adherence to the MDP was significantly higher in MHO than in MUO adolescents regardless of age, sex, body fat percentage, energy intake and center (MDP score: 4.6 ± 1.6 vs. 3.9 ± 1.5, p = 0.036), but this difference became non-significant after further adjustment for cardiorespiratory fitness. Participants who had a low adherence to the MDP (MDP score ≤ 4) had a higher likelihood of having MUO phenotype regardless of sex, age, energy intake, center and body fat percentage (OR 2.2; 95% CI 1.01-4.81, p = 0.048). CONCLUSIONS: Adherence to the MDP might be beneficial to maintain metabolic health in overweight/obese adolescents, yet cardiorespiratory fitness seems to play a key role on the metabolic phenotype.

Hepatic fat content and bone mineral density in children with overweight/obesity.

OBJECTIVES: To examine the influence of non-alcoholic fatty liver disease (NAFLD) and hepatic fat content on bone mineral density (BMD), and to investigate whether the relationship between NAFLD and BMD is independent of lifestyle factors related to BMD. METHODS: Hepatic fat content (magnetic resonance imaging), BMD, lean mass index, total and abdominal fat mass (dual-energy-X-ray absorptiometry), moderate to vigorous physical activity (MVPA) (accelerometry), and calcium and vitamin D intake (two 24 h recalls) were measured in 115 children with overweight/obesity aged 10.6 ± 1.1 years old. RESULTS: Children with NAFLD had lower BMD than children without NAFLD regardless of sex, puberty stage, lean mass index, fat mass, MVPA, and calcium and vitamin D intake (0.89 ± 0.01 vs. 0.93 ± 0.01 g/cm2 for NAFLD and non-NAFLD, respectively, P < 0.01). Higher hepatic fat content was significantly associated with lower BMD regardless of confounders (adjusted P < 0.05). CONCLUSIONS: Findings of the current study suggest that hepatic fat accumulation is associated with decreased BMD independently of adiposity, and regardless of those lifestyle factors closely related to bone mineral accrual in children. These results may have implication in the clinical management of children with overweight/obesity given the high prevalence of pediatric NAFLD.

Associations between the adherence to the Mediterranean diet and cardiorespiratory fitness with total and central obesity in preschool children: the PREFIT project.

PURPOSE: Early recognition of risk factors associated with overweight/obesity is an important step towards preventing long-term health consequences. The aim of the current study was to examine the associations of the adherence to the Mediterranean dietary pattern (MDP) and cardiorespiratory fitness (CRF) with adiposity in preschool children from the north of Spain. METHODS: The adherence to the MDP (KIDMED), CRF (20-m shuttle run test), total (BMI) and central (waist circumference) adiposity and socio-demographic factors were assessed in 619 children (48.6% girls) who were on average 4.7 years old. RESULTS: Higher MDP index (P < 0.05) and CRF levels (P < 0.01) were significantly related to lower waist circumference. CRF was inversely associated with BMI (P ≤ 0.001), yet no significant association was observed between MDP and BMI. Children not having high CRF levels and high MDP (i.e., non-upper sex-specific tertile of CRF or MDP, respectively) had the highest waist circumference. CONCLUSIONS: Our findings support that higher adherence to the MDP and higher CRF are associated with lower waist circumference in preschool children, pointing them as relevant modifiable factors to be targeted by educational strategies aiming to prevent central obesity and later obesity-related comorbidities.

Clinical, physical, physiological, and dietary patterns of obese and sedentary adults with primary hypertension characterized by sex and cardiorespiratory fitness: EXERDIET-HTA study.

The main purpose of this study was to determine some key physical, physiological, clinical, and nutritional markers of health status in obese and sedentary adults (54.0 ± 8.1 years, 141 men and 68 women) with primary hypertension (HTN) characterized by sex and cardiorespiratory fitness (CRF) level. The studied population showed a high cardiovascular risk (CVR) profile including metabolically abnormal obese, with poor CRF level (22.5 ± 5.6 mL·kg-1·min-1), exercise-induced HTN (Systolic Blood Pressure>210 mmHg in men and >190 mmHg in women at the end of the exercise test) and with non-healthy adherence to dietary pattern (Dietary Approaches to Stop Hypertension, 46.3%; Mediterranean Diet, 41.1%; and Healthy Diet Indicator, 37.1%). Women showed a better biochemical and dietary pattern profile than men (lower values, P < 0.05, in triglycerides, mean difference = 26.3; 95% CI = 0.9-51.7 mg/dL, aspartate transaminase, mean difference = 4.2; 95% CI = 0.3-8.0 U/L; alanine transaminase, mean difference = 8.2; 95% CI = 1.6-14.8 U/L; gamma-glutamyl transpeptidase, mean difference = 11.0; 95% CI = -1.1-23.2 U/L and higher values, P = 0.002, in high-density lipoprotein cholesterol, mean difference = 5.0, 95% CI = -13.3-3.3 mg/dL), but physical and peak exercise physiological characteristics were poorer. A higher CRF level might contribute to the attenuation of some CVR factors, such as high body mass index, non-dipping profile, and high hepatic fat. The results strongly suggest that targeting key behaviors such as improving nutritional quality and CRF via regular physical activity will contribute to improving the health with independent beneficial effects on CVR factors.

Effects of a Family-Based Lifestyle Intervention Plus Supervised Exercise Training on Abdominal Fat Depots in Children With Overweight or Obesity: A Secondary Analysis of a Nonrandomized Clinical Trial.

Importance: Excess abdominal fat is a major determinant in the development of insulin resistance and other metabolic disorders. Increased visceral adipose tissue (VAT) seems to precede the development of insulin resistance and is therefore a prime target of childhood lifestyle interventions aimed at preventing diabetes. Objectives: To examine the effect of added exercise to a family-based lifestyle intervention program designed to reduce VAT plus subcutaneous (ASAT), intermuscular (IMAAT), and pancreatic (PAT) adipose tissue in children with overweight or obesity and to explore the effect of changes in VAT on insulin resistance. Design, Setting, and Participants: This 2-group, parallel-design clinical trial was conducted in Vitoria-Gasteiz, Spain. A total of 116 children with overweight or obesity participated and were assigned to a 22-week family-based lifestyle program (control group [n = 57]) or the same program plus an exercise intervention (exercise group [n = 59]). Data were collected between September 1, 2014, and June 30, 2017, and imaging processing for fat depot assessments and data analysis were performed between May 1, 2019, and February 12, 2021. Interventions: The compared interventions consisted of a family-based lifestyle and psychoeducation program (two 90-minute sessions per month) and the same program plus supervised exercise (three 90-minute sessions per week). Main Outcomes and Measures: The primary outcome of this study was the change in VAT between baseline and 22 weeks as estimated by magnetic resonance imaging. The secondary outcomes were changes in ASAT, IMAAT, and PAT. The effect of changes in VAT area on insulin resistance was also recorded. Results: The 116 participants included in the analysis (62 girls [53.4%]) had a mean (SD) age of 10.6 (1.1) years, and 67 (57.8%) presented with obesity. Significantly greater reductions were recorded for the exercise group in terms of reduction in VAT (-18.1% vs -8.5% for the control group; P = .004), ASAT (-9.9% vs -3.0%; P = .001), and IMAAT (-6.0% vs -2.6%; P = .02) fat fractions compared with the control group. Changes in VAT explained 87.6% of the improvement seen in insulin resistance (ß = -0.102 [95% CI, -0.230 to -0.002]). Conclusions and Relevance: These findings suggest that the addition of exercise to a lifestyle intervention program substantially enhanced the positive effects on abdominal fat depots in children with overweight or obesity. In addition, the reduction in VAT seemed to largely mediate the improvement of insulin sensitivity. These results highlight the importance of including exercise as part of lifestyle therapies aimed at treating childhood obesity and preventing the development of type 2 diabetes. Trial Registration: ClinicalTrials.gov Identifier: NCT02258126.

Association between Mediterranean Dietary Pattern and Breakfast Quality with Physical Fitness in School Children: The HIIT Project.

Dietary habits have been linked with health in childhood. However, few studies have examined the association between healthy dietary patterns and physical fitness. Therefore, the aim of this study was to examine the associations of adherence to the Mediterranean dietary pattern (MDP) and breakfast quality with physical fitness in children. Further to this, we examined the role of physical activity in these associations. A total of 175 children (86 girls, 9.7 ± 0.3 years) participated. Adherence to MDP and breakfast quality were assessed by the KIDMED questionnaire and 24 h recall, respectively. Cardiorespiratory fitness, muscular strength, and speed-agility were assessed. Physical activity was evaluated by wrist-worn accelerometers. Greater adherence to the MDP was related with higher cardiorespiratory fitness, lower-limbs muscular strength, and speed-agility (all ß ≥ 0.189, all p ≤ 0.02). No significant associations were observed between breakfast quality and physical fitness (all p > 0.05). However, all the significant associations disappeared after adjusting for physical activity (all p > 0.05). Our study sheds light on the relevance of adhering to the MDP over physical fitness in school children. However, there is no association between breakfast quality and physical fitness. Furthermore, physical activity seems to explain, at least partially, these findings.

Changes in lifestyle behaviours during the COVID-19 confinement in Spanish children: A longitudinal analysis from the MUGI project.

BACKGROUND: Home confinement during the COVID-19 pandemic could have affected lifestyle behaviours of children, however evidence about it is emerging and yet scarce. OBJECTIVES: To examine the effects of the COVID-19 confinement on lifestyle behaviours in Spanish children, and to assess the influence of social vulnerabilities on changes in lifestyle behaviours. METHODS: Physical activity (PA), screen time, sleep time, adherence to the Mediterranean diet (KIDMED) and sociodemographic information were longitudinally assessed before (N = 291, 12.1 ± 2.4 years, 47.8% girls) and during the COVID-19 confinement (N = 113, 12.0 ± 2.6 years, 48.7% girls) by online questionnaires. RESULTS: During the COVID-19 confinement, PA (-91 ± 55 min/d, P < .001) and screen time (±2.6 h/d, P < .001) worsened, whereas the KIDMED score improved (0.5 ± 2.2 points, P < .02). The decrease of PA was higher in children with mother of non-Spanish origin (-1.8 ± 0.2 vs -1.5 ± 0.1 h/d, P < .04) or with non-university studies (-1.7 ± 0.1 vs -1.3 ± 0.1 h/d, P < .005) in comparison to their counterparts. CONCLUSION: This study evidence the negative impact of the COVID-19 confinement on PA levels and sedentary behaviours of Spanish children. These findings should be taken into account to design and implement public health strategies for preserving children´s health during and after the pandemic, particularly, in children with social vulnerabilities.

A sociodemographic, anthropometric and lifestyle-based prediction score for screening children with overweight and obesity for hepatic steatosis: The HEPAKID index.

BACKGROUND: Hepatic steatosis (HS) is currently the most prevalent hepatic disease in paediatric population and a major risk factor for type 2 diabetes and cardiovascular diseases. The proper identification of children with HS is therefore of great public health interest. OBJECTIVE: To develop a new prediction score using anthropometric, sociodemographic and lifestyle factors to identify children with HS (the HEPAKID index). Previously published biochemical paediatric screening tools were validated in the same cohort. METHODS: A total of 115 pre-adolescent children aged 8 to 12 years with overweight/obesity, recruited at hospital paediatric units were enrolled in this cross-sectional study. HS (≥5.5% hepatic fat) was assessed by magnetic resonance imaging (MRI). Anthropometric, sociodemographic and lifestyle variables were collected by validated tests/questionnaires. RESULTS: Forty-one children had MRI-diagnosed HS (35.6%, 49% girls). These children had (P < .01) a higher waist-height ratio, a lower cardiorespiratory fitness, a younger gestational age, and consumed more sugar-sweetened beverages than their HS-free peers. Children with HS were more likely to belong to an ethnic minority (P < .01) and to spend longer viewing screens than recommended (P < .05). The addition of these variables to the multivariate logistic regression model afforded a HEPAKID index with high discriminatory capacity (area under the receiver-operating characteristic curve: 0.808, 95% CI 0.715-0.901), and score of ≥25.0 was associated with high sensitivity (82%, 95% CI 68%-96%). Biochemical biomarker-based paediatric tools for identifying HS showed only moderate discriminatory capacity and low sensitivity (5%-41%) in this cohort. CONCLUSIONS: The HEPAKID index is the first simple, non-invasive, sensitive, inexpensive and easy-to-perform screening that can identify children with overweight or obesity who have HS.

PNPLA3 Genotype, Arachidonic Acid Intake, and Unsaturated Fat Intake Influences Liver Fibrosis in Hispanic Youth with Obesity.

Non-alcoholic fatty liver disease impacts 15.2% of Hispanic adolescents and can progress to a build-up of scared tissue called liver fibrosis. If diagnosed early, liver fibrosis may be reversible, so it is necessary to understand risk factors. The aims of this study in 59 Hispanic adolescents with obesity were to: (1) identify potential biological predictors of liver fibrosis and dietary components that influence liver fibrosis, and (2) determine if the association between dietary components and liver fibrosis differs by PNPLA3 genotype, which is highly prevalent in Hispanic adolescents and associated with elevated liver fat. We examined liver fat and fibrosis, genotyped for PNPLA3 gene, and assessed diet via 24-h diet recalls. The prevalence of increased fibrosis was 20.9% greater in males, whereas participants with the GG genotype showed 23.7% greater prevalence. Arachidonic acid was associated with liver fibrosis after accounting for sex, genotype, and liver fat (ß = 0.072, p = 0.033). Intakes of several dietary types of unsaturated fat have different associations with liver fibrosis by PNPLA3 genotype after accounting for sex, caloric intake, and liver fat. These included monounsaturated fat (ßCC/CG = -0.0007, ßGG = 0.03, p-value = 0.004), polyunsaturated fat (ßCC/CG = -0.01, ßGG = 0.02, p-value = 0.01), and omega-6 (ßCC/CG = -0.0102, ßGG = 0.028, p-value = 0.01). Results from this study suggest that reduction of arachidonic acid and polyunsaturated fatty acid intake might be important for the prevention of non-alcoholic fatty liver disease progression, especially among those with PNPLA3 risk alleles.

The Effect of a Family-Based Lifestyle Education Program on Dietary Habits, Hepatic Fat and Adiposity Markers in 8-12-Year-Old Children with Overweight/Obesity.

Healthy lifestyle education programs are recommended for obesity prevention and treatment. However, there is no previous information on the effects of these programs on the reduction of hepatic fat percentage. The aims were (i) to examine the effectiveness of a 22-week family-based lifestyle education program on dietary habits, and (ii) to explore the associations of changes in dietary intake with percent hepatic fat reduction and adiposity in children with overweight/obesity. A total of 81 children with overweight/obesity (aged 10.6 ± 1.1 years, 53.1% girls) and their parents attended a 22-week family based healthy lifestyle and psychoeducational program accompanied with (intensive group) or without (control) an exercise program. Hepatic fat (magnetic resonance imaging), adiposity (dual energy X-ray absorptiometry) and dietary habits (two non-consecutive 24 h-recalls) were assessed before and after the intervention. Energy (p < 0.01) fat (p < 0.01) and added sugar (p < 0.03) intake were significantly reduced in both groups at the end of the program, while, in addition, carbohydrates intake (p < 0.04) was reduced exclusively in the control group, and simple sugar (p < 0.05) and cholesterol (p < 0.03) intake was reduced in the exercise group. Fruit (p < 0.03) and low-fat/skimmed dairy consumption (p < 0.02), the adherence to the Mediterranean Diet Quality Index for children and teenagers (KIDMED, p < 0.01) and breakfast quality index (p < 0.03) were significantly higher in both control and intervention groups after the intervention. Moreover, participants in the exercise group increased the adherence to the Dietary Approaches to Stop Hypertension (DASH) diet (p < 0.001), whereas the ratio of evening-morning energy intake was significantly lower exclusively in the control group after the program (p < 0.02). Changes in energy intake were significantly associated with changes in fat mass index (FMI) in the exercise group, whereas changes in sugar-sweetened beverages (SSB) consumption was associated with percent hepatic fat reduction (p < 0.05) in the control group. A 22-week family-based healthy lifestyle program seems to be effective on improving diet quality and health in children with overweight/obesity and these should focus on SSB avoidance and physical activity.

Effects of Exercise in Addition to a Family-Based Lifestyle Intervention Program on Hepatic Fat in Children With Overweight.

OBJECTIVE: Pediatric hepatic steatosis is highly prevalent and closely related to type 2 diabetes. This study aimed to determine whether the addition of supervised exercise to a family-based lifestyle and psycho-educational intervention results in greater reduction of percentage of hepatic fat (HF), adiposity, and cardiometabolic risk factors in children with overweight/obesity. RESEARCH DESIGN AND METHODS: The study subjects of this nonrandomized, two-arm, parallel design clinical trial were 116 overweight/obese children (10.6 ± 1.1 years of age, 53.4% girls) living in Vitoria-Gasteiz (Spain). For 22 weeks, they followed either a lifestyle and psycho-education program (control intervention [CInt], N = 57), consisting of two family-based education sessions/month, or the same plus supervised exercise (intensive intervention [II], N = 59) focused mainly on high-intensity aerobic workouts (3 sessions/week, 90 min/session). The primary outcome was the change in percentage of HF (as measured by MRI) between baseline and the end of the intervention period. Secondary outcomes included changes in BMI, fat mass index (FMI), abdominal fat (measured by DEXA), blood pressure, triglycerides, HDL, LDL, γ-glutamyl transferase, glucose, and insulin concentrations. RESULTS: A total of 102 children completed the trial (N = 53 and N = 49 in the CInt and II groups, respectively). Percentage of HF decreased only in the II group (-1.20 ± 0.31% vs. 0.04 ± 0.30%, II and CInt groups, respectively), regardless of baseline value and any change in adiposity (P < 0.01). BMI, FMI, abdominal fat (P ≤ 0.001), and insulin (P < 0.05) were reduced in both groups. CONCLUSIONS: Multicomponent intervention programs that include exercise training may help to reduce adiposity, insulin resistance, and hepatic steatosis in overweight/obese children.

Association of Breakfast Quality and Energy Density with Cardiometabolic Risk Factors in Overweight/Obese Children: Role of Physical Activity.

There is a general belief that having breakfast is an important healthy lifestyle factor; however, there is scarce evidence on the influence of breakfast quality and energy density on cardiometabolic risk in children, as well as on the role of physical activity in this association. The aims of this paper were (i) to examine the associations of breakfast quality and energy density from both solids and beverages with cardiometabolic risk factors, and (ii) to explore whether physical activity levels may attenuate these relationships in children with overweight/obesity from two projects carried out in the north and south of Spain. Breakfast consumption, breakfast quality index (BQI) score, BEDs/BEDb (24 h-recalls and the KIDMED questionnaire), and physical activity (PA; accelerometry) were assessed, in 203 children aged 8⁻12 years who were overweight or obese. We measured body composition (Dual X-ray Absorptiometry), uric acid, blood pressure, lipid profile, gamma-glutamyl-transferase (GGT), glucose, and insulin, and calculated the HOMA and metabolic syndrome z-score. The BQI score was inversely associated with serum uric acid independently of a set of relevant confounders (ß = -0.172, p = 0.028), but the relationship was attenuated after further controlling for total PA (p < 0.07). BEDs was positively associated with total and HDL cholesterol, and systolic blood pressure regardless of confounders (all p < 0.05), while BEDb was positively associated with HOMA in either active/inactive children (all p < 0.03). In conclusion, higher breakfast quality and lower breakfast energy density should be promoted in overweight/obesity children to improve their cardiometabolic health.

Influence of Physical Activity on Bone Mineral Content and Density in Overweight and Obese Children with Low Adherence to the Mediterranean Dietary Pattern.

The objective of the present cross-sectional study was to examine the associations of physical activity and the adherence to the Mediterranean dietary pattern (MDP) with bone mineral content (BMC) and density (BMD) in children with overweight and obesity. A total of 177 (n = 80 girls) children with overweight and obesity aged 8 to 12 years old participated in the study. Both BMC and BMD were assessed by Dual-Energy X-ray absorptiometry. Dietary patterns were assessed by the KIDMED questionnaire and two 24-hour recalls. Physical activity was assessed by accelerometers for 7 consecutive days (24 hours/day). Low adherence to the MDP was observed in 82.4% of participants. Higher physical activity levels (of at least moderate intensity) and lower sedentary time were significantly associated with BMC and BMD in children with low adherence to the MDP (all p < 0.05). No associations were observed between physical activity and BMC and BMD in children with high adherence to the MDP. In conclusion, engaging in moderate to vigorous physical activity and reducing the time spent in sedentary behavior might be particularly beneficial for improving bone health in overweight or obese children with poor adherence to the Mediterranean dietary pattern.

Prevention of diabetes in overweight/obese children through a family based intervention program including supervised exercise (PREDIKID project): study protocol for a randomized controlled trial.

BACKGROUND: The global pandemic of obesity has led to an increased risk for prediabetes and type-2 diabetes (T2D). The aims of the current project are: (1) to evaluate the effect of a 22-week family based intervention program, including supervised exercise, on insulin resistance syndrome (IRS) risk in children with a high risk of developing T2D and (2) to identify the profile of microRNA in circulating exosomes and in peripheral blood mononuclear cells in children with a high risk of developing T2D and its response to a multidisciplinary intervention program including exercise. METHODS: A total of 84 children, aged 8-12 years, with a high risk of T2D will be included and randomly assigned to control (N = 42) or intervention (N = 42) groups. The control group will receive a family based lifestyle education and psycho-educational program (2 days/month), while the intervention group will attend the same lifestyle education and psycho-educational program plus the exercise program (3 days/week, 90 min per session including warm-up, moderate to vigorous aerobic activities, and strength exercises). The following measurements will be evaluated at baseline prior to randomization and after the intervention: fasting insulin, glucose and hemoglobin A1c; body composition (dual-energy X-ray absorptiometry); ectopic fat (magnetic resonance imaging); microRNA expression in circulating exosomes and in peripheral blood mononuclear cells (MiSeq; Illumina); cardiorespiratory fitness (cardiopulmonary exercise testing); dietary habits and physical activity (accelerometry). DISCUSSION: Prevention and identification of children with a high risk of developing T2D could help to improve their cardiovascular health and to reduce the comorbidities associated with obesity. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03027726 . Registered on 16 January 2017.