Pediatricians' practices and knowledge of metabolic dysfunction-associated steatotic liver disease: An international survey.

OBJECTIVE: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading cause of chronic liver disease in children. It is associated with significant intra- and extrahepatic comorbidity. Current guidelines lack consensus, potentially resulting in variation in screening, diagnosis and treatment practices, which may lead to underdiagnosing and/or insufficient treatment. The increasing prevalence of MASLD and associated long-term health risks demand adequate clinical management and consensus in guidelines. This study aims to evaluate the daily practices of pediatricians in screening, diagnosis and treatment of MASLD in children. METHODS: An online survey with 41 questions (single/multiple response options) was sent to pediatricians (with/without subspecialty) in Europe and Israel, via members of the ESPGHAN Fatty Liver Special Interest Group, between June and November 2022. The 454 pediatricians were included in this study. RESULTS: 51% of pediatricians indicated using any guideline for diagnosis and treatment of MASLD, with 68% reporting to follow recommendations only partially. 63% is of the opinion that guidelines need revision. The majority of pediatricians screen for MASLD with liver function tests and/or abdominal ultrasound. A large variety of treatment options is utilized, including lifestyle management, supplements and probiotics, with a notable 34% of pediatricians prescribing pharmacotherapy. When asked how often pediatricians request a liver biopsy in children with MASLD, 17% indicates they request a liver biopsy in more than 10% of cases. CONCLUSIONS: There is limited awareness and considerable variation in screening, diagnosis and treatment practices among European pediatricians, and a clear demand for new, uniform guidelines for MASLD in children.

The evaluation of kidney function estimation during lifestyle intervention in children with overweight and obesity.

BACKGROUND: Children with overweight and obesity are at risk for developing chronic kidney disease (CKD). During lifestyle adjustment, the first step in the treatment of childhood obesity, body proportions are likely to change. The aim of this study was to examine how lifestyle intervention affects creatinine-based kidney function estimation in children with overweight and obesity. METHODS: This longitudinal lifestyle intervention study included 614 children with overweight and obesity (mean age 12.17 ± 3.28 years, 53.6% female, mean BMI z-score 3.32 ± 0.75). Loss to follow-up was present: 305, 146, 70, 26, and 10 children were included after 1, 2, 3, 4, and 5 (about yearly) follow-up visits, respectively. Serum creatinine (SCr) was rescaled using Q-age and Q-height polynomials. RESULTS: At baseline, 95-97% of the children had a SCr/Q-height and SCr/Q-age in the normal reference range [0.67-1.33]. SCr/Q significantly increased each (about yearly) follow-up visit, and linear mixed regression analyses demonstrated slopes between 0.01 and 0.04 (corresponding with eGFR FAS reduction of 1.1-4.1 mL/min/1.73 m2) per visit. BMI z-score reduced in both sexes and this reduction was significantly higher in males. No correlation between change in rescaled SCr and BMI z-score reduction could be demonstrated. CONCLUSIONS: Rescaled serum creatinine (SCr/Q) slightly increases during multidiscipline lifestyle intervention in this cohort of children with overweight and obesity. This effect seems to be independent from change in BMI z-score. Whether this minor decrease in estimated kidney function has clinical consequences in the long term remains to be seen in trials with a longer follow-up period. CLINICAL TRIAL REGISTRATION: ClinicalTrial.gov; Registration Number: NCT02091544.

Relation between obesity-related comorbidities and kidney function estimation in children.

BACKGROUND: The current childhood obesity pandemic is likely to result in an increased risk of chronic kidney disease (CKD) later in life. Correlations between obesity-related comorbidities and kidney function can be found, but it is unclear to what extent this is caused by bias due to different mathematical forms of the estimated glomerular filtration rate (eGFR) equations. The present study aimed to analyze correlations between obesity-related comorbidities and different eGFR equations and to investigate whether rescaled serum creatinine (SCr/Q) for sex and age or height might be an alternative biomarker for kidney function estimation. METHODS: This cross-sectional cohort study included 600 children with overweight and obesity. Mean age was 12.20 ± 3.28 years, 53.5% were female, and mean BMI z-score was 3.31 ± 0.75. All children underwent a comprehensive assessment that included anthropometrical and blood pressure measurements, laboratory examination, air displacement plethysmography, and polysomnography. Qage and Qheight polynomials were used to rescale SCr and multiple creatinine-based eGFR equations were compared. RESULTS: SCr/Q and almost all GFR estimations significantly correlated with a waist-to-hip ratio, fat mass, homeostasis model assessment for insulin resistance, and triacylglyceride, HDL cholesterol, alanine transaminase, and serum uric acid concentrations. Multiple correlations, however, were not confirmed by all equations, which suggests dependency on the mathematical form of the different eGFR equations. CONCLUSIONS: Correlations between obesity-related comorbidities and creatinine-based eGFR are present in children with overweight and obesity, but depend to a large extent on the eGFR equation of choice. SCr/Q might be an alternative biomarker for assessing correlations between obesity-related comorbidities and kidney function in children with overweight and obesity. A higher resolution version of the Graphical abstract is available as Supplementary information.

Celiac Disease and the Gluten Free Diet during the COVID-19 Pandemic: Experiences of Children and Parents.

The COVID-19 pandemic perturbed the everyday life of children and those with chronic illnesses, along with the lives of their families. Patients with celiac disease (CD) follow a strict gluten-free diet (GFD), and gluten ingestion is associated with negative health outcomes. The aim of this study was to investigate the experiences of children with CD and their families concerning their GFD, symptoms and CD management during the first period of the COVID-19 pandemic. A cross-sectional questionnaire-based study was performed including 37 Dutch pediatric patients with CD, along with their parents. The majority reported good compliance to the GFD and stated that the diet was easier to follow during the pandemic, mainly due to eating more meals in the home. Some discovered a greater variety of GF products by utilizing online shopping, potentially increasing the financial burden of the GFD. Concerning general dietary habits, 21.6% reported a healthier eating pattern, in contrast to 37.8% and 10.8% who consumed more unhealthy snacks and fewer fruits and vegetables, respectively, than normal during the pandemic. The natural experiment of the COVID-19 pandemic provides valuable information regarding the management of pediatric CD. Education on healthy dietary patterns is important, especially for children with restrictive diets, and the findings of this study show that there is room for improvement in this respect, regardless of the current pandemic.

Creatinine-based GFR-estimating equations in children with overweight and obesity.

BACKGROUND: With the increasing prevalence of childhood obesity and related development of chronic kidney disease (CKD), there is a critical need to understand how best to assess kidney function in children with obesity. Since serum creatinine (SCr) is recommended as marker of first choice for GFR estimation, we evaluated and compared creatinine-based GFR equations in children with overweight and obesity. METHODS: Six hundred children with overweight and obesity (53.5% female; mean age 12.20 ± 3.28 years; mean BMI z-score 3.31 ± 0.75) were included from the Centre for Overweight Adolescent and Children's Healthcare (COACH). RESULTS: Serum creatinine (SCr), normalized using Q-age polynomials obtained from reference values, results in median and mean SCr/Q value close to "1" for all age groups, and 96.5% of the children have a SCr/Q within the reference band [0.67-1.33], corresponding to the 2.5th and 97.5th percentile. eGFR CKiD (bedside Schwartz equation) and Schwartz-Lyon decreased with age, whereas eGFR EKFC and modified CKD-EPI40 showed no age-dependency, but the distribution of eGFR values was not symmetrical. eGFR CKiD under 25 (CKiDU25) demonstrated no age-dependency but major sex differences were observed. eGFR FAS age, FAS height, and adjusted-creatinine revised Lund-Malmö (LMR18) showed a relatively symmetrical distribution and no age-dependency. CONCLUSIONS: Serum creatinine (SCr) values of children with overweight and obesity are mostly within the reference range for children. Normalization of SCr using reference Q-age polynomials works very well in this cohort. After evaluation of the different equations, we suggest that FAS age, FAS height, and LMR18 are the preferred creatinine-based GFR-estimating equations in children with overweight and obesity. CLINICALTRIAL: gov; Registration Number: NCT02091544. A higher resolution version of the Graphical abstract is available as Supplementary information.

Serum CathepsinD in pregnancy: Relation with metabolic and inflammatory markers and effects of fish oils and probiotics.

BACKGROUND AND AIMS: Elevated circulating levels of CathepsinD (CatD) have been linked to metabolic deviations including liver inflammation. We investigated 1) whether supplementation with probiotics and/or fish oil affects CatD and 2) whether the CatD concentration would associate with gestational diabetes (GDM), low-grade inflammation, lipid metabolism, body fat % and dietary composition. METHODS AND RESULTS: Overweight/obese pregnant women (n = 438) were randomized into fish oil + placebo, probiotics + placebo, fish oil + probiotics or placebo + placebo groups. Fish oil contained 1.9 g docosahexaenoic acid and 0.22 g eicosapentaenoic acid and probiotics were Lacticaseibacillusrhamnosus HN001 (formerly Lactobacillusrhamnosus HN001) and Bifidobacteriumanimalis ssp. lactis 420, 1010 colony-forming units each). Serum CatD levels were analysed by ELISA, GlycA and lipid metabolites by NMR, high sensitive C-reactive protein (hsCRP) by immunoassay, and intakes of energy yielding nutrients and n-3 and n-6 fatty acids from food diaries at both early and late pregnancy. GDM was diagnosed by OGTT. CatD concentrations did not differ between the intervention groups or by GDM status. Multivariable linear models revealed that body fat % and GlycA affected CatD differently in healthy women and those with GDM. CONCLUSION: The serum CatD concentration of pregnant women was not modified by this dietary intervention. Serum CatD was influenced by two parameters, body fat and low grade inflammation, which were dependent on the woman's GDM status. CLINICAL TRIAL REG. NO: NCT01922791, clinicaltrials.gov (secondary analysis).

Laparoscopic roux-en-Y gastric bypass versus sleeve gastrectomy for teenagers with severe obesity - TEEN-BEST: study protocol of a multicenter randomized controlled trial.

BACKGROUND: Recent data support the use of bariatric surgery in adolescents with severe obesity following unsuccessful non-surgical treatments. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) have demonstrated reasonably similar weight loss and reduction of obesity related comorbidities in randomized trials in adults. SG has internationally become the most commonly used procedure in adolescents, yet long-term outcome data are lacking. No randomized controlled trial comparing SG and RYGB has been performed in adolescents. OBJECTIVE: Determine whether SG is non-inferior to RYGB in terms of total body weight (TBW) loss in adolescents with severe obesity. METHODS: A multicenter randomized controlled non-inferiority trial. Two hundred sixty-four adolescents aged 13-17 (Tanner stage ≥IV) with severe obesity (corrected for age and sex) will be included. Adolescents agreeing to participate will be randomized to either RYGB or SG. The primary outcome is the proportion of participants achieving 20% TBW loss at 3 years postoperatively. Secondary outcomes include (i) change in body weight, body mass index (BMI) and BMI standard deviation score, (ii) incidence of adverse health events and need for additional surgical intervention, (iii) resolution of obesity-related comorbidities, (iv) prevalence of cardio metabolic risk factor measures, (v) bone health measures and incidence of bone fractures, (vi) quality of life including psychosocial health, patient satisfaction and educational attainment and (vii) body composition. Follow-up will extend into the long term. RESULTS: Not applicable. DISCUSSION: This study will, to our knowledge, be the first randomized controlled trial comparing SG and RYGB in adolescents with severe obesity. TRIAL REGISTRATION: The trial is registered at the Netherlands Trial Register on July 26th, 2018 - NTR7191 - https://www.trialregister.nl/trial/7191 (protocol version 5.0 - February 3th 2020).

Serum I-FABP Detects Gluten Responsiveness in Adult Celiac Disease Patients on a Short-Term Gluten Challenge.

OBJECTIVES: Response to gluten challenge (GC) is a key feature in diagnostic algorithms and research trials in celiac disease (CD). Currently, autoantibody titers, late responders to GC, and invasive duodenal biopsies are used to evaluate gluten responsiveness. This study investigated the accuracy of serum intestinal-fatty acid binding protein (I-FABP), a marker for intestinal epithelial damage, to predict intestinal damage during GC in patients with CD. METHODS: Twenty adult CD patients in remission underwent a two-week GC with 3 or 7.5 g of gluten daily. Study visits occurred at day -14, 0, 3, 7, 14, and 28. Serum I-FABP, antibodies to tissue transglutaminase (tTG-IgA), deamidated gliadin peptides (IgA-DGP), and anti-actin (AAA-IgA) were assessed at each visit. Villous-height to crypt-depth ratio (Vh:Cd) and intraepithelial lymphocyte (IEL) count were evaluated at day -14, 3, and 14. Forty-three CD-serology negative individuals were included to compare serum I-FABP levels in CD patients on a gluten-free diet (GFD) with those in healthy subjects. RESULTS: Serum I-FABP levels increased significantly during a two-week GC. In contrast, the most pronounced autoantibody increase was found at day 28, when patients had already returned to a GFD for two weeks. IgA-AAA titers were only significantly elevated at day 28. I-FABP levels and IEL count correlated at baseline (r=0.458, P=0.042) and at day 14 (r=0.654, P=0.002) of GC. Neither gluten dose nor time on a GFD influenced I-FABP change during GC. CONCLUSIONS: Serum I-FABP levels increased significantly during a two-week GC in adult CD patients and correlated with IEL count. The data suggest that serum I-FABP is an early marker of gluten-induced enteropathy in celiac patients and may be of use in both clinical and research settings.

Human leukocyte antigen typing using buccal swabs as accurate and non-invasive substitute for venipuncture in children at risk for celiac disease.

BACKGROUND AND AIM: Human leukocyte antigen (HLA) typing is an important step in the diagnostic algorithm for celiac disease (CD) and is also used for screening purposes. Collection of blood is invasive and accompanied with emotional impact especially in children. Genetic technological progress now enables HLA typing from buccal cell samples. This study evaluated the reliability and feasibility of HLA typing for CD-associated HLA polymorphisms using buccal swabs as routine test in high-risk individuals. METHODS: Blood and buccal swabs of 77 children and adolescents with high risk for CD were prospectively collected in this cohort study. Buccal swab collection was performed either by the investigator at the outpatient clinic or by the patient or its parents at home. To evaluate the possibility of self-administration, three families performed the test at home. DNA was extracted using an adapted QIAamp method. Quantity, quality, and purity of DNA were recorded. HLA-DRB1, HLA-DQA1, and HLA-DQB1 typing was examined on buccal cell-derived and blood-derived DNA at low and, if necessary, high resolution level, using sequence-specific oligonucleotide and sequence-based typing, respectively. RESULTS: DNA isolation using buccal swabs yielded a good quality and sufficient quantity of DNA to perform HLA-DQ typing in all individuals. HLA typing results on buccal cell-derived DNA were identical to typing on blood-derived DNA, also for the self-administered samples. CONCLUSION: Introduction of the buccal swab test for HLA typing of CD risk in routine diagnostics can omit the current venipuncture and enables self-administration at home. Therefore, the buccal swab test is beneficial for individuals with a clinical suspicion for CD, as well as for screening purposes in high-risk populations.

Plasma cathepsin D levels: a novel tool to predict pediatric hepatic inflammation.

OBJECTIVES: Nonalcoholic steatohepatitis (NASH) is the most severe form of a hepatic condition known as nonalcoholic fatty liver disease (NAFLD). NASH is histologically characterized by hepatic fat accumulation, inflammation, and ballooning, and eventually coupled with fibrosis that, in turn, may progress to end-stage liver disease even in young individuals. Hence, there is a critical need for specific noninvasive markers to predict hepatic inflammation at an early age. We investigated whether plasma levels of cathepsin D (CatD), a lysosomal protease, correlated with the severity of liver inflammation in pediatric NAFLD. METHODS: Liver biopsies from children (n=96) with NAFLD were histologically evaluated according to the criteria of Kleiner (NAFLD activity score) and the Brunt's criteria. At the time of liver biopsy, blood was taken and levels of CatD, alanine aminotransferase (ALT), and cytokeratin-18 (CK-18) were measured in plasma. RESULTS: Plasma CatD levels were significantly lower in subjects with liver inflammation compared with steatotic subjects. Furthermore, we found that CatD levels were gradually reduced and corresponded with increasing severity of liver inflammation, steatosis, hepatocellular ballooning, and NAFLD activity score. CatD levels correlated with pediatric NAFLD disease progression better than ALT and CK-18. In particular, CatD showed a high diagnostic accuracy (area under receiver operating characteristic curve (ROC-AUC): 0.94) for the differentiation between steatosis and hepatic inflammation, and reached almost the maximum accuracy (ROC-AUC: 0.998) upon the addition of CK-18. CONCLUSIONS: Plasma CatD holds a high diagnostic value to distinguish pediatric patients with hepatic inflammation from children with steatosis.

Weight Loss and Glycemic Control After Bariatric Surgery in Adolescents With Severe Obesity: A Randomized Controlled Trial.

PURPOSE: Bariatric surgery is regarded as a valuable treatment option for adolescents with severe obesity. However, high-quality evidence of its superiority over prolonged conservative treatment with multidisciplinary lifestyle intervention (MLI) is limited. This study investigated the efficacy and safety of bariatric surgery in adolescents without sufficient weight loss after MLI for severe obesity. METHODS: A two-group randomized controlled trial was designed to assess one-year health effects of bariatric surgery in adolescents with severe obesity. The participants were referred by pediatricians after completing MLI without sufficient effects. Eligible for participation were adolescents aged 14-16 years with severe obesity (age- and sex-adjusted body mass index (BMI) using the International Obesity Task Force cutoffs: BMI ≥40 kg/m2, or ≥35 kg/m2 in combination with comorbidity). Participants were assigned to MLI combined with laparoscopic adjustable gastric banding (n = 29) versus only MLI (n = 30). Participants were included from 2011 to 2019. Main outcomes were weight change and sex- and age-specific BMI loss. Additionaly, glucose metabolism, blood pressure and lipid profile were analysed. RESULTS: 53 patients completed the 12-months follow-up (89.8%). Mean (±standard deviation [SD]) weight loss in the surgery group was 11.2 ± 7.8% after 12 months, compared to a weight gain of 1.7 ± 8.1% in the control group. The fasting insulin, insulin resistance score and lipid profile improved significantly in the surgery group. DISCUSSION: Bariatric surgery was associated with substantial weight loss and improvements in glucose and lipid metabolism after 12 months compared to conservative treatment in adolescents with severe obesity.

Development of a Clinical Pathway for Bariatric Surgery as an Integral Part of a Comprehensive Treatment for Adolescents with Severe Obesity in the Netherlands.

INTRODUCTION: In the Netherlands, bariatric surgery in adolescents is currently only allowed in the context of scientific research. Besides this, there was no clinical pathway for bariatric surgery in adolescents. In this paper, the development of a comprehensive clinical pathway for bariatric surgery in adolescents with severe obesity in the Netherlands is described. METHODS: The clinical pathway for bariatric surgery in adolescents consists of an eligibility assessment as well as comprehensive peri- and postoperative care. Regarding the eligibility assessment, the adolescents need to be identified by their attending pediatricians and afterwards be evaluated by specialized pediatric obesity units. If the provided treatment is considered to be insufficiently effective, the adolescent will anonymously be evaluated by a national board. This is an additional diligence procedure specifically established for bariatric surgery in adolescents. The national board consists of independent experts regarding adolescent bariatric surgery and evaluates whether the adolescents meet the criteria defined by the national professional associations. The final step is an assessment by a multidisciplinary team for adolescent bariatric surgery. The various disciplines (pediatrician, bariatric surgeon, psychologist, dietician) evaluate whether an adolescent is eligible for bariatric surgery. In this decision-making process, it is crucial to assess whether the adolescent is expected to adhere to postoperative behavioral changes and follow-up. When an adolescent is deemed eligible for bariatric surgery, he or she will receive preoperative counseling by a bariatric surgeon to decide on the type of bariatric procedure (Roux-en-Y gastric bypass or sleeve gastrectomy). Postoperative care consists of intensive guidance by the multidisciplinary team for adolescent bariatric surgery. In this guidance, several regular appointments are included and additional care will be provided based on the needs of the adolescent and his or her family. Furthermore, the multidisciplinary lifestyle intervention, in which the adolescents participated before bariatric surgery, continues in coordination with the multidisciplinary team for adolescent bariatric surgery, and this ensures long-term counseling and follow-up. CONCLUSION: The implementation of bariatric surgery as an integral part of a comprehensive treatment for adolescents with severe obesity requires the development of a clinical pathway with a variety of disciplines.

Health-Related Quality of Life in Children and Adolescents with Overweight, Obesity, and Severe Obesity: A Cross-Sectional Study.

INTRODUCTION: Children and adolescents with overweight and obesity have an impaired health-related quality of life (HRQoL). However, it is unclear which of these children are most affected in their physical, psychological, and social functioning. Therefore, this study aimed to evaluate HRQoL in treatment-seeking children and adolescents with overweight, obesity, and severe obesity. METHODS: A cross-sectional study was performed at the Centre for Overweight Adolescent and Children's Healthcare (COACH). Children and adolescents (8-17 years) with overweight, obesity, and severe obesity were included. The primary outcome was the self-reported HRQoL measured with the KIDSCREEN-27. RESULTS: A total of 419 participants with overweight (N = 121), obesity (N = 182), and severe obesity (N = 116) were included. One-way ANOVA analysis showed that children and adolescents with severe obesity reported significantly lower physical well-being (41.25 ± 13.14) compared to those with overweight (47.91 ± 12.53; p < 0.001) and obesity (46.74 ± 11.93; p < 0.001). Furthermore, impaired psychological well-being was found in the group with severe obesity (45.14 ± 13.27) in comparison to the group with overweight (50.90 ± 9.48; p < 0.001) and obesity (49.71 ± 10.95; p = 0.002). Multivariable linear regression analysis, while correcting for age, sex, cardio metabolic health risk, and ethnicity, revealed similar results. Additionally, children and adolescents with severe obesity scored lower regarding autonomy and parent relation than those with overweight (B = 3.95; p = 0.009). In almost all groups and dimensions of the KIDSCREEN-27, caregivers scored lower compared to the children and adolescents themselves. Furthermore, a low child-caregiver agreement seemed to exist, especially in the children and adolescents with overweight. CONCLUSION: The HRQoL of treatment-seeking children and adolescents with overweight and obesity was most affected in children and adolescents with the most severe grade of obesity. Following these findings, lifestyle intervention programs targeting childhood obesity should be aware of this even more vulnerable group so that treatments can be tailored according to their needs.

A Population-Based Cohort Study on Efficacy and Safety of Bariatric Surgery in Young Adults Versus Adults.

PURPOSE: Bariatric surgery is the most effective treatment for severe obesity in adults and has shown promising results in young adults. Lack of insight regarding efficacy and safety outcomes might result in delayed bariatric surgery utilization in young adults. Therefore, this study aimed to assess the efficacy and safety of bariatric surgery in young adults compared to adults. METHODS: This is a nationwide population-based cohort study utilizing data from the Dutch Audit Treatment of Obesity (DATO). Young adults (aged 18-25 years) and adults (aged 35-55 years) who underwent primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were included. Primary outcome was percentage total weight loss (%TWL) until five years postoperatively. RESULTS: A total of 2,822 (10.3%) young adults and 24,497 (89.7%) adults were included. The follow-up rates of the young adults were lower up to five years postoperatively (46.2% versus 56.7% three years postoperatively; p < 0.001). Young adults who underwent RYGB showed superior %TWL compared to adults until four years postoperatively (33.0 ± 9.4 versus 31.2 ± 8.7 three years after surgery; p < 0.001). Young adults who underwent SG showed superior %TWL until five years postoperatively (29.9 ± 10.9 versus 26.2 ± 9.7 three years after surgery; p < 0.001). Postoperative complications ≤ 30 days were more prevalent among adults, 5.3% versus 3.5% (p < 0.001). No differences were found in the long term complications. Young adults revealed more improvement of hypertension (93.6% versus 78.9%), dyslipidemia (84.7% versus 69.2%) and musculoskeletal pain (84.6% versus 72.3%). CONCLUSION: Bariatric surgery appears to be at least as safe and effective in young adults as in adults. Based on these findings the reluctance towards bariatric surgery in the younger age group seems unfounded.

Comparing the use of food and physical activity parenting practices: Parents of children with overweight and obesity versus parents of children with a healthy weight.

Background: Paediatric overweight and obesity are caused by a complex imbalance between energy intake and expenditure. Parents may influence this imbalance through energy balance-related parenting practices. This study aims to compare the use of energy balance-related parenting practices between parents of children with overweight and obesity and children with a healthy weight. Methods: This study compares energy balance-related parenting practices among a group of parents with children with overweight and obesity at the start of a lifestyle intervention (N = 107) and children with a healthy weight (N = 137). Specifically, it compares the feeding practices 'overt control' (open control over eating), 'encouragement', 'instrumental feeding', 'emotional feeding', and 'covert control' (hidden control over eating), as well as the physical activity parenting practice 'promoting physical activity'. Multiple regression analyses are used to calculate associations between child weight groups and parenting practices when corrected for children's characteristics. Results: Parents of children with overweight and obesity reported significantly different scores on control over eating practices than parents of children with a healthy weight, namely a significantly higher score on covert control (B = 0.397, S.E. 0.123, p = 0.001) and a significantly lower score for overt control (B = -0.136, S.E. 0.068, p = 0.046). Conclusion: Covert control is reported more, while overt control is reported less in parents of children with overweight and obesity compared to parents of children with a healthy weight, even after correction for the child's, family, and maternal characteristics. Future longitudinal research and intervention trials are recommended to determine whether and how the use of control over eating practices changes.

The Side-Effects of the COVID-19 Pandemic: Increased BMI z-Score in Children with Overweight and Obesity in a Personalised Lifestyle Intervention One Year after the Start of the Pandemic in The Netherlands.

BACKGROUND: Early research showed weight gain in children during the COVID-19 pandemic. OBJECTIVE: To compare changes in BMI z-score of children with overweight and obesity in a personalised lifestyle intervention before and during the pandemic. METHODS: Changes in BMI z-score half a year (T6) and twelve months (T12) after the first lockdown were included for 71 children in the '2020 during COVID' group and compared to 48 children in the '2019 before COVID' group, using a marginal model for repeated measures (model 1). Model 2 corrected for lifestyle intervention characteristics, and model 3 corrected additionally for family characteristics. RESULTS: The mean difference in BMI z-score change was significantly different at T12 (+0.07 in 2020 versus -0.09 in 2019, p = 0.022). Model 3 showed significant differences in BMI z-score change at both T6 (+0.15, p = 0.024) and T12 (+0.18, p = 0.016). This model also defined 'having a mother with obesity' (+0.13, p = 0.019) and the frequency of no-show consultations (+0.41 per missed consultation per month, p = 0.025) as related factors. CONCLUSIONS: Lifestyle intervention in children with overweight and obesity is less successful in decreasing BMI z-score during the COVID-pandemic. Identified risk factors for less success could contribute to identifying children with higher risks for, and possibly prevent, BMI z-score increase.

The Impact of the COVID-19 Pandemic on Lifestyle and Wellbeing of Children, Adolescents and Their Parents: A Qualitative Study.

Prior studies have shown that changes in daily structure and habits due to the COVID-19 pandemic affected the lifestyle and wellbeing of families. This study aimed to obtain in-depth information on children's and adolescents' experiences regarding their lifestyle and wellbeing during the pandemic. Semi-structured interviews with fifteen families were carried out between May and November 2021. Directed content analysis was used to analyze the transcripts and fundamental qualitative description to describe the results. Children and adolescents revealed an overall unhealthier lifestyle and decreased wellbeing. These negative effects were even larger in adolescents and children with overweight or psychosocial complaints. Our results revealed that parents were actively involved in maintaining a normal daily structure. Furthermore, diet changes were inconsistent and dependent on food availability. An increase in screen time was experienced as inevitable, and external influences were necessary to keep children and adolescents active. Almost no effects were reported on physical health, whereas negative emotions were experienced in varying degrees. Moreover, the decrease in social interactions was reported as the most negative effect of the pandemic. The above-mentioned insights may contribute to the development of preventive measures to promote a healthy lifestyle and wellbeing of children and adolescents during future pandemics.

The Effect of a Multidisciplinary Lifestyle Intervention on Health Parameters in Children versus Adolescents with Severe Obesity.

Lifestyle interventions are the common treatment for children and adolescents with severe obesity. The efficacy of these interventions across age groups remain unknown. Therefore, this study aimed to compare the effectiveness of a lifestyle intervention on health parameters between children and adolescents with severe obesity. A longitudinal design was carried out at the Centre for Overweight Adolescent and Children's Healthcare (COACH) between December 2010 and June 2020. Children (2-11 years old, n = 83) and adolescents (12-18 years old, n = 77) with severe obesity received a long-term, tailored, multidisciplinary lifestyle intervention. After 1 year, 24 children (28.9%) and 33 adolescents (42.9%) dropped out of the intervention. The primary outcome was the change in body mass index (BMI) z-score after one and two years of intervention. The decrease in BMI z-score over time was significantly higher in children compared to adolescents, the mean decrease was 0.15 (0.08-0.23) versus 0.03 (-0.05-0.11) after one year and 0.25 (0.15-0.35) versus 0.06 (-0.06-0.17) after two years of intervention; p values for the difference between children and adolescents were 0.035 and 0.012. After two years, multiple improvements in cardio metabolic health parameters were observed, especially in children. In conclusion, during our tailored lifestyle intervention, a positive and maintained effect on health parameters was observed in children with severe obesity. Compared to children, the effect on health parameters was less pronounced in adolescents.

Weight Gain in Children during the COVID-19 Pandemic and the Protective Effect of Lifestyle Intervention in Children with Obesity.

INTRODUCTION: School closures due to the COVID-19 pandemic affect children's daily structure, mealtimes, physical activity, and sleeping habits, possibly exacerbating weight gain, particularly in vulnerable children with overweight and obesity. This study aimed to evaluate both perceived and objectively measured weight gain in children in the Netherlands during the COVID-19 pandemic and the effect of prior lifestyle intervention. METHODS: A total of 150 children of the Children, Obesity and Lifestyle during COVID-19 (COLC) study (cohort A) reported perceptions of weight change during the COVID-19 pandemic. Anthropometric data of 65 children with overweight and obesity were collected at the expertise Centre for Overweight Adolescent and Children's Healthcare in the same period (COACH; cohort B). RESULTS: In cohort A, 43% of children with overweight and obesity perceived weight gain during the pandemic, compared to 15% of lean children. In cohort B, the BMI z-score increased significantly (+0.065 SD) within 5 months. Participation in a lifestyle intervention for >1 year and having parents with Dutch background was associated with less weight gain, specifically in children with obesity. DISCUSSION/CONCLUSION: In particular, children with overweight and obesity seem to be at risk for accelerated weight gain during the COVID-19 pandemic. Prior long-term participation in a lifestyle intervention protects against this weight gain, which emphasizes the importance of strong support for vulnerable populations during health crises and pleads for wide implementation of lifestyle interventions for children.

Bariatric Surgery in Youth: the Perspective of Dutch Pediatricians, Parents, and Adolescents.

BACKGROUND: Recent studies have indicated that bariatric surgery is effective for the treatment of youth with severe obesity. The attitudes of pediatricians, parents, and adolescents regarding this topic remain unclear. Therefore, the aim of this study was to assess the current thoughts and beliefs of Dutch pediatricians, parents, and adolescents regarding bariatric surgery in youth. METHODS: An online survey containing twenty questions on bariatric surgery in youth was distributed to pediatricians of the Dutch Society of Pediatrics. Parents and adolescents who participated in an interdisciplinary care program for overweight, obesity, and severe obesity filled out an online survey of twelve questions. RESULTS: One hundred and twenty-one pediatricians, 49 parents, and 19 adolescents completed the surveys. Seventy-two pediatricians (59.5%) considered bariatric surgery to be an effective treatment for youth with severe obesity when conventional treatment fails, and intend to refer patients for bariatric surgery. The most frequently suggested conditions for bariatric surgery were a minimum age of 16 years (n = 59, 48.7%), a BMI threshold of 40 kg/m2 (n = 51, 42.2%), and a minimum Tanner stage of IV (n = 59, 48.8%). Thirty parents (61.2%) and fourteen adolescents (73.7%) responded that bariatric surgery should become available for youth with severe obesity. CONCLUSION: Dutch pediatricians, parents, and adolescents increasingly accept bariatric surgery as a treatment modality in youth with severe obesity who do not respond successfully to lifestyle intervention. Whether pediatricians will actually refer youth for bariatric surgery remains to be seen when this treatment option will be implemented in the Netherlands.