Randomized Trial of Metformin, Ivermectin, and Fluvoxamine for Covid-19.

BACKGROUND: Early treatment to prevent severe coronavirus disease 2019 (Covid-19) is an important component of the comprehensive response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. METHODS: In this phase 3, double-blind, randomized, placebo-controlled trial, we used a 2-by-3 factorial design to test the effectiveness of three repurposed drugs - metformin, ivermectin, and fluvoxamine - in preventing serious SARS-CoV-2 infection in nonhospitalized adults who had been enrolled within 3 days after a confirmed diagnosis of infection and less than 7 days after the onset of symptoms. The patients were between the ages of 30 and 85 years, and all had either overweight or obesity. The primary composite end point was hypoxemia (≤93% oxygen saturation on home oximetry), emergency department visit, hospitalization, or death. All analyses used controls who had undergone concurrent randomization and were adjusted for SARS-CoV-2 vaccination and receipt of other trial medications. RESULTS: A total of 1431 patients underwent randomization; of these patients, 1323 were included in the primary analysis. The median age of the patients was 46 years; 56% were female (6% of whom were pregnant), and 52% had been vaccinated. The adjusted odds ratio for a primary event was 0.84 (95% confidence interval [CI], 0.66 to 1.09; P = 0.19) with metformin, 1.05 (95% CI, 0.76 to 1.45; P = 0.78) with ivermectin, and 0.94 (95% CI, 0.66 to 1.36; P = 0.75) with fluvoxamine. In prespecified secondary analyses, the adjusted odds ratio for emergency department visit, hospitalization, or death was 0.58 (95% CI, 0.35 to 0.94) with metformin, 1.39 (95% CI, 0.72 to 2.69) with ivermectin, and 1.17 (95% CI, 0.57 to 2.40) with fluvoxamine. The adjusted odds ratio for hospitalization or death was 0.47 (95% CI, 0.20 to 1.11) with metformin, 0.73 (95% CI, 0.19 to 2.77) with ivermectin, and 1.11 (95% CI, 0.33 to 3.76) with fluvoxamine. CONCLUSIONS: None of the three medications that were evaluated prevented the occurrence of hypoxemia, an emergency department visit, hospitalization, or death associated with Covid-19. (Funded by the Parsemus Foundation and others; COVID-OUT ClinicalTrials.gov number, NCT04510194.).

Favorable Antiviral Effect of Metformin on Severe Acute Respiratory Syndrome Coronavirus 2 Viral Load in a Randomized, Placebo-Controlled Clinical Trial of Coronavirus Disease 2019.

BACKGROUND: Metformin has antiviral activity against RNA viruses including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The mechanism appears to be suppression of protein translation via targeting the host mechanistic target of rapamycin pathway. In the COVID-OUT randomized trial for outpatient coronavirus disease 2019 (COVID-19), metformin reduced the odds of hospitalizations/death through 28 days by 58%, of emergency department visits/hospitalizations/death through 14 days by 42%, and of long COVID through 10 months by 42%. METHODS: COVID-OUT was a 2 × 3 randomized, placebo-controlled, double-blind trial that assessed metformin, fluvoxamine, and ivermectin; 999 participants self-collected anterior nasal swabs on day 1 (n = 945), day 5 (n = 871), and day 10 (n = 775). Viral load was quantified using reverse-transcription quantitative polymerase chain reaction. RESULTS: The mean SARS-CoV-2 viral load was reduced 3.6-fold with metformin relative to placebo (-0.56 log10 copies/mL; 95% confidence interval [CI], -1.05 to -.06; P = .027). Those who received metformin were less likely to have a detectable viral load than placebo at day 5 or day 10 (odds ratio [OR], 0.72; 95% CI, .55 to .94). Viral rebound, defined as a higher viral load at day 10 than day 5, was less frequent with metformin (3.28%) than placebo (5.95%; OR, 0.68; 95% CI, .36 to 1.29). The metformin effect was consistent across subgroups and increased over time. Neither ivermectin nor fluvoxamine showed effect over placebo. CONCLUSIONS: In this randomized, placebo-controlled trial of outpatient treatment of SARS-CoV-2, metformin significantly reduced SARS-CoV-2 viral load, which may explain the clinical benefits in this trial. Metformin is pleiotropic with other actions that are relevant to COVID-19 pathophysiology. CLINICAL TRIALS REGISTRATION: NCT04510194.

Impact of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Vaccination and Booster on Coronavirus Disease 2019 (COVID-19) Symptom Severity Over Time in the COVID-OUT Trial.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination has decreasing protection from acquiring any infection with emergence of new variants; however, vaccination continues to protect against progression to severe coronavirus disease 2019 (COVID-19). The impact of vaccination status on symptoms over time is less clear. METHODS: Within a randomized trial on early outpatient COVID-19 therapy testing metformin, ivermectin, and/or fluvoxamine, participants recorded symptoms daily for 14 days. Participants were given a paper symptom diary allowing them to circle the severity of 14 symptoms as none (0), mild (1), moderate (2), or severe (3). This is a secondary analysis of clinical trial data on symptom severity over time using generalized estimating equations comparing those unvaccinated, SARS-CoV-2 vaccinated with primary vaccine series only, or vaccine-boosted. RESULTS: The parent clinical trial prospectively enrolled 1323 participants, of whom 1062 (80%) prospectively recorded some daily symptom data. Of these, 480 (45%) were unvaccinated, 530 (50%) were vaccinated with primary series only, and 52 (5%) vaccine-boosted. Overall symptom severity was least for the vaccine-boosted group and most severe for unvaccinated at baseline and over the 14 days (P < .001). Individual symptoms were least severe in the vaccine-boosted group including cough, chills, fever, nausea, fatigue, myalgia, headache, and diarrhea, as well as smell and taste abnormalities. Results were consistent over Delta and Omicron variant time periods. CONCLUSIONS: SARS-CoV-2 vaccine-boosted participants had the least severe symptoms during COVID-19, which abated the quickest over time. Clinical Trial Registration. NCT04510194.

Household Income, Cortisol, and Obesity During Early Childhood: A Prospective Longitudinal Study.

OBJECTIVE: To prospectively evaluate the relationship between household income, children's cortisol, and body mass index (BMI) trajectories over a 3-year period in early childhood. STUDY DESIGN: Household income, child hair cortisol levels, and BMI were measured at baseline, 12-, 24-, and 36-month follow-up visits in the Now Everybody Together for Amazing and Healthful Kids (NET-Works) Study (n = 534, children ages 2-4 years, and household income <$65 000/year at baseline). Relationships were examined between very low household income (<$25 000/year) at baseline, income status over time (remained <$25 000/year or had increasing income), cortisol accumulation from hair samples, and BMI percent of the 95th percentile (BMIp95) trajectories using adjusted linear growth curve modeling. Households with baseline income between $25 000 and $65 000/year were the reference group for all analyses. RESULTS: Children from very low-income households at baseline had annual changes in BMIp95 that were higher (P < .001) than children from reference group households (0.40 vs -0.62 percentage units/year). Annual increases in BMIp95 were also greater among children from households that remained very low income (P < .01, .34 percentage units/year) and among those with increasing income (P = .01, .51 percentage units/year) compared with the reference group (-0.61 percentage units/year). Children from households that remained very low income had higher hair cortisol accumulations (0.22 pg/mg, P = .02) than reference group children, whereas hair cortisol concentrations of children from households with increasing income (0.03 pg/mg) did not differ significantly from the reference group. Cortisol was not related to BMIp95. CONCLUSIONS: The economic circumstances of families may impact children's BMI trajectories and their developing stress systems, but these processes may be independent of one another.

Is economic hardship associated with young children's cortisol levels?

Economic hardship during childhood has been linked to poor physical and mental health. This study examines cross-sectional and longitudinal associations of a summed economic hardship score of poverty, food insecurity, and financial hardship with hair cortisol in young children. Data from 24-month (Time 1, mean age 5 years) and 36-month (Time 2, mean age 6 years) follow-up from the NET-Works obesity prevention trial (NET-Works, NCT0166891) were used. Hair cortisol measures obtained at each time point were log-transformed and regressed on economic hardship at Time 1 and a cumulative economic hardship from Time 1 to Time 2, using generalized linear regressions. All models were adjusted for child age, sex, race/ethnicity, and intervention (prevention vs. control) arm. The final analytic sample sizes ranged from 248 to 287. Longitudinal analyses indicated that for every 1-unit higher economic hardship score at Time 1, hair cortisol at Time 2 follow-up was on average 0.07 log-picograms per milligram (pg/mg) higher (95% confidence interval [CI]: 0.01, 0.13). For every 1-unit increase in the cumulative economic hardship score between Time 1 and 2, there was a 0.04 log-pg/mg (95% CI: 0.00, 0.07) average higher level of hair cortisol at Time 2 follow-up. Results show suggestive but limited evidence for an association between economic hardship and cortisol in young children.

BMI metrics and their association with adiposity, cardiometabolic risk factors, and biomarkers in children and adolescents.

BACKGROUND: There are limited data comparing the relative associations of various BMI metrics with adiposity and cardiometabolic risk factors in youth. OBJECTIVE: Examine correlations of 7 different BMI metrics with adiposity, cardiometabolic risk factors, and biomarkers (i.e. blood pressure, waist circumference, cholesterol, leptin, insulin, high molecular weight adiponectin, high-sensitivity c-reactive protein (hsCRP)). METHODS: This was a cross-sectional analysis of youth in all BMI categories. BMI metrics: BMI z-score (BMIz), extended BMIz (ext.BMIz), BMI percentile (BMIp), percent of the BMI 95th percentile (%BMIp95), percent of the BMI median (%BMIp50), triponderal mass index (TMI), and BMI (BMI). Correlations between these BMI metrics and adiposity, visceral adiposity, cardiometabolic risk factors and biomarkers were summarized using Pearson's correlations. RESULTS: Data from 371 children and adolescents ages 8-21 years old were included in our analysis: 52% were female; 20.2% with Class I obesity, 20.5% with Class II, and 14.3% with Class III obesity. BMIp consistently demonstrated lower correlations with adiposity, risk factors, and biomarkers (r = 0.190-0.768) than other BMI metrics. The %BMIp95 and %BMIp50 were marginally more strongly correlated with measures of adiposity as compared to other BMI metrics. The ext.BMIz did not meaningfully outperform BMIz. CONCLUSION: Out of all the BMI metrics evaluated, %BMIp95 and %BMIp50 were the most strongly correlated with measures of adiposity. %BMIp95 has the benefit of being used currently to define obesity and severe obesity in both clinical and research settings. BMIp consistently had the lowest correlations. Future research should evaluate the longitudinal stability of various BMI metrics and their relative associations with medium to long-term changes in adiposity and cardiometabolic outcomes in the context of intervention trials.

BestFIT Sequential Multiple Assignment Randomized Trial Results: A SMART Approach to Developing Individualized Weight Loss Treatment Sequences.

BACKGROUND: State-of-the-art behavioral weight loss treatment (SBT) can lead to clinically meaningful weight loss, but only 30-60% achieve this goal. Developing adaptive interventions that change based on individual progress could increase the number of people who benefit. PURPOSE: Conduct a Sequential Multiple Assignment Randomized Trial (SMART) to determine the optimal time to identify SBT suboptimal responders and whether it is better to switch to portion-controlled meals (PCM) or acceptance-based treatment (ABT). METHOD: The BestFIT trial enrolled 468 adults with obesity who started SBT and were randomized to treatment response assessment at Session 3 (Early TRA) or 7 (Late TRA). Suboptimal responders were re-randomized to PCM or ABT. Responders continued SBT. Primary outcomes were weight change at 6 and 18 months. RESULTS: PCM participants lost more weight at 6 months (-18.4 lbs, 95% CI -20.5, -16.2) than ABT participants (-15.7 lbs, 95% CI: -18.0, -13.4), but this difference was not statistically significant (-2.7 lbs, 95% CI: -5.8, 0.5, p = .09). PCM and ABT participant 18 month weight loss did not differ. Early and Late TRA participants had similar weight losses (p = .96), however, Early TRA PCM participants lost more weight than Late TRA PCM participants (p = .03). CONCLUSIONS: Results suggest adaptive intervention sequences that warrant further research (e.g., identify suboptimal responders at Session 3, use PCMs as second-stage treatment). Utilizing the SMART methodology to develop an adaptive weight loss intervention that would outperform gold standard SBT in a randomized controlled trial is an important next step, but may require additional optimization work. CLINICAL TRIAL INFORMATION: ClinicalTrials.gov identifier; NCT02368002.

Dietary patterns and associations with BMI in low-income, ethnic minority youth in the USA according to baseline data from four randomised controlled trials.

Few studies have derived data-driven dietary patterns in youth in the USA. This study examined data-driven dietary patterns and their associations with BMI measures in predominantly low-income, racial/ethnic minority US youth. Data were from baseline assessments of the four Childhood Obesity Prevention and Treatment Research (COPTR) Consortium trials: NET-Works (534 2-4-year-olds), GROW (610 3-5-year-olds), GOALS (241 7-11-year-olds) and IMPACT (360 10-13-year-olds). Weight and height were measured. Children/adult proxies completed three 24-h dietary recalls. Dietary patterns were derived for each site from twenty-four food/beverage groups using k-means cluster analysis. Multivariable linear regression models examined associations of dietary patterns with BMI and percentage of the 95th BMI percentile. Healthy (produce and whole grains) and Unhealthy (fried food, savoury snacks and desserts) patterns were found in NET-Works and GROW. GROW additionally had a dairy- and sugar-sweetened beverage-based pattern. GOALS had a similar Healthy pattern and a pattern resembling a traditional Mexican diet. Associations between dietary patterns and BMI were only observed in IMPACT. In IMPACT, youth in the Sandwich (cold cuts, refined grains, cheese and miscellaneous) compared with Mixed (whole grains and desserts) cluster had significantly higher BMI (ß = 0·99 (95 % CI 0·01, 1·97)) and percentage of the 95th BMI percentile (ß = 4·17 (95 % CI 0·11, 8·24)). Healthy and Unhealthy patterns were the most common dietary patterns in COPTR youth, but diets may differ according to age, race/ethnicity or geographic location. Public health messages focused on healthy dietary substitutions may help youth mimic a dietary pattern associated with lower BMI.

Designing online grocery stores to support healthy eating for weight loss.

OBJECTIVES: The current study aimed to identify features to include in online grocery stores to support healthful food purchasing by those striving to lose weight. DESIGN: A Value Proposition Design approach was used to gain shopper insights, devise potential online grocery store features and obtain feedback on these features. SETTING: Telephone interviews were conducted to gain insight into shoppers' needs and perceptions. Results were used by the research team to identify potential online grocery shopping features that may support healthful purchase decisions, and interviews were conducted with a different sample of shoppers to gather feedback on features. PARTICIPANTS: Insight (n 25) and feedback (n 25) interviews were conducted with convenience samples of adults trying to lose weight. RESULTS: Participants were primarily female, white, college educated and with obesity or overweight. Online grocery features devised by the research team based on findings from the insight interviews included (1) shopping cart nutrition rating tool; (2) healthy meal planning tool; (3) interactive healthy eating inspiration aisle and (4) healthy shopping preference settings option. Findings from the feedback interviews indicated that the healthy meal planning tool, healthy shopping preference settings option and shopping cart nutrition rating tool features were positively rated by most participants. CONCLUSIONS: There are multiple features grocers should consider including in their online stores to attract and support customers striving to eat healthy for weight loss.

A Bidirectional Analysis of Feeding Practices and Eating Behaviors in Parent/Child Dyads from Low-Income and Minority Households.

OBJECTIVE: To prospectively examine the bidirectional relationship between parental feeding practices (eg, instrumental feeding, encouragement to eat) and child eating behaviors (eg, food responsiveness, emotional eating) in low-income, ethnically diverse preschool children over a 3-year period. STUDY DESIGN: Parent/child (age 2-4 years at baseline) pairs (n = 222 non-Hispanics; n = 312 Hispanics) participated in NET-Works (Now Everybody Together for Amazing and Healthful Kids), a randomized controlled trial carried out in community and in-home settings in urban areas of Minnesota. Data were collected at baseline and 12, 24, and 36 months. The present study is a secondary data analysis using cross-lagged models to identify bidirectional associations between parental feeding practices and child eating behaviors. RESULTS: Three models showed significant cross-lagged effects (P < .05): model 1, parental instrumental feeding influencing later child food responsiveness; model 2, parental emotional feeding influencing later child food responsiveness; and model 3, parental emotional feeding influencing later child eating satiety. Model 1 showed significant bidirectional temporal paths, whereas models 2 and 3 showed significant unidirectional temporal paths from parental feeding practices to child eating behaviors. CONCLUSIONS: Parental instrumental and emotional feeding practices prospectively influence child food responsiveness and satiety. This study demonstrates causal temporality between parental feeding practices and child eating behaviors. Heath care providers may want to use findings regarding parent feeding practices as part of their anticipatory guidance during well-child visits with parents of preschoolers.

A healthful home food environment: Is it possible amidst household chaos and parental stress?

PURPOSE: This study examines how household chaos and unmanaged parental stress are associated with and contribute to variance in markers of the home food environment (family meal frequency, perceived barriers to cooking, healthful home food availability). Obtaining a better understanding of these relationships could guide more effective family-based interventions to promote healthful home food environments. METHODS: The analytic sample included 819 households with children in the population-based Project EAT-IV cohort with survey data from 2015 to 2016. Multiple linear regression was used to generate means and 95% confidence intervals of home food environment variables, and estimates for the contribution of household chaos (defined by frenetic activity, loud noises and disorder), and quartiles of unmanaged parental stress (ratio of perceived stress and ability to manage stress). Model fit was also examined. RESULTS/FINDINGS: Both household chaos and quartiles of unmanaged parental stress were independently and inversely associated with family meal frequency (p's < 0.001) and positively associated with perceived mealtime preparation barriers (p's < 0.001). Unmanaged parental stress was also inversely associated with healthful home food availability (p = 0.004). Models including demographic characteristics, household chaos scores, and quartiles of unmanaged parental stress index showed significantly improved model fit for all outcomes compared to less comprehensive models. Among families with high chaos, those having 7 + family meals/week were significantly more likely to have lower mealtime preparation barrier scores, younger children and higher healthful home food availability scores than families eating together less often. CONCLUSIONS: Interventions to assist with parental management of stress and chaos within the home environment (e.g., establishing routines) may increase family meal frequency and the quality of children's home food environments.

Multicomponent Obesity Prevention Intervention in Low-Income Preschoolers: Primary and Subgroup Analyses of the NET-Works Randomized Clinical Trial, 2012-2017.

OBJECTIVES: To evaluate a multicomponent obesity prevention intervention among diverse, low-income preschoolers. METHODS: Parent-child dyads (n = 534) were randomized to the Now Everybody Together for Amazing and Healthful Kids (NET-Works) intervention or usual care in Minneapolis, MN (2012-2017). The intervention consisted of home visits, parenting classes, and telephone check-ins. The primary outcomes were adjusted 24- and 36-month body mass index (BMI). RESULTS: Compared with usual care, the NET-Works intervention showed no significant difference in BMI change at 24 (-0.12 kg/m2; 95% confidence interval [CI] = -0.44, 0.19) or 36 months (-0.19 kg/m2; 95% CI = -0.64, 0.26). Energy intake was significantly lower in the NET-Works group at 24 (-90 kcal/day; 95% CI = -164, -16) and 36 months (-101 kcal/day; 95% CI = -164, -37). Television viewing was significantly lower in the NET-Works group at 24 (rate ratio = 0.84; 95% CI = 0.75, 0.93) and 36 months (rate ratio = 0.88; 95% CI = 0.78, 0.99). Children with baseline overweight or obesity had lower BMI in the NET-Works group than those in usual care at 36 months (-0.71 kg/m2; 95% CI = -1.30, -0.12). Hispanic children had lower BMI in the NET-Works group than those in usual care at 36 months (-0.59 kg/m2; 95% CI = -1.14, -0.04). CONCLUSIONS: In secondary analyses, NET-Works significantly reduced BMI over 3 years among Hispanic children and children with baseline overweight or obesity. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01606891.

The dose of behavioral interventions to prevent and treat childhood obesity: a systematic review and meta-regression.

BACKGROUND: A better understanding of the optimal "dose" of behavioral interventions to affect change in weight-related outcomes is a critical topic for childhood obesity intervention research. The objective of this review was to quantify the relationship between dose and outcome in behavioral trials targeting childhood obesity to guide future intervention development. METHODS: A systematic review and meta-regression included randomized controlled trials published between 1990 and June 2017 that tested a behavioral intervention for obesity among children 2-18 years old. Searches were conducted among PubMed (Web-based), Cumulative Index to Nursing and Allied Health Literature (EBSCO platform), PsycINFO (Ovid platform) and EMBASE (Ovid Platform). Two coders independently reviewed and abstracted each included study. Dose was extracted as intended intervention duration, number of sessions, and length of sessions. Standardized effect sizes were calculated from change in weight-related outcome (e.g., BMI-Z score). RESULTS: Of the 258 studies identified, 133 had sufficient data to be included in the meta-regression. Average intended total contact (# sessions x length of sessions) was 27.7 (SD 32.2) hours and average duration was 26.0 (SD 23.4) weeks. When controlling for study covariates, a random-effects meta-regression revealed no significant association between contact hours, intended duration or their interaction and effect size. CONCLUSIONS: This systematic review identified wide variation in the dose of behavioral interventions to prevent and treat pediatric obesity, but was unable to detect a clear relationship between dose and weight-related outcomes. There is insufficient evidence to provide quantitative guidance for future intervention development. One limitation of this review was the ability to uniformly quantify dose due to a wide range of reporting strategies. Future trials should report dose intended, delivered, and received to facilitate quantitative evaluation of optimal dose. TRIAL REGISTRATIONS: The protocol was registered on PROSPERO (Registration # CRD42016036124 ).

Beyond the dinner table: who's having breakfast, lunch and dinner family meals and which meals are associated with better diet quality and BMI in pre-school children?

OBJECTIVE: Having frequent family dinners is associated with better diet quality in children; however, it is unknown whether the frequency of certain family meal types (i.e. dinner) is more strongly associated with better child weight and diet quality compared with other meal types (i.e. breakfast, lunch). Thus, the current study examined the frequency of eating breakfast, lunch or dinner family meals and associations with pre-school children's overall diet quality (HEI-2010) and BMI percentile. DESIGN: Cross-sectional baseline data (2012-2014) from two randomized controlled childhood obesity prevention trials, NET-Works and GROW, were analysed together. SETTING: Studies were carried out in community and in-home settings in urban areas of Minnesota and Tennessee, USA. SUBJECTS: Parent-child (ages 2-5 years) pairs from Minnesota (n 222 non-Hispanics; n 312 Hispanics) and Tennessee (n 545 Hispanics; n 55 non-Hispanics) participated in the study. RESULTS: Over 80 % of families ate breakfast or lunch family meals at least once per week. Over 65 % of families ate dinner family meals ≥5 times/week. Frequency of breakfast family meals and total weekly family meals were significantly associated with healthier diet quality for non-Hispanic pre-school children (P<0·05), but not for Hispanic children. Family meal frequency by meal type was not associated with BMI percentile for non-Hispanic or Hispanic pre-school children. CONCLUSIONS: Breakfast family meal frequency and total weekly family meal frequency were associated with healthier diet quality in non-Hispanic pre-school children but not in Hispanic children. Longitudinal research is needed to clarify the association between family meal type and child diet quality and BMI percentile.

Feasibility of standardized methods to specify behavioral pediatric obesity prevention interventions.

Standardized methods are needed to evaluate what occurs within the 'black box' of behavioral interventions to prevent pediatric obesity. The purpose of this research is to evaluate methods to specify the behavior change techniques used and the amount of time spent discussing target weight-related behaviors in an intervention for parents of children at risk for becoming overweight or obese. Independent coders were trained to identify behavior change techniques and time spent discussing weight-related behaviors in audio recordings and transcripts of intervention sessions from 100 randomly selected participants. The behavior change technique taxonomy (BCTTv1) was used to code techniques present in sessions. A newly-developed tool was used to code time spent discussing each target weight-related behavior (e.g., physical activity, screen time). Sessions from a subset of these participants (N = 20) were double coded to evaluate inter-rater reliability. After revisions to coding protocols, coders reliably coded behavior change techniques used and time spent discussing target weight-related behaviors in sessions from the subset of 20 participants. The most commonly discussed target weight-related behavior was physical activity followed by energy intake and fruit and vegetable intake. On average, 13.9 (SD = 2.8) unique behavior change techniques were present across sessions for a given participant. These results offer reliable methods for systematically identifying behavior change techniques used and time spent discussing weight-related behaviors in a pediatric obesity prevention intervention. This work paves the way for future research to identify which specific target behaviors and techniques are most associated with the prevention of unhealthy weight gain in children.

Predicting dietary intake among children classified as overweight or at risk for overweight: Independent and interactive effects of parenting practices and styles.

Using baseline data from a randomized controlled pediatric obesity prevention trial, this study sought to examine general parenting style as a potential moderator of the association between feeding-specific parenting practices and child dietary intake. Four hundred and twenty-one parent-child dyads served as participants (49% girls and 93% mothers). Children were, on average, 6.6 years old and either overweight or at-risk for overweight (mean BMI percentile = 84.9). Data were collected in participants' homes. Study staff measured children's height and weight. Parents completed questionnaires designed to assess general parenting styles (authoritative, authoritarian and permissive) and child feeding practices (restriction and monitoring). Child dietary intake was assessed using a 24-h recall system. Outcomes were daily servings of fruits and vegetables, sugar-sweetened beverages (SSB), and unhealthy snacks. Results were as follows: Permissive parenting was inversely associated with fruit and vegetable consumption, and parental monitoring was inversely associated with SSB consumption. There were no other main effects of parenting style or feeding practice on child dietary consumption. Authoritarian parenting moderated the association between restriction and SSB intake (a marginally significant effect after correcting for multiple comparisons). Restriction was inversely associated with SSB consumption when authoritarianism was high but unassociated with SSB consumption when authoritarianism was low. Findings indicate that the parenting practice of monitoring child dietary intake was associated with more healthful consumption regardless of parenting style; interventions may thus benefit from encouraging parental monitoring. The parenting strategy of restricting child dietary intake, in contrast, was associated with lower SSB intake in the context of higher parental authoritarianism but inconsequential in the context of lower parental authoritarianism. This exploratory finding warrants further investigation.

Cardiometabolic Risk Factors Among 1.3 Million Adults With Overweight or Obesity, but Not Diabetes, in 10 Geographically Diverse Regions of the United States, 2012-2013.

INTRODUCTION: Various phenotypes of overweight and obesity pose various health risks. The objective of this study was to determine the prevalence of 4 commonly measured cardiometabolic risk factors (CRFs) among adults with overweight or obesity, but not diabetes, at the time of the study. METHODS: We analyzed data for 1,294,174 adults (aged ≥20 y) who were members of one of 4 integrated health systems. Each cohort member had a body mass index in 2012 or 2013 that indicated overweight or obesity. We determined the presence of 4 CRFs within 1 year of the first BMI measurement: elevated blood pressure (systolic ≥130 mm Hg or diastolic >85 mm Hg or ICD-9-CM [International Classification of Diseases, Ninth Revision, Clinical Modification] diagnosis code 401.0-405.9); elevated triglycerides (≥150 mg/dL or ICD-9-CM 272.1); low high-density lipoprotein cholesterol (<40 mg/dL for men or <50 mg/dL for women or ICD-9-CM 272.5); and prediabetes (fasting glucose 100-125 mg/dL or HbA1c 5.7%-6.4% or ICD-9-CM 790.2x). We tested the risk of having 1 or more CRFs after adjusting for obesity class and demographic characteristics with multivariable logistic regression. RESULTS: Among participants with overweight (52.5% of the sample), 18.6% had none of the 4 CRFs. Among the 47.5% of participants with obesity, 9.6% had none; among participants with morbid obesity, 5.8% had none. Age was strongly associated with CRFs in multivariable analysis. CONCLUSION: Almost 10% of participants with obesity had no CRFs. Overweight or obesity increases cardiometabolic risk, but the number and type of CRFs varied substantially by age, even among participants with morbid obesity.

A novel dietary improvement strategy: examining the potential impact of community-supported agriculture membership.

OBJECTIVE: To investigate the use of community-supported agriculture (CSA) as an employer-based health promotion intervention. DESIGN: Quasi-experimental study using a convenience sample of employees at three employers. SETTING: Participants and controls from three Minnesota employers completed baseline and follow-up health assessments and surveys about their experiences with CSA. SUBJECTS: A total of 324 participants purchased a CSA share and were eligible for study inclusion. Study participants were matched by age, sex, employer and occupation to a non-randomized control group of individuals who did not purchase a CSA share but completed health assessments during the same time frame as the study participants. RESULTS: The majority of participants were female, white, middle-aged and highly educated. The most common reason for purchasing a CSA share was a desire for fresh food, and the majority of participants were satisfied with their experience. Participants reported a significant increase in the number of vegetables present in the household and the frequency of family meals. The frequency of eating out decreased significantly, especially at fast-food restaurants. Participants also reported an increase in the amount and variety of produce consumed. However, health assessment data did not show significant changes in dietary intake, health status or BMI. CONCLUSIONS: CSA participation was associated with improvement in some aspects of the household environment and dietary behaviours. Further research is needed to determine whether employer-based CSA interventions may also lead to improvements in dietary intake and health.

Emotional eating is associated with weight loss success among adults enrolled in a weight loss program.

To examine associations between decreased emotional eating and weight loss success; and whether participation in a behavioral weight loss intervention was associated with a greater reduction in emotional eating over time compared to usual care. Secondary data analysis of a randomized controlled trial conducted at two university medical centers with 227 overweight adults with diabetes. Logistic and standard regression analyses examined associations between emotional eating change and weight loss success (i.e., weight loss of ≥7 % of body weight and decrease in BMI). After 6 months of intervention, decreased emotional eating was associated with greater odds of weight loss success (p = .05). The odds of weight loss success for subjects with decreased emotional eating at 12 months were 1.70 times higher than for subjects with increased emotional eating. No differences in change in emotional eating were found between subjects in the behavioral weight loss intervention and usual care. Strategies to reduce emotional eating may be useful to promote greater weight loss among overweight adults with diabetes.

Managing temptation in obesity treatment: A neurobehavioral model of intervention strategies.

Weight loss outcomes in lifestyle interventions for obesity are primarily a function of sustained adherence to a reduced-energy diet, and most lapses in diet adherence are precipitated by temptation from palatable food. The high nonresponse and relapse rates of lifestyle interventions suggest that current temptation management approaches may be insufficient for most participants. In this conceptual review, we discuss three neurobehavioral processes (attentional bias, temporal discounting, and the cold-hot empathy gap) that emerge during temptation and contribute to lapses in diet adherence. Characterizing the neurobehavioral profile of temptation highlights an important distinction between temptation resistance strategies aimed at overcoming temptation while it is experienced, and temptation prevention strategies that seek to avoid or minimize exposure to tempting stimuli. Many temptation resistance and temptation prevention strategies heavily rely on executive functions mediated by prefrontal systems that are prone to disruption by common occurrences such as stress, insufficient sleep, and even exposure to tempting stimuli. In contrast, commitment strategies are a set of devices that enable individuals to manage temptation by constraining their future choices, without placing heavy demands on executive functions. These concepts are synthesized in a conceptual model that categorizes temptation management approaches based on their intended effects on reward processing and degree of reliance on executive functions. We conclude by discussing the implications of our model for strengthening temptation management approaches in future lifestyle interventions, tailoring these approaches based on key individual difference variables, and suggesting high-priority topics for future research.