Effectiveness of surgical 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: To summarize the literature on bariatric surgery for managing pediatric obesity, including intervention effects to improve patient-reported outcome measures (PROMs), cardiometabolic risk factors, anthropometry, and assess adverse events (AEs). METHODS: Eligible studies were published between January 2012 and January 2022 and included randomized controlled trials (RCTs) and observational (controlled and uncontrolled) studies before and after surgery with a mean age <18 years old. Outcomes and subgroups were selected a priori by stakeholders; estimates of effect for outcomes were presented relative to minimal important differences (MIDs) and GRADE certainty of evidence. We examined data on PROMs, cardiometabolic risk factors, anthropometry, and AEs. Subgroup analyses examined outcomes by follow-up duration and surgical technique, when possible. RESULTS: Overall, 63 publications (43 original studies) met our inclusion criteria (n = 6128 participants; 66% female). Studies reported six different surgical techniques that were evaluated using uncontrolled single arm observational (n = 49), controlled observational (n = 13), and RCT (n = 1) designs. Most studies included short-term follow-up (<18 months) only. PROMs were measured in 12 (28%) studies. Surgery led to large improvements in health-related quality of life compared to baseline and control groups, and moderate to very large improvements in cardiometabolic risk factors compared to baseline. Large to very large improvements in BMIz were noted compared to baseline across all follow-up periods. There was limited evidence of AEs with most reporting mild or non-specific AEs; serious AEs were uncommon. CONCLUSION: Bariatric surgery demonstrated primarily moderate to very large improvements across diverse outcomes with limited evidence of AEs, albeit with low to moderate certainty of evidence.

Adiposity and cardiac autonomic function in children with a family history of obesity.

PURPOSE: Data on associations between adiposity and heart rate variability (HRV) in prepubertal children are limited. We examined the associations between adiposity indices and HRV, independent of lifestyle behaviors, comparing multiple indicators of adiposity, and explored differences between boys and girls. METHODS: Data stem from 469 participants of the QUALITY cohort (630 children aged 8-10 years with a parental history of obesity). Adiposity indices included waist-to-height ratio, body mass index (BMI) percentiles and categories (overweight, obesity), dual-energy x-ray absorptiometry (DEXA) defined fat mass percentage and android/gynoid ratio. HRV indices in the frequency and the spectral domain were derived from a daytime 3-h Holter recording. Multivariable linear regression models were adjusted for age, sex, Tanner stage, physical activity, screen time, and fitness. Interactions between sex and adiposity were tested. RESULTS: Greater adiposity was associated with decreased parasympathetic modulation and increased sympathetic dominance. Waist-to-height ratio was associated with lower parasympathetic activity: root mean square of the successive differences (RMSSD) [B = -23.32, 95% confidence interval (CI) -42.42, -4.22], pNN50 (B = -16.93, 95% CI - 28.58, - 5.27), LF/HF ratio (B = 1.83, 95% CI 0.97-2.70). Patterns of association were similar for android/gynoid ratio. Overweight was not associated with altered HRV. Obesity was negatively associated with RMSSD and pNN50 and positively with LF/HF ratio. Greater fat mass percentage was associated with lower RMSSD, pNN50, and HF, and increased LF/HF ratio. There were no differences between boys and girls. CONCLUSIONS: Specific markers of adiposity relate to altered HRV in childhood, with waist-to-height ratio being potentially a more relevant marker of HRV than BMI and more pragmatic than percent body fat. TRIAL REGISTRATION: NCT03356262, 11 November 2017.

Effectiveness of pharmacological 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: To summarize the literature on pharmacotherapy for managing paediatric obesity. METHODS: A systematic review and meta-analysis were conducted of randomized controlled trials (RCTs) with <18-year-olds of pharmacotherapeutic agents published up to November 2022. Estimates of effect for outcomes were presented relative to minimal important differences and GRADE certainty of evidence. We examined data on patient/proxy-reported outcome measures (PROMs), cardiometabolic risk factors, anthropometry and adverse events (AEs). RESULTS: Overall, 35 RCTs were included. Trials examined metformin (n = 26), glucagon-like peptide-1 receptor agonists (GLP1RAs) (n = 7) and a lipase inhibitor (orlistat; n = 2). Intervention duration varied (3-24 months). Metformin had little to no benefit on PROMs (e.g., health-related quality of life [HRQoL]; 6 RCTs), moderate reductions in triglycerides, a moderate decline in insulin resistance, a small to moderate decline in BMI z-score (BMIz) and a moderate increase in mild to moderate gastrointestinal AEs. Response to GLP1RAs was heterogeneous and results of subgroup analysis demonstrated variability of impact. Liraglutide (2 RCTs) resulted in a small reduction in HOMA-IR and BMIz, but little to no benefit on other outcomes. Exenatide (4 RCTs) had a moderate reduction on blood pressure and a small decrease in BMIz with little to no benefit on other outcomes. Semaglutide (1 RCT) had a small benefit on HRQoL, a small reduction on SBP, a moderate reduction on total cholesterol and LDL-cholesterol, a large reduction on triglyceride, and a very large decline in BMIz accompanied by a small increase in mild to moderate gastrointestinal AEs. Orlistat had a moderate reduction in DBP and little to no benefit in other outcomes measured, but had a very large increased risk of mild to moderate gastrointestinal AEs. Serious AEs were rare and for interventions with sufficent AE reporting, were considered not likely attributable to the interventions. CONCLUSION: Few studies examined the impact of pharmacotherapy on PROMs. There is evidence that metformin and GLP1RAs lead to important improvements in cardiometabolic and anthropometric outcomes while accompanied by mild to moderate AEs. Long-term effectiveness and safety of GLP1RAs remain to be evaluated.

Neighbourhood Environments and Lifestyle Behaviours in Adolescents With Type 1 Diabetes.

OBJECTIVES: Early prevention strategies are needed to mitigate the high risk of cardiovascular disease in adolescents with type 1 diabetes (T1D). Residential neighbourhood features can promote healthy lifestyle behaviours and reduce cardiovascular risk, but less is known about their role in lifestyle behaviours in adolescents with T1D, and no studies used comparisons to healthy controls. METHODS: We examined associations between residential neighbourhood features and lifestyle behaviours in adolescents with T1D and healthy controls. Data were analyzed from the CARdiovascular Disease risk factors in pEdiatric type 1 diAbetes (CARDEA) study, a cross-sectional investigation of 100 adolescents with T1D (14 to 18 years) from a pediatric diabetes clinic in Montréal, Canada, and 97 healthy controls. Outcomes included physical activity and sedentary behaviour (accelerometry), screen time and sleep duration (questionnaires), and dietary habits (24-hour recalls). Cluster analysis of selected neighbourhood indicators computed for participants' postal codes resulted in 2 neighbourhood types: central urban and peri-urban. Central urban neighbourhoods were characterized by very high population density, high active living index, numerous points of interest, higher social deprivation, higher residential mobility, and lower median household income compared with peri-urban neighbourhoods. Associations of neighbourhood type with lifestyle behaviours were estimated with multiple linear regressions and interactions by T1D status were tested. RESULTS: Living in central urban neighbourhoods was associated with greater daily minutes of moderate-to-vigourous physical activity (beta = 8.61, 95% confidence interval 1.79 to 15.44) compared with living in peri-urban neighbourhoods. No associations were observed for other lifestyle behaviours, and no statistically significant interactions were found between neighbourhood type and T1D status. CONCLUSION: Features that characterize central urban built environments appear to promote physical activity in adolescents, regardless of T1D status.

The association between depressive symptoms and overweight or obesity in prepubertal children: Findings from the QUALITY cohort.

BACKGROUND: Youth obesity and depression are public health concerns. Although meta-analyses suggest a positive association between those conditions in adults and adolescents, evidence remains unclear in prepubertal children. We examined the bidirectional associations between levels of depressive symptoms and weight status in 8-10-year-old children with a parental history of obesity, over two years, and whether they differ by sex. METHODS: Data were drawn from the QUebec Adipose and Lifestyle InvesTigation in Youth Cohort Study's baseline and first follow-up evaluations (n = 558). Depressive symptoms were assessed using the 12-item Center for Epidemiological Studies Depression scale and weight status using body mass index z-scores based on World Health Organization standards. Linear and logistic regression models were used to test the directionality and magnitude of the associations, adjusting for age, sex, physical activity, screen time, parental education, alcohol and cigarette use, and baseline outcome measure. RESULTS: Children with higher levels of depressive symptoms at baseline were not more likely to have overweight/obesity at follow-up (odds ratio [95 % Coefficient Interval] = 0.95[0.88;1.02]). Baseline overweight/obesity was not associated with subsequent higher levels of depressive symptoms (beta coefficient [95 % Coefficient Interval] = 0.20 [-0.47;0.87]). No sex differences emerged. LIMITATIONS: Selection bias may have occurred due to loss at follow-up (10 % attrition) and exclusion of 6 participants taking mood disorder medication. CONCLUSIONS: Unlike in adults and adolescents, no association between weight status and depressive symptoms was observed in childhood over two years. Underlying mechanisms linking both conditions later in life may not apply as early as prepubertal childhood.

Role of Physical Activity and Sedentary Behaviors on Vascular and Myocardial Structure and Function in Type 1 Diabetes.

OBJECTIVE: To estimate associations between physical activity and sedentary behaviors and early markers of cardiovascular diseases in adolescents with and without type 1 diabetes. STUDY DESIGN: Cross-sectional data stem from the CARdiovascular Disease risk in pEdiatric type 1 diAbetes (CARDEA) study, a study investigating early cardiovascular disease development in 100 adolescents with type 1 diabetes recruited at Sainte-Justine University Hospital Diabetes Clinic and 97 healthy adolescents without diabetes (14-18 years), in Montreal, Canada. Outcomes included arterial stiffness by pulse-wave velocity, endothelial function (velocity time integral) by flow-mediated dilation test, and cardiac magnetic resonance imaging markers. Moderate-to-vigorous physical activity (MVPA) and sedentary time were estimated by accelerometry and leisure screen time by questionnaire. We estimated multivariable linear regression models stratified by group. RESULTS: In adolescents with type 1 diabetes, 10-minutes daily increase in MVPA was associated with 3.69 g/m (95% CI: -1.16; 8.54) higher left ventricular (LV) mass/height and 1-hour increase in device-measured sedentary time with 0.68 mm (0.20; 1.16) higher wall thickness but only in those with glycated hemoglobin ≤7.5%. In healthy adolescents, a 10-minute increase in MVPA was associated with 1.32 g/m (-0.03; 2.66) higher LV mass/height. Every 1-hour increase in sedentary time was associated with -1.82 cm (-3.25; -0.39) lower velocity time integral, -2.99 g/m (-5.03; -0.95) lower LV mass/height, and -0.47 mm (-0.82; -0.12) lower wall thickness. CONCLUSIONS: Being active and limiting sedentary time appears beneficial for cardiac structure and endothelial function in healthy adolescents; however, adequate glycemic control combined with higher levels of MVPA may be required for adolescents with type 1 diabetes to overcome the impact of diabetes.

Physiological response during exercise is preserved in children exposed to a suboptimal gestational environment.

OBJECTIVE: This study investigated whether exposure to suboptimal gestational factors (SGFs) alters mechanical efficiency (ME) and substrate oxidation during rest and exercise in children as a mechanism contributing to obesity. METHODS: Data from the Quebec Adiposity and Lifestyle Investigation in Youth cohort were used. Children aged 8 to 10 years performed an incremental maximal cycling test with indirect calorimetry. Their ME was measured during submaximal and maximal effort. The substrate oxidation during rest and submaximal effort was also computed. ME and substrate oxidation results between children exposed to each SGF during pregnancy (gestational diabetes mellitus: n = 68; hypertensive disorders: n = 49; maternal smoking: n = 77) and nonexposed children (n = 370) were compared. RESULTS: No difference was observed for ME during submaximal (F[3,540] = 0.46, p = 0.713) and maximal effort (F[3,545] = 0.86, p = 0.463) between exposed and nonexposed children. The percentage contributions of lipids and carbohydrates did not differ during rest (F[3,545] =1.68, p = 0.169) or submaximal exercise (F[3,544] = 0.31, p = 0.534) between exposed and nonexposed children. CONCLUSIONS: Children exposed to investigated SGFs display a similar physiological response regarding ME and substrate oxidation during rest and exercise compared to nonexposed children. Future studies should confirm these novel results and continue investigating other research avenues to explain the higher risk of obesity in this population.

DXA-based Fat Mass With Risk of Worsening Insulin Resistance in Adolescents: A 9-Year Temporal and Mediation Study.

CONTEXT: Surrogate measures of childhood and adolescent obesity have impaired the understanding of the relationship of body composition with insulin resistance in the young population. OBJECTIVE: We aim to examine the longitudinal associations of directly measured total fat mass, trunk fat mass, and lean mass with the risk of hyperglycemia, hyperinsulinemia, and insulin resistance from ages 15 to 24 years, the mediation path through which lipids and inflammation influence insulin resistance, and whether increased fat mass temporally precede insulin resistance. METHODS: We studied 3160 adolescents from the Avon Longitudinal Study of Parents and Children (ALSPAC), UK birth cohort, who had complete dual-energy x-ray absorptiometry measure and fasting blood samples at age 15 years and repeated measures at ages 17- and 24-years clinic visit. Fasting glucose greater than 6.1 mmol/L, insulin greater than 11.78 mU/L, and homeostatic model assessment for insulin resistance (HOMA-IR) greater than or equal to the 75th percentile were categorized as hyperglycemia, hyperinsulinemia, and high insulin resistance, respectively. Longitudinal associations were examined with generalized logit-mixed-effect models, while mediation and temporal path analyses were examined using structural equation models, adjusting for cardiometabolic and lifestyle factors. RESULTS: Among 3160 participants (51% female), fat mass and lean mass increased linearly both in males and females, while glucose, insulin, and HOMA-IR had a U-shaped course from age 15 through 24 years. After full adjustment, each 1-kg cumulative increase in total fat mass (odds ratio 1.12 [95% CI, 1.11-1.13]) and trunk fat mass (1.21 [1.19-1.23]) from ages 15 through 24 years were associated with a progressively worsening risk of high insulin resistance as well as hyperglycemia and hyperinsulinemia. The association of increased total fat mass with increased insulin resistance was partly mediated by triglycerides (9% mediation). In the temporal path analysis, higher total fat mass at age 15 years was associated with higher insulin resistance at age 17 years, but not vice versa. Higher total fat mass at age 17 years was bidirectionally associated with higher insulin resistance at 24 years. CONCLUSION: Mid-adolescence may be an optimal time for interrupting the worsening fat mass-insulin resistance pathologic cycle and attenuating the risk of progressively worsening metabolic dysfunction before young adulthood.

Associations Between Weight-Loss Attempts, Weight-Related Stress, and Body Image During Childhood and Adolescence in Children With Parental Obesity.

Background: Few longitudinal studies have investigated the role of weight-loss attempts or weight-related stress on body image during childhood. We examined whether weight-loss attempts and weight-related stress are associated with weight misperception and body dissatisfaction across childhood and adolescence. Methods: Data were drawn from the Quebec Adipose and Lifestyle InvesTigation in Youth (QUALITY) cohort of Canadian children with parental obesity (8-10 years: n = 630; 10-12 years: n = 564; 15-17 years: n = 377). We assessed weight-loss attempts and weight-related stress at baseline and first follow-up, and perceived and desired silhouettes at first and second follow-up with questionnaires. Weight misperception consisted of the difference in BMI z-score (zBMI) from the perceived silhouette and the measured zBMI. Body dissatisfaction consisted of the discordance between perceived and desired silhouettes. We estimated multivariable mixed-effects regression models adjusting for age, sex, pubertal stage, parental BMI and education, and sport-based teasing. Results: Weight loss attempts were associated with a higher weight misperception score (ever tried, beta [95% confidence intervals; CI]: 0.13 [0.01-0.24]) and with 2.13 times higher desire to be thinner (95% CI: 1.39-3.26) at the subsequent follow-up. Similarly, children stressed by their weight had a higher misperception score (beta [95% CI]: 0.15 [0.02-0.27]) and greater desire to be thinner at the next follow-up (odds ratio [95% CI]: 1.73 [0.999-3.00]). Conclusions: Weight-loss attempts and weight-related stress in children and adolescents are associated with weight misperception and body dissatisfaction, supporting empowerment and counseling focusing on healthy eating behaviors and a positive body image. Clinical Trial Registration Number: NCT03356262.

Children and chrono-exercise: Timing of physical activity on school and weekend days depends on sex and obesity status.

Recommendations for physical activity (PA) typically focus on frequency, intensity, duration, and type, but timing (chrono-exercise) is also important. The objective of this study is to describe when children are active on school and weekend days and explore PA timing across sex and body mass index (BMI) categories. 359 children (53% male), aged 9.6 (0.9) y, were categorized as normal weight (≥-1 standard deviations (SD) and <1SD; n = 193), overweight (≥1SD and <2SD; n = 80), or obese (≥2SD; n = 86) using WHO BMIz. Moderate-to-vigorous PA (MVPA) was assessed using ActiGraph LS-7164. The results are described as Mean(SD). ANOVA evaluated MVPA across sexes and BMI categories. Normal weight boys were more active than boys with obesity on school (Δ20.33 min; p < 0.001) and weekend days (Δ15.04 min; p < 0.05). On school days, significant differences existed between 9:00 h-11:00 h and 12:00 h-14:00 h (p < 0.017), while on weekends, smaller differences existed throughout the day. Girls' MVPA was similar across BMI categories, on all days (p > 0.05). On school days, 12:00 h-13:00 h represented the most active hour for all participants (~14% total daily MVPA). Peak weekend MVPA was distributed across multiple hours. Differences in MVPA timing emerged on school-days and weekends. Timing may be important when examining the nuances of MVPA in relation to sex and bodyweight in children.

Early Lifestyle Determinants of Adiposity Trajectories from Childhood into Late Adolescence.

Objective: The aim of this study was to examine associations of childhood physical activity, sedentary behavior, and dietary intake with adiposity trajectories from childhood to adolescence. Methods: Quebec Adipose and Lifestyle Investigation in Youth (QUALITY) cohort (n = 630) data from 3 time points (8-10, 10-12, and 15-17 years) for 377 Caucasian children with parental obesity were analyzed. Height and weight, physical activity and sedentary behavior (7-day accelerometry), screen time (self-reported), and dietary intake (three 24-hour diet recalls) were measured. Group-based trajectory modeling identified longitudinal trajectories of body-mass index z-scores (zBMIs). Inverse probability of exposure-weighted multinomial logistic regressions examined associations between baseline lifestyles and zBMI trajectory groups. Results: Six trajectory groups were identified: Stable-Low-Normal-Weight (two groups, 5.7% and 33.0%, which were combined), Stable-High-Normal-Weight (24.8%), Stable-Overweight (19.8%), Stable-Obesity (8.8%), and Overweight-Decreasers (7.9%). For every additional portion of fruits and vegetables, the likelihood of being in the group of Overweight-Decreasers increased by 29% (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.09-1.55) compared with the reference group (Stable-Low-Normal-Weight). For every additional hour of sedentary behavior, the likelihood of belonging to the group of Overweight-Decreasers increased 2-fold (OR: 1.99, 95% CI: 1.28-3.21) and Stable-Obesity increased 1.5-fold (OR: 1.56, 95% CI: 1.08-2.23), compared with the reference. Every additional 10 minutes of moderate-to-vigorous physical activity was associated with a lower likelihood of belonging to the Stable-Obesity group (OR: 0.75, 95% CI: 0.61-0.89) and to the group of Overweight-Decreasers (OR: 0.79, 95% CI: 0.64-0.95) compared with the reference. Finally, children were more likely to belong to the Stable-Obesity group with each additional hour/day of screen time (OR: 1.23, 95% CI: 1.01-1.58). Conclusions: Trajectories of zBMIs from childhood to late adolescence were stable, except for one group which decreased from overweight in childhood to normal weight in adolescence. The latter had more favorable baseline dietary intake of fruits and vegetables. ClinicalTrials.org no. NCT03356262.

Association of stigma, diabetes distress and self-efficacy with quality of life in adolescents with type 1 diabetes preparing to transition to adult care.

AIMS: In type 1 diabetes (T1D), psychosocial factors may impact quality of life (QOL) and clinical outcomes, but remain understudied, particularly during late adolescence. Our aim was to determine whether stigma, diabetes distress and self-efficacy are associated with QOL in adolescents with T1D as they are preparing to transition to adult care. METHODS: We conducted a cross-sectional study of adolescents (ages 16-17 years) with T1D participating in the Group Education Trial to Improve Transition (GET-IT) in Montreal, Canada. Participants completed validated questionnaires on stigma using the Barriers to Diabetes Adherence (BDA) stigma subscale, self-efficacy (Self-Efficacy for Diabetes Self-Management Measure [SEDM], score 1-10), diabetes distress (Diabetes Distress Scale for Adults with type 1 diabetes) and QOL (Pediatric Quality of Life Inventory [PedsQL] 4.0 Generic Core Scale and PedsQL 3.2 Diabetes Module). We examined associations of stigma, diabetes distress and self-efficacy with QOL using multivariate linear regression models adjusted for sex, diabetes duration, socioeconomic status and HbA1c. RESULTS: Of 128 adolescents with T1D, 76 (59%) self-reported having the diabetes-related stigma and 29 (22.7%) reported experiencing diabetes distress. Those with stigma had lower diabetes-specific and general QOL scores compared with those without stigma, and stigma and diabetes distress were both associated with lower diabetes-specific QOL and lower general QOL. Self-efficacy was associated with higher diabetes-specific and general QOL. CONCLUSIONS: Stigma and diabetes distress are associated with lower QOL, whereas self-efficacy is associated with higher QOL in adolescents with T1D preparing to transfer to adult care.

Diabetes duration, perceived comfort with self-management and glycaemic control in adolescents with type 1 diabetes: A cross-sectional study.

AIMS: Evidence is lacking on whether diabetes duration is associated with type 1 diabetes (T1D) self-management during late adolescence before transfer from paediatric to adult care. We examined associations of diabetes duration with dimensions of perceived comfort with diabetes self-management (self-efficacy, transition readiness, diabetes distress) and glycaemic control in late adolescence. METHODS: Using a cross-sectional design, we conducted a secondary analysis of baseline data of adolescents (ages 16-17 years) with T1D followed at paediatric diabetes academic hospitals in Montreal and enrolled in the Group Education Trial to Improve Transition (GET-IT-T1D). Participants completed validated questionnaires on self-efficacy (Self-Efficacy for Diabetes Self-Management Measure [SEDM], score 1 to 10), diabetes distress and transition readiness, as well as a haemoglobin (HbA1c) capillary blood test. Our primary outcome was self-efficacy. We examined associations of diabetes duration with self-efficacy, diabetes distress, transition readiness and HbA1c using linear and logistic regression models adjusted for sex, socioeconomic status, insulin pump use, glucose sensor use and psychiatric comorbidity. RESULTS: Of 203 adolescents with T1D, mean diabetes duration (SD) was 7.57 (4.44) years. Mean SEDM score was 6.83 (SD 1.62). Diabetes duration was not associated with self-efficacy, diabetes distress or transition readiness. Each additional year of diabetes duration was associated with 0.11% (95% CI, 0.05 to 0.16) higher HbA1c. CONCLUSIONS: Although diabetes duration is not associated with dimensions of perceived comfort with diabetes self-management, adolescents with longer diabetes duration are at risk for higher HbA1c and may need additional support to improve glycaemic control before transition to adult care.

Supporting and Incentivizing Peer Leaders for an Internet-Based Private Peer Community for Youths With Type 1 Diabetes: Social Network and Directed Content Analysis.

BACKGROUND: Youths with type 1 diabetes (T1D) frequently experience stigma. Internet-based peer communities can mitigate this through social support but require leaders to catalyze exchange. Whether nurturing potential leaders translates into a central role has not been well studied. Another issue understudied in such communities is lurking, the viewing of exchanges without commenting or posting. OBJECTIVE: We aimed to assess the centrality of the peer leaders we selected, trained, and incentivized within the Canadian Virtual Peer Network (VPN)-T1D. This is a private Facebook (Meta Platforms, Inc) group that we created for persons aged 14 to 24 years with T1D. We specifically sought to (1) compare a quantitative estimate of network centrality between peer leaders and regular members, (2) assess the proportions of network exchanges that were social support oriented, and (3) assess proportions of high engagement (posts, comments, reactions, and votes) and low engagement (lurking) exchanges. METHODS: We recruited peer leaders and members with T1D from prior study cohorts and clinics. We trained 10 leaders, provided them with a monthly stipend, and encouraged them to post on the private Facebook group we launched on June 21, 2017. We extracted all communications (posts, messages, reactions, polls, votes, and views) that occurred until March 20, 2020. We calculated each member's centrality (80% of higher engagement communications comprising posts, comments, and reactions plus 20% of members with whom they connected). We divided each member's centrality by the highest centrality to compute the relative centrality, and compared the mean values between leaders and members (linear regression). We calculated the proportions of communications that were posts, comments, reactions, and views without reaction. We performed content analysis with a social support framework (informational, emotional, esteem-related, network, and tangible support), applying a maximum of 3 codes per communication. RESULTS: VPN-T1D gained 212 regular members and 10 peer leaders over 33 months; of these 222 members, 26 (11.7%) exited. Peer leaders had 10-fold higher relative centrality than regular members (mean 0.53, SD 0.26 vs mean 0.04, SD 0.05; 0.49 difference; 95% CI 0.44-0.53). Overall, 91.4% (203/222) of the members connected at least once through posts, comments, or reactions. Among the 75,051 communications, there were 5109 (6.81%) posts, comments, and polls, 6233 (8.31%) reactions, and 63,709 (84.9%) views (lurking). Moreover, 54.9% (3430/6253) of codes applied were social support related, 66.4% (2277/3430) of which were informational (eg, insurance and travel preparation), and 20.4% (699/3430) of which were esteem related (eg, relieving blame). CONCLUSIONS: Designating, training, and incentivizing peer leaders may stimulate content exchange and creation. Social support was a key VPN-T1D deliverable. Although lurking accounted for a high proportion of the overall activity, even those demonstrating this type of passive participation likely derived benefits, given that the network exit rate was low. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/18714.

Comparison of Intranasal and Injectable Glucagon Administration Among Pediatric Population Responders.

Aims: Ease of use and acceptability of nasal versus injectable glucagon (IG) among pediatric responders have been little investigated. This study compared the performance of administering nasal and IG in parents of youth with type 1 diabetes (T1D) and in school workers. Enablers and barriers associated with each glucagon and preferred glucagon administration learning modality were also evaluated. Methods: Three months after watching short pedagogical videos, 30 parents and 30 school workers performed simulated scenarios where they administered both glucagon. Completion time and successful execution of critical steps were collected. Interviews assessed preferred learning modalities, barriers, and enablers associated with each glucagon. Results: Both groups administered nasal glucagon faster than IG (median [interquartile range]: parents 19 [12-29] vs. 97 [71-117] s, P < 0.001; school workers 24 [16-33] vs. 129 [105-165] s, P < 0.001). A lower proportion of participants successfully executed all critical steps for injectable versus nasal glucagon (significant difference for school workers [53% vs. 90%; P = 0.007] but not for parents [68% vs. 83%; P = 0.227]). Nasal glucagon was preferred for ease of use and acceptability. Preferred learning modalities were a combination of videos and workshops, but videos alone could suffice for nasal glucagon. Conclusions: Nasal glucagon is faster to use, more likely to be successfully administered, and more acceptable than IG for parents of children with T1D and school workers. Nasal glucagon training with videos could improve school workers' involvement in severe hypoglycemia management. Clinical Trial number, URL to the registration: NCT05395000, https://clinicaltrials.gov/ct2/show/NCT05395000.

Trajectories of cardiorespiratory fitness from childhood to adolescence: Findings from the QUALITY cohort.

Estimate the shape and number of cardiorespiratory fitness (CRF) trajectories from childhood to adolescence; and verify whether CRF trajectory membership can be predicted by sex, biological maturation, body weight, body composition and physical activity (PA) in childhood. Data from QUALITY were used. Participants attended baseline (8-10 y old, n = 630) and follow-ups 2 years (n = 564) and 7 years (n = 359) after baseline. Group-based trajectory analysis for relative peak oxygen consumption (VO2peak, ml·kg-1·min-1) was performed. A multinomial logistic regression model was used to estimate the associations between baseline predictors and trajectory membership. Mean age of the 454 participants was 9.7 ± 0.9 years at baseline. Three distinct VO2peak trajectories were identified and all tended to decrease. They were labelled according to the starting point and slope. High-Decreasers were mostly boys, had lower body weight and fat-free mass index and higher PA levels at baseline (p < 0.05). Female sex and higher weight were associated with higher odds of being classified in the Low-Decreaser trajectory (OR = 74.03, 95%CI = 27.06-202.54; OR = 1.48, 95%CI = 1.36-1.60). Those with higher PA were less likely to be Low-Decreasers (OR = 0.96, 95%CI = 0.94-0.97). Sex, body weight and PA in childhood are important influencing factors of VO2peak (ml·kg-1·min-1) trajectories across adolescence.

Text message-based intervention, Keeping in Touch (KiT), to support youth as they transition to adult type 1 diabetes care: a protocol for a multisite randomised controlled superiority trial.

INTRODUCTION: Transition from paediatric to adult care can be challenging for youth living with type 1 diabetes (T1D), as many youth feel unprepared to transfer to adult care and are at high risk for deterioration of glycaemic management and acute complications. Existing strategies to improve transition experience and outcomes are limited by cost, scalability, generalisability and youth engagement. Text messaging is an acceptable, accessible and cost-effective way of engaging youth. Together with adolescents and emerging adults and paediatric and adult T1D providers, we co-designed a text message-based intervention, Keeping in Touch (KiT), to deliver tailored transition support. Our primary objective is to test the effectiveness of KiT on diabetes self-efficacy in a randomised controlled trial. METHODS AND ANALYSIS: We will randomise 183 adolescents with T1D aged 17-18 years within 4 months of their final paediatric diabetes visit to the intervention or usual care. KiT will deliver tailored T1D transition support via text messages over 12 months based on a transition readiness assessment. The primary outcome, self-efficacy for diabetes self-management, will be measured 12 months after enrolment. Secondary outcomes, measured at 6 and 12 months, include transition readiness, perceived T1D-related stigma, time between final paediatric and first adult diabetes visits, haemoglobin A1c, and other glycaemia measures (for continuous glucose monitor users), diabetes-related hospitalisations and emergency department visits and the cost of implementing the intervention. The analysis will be intention-to-treat comparing diabetes self-efficacy at 12 months between groups. A process evaluation will be conducted to identify elements of the intervention and individual-level factors influencing implementation and outcomes. ETHICS AND DISSEMINATION: The study protocol version 7 July 2022 and accompanying documents were approved by Clinical Trials Ontario (Project ID: 3986) and the McGill University Health Centre (MP-37-2023-8823). Study findings will be presented at scientific conferences and in peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT05434754.

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.

The longitudinal effects of maternal parenting practices on children's body mass index z-scores are lagged and differential.

BACKGROUND: The longitudinal relation between parenting practices and styles with children's body mass index z-scores (zBMI) is poorly understood. Previous studies suggest the relationship may be complex, but small samples and short follow-ups diminish the strength of the evidence. The objectives of this study were to investigate whether the relationship is bidirectional, time-varying, and lagged using data from a large, representative birth cohort of Quebec children. METHODS: Data were from the Québec Longitudinal Study of Child Development (QLSCD), a prospective birth cohort (n = 1,602). The mothers' interactions with their children (at ages 6, 8, 10, and 12 years) were utilized in factor analysis to identify three latent parenting practices (disciplinarian, lenient, and responsive). The parenting practices were analyzed with K-means clustering to identify the parenting styles. The temporal and bidirectional relationships were assessed in a cross-lagged path analysis using a structural equation modelling framework. Mixed models controlling for age, sex, income, mother's education, and whether the participant was first-born were estimated. Missing data were handled with full information maximum likelihood. RESULTS: From the linear mixed models, greater lenient and responsive parenting practices were associated with higher zBMI (B = 0.03, p < 0.05) two years later. However, there was no evidence that the relationship was bidirectional nor that parenting style was predictive of children's zBMI. CONCLUSION: While mothers' parenting practices were unaffected by their children's zBMI, parental practices were predictive of future zBMI among their prepubertal children. More in-depth exploration of parenting practices and their potential impact on pediatric weight is needed.

Associations of Diabetes-related and Health-related Quality of Life With Glycemic Levels in Adolescents With Type 1 Diabetes Preparing to Transition to Adult Care.

OBJECTIVES: As adolescents with type 1 diabetes (T1D) progress to adulthood, they assume responsibility for diabetes self-management while dealing with competing life demands, decreasing parental support, and the transfer to adult care. Lower perceived quality of life (QOL) may hamper diabetes management, which is associated with suboptimal glycemic levels. Our objective was to determine associations of diabetes- and health-related QOL with glycemic management (glycated hemoglobin [A1C]) in adolescents with T1D before their transfer to adult care. METHODS: We conducted a cross-sectional analysis of baseline data from the Group Education Trial to Improve Transition (GET-IT- T1D) in adolescents with T1D (16 to 17 years of age). Participants completed validated questionnaires measuring diabetes-related QOL (PedsQL 3.2 Diabetes Module) and health-related QOL (PedsQL 4.0 Generic Core Scales). Associations of QOL Total and subscale scores with A1C were assessed using linear regression models adjusted for sex, diabetes duration, socioeconomic status, insulin pump use, and mental health comorbidity. RESULTS: One hundred fifty-three adolescents with T1D were included (mean age, 16.5 [standard deviation, 0.3] years). Diabetes-related QOL Total scores (adjusted ß=-0.04; 95% confidence interval [CI], -0.05 to -0.02) as well as subscale scores for Diabetes Symptoms (adjusted ß=-0.02; 95% CI, -0.04 to -0.00) and Diabetes Management (adjusted ß=-0.04; 95% CI, -0.05 to -0.02) were inversely associated with A1C. Health-related QOL Total scores were not associated with A1C, but Psychosocial Health subscale scores were (adjusted ß=-0.01; 95% CI, -0.03 to -0.00). CONCLUSION: Our results suggest that strategies focussing on diabetes-related QOL and psychosocial health may help prepare adolescents for the increasing responsibility of diabetes self-care.