Parents as Agents of Change in Managing Pediatric Obesity: A Randomized Controlled Trial Comparing Cognitive Behavioral Therapy versus Psychoeducation Interventions.

Background: Obesity interventions for parents of children with obesity can improve children's weight and health. This randomized controlled trial (RCT) evaluated whether a parent-based intervention based on cognitive behavioral therapy (CBT) principles was superior to a parent-based intervention based on a psychoeducation program (PEP) in improving children's obesity. Methods: This study was a pragmatic, two-armed, parallel, superiority RCT. Conducted at a Canadian outpatient pediatric obesity management clinic (September 2010-January 2014), this trial included families with children 8-12 years with an age- and sex-specific BMI ≥85th percentile. The 16-week manualized interventions were similar in content and delivered to parents exclusively, with different theoretical underpinnings. The primary outcome was children's BMI z-score at postintervention (4 months). Secondary outcomes included anthropometric, lifestyle, psychosocial, and cardiometabolic variables. Data were collected at preintervention (0 months), postintervention (4 months), 10, and 16 months. Intention-to-treat analysis using linear mixed models was used to assess outcomes. Results: Among 52 randomly assigned children, the mean age (standard deviation) was 9.8 (1.7) years and BMI z-score was 2.2 (0.3). Mean differences in BMI z-score were not significantly different between the CBT (n = 27) and PEP (n = 25) groups from 0 to 4-, 10-, and 16-month follow-up. At 4 months, the mean difference in BMI z-score from preintervention between the CBT (-0.05, 95% CI = -0.09 to 0.00) and PEP (-0.04, 95% CI = -0.09 to 0.01) groups was -0.01 (95% CI = -0.08 to 0.06, p = 0.80). Similar results were found across all secondary outcomes. Conclusions: Our CBT-based intervention for parents of children with obesity was not superior in reducing BMI z-score vs. our PEP-based intervention.

Impaired ApoB-Lipoprotein and Triglyceride Metabolism in Obese Adolescents With Polycystic Ovary Syndrome.

CONTEXT: Adolescents with polycystic ovary syndrome (PCOS) have atherogenic dyslipidemia and increased cardiovascular disease (CVD) risk, and this is exacerbated in obesity. OBJECTIVE: To determine and compare fasting and nonfasting lipid and apolipoprotein (Apo)B-lipoprotein metabolism in 3 groups of adolescent girls: healthy-weight controls, obese without PCOS (obese-control), and obese with PCOS (obese-PCOS). DESIGN, SETTING, AND PARTICIPANTS: Participants aged 12 to 17 years were recruited for this cross-sectional study from a pediatric weight management clinic and the local community in Alberta, Canada. MAIN OUTCOME MEASURES: Plasma lipids and ApoB lipoproteins, including triglycerides (TGs) and ApoB100- and ApoB48-lipoproteins, were measured in the fasted and postprandial state following a high-fat meal. RESULTS: Obese-control (n = 12) and obese-PCOS (n = 18) groups had twofold higher concentrations of fasting plasma TG and ApoB100- and ApoB48-lipoprotein remnants compared to healthy-weight controls (n = 10) (ApoB48-lipoproteins: 19.32 ± 2.10, 24.02 ± 4.28, and 8.95 ± 1.05 µg/mL, respectively; P < 0.001). The obese-PCOS group had 50% higher fasting plasma TG level compared to the obese-control group. The postprandial response was higher in both obese-controls and obese-PCOS subjects compared with healthy-weight controls in plasma TG area under the curve (AUC) (1028.0 ± 83.67, 1587.01 ± 259.6, and 615.42 ± 76.42 µg/mL⋅h, respectively; P < 0.01) and ApoB48(AUC) (191.30 ± 19.06, 238.8 ± 37.73, and 96.58 ± 9.17 µg/mL⋅h, respectively; P < 0.0001). Nonfasting plasma TG(AUC) and ApoB48(AUC) were positively correlated with free testosterone (r = 0.38; P < 0.001 and r = 0.33; P < 0.05, respectively), and these relationships were highly associated with insulin and body mass index. CONCLUSIONS: Adolescent girls with obesity and PCOS have elevated fasting and postprandial plasma TG and ApoB-lipoprotein remnants, providing evidence of early subclinical CVD risk, and these indices are highly associated with impaired insulin metabolism and hyperandrogenemia.

Predictors of Short- and Long-Term Attrition From the Parents as Agents of Change Randomized Controlled Trial for Managing Pediatric Obesity.

INTRODUCTION: Attrition in pediatric weight management is a substantial problem. This study examined factors associated with short- and long-term attrition from a lifestyle and behavioral intervention for parents of children with overweight or obesity. METHOD: Fifty-two families with children ages 6 to 12 years old and body mass index at or above the 85th percentile participated in a randomized controlled trial focused on parents, comparing parent-based cognitive behavioral therapy with parent-based psychoeducation for pediatric weight management. We examined program attrition using two clinical phases of the intervention: short-term and long-term attrition, modeled using the general linear model. Predictors included intervention type, child/parent weight status, sociodemographic factors, and health of the family system. RESULTS: Higher self-assessed health of the family system was associated with lower short-term attrition; higher percentage of intervention sessions attended by parents was associated with lower long-term attrition. DISCUSSION: Different variables were significant in our short- and long-term models. Attrition might best be conceptualized based on short- and long-term phases of clinical, parent-based interventions for pediatric weight management.

46,XY disorder of sex development due to 17-beta hydroxysteroid dehydrogenase type 3 deficiency: a plea for timely genetic testing.

BACKGROUND: 17ß-hydroxysteroid dehydrogenase type 3 (17ßHSD3) deficiency is a rare cause of disorder of sex development (DSD) due to impaired conversion of androstenedione to testosterone. Traditionally, the diagnosis was determined by ßHCG-stimulated ratios of testosterone:androstenedione < 0.8. CASE PRESENTATION: An otherwise phenotypically female infant presented with bilateral inguinal masses and a 46,XY karyotype. ßHCG stimulation (1500 IU IM for 2 days) suggested 17ßHSD3 deficiency although androstenedione was only minimally stimulated (4.5 nmol/L to 5.4 nmol/L). Expedient genetic testing for the HSD17B3 gene provided the unequivocal diagnosis. CONCLUSION: We advocate for urgent genetic testing in rare causes of DSD as indeterminate hormone results can delay diagnosis and prolong intervention.

The Edmonton Obesity Staging System for Pediatrics: A proposed clinical staging system for paediatric obesity.

Traditionally, clinical recommendations for assessing and managing paediatric obesity have relied on anthropometric measures, such as body mass index (BMI), BMI percentile and/or BMI z-score, to monitor health risks and determine weight management success. However, anthropometric measures do not always accurately and reliably identify children and youth with obesity-related health risks or comorbidities. The authors propose a new clinical staging system (the Edmonton Obesity Staging System for Pediatrics, EOSS-P), adapted from the adult-oriented EOSS. The EOSS-P is used to stratify patients according to severity of obesity-related comorbidities and barriers to weight management into four graded categories (0 to 3) within four main health domains: metabolic, mechanical, mental health and social milieu (the 4Ms). The EOSS-P is based on common clinical assessments that are widely available and routinely completed by clinicians, and has the potential to provide clinical and prognostic information to help evaluate and inform the management of paediatric obesity.

D'ordinaire, les recommandations cliniques pour évaluer et prendre en charge l'obésité juvénile reposent sur des mesures anthropométriques, telles que l'indice de masse corporelle (IMC), le percentile d'IMC ou l'écart réduit de l'IMC, pour surveiller les risques sur la santé et déterminer la bonne gestion du poids. Cependant, les mesures anthropométriques ne permettent pas toujours de déterminer avec précision et fiabilité les enfants et les adolescents présentant des risques de santé ou des comorbidités liés à l'obésité. Les auteurs proposent un nouveau système clinique d'établissement du stade de l'obésité (le système d'Edmonton pour évaluer le stade de l'obésité, ou EOSS-P), adapté de l'EOSS destiné aux adultes. L'EOSS-P est utilisé pour stratifier les patients selon la gravité des comorbidités liées à l'obésité et les obstacles à la gestion du poids en quatre catégories (0 à 3) tirées de quatre grands domaines de santé : métabolique, mécanique, santé mentale et milieu social (les 4M). L'EOSS-P, qui repose sur des évaluations cliniques courantes généralisées souvent remplies par les cliniciens, peut fournir de l'information clinique et pronostique pour contribuer à évaluer et étayer la prise en charge de l'obésité juvénile.

Lifestyle Behaviors of Parents of Children in Pediatric Weight Management: Are They Meeting Recommendations?

OBJECTIVE: Our objective was to examine the lifestyle behaviors of parents of children in pediatric weight management. METHODS: Parents were recruited upon presentation of their children (body mass index [BMI] ≥85th percentile) to a pediatric weight management clinic. Parents' demographic, anthropometric, and lifestyle habit data were collected by self-report. Parents were grouped into weight status categories based on their BMIs; lifestyle data were compared across BMI categories and to national recommendations. RESULTS: Parents (n = 266; 84% women; BMI, mean ± SD, 31.8 ± 7.2 kg/m(2)) were predominantly overweight/obese (82%), and most did not meet dietary recommendations (71%). Healthy-weight parents reported more daily steps versus parents who were overweight/obese (all P < .05). Most parents (~60%) met guidelines for physical activity, sedentary activity, and sleep. CONCLUSION: The high prevalence of overweight and obesity combined with suboptimal dietary behaviors highlight the need to address both children's and parents' lifestyle habits in pediatric weight management.

It's like rocket science only more complex: challenges and experiences related to managing pediatric obesity in Canada.

Pediatric obesity is an urgent and complex public health issue. Approximately one-third of Canadian children are overweight or obese, a proportion that highlights the need for effective and accessible services to improve short- and long-term health risks. In our experience, we have encountered a number of challenges common in pediatric obesity management across our clinical and research centers. For the purpose of this review, these challenges and our real-world experiences are grouped as issues that span (i) caring for children, adolescents, and families, (ii) collaborating with colleagues and (iii) working within the health care system. Collectively, we highlight a number of lessons learned from our years of experience and detail ongoing initiatives designed to optimize health services for managing obesity for children and adolescents in Canada.

Modest treatment effects and high program attrition: The impact of interdisciplinary, individualized care for managing paediatric obesity.

BACKGROUND: There is an urgent need to identify effective weight management interventions in real-world, clinical settings to improve the health of children with obesity. OBJECTIVES: To determine the impact of individualized, interdisciplinary care on the weight status of children with obesity; to assess the relationship between clinical interactions and change in participants' weight status; and to document the degree of program attrition. METHODS: A retrospective medical record review of clinical and administrative data from a paediatric weight management clinic in Edmonton, Alberta, was performed, which included data from a group of five- to 18-year-olds (body mass index [BMI] ≥85th percentile) collected from 2008 to 2012. Demographic, anthropometric and attendance data were retrieved from baseline and follow-up at three-, seven- and 11-month timepoints. The primary outcomes were participants' BMI z-score and change in BMI z-score over time. RESULTS: Data from 165 individuals were included. Among those with follow-up anthropometric data, weight stabilization occurred at three (n=127) and seven months (n=84). For individuals with follow-up anthropometric data at 11 months (n=44), BMI z-score tended to decrease over time (-0.05±0.12 units; P=0.06). Program attrition increased over time (23%, 49% and 73% at three-, seven- and 11-month follow-ups, respectively). Between presentation and three-month follow-up, there was an inverse relationship between the number of clinical appointments attended and change in BMI z-score (r= -0.18; P=0.04), an association that became nonsignificant at seven and 11 months (both P>0.05). CONCLUSION: An individualized, interdisciplinary weight management intervention led to weight stabilization and a modest weight reduction in children with obesity. Strategies to minimize program attrition are needed to optimize family engagement in care and success in managing paediatric obesity.

HISTORIQUE: Il est urgent de trouver des interventions efficaces de gestion du poids en milieu clinique pour améliorer la santé des enfants obèses. OBJECTIFS: Déterminer les effets de soins personnalisés et interdisciplinaires sur le poids d'enfants obèses, évaluer le lien entre les interactions cliniques et les modifications au poids des participants et établir le taux d'abandon du programme. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des dossiers médicaux et des données administratives d'une clinique pédiatrique de gestion du poids d'Edmonton, en Alberta, qui incluait les données d'un groupe de jeunes de cinq à 18 ans (indice de masse corporelle [IMC] ≥85e percentile) colligées entre 2008 et 2012. Ils ont extrait les données démographiques, anthropométriques et de participation initiales, puis aux suivis de trois, sept et 11 mois. Les résultats primaires étaient l'écart réduit de l'IMC et le changement à cet écart au fil du temps. RÉSULTATS: Les données de 165 personnes ont été incluses dans l'étude. Parmi les personnes qui possédaient des données anthropométriques de suivi, on a observé une stabilisation du poids au bout de trois (n=127) et sept mois (n=84). Chez les personnes qui possédaient des données anthropométriques au suivi de 11 mois (n=44), l'écart réduit de l'IMC avait tendance à diminuer au fil du temps (−0,05±0,12 unités; P=0,06). L'abandon du programme a augmenté dans le temps (23 %, 49 % et 73 % au suivi de trois, sept et 11 mois, respectivement). Entre la présentation et le suivi de trois mois, le lien entre le nombre de rendez-vous cliniques auquel les patients avaient assisté était inversement proportionnel à la modification de l'écart réduit de l'IMC (r= −0,18; P=0,04), une association qui n'était plus significative au suivi de sept et 11 mois (tous deux P>0,05). CONCLUSION: Une intervention personnalisée et interdisciplinaire a suscité la stabilisation du poids et une légère perte de poids chez des enfants obèses. Des stratégies pour réduire au minimum l'abandon du programme s'imposent pour optimiser la participation familiale aux soins et réussir à gérer l'obésité en pédiatrie.

Parents as agents of change (PAC) in pediatric weight management: the protocol for the PAC randomized clinical trial.

BACKGROUND: There is an urgent need to develop and evaluate weight management interventions to address childhood obesity. Recent research suggests that interventions designed for parents exclusively, which have been named parents as agents of change (PAC) approaches, have yielded positive outcomes for managing pediatric obesity. To date, no research has combined a PAC intervention approach with cognitive behavioural therapy (CBT) to examine whether these combined elements enhance intervention effectiveness. This paper describes the protocol our team is using to examine two PAC-based interventions for pediatric weight management. We hypothesize that children with obesity whose parents complete a CBT-based PAC intervention will achieve greater reductions in adiposity and improvements in cardiometabolic risk factors, lifestyle behaviours, and psychosocial outcomes than children whose parents complete a psycho-education-based PAC intervention (PEP). METHODS/DESIGN: This study is a pragmatic, two-armed, parallel, single-blinded, superiority, randomized clinical trial. The primary objective is to examine the differential effects of a CBT-based PAC vs PEP-based PAC intervention on children's BMI z-score (primary outcome). Secondary objectives are to assess intervention-mediated changes in cardiometabolic, lifestyle, and psychosocial variables in children and parents. Both interventions are similar in frequency of contact, session duration, group facilitation, lifestyle behaviour goals, and educational content. However, the interventions differ insofar as the CBT-based intervention incorporates theory-based concepts to help parents link their thoughts, feelings, and behaviours; these cognitive activities are enabled by group leaders who possess formal training in CBT. Mothers and fathers of children (8-12 years of age; BMI ≥85th percentile) are eligible to participate if they are proficient in English (written and spoken) and agree for at least one parent to attend group-based sessions on a weekly basis. Anthropometry, cardiometabolic risk factors, lifestyle behaviours, and psychosocial health of children and parents are assessed at pre-intervention, post-intervention, 6-, and 12-months follow-up. DISCUSSION: This study is designed to extend findings from earlier efficacy studies and provide data on the effect of a CBT-based PAC intervention for managing pediatric obesity in a real-world, outpatient clinical setting. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01267097.

Xanthomata and diabetes in an adolescent with familial dysbetalipoproteinemia 9 yr after valproate-induced pancreatitis.

A 14-yr-old girl presented with eruptive xanthomata and hypertriglyceridemia. This rare presentation led to diagnoses of diabetes and familial dysbetalipoproteinemia. Type 1 diabetes is a common childhood illness often presenting in adolescence. However, this patient's past medical history revealed valproate-induced severe acute pancreatitis with necrosis at the age of 5 yr. Diabetes, in this case, developed 9 yr later as a result of inadequate pancreatic tissue to support increasing insulin requirements during growth and adolescence. Diabetes was discovered only after the appearance of cutaneous eruptive xanthomata, which appeared due to the previously undiagnosed genetic dyslipidemia. Although the relationship between xanthomata, hypertriglyceridemia, and diabetes may be well known in adults, in children, xanthomata are very rarely the presenting feature of diabetes of any cause. The patient was treated with insulin which induced rapid resolution of hypertriglyceridemia and gradual disappearance of xanthomata. This case acknowledges the rarity of diabetes presenting with xanthomata in adolescence, highlights the importance of searching for an underlying dyslipidemia in such a case, and presents diabetes as a long-term complication of acute pancreatitis in children.

In search of quality evidence for lifestyle management and glycemic control in children and adolescents with type 2 diabetes: A systematic review.

BACKGROUND: Our purpose was to evaluate the impact of lifestyle behavior modification on glycemic control among children and youth with clinically defined Type 2 Diabetes (T2D). METHODS: We conducted a systematic review of studies (randomized trials, quasi-experimental studies) evaluating lifestyle (diet and/or physical activity) modification and glycemic control (HbA1c). Our data sources included bibliographic databases (EMBASE, CINAHL®, Cochrane Library, Medline®, PASCAL, PsycINFO®, and Sociological Abstracts), manual reference search, and contact with study authors. Two reviewers independently selected studies that included any intervention targeting diet and/or physical activity alone or in combination as a means to reduce HbA1c in children and youth under the age of 18 with T2D. RESULTS: Our search strategy generated 4,572 citations. The majority of citations were not relevant to the study objective. One study met inclusion criteria. In this retrospective study, morbidly obese youth with T2D were treated with a very low carbohydrate diet. This single study received a quality index score of < 11, indicating poor study quality and thus limiting confidence in the study's conclusions. CONCLUSIONS: There is no high quality evidence to suggest lifestyle modification improves either short- or long-term glycemic control in children and youth with T2D. Additional research is clearly warranted to define optimal lifestyle behaviour strategies for young people with T2D.

Postprandial lipemia as an early predictor of cardiovascular complications in childhood obesity.

Abstract. The growing trend of childhood overweight and obesity is a major health concern worldwide. Although obesity is a key risk factor for cardiovascular disease, the etiologic link between obesity and the progression of vascular disease remains unknown. Traditionally, lowering fasting blood cholesterol concentration has been the main interventional target for decreasing the risk of heart disease. However, there is increasing evidence that elevated concentrations of intestinally-derived chylomicron particles are associated with cardiovascular disease risk and that this is particularly evident in insulin-resistance and obesity in adulthood. In this review we comment on recent evidence suggesting that overweight children have fasting chylomicron concentrations equivalent to that found in adults diagnosed with cardiovascular disease. Further, we consider the hypothesis that fasting and postprandial chylomicron metabolism has a central role in the genesis of cardiovascular disease during childhood obesity.

A novel, non-invasive 13C-glucose breath test to estimate insulin resistance in obese prepubertal children.

Insulin resistance (IR) is an important risk factor for the development of type 2 diabetes mellitus in obese boys and girls. Because needle-associated fear and anxiety are common in children, non-invasive methods to determine IR are desirable. Our objective in this cross-sectional study of obese prepubertal children (n = 39) was to compare estimates of IR using a novel, non-invasive technique (13C-glucose breath test) with common indices of IR derived from an oral glucose tolerance test (OGTT). For the 13C-glucose breath test, samples were collected before and 90 minutes after ingestion of 25 mg 13C-labelled glucose. For the OGTT, glucose and insulin samples were collected at 0, 15, 30, 45, 60, 90 and 120 minutes. The homeostatic model assessment of insulin resistance (HOMA-IR), quantitative insulin sensitivity check index (QUICKI), insulin area-under-the-curve (AUC), and sum-of-insulin were calculated as indices of IR. Pearson correlations revealed significant, but moderate, associations between the 13C-glucose breath test and fasting insulin (r = -0.50; p < 0.01), 2-hour insulin (r = plots showed acceptable levels of agreement between indices of IR. In obese prepubertal children, the 13C-glucose breath test can provide a proxy estimate of IR when gold-standard techniques are either unavailable or impractical.

Autonomous thyroid nodule in an adolescent 10 years after total body irradiation for bone marrow transplant.

A male patient with B-cell lymphoma was treated with chemotherapy and allogeneic bone marrow transplant, including preparatory total body irradiation. Ten years later, at age 15 years, the patient developed an autonomous thyroid nodule and an incidental papillary microcarcinoma. This is the first report of an autonomous thyroid nodule after total body irradiation for bone marrow transplant. The case is presented and the literature is reviewed.