The need for future research into the assessment and monitoring of eating disorder risk in the context of obesity treatment.

In adolescents and adults, the co-occurrence of eating disorders and overweight or obesity is continuing to increase, and the prevalence of eating disorders is higher in people with higher weight compared to those with lower weight. People with an eating disorder with higher weight are more likely to present for weight loss than for eating disorder treatment. However, there are no clinical practice guidelines on how to screen, assess, and monitor eating disorder risk in the context of obesity treatment. In this article, we first summarize current challenges and knowledge gaps related to the identification and assessment of eating disorder risk and symptoms in people with higher weight seeking obesity treatment. Specifically, we discuss considerations relating to the validation of current self-report measures, dietary restraint, body dissatisfaction, binge eating, and how change in eating disorder risk can be measured in this setting. Second, we propose avenues for further research to guide the development and implementation of clinical and research protocols for the identification and assessment of eating disorders in people with higher weight in the context of obesity treatment. PUBLIC SIGNIFICANCE: The number of people with both eating disorders and higher weight is increasing. Currently, there is little guidance for clinicians and researchers about how to identify and monitor risk of eating disorders in people with higher weight. We present limitations of current research and suggest future avenues for research to enhance care for people living with higher weight with eating disorders.

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

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

Anaemia in women of reproductive age in low- and middle-income countries: progress towards the 2025 global nutrition target.

Objective: To examine trends in, and projections of, the prevalence of anaemia in women of reproductive age in low- and middle-income countries at national and subpopulation levels. Methods: We used nationally representative data from repeated cross-sectional Demographic and Health Surveys (DHS) on 1 092 512 women of reproductive age (15-49 years) from 15 low- and middle-income countries. We defined anaemia as haemoglobin < 11 g/dL for pregnant women and < 12 g/dL for non-pregnant women. We analysed data using Bayesian linear regression analyses. Findings: During 2000-2018, the prevalence of anaemia in women of reproductive age decreased in nine countries, with the highest decrease in Malawi (-2.5%), and increased in six countries, with the highest increase in Burundi (10.9%). All countries are projected to have a prevalence of anaemia ≥ 15% in 2025, with the highest level in Burundi (66.8%). The prevalence of anaemia and projection of prevalence varied between and within countries. Women's education, family wealth and place of residence had the highest impact on the current and projected prevalence rates of anaemia. Seven countries had a prevalence of anaemia ≥ 40%, which we defined as a severe public health problem, in the earliest and latest DHS and this prevalence is projected to persist in 2025. Conclusion: None of the 15 countries is likely to meet the global nutrition target of a 50% reduction in the prevalence of anaemia in women of reproductive age by 2025. Global and country leaders should reconsider nutrition policies and reallocate resources targeting countries and communities at risk.

Acceptability and feasibility of a parent-targeted dietary intervention in young survivors of childhood cancer: "Reboot".

BACKGROUND: Assess the acceptability and feasibility of delivering Reboot, a telephone dietary intervention to parents of pediatric cancer survivors. The research question asks whether tailored dietary support is acceptable and feasible to deliver to parents of young cancer survivors who have recently completed cancer treatment? PROCEDURE: Pre-post study. Nineteen parents of pediatric cancer survivors (aged 2-13 years) in remission, who had received cancer treatment at a tertiary children's hospital, less than 5 years prior to the intervention. Participants received four weekly 45-min telephone sessions led by a psychologist or dietitian and one postintervention booster session 6 weeks later. Sessions addressed strategies to increase children's vegetable and fruit intake. RESULTS: Of the 19 parents who started the intervention, 14 completed all sessions within 8 weeks and 12 completed the booster session within 10 weeks. The mean session duration was 47 min. All participants reported that Reboot increased their confidence and knowledge about promoting healthy eating habits to their child. CONCLUSIONS: Reboot is an acceptable intervention in young cancer survivors aimed at increasing vegetable and fruit intake after cancer treatment. IMPLICATIONS FOR CANCER SURVIVORS: The results from the Reboot pilot provides preliminary evidence that a targeted intervention to improve the diets of childhood cancer survivors may be feasible with future modification.

Intermittent Energy Restriction Is a Feasible, Effective, and Acceptable Intervention to Treat Adolescents with Obesity.

BACKGROUND: Intermittent energy restriction (IER) is an effective obesity management strategy in adults. OBJECTIVE: The aim of this study was to investigate the feasibility, effectiveness, and acceptability of IER in adolescents (aged 12-17 y) with obesity [adult equivalent body mass index (BMI; kg/m2) ≥30]. METHODS: During weeks 1-12 participants followed an IER dietary plan consisting of a very-low-energy diet (VLED) 3 d/wk (500-600 kcal/d) and an eating plan consistent with national dietary guidelines 4 d/wk. For weeks 13-26 participants chose to continue with 1-3 VLED d/wk or follow a prescriptive eating plan. Primary outcomes were feasibility and change in BMI expressed as a percentage of the 95th percentile (BMI %95th percentile) at 12 wk. Secondary outcomes were diet acceptability, body composition, cardiometabolic risk, vascular structure and function, quality of life (Pediatric Quality of Life Inventory), and eating behaviors [Dutch Eating Behavior Questionnaire (DEBQ-C)]. Linear mixed models were used to assess change in outcome measures. RESULTS: Of 45 adolescents invited to participate, 30 adolescents (mean ± SD age: 14.5 ± 1.4 y, female n = 25) with a median BMI of 34.9 (range: 27.7-52.4) were recruited. At 12 wk, 23 participants chose to continue with the VLED 2-3 d/wk, and 21 completed the study, indicating the feasibility of IER. Consistent with intention-to-treat analysis, BMI %95th percentile was reduced at 12 wk (difference in estimated marginal means ± SEMs: -5.6 ± 1.1, P < 0.001) and 26 wk (-5.1 ± 1.9, P = 0.013) compared with baseline. Plasma triglycerides were reduced at 26 wk from baseline (-0.33 ± 0.12 mmol/L, P = 0.03). Body fat percentage reduced between 12 and 26 wk (-1.57% ± 0.76%, P = 0.05). Carotid intima-media thickness (CIMT) (-0.06 ± 0.01 mm, P < 0.001) and flow-mediated dilation (absolute increase 0.44% ± 0.11%, P = 0.001) improved between baseline and 12 wk, with reduced CIMT maintained at 26 wk (P < 0.001). DEBQ-C and Pediatric Quality of Life Inventory scores improved throughout the intervention. Nineteen adolescents completed an acceptability interview, rating IER as easy and pleasant to follow (mean ± SD: +2.1 ± 1.2; +1.9 ± 1.2, respectively) on a Likert scale from -4 to +4. CONCLUSION: IER is a feasible, effective, and acceptable intervention in adolescents with obesity achieving reductions in BMI and cardiovascular disease risk. This trial was registered at www.anzctr.org.au as ACTRN12618000200280.

Childhood cancer survivors report preferring lifestyle interventions delivered in person rather than online: An adolescent and parent perspective.

BACKGROUND: Maintaining a healthy lifestyle can protect adolescent survivors of pediatric cancer against chronic diseases such as obesity and cardiovascular disease. In this study, we examined the attitudes of adolescent survivors of pediatric cancer and their parents toward improving lifestyle behaviors after cancer treatment, including their preferences for intervention delivery and perceived barriers and benefits to healthy eating and exercise. METHODS: We recruited adolescent survivors of childhood cancer aged 11-19 years and their parents, from two hospitals. Participants completed a questionnaire via mail or at routine oncology clinic visits. RESULTS: Thirty-three adolescents (response rate 39%, mean age 15, 61% male) and 32 parents (representing 30 parent-child dyads) participated. Parents were significantly more interested in having their child participate in a lifestyle intervention than adolescents (41% of adolescents and 72% of parents, P = .012). Both groups preferred that the survivor receive lifestyle support face to face rather than online. Adolescents preferred to involve their friends (39% of adolescents and 19% of parents) whereas parents preferred to involve the family in a lifestyle intervention (15% of adolescents and 47% of parents, P = .006). Adolescents and their parents perceived a dislike of the taste of fruits and vegetables, fatigue, lack of motivation, and fear of injury as barriers to change. They perceived that keeping healthy and having more energy were benefits to participation. Participants indicated that interventions that provide face-to-face personal training and dietary education at a local gym would be well accepted. CONCLUSIONS: Adolescents who have had cancer in childhood have a preference for face-to-face contact with health professionals to overcome the barriers to participation in a lifestyle intervention.

The trends and prevalence of obesity and morbid obesity among Australian school-aged children, 1985-2014.

AIM: Children with obesity have a greater risk of adverse social and physical health outcomes. We examined temporal changes in body mass index (BMI) z-scores and the prevalence obesity and morbid obesity in children from 1985 to 2014. METHODS: Secondary data analysis of BMI data for children aged 7-15 years from five cross-sectional Australian datasets. Changes in age- and gender-adjusted BMI (BMI z-scores) and nutritional status were categorised using the International Obesity Task Force cut-off points. RESULTS: The percentage of children who were obese tripled between 1985 and 1995 from 1.6 to 4.7%, before plateauing between 1995 and 2014. The percentage of morbidly obese children was <1% in 1985 and 1995, increasing to 2% between 1995 and 2007, with no further increase between 2007 and 2014. The proportion of obese children classified as morbidly obese was 12% in 1985-1995, 24% in 2007-2012 and 28% in 2014. Between 1985 and 2012, the mean BMI z-score increased in children categorised as obese from 1.94 (standard deviation 0.15) to 2.03 (0.22), and then plateaued. For morbidly obese children, the mean BMI z-score was 2.4 (0.13) and remained similar over the study period. CONCLUSIONS: Our findings suggest that the relative fatness of children with morbid obesity, as measured by BMI z-score, has remained stable. The proportion of obese and morbidly obese children has also plateaued between 2007 and 2014. However, the prevalence of obesity remains high, and more dedicated resources are required to treat children with obesity to reduce the short- and long-term health impact.

The acceptability, effectiveness, and impact of different models of care for pediatric weight management services: protocol for a concurrent mixed-methods study.

BACKGROUND: Pediatric obesity is a serious, but clinically neglected, chronic health problem. Despite the high prevalence, excess weight problems are rarely managed when children attend clinical services. It is recommended that obesity treatment uses a "chronic-care" approach to management, with different types and intensity of treatment dependent upon severity of obesity. There are several new secondary and tertiary weight management services being implemented within New South Wales (NSW), Australia in 2017/2018 with differing models of care. This study will ascertain what factors affect acceptability, reach, and participation, as well as measure the clinical effectiveness of these services. METHODS: This is a acceptability and effectiveness study building upon existing and planned secondary and tertiary level service delivery in several health districts. This study will recruit participants from seven different pediatric weight management services (PWMS) across five Local Health Districts in NSW, Australia. Using a mixed-methods approach we will document a range of process, impact and clinical outcome measures in order to better understand the context and the effectiveness of each PWMS model. The project development and implementation is guided by the Theoretical Domains Framework. Participants will include parents of children less than 18 years of age attending PWMS, clinicians working as part of PWMS and health service managers. Data will be captured using a combination of anthropometric measures, questionnaires, one-on-one semi-structured interviews and focus groups. DISCUSSION: Results from this study will assess the acceptability and effectiveness of different models of care for pediatric weight management. Such information is required to inform long-term sustainability and scalability of secondary and tertiary care services to the large number of families with children above a healthy weight.

Reversal of type 2 diabetes in youth who adhere to a very-low-energy diet: a pilot study.

AIMS/HYPOTHESIS: The aim of the study was to investigate whether a very-low-energy diet (VLED) is a feasible and acceptable treatment option for type 2 diabetes in children and adolescents, and whether adherence can lead to rapid weight loss, reversal of type 2 diabetes and reduced liver fat as seen in adult studies. METHODS: Eight participants with type 2 diabetes and obesity, aged 7-16 years, non-medicated (n = 1) or treated with metformin (n = 7) and in some cases insulin (n = 3), followed a VLED (<3360 kJ/day) for 8 weeks, then transitioned to a hypocaloric diet (∼6300 kJ/day) that they followed to 34 weeks. HbA1c, fasting glucose and 2 h post-glucose load plasma glucose (2hG) were determined from fasting blood and an OGTT. Liver fat concentration was quantified using proton magnetic resonance spectroscopy. Adherence was defined as ≥5% weight loss during the 8 week VLED. RESULTS: Adherers (n = 5) and non-adherers (n = 3) had median weight loss of 7.5% and 0.5%, respectively, at 8 weeks. Overall, HbA1c (mean [SE] 8.1% [0.7%] to 6.6% [0.5%]; p = 0.004) and 2hG (15.6 [1.6] mmol/l to 11.3 [1.0] mmol/l; p = 0.009) were significantly reduced at 8 weeks compared with baseline. Liver fat was also significantly reduced from baseline (14.7% [2.2%]) to 8 weeks (5.8% [1.7%]; p = 0.001). Only three out of eight participants met non-alcoholic fatty liver disease (NAFLD) criteria (≥5.5%) at 8 weeks, compared with eight out of eight at baseline. The three participants on insulin therapy at baseline were able to cease therapy during the 8 week VLED. At 34 weeks, adherers (n = 5) achieved 12.3% weight loss, none met NAFLD criteria and four did not meet American Diabetes Association criteria for type 2 diabetes. CONCLUSIONS/INTERPRETATION: A VLED appears to be a feasible treatment option for some youth with type 2 diabetes on metformin therapy. Youth who agree to participate and adhere to a VLED achieve rapid weight loss, dramatic reductions in liver fat and reversal of type 2 diabetes. This highlights the capacity of a VLED to be used as a first-line treatment option in newly diagnosed youth. A larger trial with a control group and longer follow-up will be required to encourage a change in standard treatment. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registration Number (ACTRN) ACTRN12616000375459 ( www.ANZCTR.org.au/ACTRN12616000375459.aspx ).

Changes in body mass index in long-term survivors of childhood acute lymphoblastic leukemia treated without cranial radiation and with reduced glucocorticoid therapy.

BACKGROUND: Cranial radiation and glucocorticoids are associated with an increase in body mass index (BMI) z-score in survivors of childhood acute lymphoblastic leukemia (ALL). We aimed to investigate the impact of a contemporary treatment protocol that omitted prophylactic cranial radiation and glucocorticoids from the maintenance phase on longitudinal BMI, height, and weight z-scores in children with ALL. METHOD: We retrospectively studied 184 children with standard- and medium-risk ALL treated without cranial radiation or glucocorticoids. Height, weight, and BMI z-scores were collected from diagnosis to 7 years after diagnosis. Longitudinal changes in anthropometric data were compared to diagnosis using separate linear mixed models, adjusting for age, sex, and socioeconomic status (SES). RESULTS: Relative to diagnosis, there was a significant increase in estimated marginal mean BMI z-score during dexamethasone-containing re-induction (1.08, P < 0.001) that persisted throughout intensification (0.85, P < 0.001) and maintenance phases (0.81, P < 0.001), and up to 7 years after diagnosis (0.76, P = 0.002). Height z-scores decreased over the same time (P < 0.001), whereas weight z-scores fluctuated during treatment and declined thereafter (P = 0.007). A higher BMI z-score at diagnosis was associated with a younger age (P < 0.001), male sex (P < 0.001), and lower SES (P < 0.001). CONCLUSIONS: Children who did not receive cranial radiation or glucocorticoids during maintenance remain at increased risk of treatment-related increases in BMI z-score, which is associated with a loss of height z-score. Interventions designed to mediate this risk should begin early, even while children are on treatment because of the association with cardiovascular risk. Monitoring of survivors of ALL should include anthropometric measures.

Cross-sectional and prospective mediating effects of dietary intake on the relationship between sedentary behaviour and body mass index in adolescents.

BACKGROUND: Cross-sectional evidence suggests TV viewing, but not objectively-measured sedentary time or bouts of sedentary time, is consistently associated with body mass index (BMI) in adolescents. However, it is unclear whether dietary intake is a potential mediator of these relationships. The aim of this study was to explore the cross-sectional and prospective mediating effects of dietary intake on the association of sedentary behaviour with BMI z-score (zBMI) in a cohort of Australian adolescents. METHODS: Cross-sectional and prospective analyses were conducted in adolescents aged 12-15 years participating in the 2002/03 (baseline) and 2004/05 (follow-up) Nepean Growing Up Study. The independent variables were television (TV) viewing, an objective measure of total sedentary time and average sedentary bout duration, and the outcome variable zBMI. Using the Sobel-Goodman method with bootstrapping, mediation analyses were conducted examining three dietary components (discretionary foods, sugar-sweetened beverages [SSB] and takeaway foods) as mediators of associations between TV viewing and zBMI (n = 259) and between total sedentary time and average sedentary bout duration with zBMI (n = 140). RESULTS: No significant cross-sectional or prospective total or direct associations were observed for TV viewing, total sedentary time and average sedentary bout duration with zBMI. However, TV viewing was positively associated with consumption of takeaway foods cross-sectionally (ß = 0.06; 95% CI 0.01 to 0.12), prospectively at baseline (ß = 0.07; 95% CI 0.01 to 0.12) and prospectively at follow-up (ß = 0.10; 95% CI 0.04, 0.16), and average sedentary bout duration was inversely associated with SSB consumption both cross-sectionally (ß = -0.36; 95% CI -0.69 to -0.02) and prospectively at baseline (ß = -0.36; 95% CI -0.70 to -0.02). No mediation effects were identified. CONCLUSIONS: TV viewing, total sedentary time and bouts of sedentary time were not associated cross-sectionally or prospectively with adolescents' zBMI, and three elements of dietary intake (e.g. intake of discretionary foods, SSB and takeaway foods) did not mediate this relationship. The role of dietary intake and sedentary behaviour in relation to adolescent health requires further clarification.

Can early weight loss, eating behaviors and socioeconomic factors predict successful weight loss at 12- and 24-months in adolescents with obesity and insulin resistance participating in a randomised controlled trial?

BACKGROUND: Lifestyle interventions in adolescents with obesity can result in weight loss following active intervention but individual responses vary widely. This study aimed to identify predictors of weight loss at 12- and 24-months in adolescents with obesity and clinical features of insulin resistance. METHODS: Adolescents (n = 111, 66 girls, aged 10-17 years) were participants in a randomised controlled trial, the RESIST study, examining the effects of two diets differing in macronutrient content on insulin sensitivity. Eighty-five completed the 12-month program and 24-month follow-up data were available for 42 adolescents. Change in weight was determined by BMI expressed as a percentage of the 95th percentile (BMI95). The study physician collected socioeconomic data at baseline. Physical activity and screen time, and psychological dimensions of eating behavior were self-reported using the validated CLASS and EPI-C questionnaires, respectively. Stepwise multiple regressions were conducted to identify models that best predicted change in BMI95 at 12- and 24-months. RESULTS: Mean BMI95 was reduced at 12-months compared with baseline (mean difference [MD] ± SE: -6.9 ± 1.0, P < 0.001) but adolescents had significant re-gain from 12- to 24-months (MD ± SE: 3.7 ± 1.5, P = 0.017). Participants who achieved greater 12-month weight loss had: greater 3-month weight loss, a father with a higher education, lower baseline external eating and parental pressure to eat scores and two parents living at home. Participants who achieved greater 24-month weight loss had: greater 12-month weight loss and a lower baseline emotional eating score. CONCLUSIONS: Early weight loss is consistently identified as a strong predictor of long-term weight loss. This could be because early weight loss identifies those more motivated and engaged individuals. Patients who have baseline factors predictive of long-term weight loss failure may benefit from additional support during the intervention. Additionally, if a patient does not achieve early weight loss, further support or transition to an alternate intervention where they may have increased success may be considered. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registration Number (ACTRN) 12608000416392 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=83071.

Zinc Intake, Zinc Bioavailability and Plasma Zinc in Obese Adolescents with Clinical Insulin Resistance Following Low Energy Diets.

BACKGROUND: Zinc has a critical role in metabolism and growth. This study aims to determine the effects of low-energy diets differing in macronutrient composition on zinc intake, estimated zinc bioavailability (phytate:zinc molar ratio) and plasma zinc concentration and associations between zinc status and cardiometabolic markers in obese adolescents with clinical insulin resistance (IR). METHODS: Eighty-seven obese adolescents (10-17 years, body mass index z-score 2.3 ± 0.37) with clinical IR were randomized to a low-energy diet (6.0-8.0 MJ), which was either high carbohydrate or moderate carbohydrate with increased protein. Twenty-four-hour dietary recalls were collected at 6, 9 and 12 weeks. Plasma zinc concentration and cardiometabolic markers were assessed at baseline and 12 weeks. RESULTS: Zinc intake did not differ between the 2 diet groups (p = 0.612). The high-carbohydrate group had a higher phytate intake (894 vs. 671 mg, p = 0.018) and phytate:zinc molar ratio (9.4 vs. 7.4, p = 0.009) than the increased-protein group. Plasma zinc concentration did not change from baseline in either of the diet groups, but correlated positively with zinc intake (r = 0.235, p = 0.042) and % energy from protein (r = 0.383, p = 0.001), and inversely with % energy from carbohydrate (r = -0.296, p = 0.010). CONCLUSIONS: Low energy diets for obese adolescents at risk of diabetes may need increased protein content to optimize zinc bioavailability.

Bioelectrical impedance analysis to estimate body composition, and change in adiposity, in overweight and obese adolescents: comparison with dual-energy x-ray absorptiometry.

BACKGROUND: There is a need for a practical, inexpensive method to assess body composition in obese adolescents. This study aimed to 1) compare body composition parameters estimated by a stand-on, multi-frequency bioelectrical impendence (BIA) device, using a) the manufacturers' equations, and b) published and derived equations with body composition measured by dual-energy x-ray absorptiometry (DXA) and 2) assess percentage body fat (%BF) change after a weight loss intervention. METHODS: Participants were 66 obese adolescents, mean age (SD) 12.9 (2.0) years. Body composition was measured by Tanita BIA MC-180MA (Tanita BIA8) and DXA (GE-Lunar Prodigy). BIA resistance and reactance data at frequencies of 5, 50, 250 and 500 kHz, were used in published equations, and to generate a new prediction equation for fat-free mass (FFM) using a split-sample method. Approximately half (n = 34) of the adolescents had their body composition measured by DXA and BIA on two occasions, three to nine months apart. RESULTS: The correlations between FFM (kg), fat mass (kg) and %BF measured by BIA and DXA were 0.92, 0.93 and 0.78, respectively. The Tanita BIA8 manufacturers equations significantly (P < 0.001) overestimated FFM (4.3 kg [-5.3 to 13.9]) and underestimated %BF (-5.0% [-15 to 5.0]) compared to DXA. The mean differences between BIA derived equations and DXA measured body composition parameters were small (0.4 to 2.1%), not significant, but had large limits of agreements (~ ±15% for FFM). After the intervention mean %BF loss was similar by both methods (~1.5%), but with wide limits of agreement. CONCLUSION: The Tanita BIA8 could be a valuable clinical tool to measure body composition at the group level, but is inaccurate for the individual obese adolescent.

Improved insulin sensitivity and body composition, irrespective of macronutrient intake, after a 12 month intervention in adolescents with pre-diabetes; RESIST a randomised control trial.

BACKGROUND: A higher protein to carbohydrate ratio in the diet may potentiate weight loss, improve body composition and cardiometabolic risk, including glucose homeostasis in adults. The aim of this randomised control trial was to determine the efficacy of two structured lifestyle interventions, differing in dietary macronutrient content, on insulin sensitivity and body composition in adolescents. We hypothesised that a moderate-carbohydrate (40-45% of energy), increased-protein (25-30%) diet would be more effective than a high-carbohydrate diet (55-60%), moderate-protein (15%) diet in improving outcomes in obese, insulin resistant adolescents. METHODS: Obese 10-17 year olds with either pre-diabetes and/or clinical features of insulin resistance were recruited at two hospitals in Sydney, Australia. At baseline adolescents were prescribed metformin and randomised to one of two energy restricted diets. The intervention included regular contact with the dietician and a supervised physical activity program. Outcomes included insulin sensitivity index measured by an oral glucose tolerance test and body composition measured by dual-energy x-ray absorptiometry at 12 months. RESULTS: Of the 111 adolescents recruited, 85 (77%) completed the intervention. BMI expressed as a percentage of the 95th percentile decreased by 6.8% [95% CI: -8.8 to -4.9], ISI increased by 0.2 [95% CI: 0.06 to 0.39] and percent body fat decreased by 2.4% [95% CI: -3.4 to -1.3]. There were no significant differences in outcomes between diet groups at any time. CONCLUSION: When treated with metformin and an exercise program, a structured, reduced energy diet, which is either high-carbohydrate or moderate-carbohydrate with increased-protein, can achieve clinically significant improvements in obese adolescents at risk of type 2 diabetes. TRIAL REGISTRATION: Australian New Zealand Clinical Trail Registry ACTRN12608000416392 . Registered 25 August 2008.

Animal protein intakes during early life and adolescence differ in their relation to the growth hormone-insulin-like-growth-factor axis in young adulthood.

Recent studies provide evidence that insulin-like-growth-factor I (IGF-I) and its binding proteins (IGFBP) IGFBP-2 and IGFBP-3 are related to the risk of several common cancers. It remains to be clarified whether their concentrations can be programmed by protein intake from different sources during growth. This study addressed the hypothesis that animal protein intakes during infancy, mid-childhood, and adolescence differ in their relevance for the growth-hormone (GH)-IGF-I axis in young adulthood. Data from the Dortmund Nutritional and Anthropometric Longitudinally Designed Study participants with at least 2 plausible 3-d weighed dietary records during adolescence (age: girls, 9-14 y; boys, 10-15 y; n = 213), around the adiposity rebound (age 4-6 y; n = 179) or early life (age 0.5-2 y; n = 130), and one blood sample in young adulthood were included in the study. Mean serum concentrations of IGF-I, IGFBP-1, IGFBP-2, and IGFBP-3 were compared between tertiles of habitual animal protein intake using multivariable regression analysis. Habitually higher animal protein intakes in females during puberty were related to higher IGF-I (P-trend = 0.005) and IGFBP-3 (P-trend = 0.01) and lower IGFBP-2 (P-trend = 0.04), but not to IGFBP-1 in young adulthood. In turn, IGF-I concentrations in young adulthood were inversely related to animal protein intakes in early life among males only (P-trend = 0.03), but not to animal protein intake around adiposity rebound (P-trend > 0.5). Our data suggest that, among females, a habitually higher animal protein intake during puberty may precipitate an upregulation of the GH-IGF-I axis, which is still discernible in young adulthood. By contrast, among males, higher animal protein intakes in early life may exert a long-term programming of the GH-IGF-I axis.

Effect of a prescriptive dietary intervention on psychological dimensions of eating behavior in obese adolescents.

BACKGROUND: Overweight adolescents are more likely to have dysfunctional eating behaviours compared to normal weight adolescents. Little is known about the effects of obesity treatment on the psychological dimensions of eating behavior in this population. OBJECTIVE: To examine the effects of a prescriptive dietary intervention on external eating (eating in response to food cues, regardless of hunger and satiety), emotional eating and dietary restraint and their relation to weight loss. Parental acceptability was also examined. METHOD: This is a secondary study of a 12-month randomized trial, the RESIST study, which examined the effects of two diets on insulin sensitivity. Participants were 109 obese 10- to 17-year-olds with clinical features of insulin resistance. The program commenced with a 3-month dietary intervention using a structured meal plan, with the addition of an exercise intervention in the next 3 months and followed by a 6 month maintenance period.This paper presents changes in eating behaviors measured by the Eating Pattern Inventory for Children and parent rated diet acceptability during the first 6 months of the trial. As there was no difference between the diets on outcome of interest, both diet groups were combined for analyses. RESULTS: After 6 months, the proportion of participants who reported consuming more in response to external eating cues decreased from 17% to 5% (P = 0.003), whereas non- emotional eating increased from 48% to 65% (p = 0.014). Dietary restraint and parental pressure to eat remained unchanged. A reduction in external eating (rho = 0.36, P < 0.001) and a reduction in dietary restraint (r = 0.26, P = 0.013) were associated with greater weight loss at 3 and 6 months, respectively. Overall this approach was well accepted by parents with 72% of parents considered that their child would be able to follow the meal plan for the longer term. CONCLUSIONS: In the short to medium term, a prescriptive dietary intervention approach is a well-accepted and suitable option for obese adolescents with clinical features of insulin resistance. It may reduce external and emotional eating, led to modest weight loss and did not cause any adverse effect on dietary restraint. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registration Number (ACTRN) 12608000416392 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=83071.

Growth and pubertal development of adolescent boys on stimulant medication for attention deficit hyperactivity disorder.

OBJECTIVE: To investigate the growth and pubertal attainment of boys with attention deficit hyperactivity disorder (ADHD) on stimulant medication. DESIGN, SETTING AND PARTICIPANTS: Longitudinal study of boys aged 12.00-15.99 years at recruitment in 2005-2011, with stimulant-treated ADHD for at least 3 years, attending three paediatric practices (subjects), compared with longitudinal data from 174 boys from the Nepean longitudinal study (controls). MAIN OUTCOME MEASURES: Subjects' growth parameters before treatment were compared with controls aged 7 or 8 years; growth parameters and longitudinal changes on treatment to ages 12.00-13.99 and 14.00-15.99 years were compared with controls reviewed at 13 and 15 years of age, respectively. The subjects' pubertal staging and height velocity were related to their treatment history. RESULTS: Sixty-five subjects were recruited; mean duration of treatment was 6.3 ± 1.9 years. At baseline, their growth parameters were not significantly different from those of the controls after adjusting for age. Compared with the controls, after adjusting for current age and baseline growth parameter z score, subjects aged 12.00-13.99 years had significantly lower weight and body mass index (P < 0.01), and those aged 14.00-15.99 years had significantly lower height and weight (P < 0.05). At 12.00-13.99 years of age, the subjects were comparable to the controls in their pubertal development adjusted for age, but those aged 14.00-15.99 years reported significant delay (mean Tanner stage, 3.6 for subjects v 4.0 for controls; P < 0.05). The dose of medication was inversely correlated with the height velocity from baseline to 14.00-15.99 years of age (P < 0.05). CONCLUSIONS: Prolonged treatment (more than 3 years) with stimulant medication was associated with a slower rate of physical development during puberty. To maintain adequate height velocity during puberty, we recommend keeping the dose as low as possible.

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

AIM: This systematic review explored the feasibility, acceptability and effect on health outcomes of weight-neutral interventions in health improvement-seeking young people with overweight/obesity. METHODS: Six databases were searched to March 2021 for health, but not weight, focused interventions (PROSPERO, CRD42020152671). Eligible studies recruited young people (10-24 years) with overweight/obesity. The studies were described using narrative synthesis, with numerical results summarised. The quality of included studies was assessed using the Joanna Briggs Institute critical appraisal tools. RESULTS: Six articles were included, representing three pilot studies. Study 1 (n = 37, 14-17 years) compared a 6-week mindful eating program with single-session lifestyle education; Study 2 (n = 35, 14-17 years) compared 12-week weight-neutral lifestyle education focused on intuitive eating and carbohydrate quality, with/without guided imagery; and Study 3 (n = 33, 12-17 years) compared a 6-week mindfulness intervention with cognitive behavioural therapy in adolescents with depressive symptoms at risk of type 2 diabetes. All interventions explored feasibility (intervention group retention 57%-88%, attendance >80%) and reported interventions were acceptable. Studies 1 and 3 reported no change in mindfulness. Study 2 reported an increase (p < 0.05) in intuitive eating following weight-neutral plus guided imagery (0.32 ± 0.36, Hawks' Scale, score 1-4), compared with weight-neutral alone (0.15 ± 0.29). Study 1 reported decreased body mass index (p < 0.001) following mindful eating (-1.1 kg/m2 ), compared with single-session lifestyle education (+0.7 kg/m2 ); Studies 2 and 3 found no change in body mass index or body mass index z-score. CONCLUSIONS: Weight-neutral interventions may be feasible and acceptable in adolescents with overweight/obesity in the short term (≤12 weeks), but data are limited.