Implementation of recommended treatment for children in weight management programs: Lessons from the stay in treatment study sites.

OBJECTIVES: Pediatric obesity remains a public health crisis in the United States, exacerbated by the COVID-19 pandemic. There are recommended guidelines for multidisciplinary care, but they remain challenging to implement, even in tertiary care weight management programs. The aim of this analysis is to describe the implementation of these recommendations among four pediatric weight management programs in the United States. METHODS: This report capitalizes on a convenience sample of programs participating in the Stay In Treatment (SIT) Study, a multicenter study to address attrition among pediatric weight management programs in tertiary care, academic institutions in diverse geographic locations. The programs were compared regarding structure, program offerings, and funding support. RESULTS: The four programs were interdisciplinary, offered individual and group treatment options, and were family-based. A range of clinicians provided interventions with nutrition, physical activity, behavioral and psychosocial components. Anti-obesity pharmacotherapy and bariatric surgery were offered, when appropriate. None of the programs were self-sustaining; they required institutional and philanthropic support to provide recommended, comprehensive treatment. CONCLUSIONS: Ongoing state and national advocacy are needed in the US to create consistent coverage for private and public insurance plans, so that high-risk children can have access to recommended treatment.

Special considerations for the adolescent with obesity: An obesity medicine association (OMA) clinical practice statement (CPS) 2024.

Background: This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details special considerations for the management of the adolescent with obesity. The information in this CPS is based on scientific evidence, supported by medical literature, and derived from the clinical experiences of members of the OMA. Methods: The scientific information and clinical guidance in this CPS are based on scientific evidence, supported by the medical literature, and derived from the clinical perspectives of the authors. Results: This OMA Clinical Practice Statement addresses special considerations in the management and treatment of adolescents with overweight and obesity. Conclusions: This OMA Clinical Practice Statement on the adolescent with obesity is an overview of current recommendations. These recommendations provide a roadmap to the improvement of the health of adolescents with obesity, especially those with metabolic, physiological, and psychological complications. This CPS also addresses treatment recommendations and is designed to help the provider with clinical decision making.

Treating Children and Adolescents With Obesity: Characteristics of Success.

Background: Factors related to clinically meaningful outcomes for pediatric patients seeking care for severe obesity are not well known. Examining patient-level and program-level characteristics related to success may inform future care. Objectives: To determine factors associated with a clinically significant reduction in weight status measured by %BMIp95 after 6 months of treatment. Study Design: This is a retrospective study of youth 5-17 years of age seeking multicomponent weight management care to determine if patient characteristics, treatment recommendations, reported adherence, and additional program-affiliated class participation are associated with 6-month change in %BMIp95. Results: Among 170 children with obesity, higher reductions in %BMIp95 were seen in those with medium-high dietary adherence compared to low-none (-10.8 vs. -4.0, p = 0.002). Post hoc analysis showed higher dietary adherence among those with private insurance than public insurance (59% vs. 41%, respectively, p = 0.04). Conclusion: Children receiving multidisciplinary multicomponent weight management, who achieve clinically meaningful outcomes, are more likely to be adherent to dietary recommendations regardless of the type. Further study is needed of how best to address social determinants of health to improve dietary adherence. Clinical Trial Registration Number: NCT02121132.

Challenges and solutions to sustaining paediatric weight management programs in the United States.

Paediatric weight management (PWM) programs in the United States (US) face challenges in providing sustainable multidisciplinary care for patients. The aim of this study was to report PWM program approaches to sustaining program delivery. A survey of 39 PWM programs was administered to identify challenges and solutions to program sustainability. Common and useful strategies for optimizing reimbursement for services included the use of applicable reimbursable diagnostic codes and management, billing for assessments and non-medical personnel services, and the use of hospital outpatient department clinic billing. Increasing clinical breadth and capacity was achieved by offering telemedicine and other services, such as psychotherapy, pharmacotherapy, and metabolic and bariatric surgery, as well as active management of schedules. Securing institutional and extramural funding was also reported. One of the positive changes during the pandemic was the fast adoption of telemedicine services. Although delivering sustainable evidence-based multidisciplinary PWM under the current US payment models has its challenges, PWM programs implement practical operational strategies to support this work.

Treating Obesity in Children and Adolescents with Special Healthcare Needs.

PURPOSE OF REVIEW: This paper aims to summarize the literature regarding treatment of obesity in children with special healthcare needs and provide examples of implementation based on the available scientific evidence and the clinical experience of the authors. RECENT FINDINGS: Due to the complexity of providing treatment for children with obesity and special healthcare needs, multidisciplinary teams are recommended to adapt care to meet the children's unique needs and ensure coordination of care across settings/caregivers. Medication management is often required to assist with the side effects of psychotropic medications. Children with special healthcare needs (SHCN) such as intellectual and developmental disabilities (IDD) should be considered for metabolic and bariatric surgery as they have similar outcomes to children without SHCN. Children with special healthcare needs can be successful in weight management treatment when they have access to comprehensive care including dietary, behavioral, pharmacological, and surgical interventions. Each child requires a tailored approach to ensure their special healthcare needs are addressed within the treatment plan.

Pediatric growth patterns in youth-onset type 2 diabetes mellitus: Implications for physiologically-based pharmacokinetic models.

An accurate understanding of the changes in height and weight of children with age is critical to the development of models predicting drug concentrations in children (i.e., physiologically-based pharmacokinetic models). However, curves describing the growth of a typical population of children may not accurately characterize growth of children with various conditions, such as obesity. Therefore, to develop height and weight versus age growth curves for youth who were diagnosed with type 2 diabetes, we extracted data from electronic medical records. Robust nonlinear models were parameterized to the equations describing height and weight versus age as defined by the Centers for Disease Control and Prevention (CDC). CDC z-scores were calculated using an internal program. The growth curves and z-scores were compared to CDC norms. Youth with type 2 diabetes were increasingly heavier than CDC norms from early childhood. Except for a period around puberty, youth with type 2 diabetes were, on average, shorter than CDC norms, resulting in shorter average adult height. Deviations in growth were apparent in youth who develop type 2 diabetes; such deviations may be expected for other conditions as well, and disease-specific growth curves should be considered during development of model-informed drug development for pediatric conditions.

Weight Management Outcomes of Youth with Autism Spectrum Disorder Seeking Treatment from a Multidisciplinary Team.

Youth with Autism Spectrum Disorder (ASD) are at an increased risk for developing obesity when compared to their typically developing peers. Given higher prevalence of obesity in youth with ASD, understanding factors relating to success in obesity treatment provides insight into implementing efficacious treatments for youth. The current study examines age, sleep, and metabolic factors potentially affecting success in 74 youth (Mage = 11.66) attending a multidisciplinary weight management treatment program over a year. Multilevel modeling indicated that higher baseline BMI class category, medications at baseline, and absence of sleep difficulties predicted greater reduction in BMI after a year of treatment.

Characteristics of paediatric weight management in the United States: Associations with program retention and BMI outcomes in the paediatric obesity weight evaluation registry (POWER).

OBJECTIVE: To describe characteristics of paediatric weight management (PWM) programs across the United States and evaluate associations with program-specific retention rates and body mass index (BMI) outcomes at 6 months. METHODS: A program profile survey was administered to 33 programs within the Paediatric Obesity Weight Evaluation Registry (POWER) to assess program staffing, services, and treatment format. Patient retention and percent of the 95th BMI percentile (%BMIp95) changes were assessed for each program. RESULTS: At 6 months program retention rates ranged from 15% to 74% (median: 41%), and program %BMIp95 changes ranged from -9.0 to +0.5 percentage points (median: -1.7). Percent of patients with ≥5 percentage-point decrease in %BMIp95 ranged from 17% to 71% across programs (median: 29%). No associations were detected between program characteristics and retention or %BMIp95 changes. CONCLUSIONS: Six-month patient retention and BMI outcomes vary substantially in PWM programs across the United States. Yet, no associations were found between PWM treatment factors and these program-level patient outcomes.

Stay in treatment: Predicting dropout from pediatric weight management study protocol.

INTRODUCTION: Childhood obesity is a serious public health concern. Multidisciplinary pediatric weight management programs have been deemed effective. However, effectiveness of these programs is impacted by attrition, limiting health benefits to children, and inefficiently utilizing scarce resources. METHODS: We have developed a model (the Outcomes Forecasting System, OFS) that isolates variables associated with attrition from pediatric weight management, with the potential to forecast participant dropout. In Aim 1, we will increase the power and precision of the OFS and then validate the model through the consistent acquisition of key patient, family, and treatment data, from three different weight management sites. In Aim 2, external validity will be established through the application of the OFS at a fourth pediatric weight management program. Aim 3 will be a pilot clinical trial, incorporating an intervention built on the results of Aims 1 and 2 and utilizing the OFS to reduce attrition. DISCUSSION: A greater understanding of the patient, family, and disease-specific factors that predict dropout from pediatric weight management can be utilized to prevent attrition. The goal of the current study is to refine the OFS to a level of precision and efficiency to be a valuable tool to any weight management program. By identifying the most pertinent factors driving attrition across weight management sites, new avenues for treatment will be identified. This study will result in a valuable forecasting tool that will be applicable for diverse programs and populations, decrease program costs, and improve patient retention, adherence, and outcomes. CLINICALTRIALSGOV IDENTIFIER: NCT04364282.

Aversion to Off-label Prescribing in Clinical Pediatric Weight Management: The Quintessential Double Standard.

CONTEXT: Pediatric obesity is now recognized as a chronic disease; yet few treatment options exist besides lifestyle modification therapy and bariatric surgery. We describe the limited availability of United States Food and Drug Administration (FDA)-approved antiobesity medications for adolescents and compare this to what is available for adults. We offer a rationale for off-label prescribing to assist with lifestyle modification therapy. We also highlight the need for more pharmacotherapy options and additional research into novel treatments for pediatric obesity. CASE DESCRIPTION: We describe a patient who is struggling with managing her weight and starting to develop complications of obesity. We offer a framework in which off-label prescribing may be beneficial to patients who have been engaging in lifestyle modification therapy yet fail to see improvement. CONCLUSION: Lifestyle modification therapy is necessary but often insufficient in stimulating clinically meaningful weight loss when used alone in children and adolescents who struggle with weight management. Until more FDA-approved antiobesity medications are available, pediatricians may be able to help more patients achieve weight reduction goals by familiarizing themselves with the responsible use of off-label medications and implementing these tools to improve clinical outcomes. There is a critical need for more pharmacotherapy options to help pediatric patients in managing their weight and preventing or improving the insidious complications resulting from untreated obesity.

Health-Related Quality of Life across Recent Pediatric Obesity Classification Recommendations.

Extreme body mass index (BMI) values (i.e., above the 97th and below the 3rd percentiles) are inaccurately represented on the Centers for Disease Control and Prevention's growth curves, which may limit the utility of BMI percentile and BMI z-score for capturing changes in clinical outcomes for patients at extreme weights. Modeling child obesity severity based upon the percentage of BMI in excess of the 95th percentile (BMI95pct) has been proposed as an improved metric to better capture variability in weight at extreme ends of growth curves, which may improve our understanding of relationships between weight status and changes in clinical outcomes. However, few studies have evaluated whether the use of BMI95pct would refine our understanding of differences in clinical psychosocial constructs compared to previous methods for categorization. This cross-sectional study evaluated child obesity severity based on BMI95pct to examine potential group differences in a validated, obesity-specific measure of Health-Related Quality of Life (HRQoL). Four hundred and sixty-five children with obesity completed Sizing Me Up, a self-report measure of HRQoL. Children were classified into categories based on BMI95pct (i.e., class I: ≥100% and <120%; class II: ≥120% and <140%; class III: ≥140%). The results indicate that children with class III obesity reported lower HRQoL than children with class I and class II obesity; however, there were no differences between Class II and Class I. In much of the previous literature, children with class II and class III obesity are often combined under the category "Severe Obesity" based upon BMI above the 99th percentile. This study suggests that grouping children from various classes together would neglect to capture critical differences in HRQoL. Future research including children with severe obesity should consider obesity classes to best account for functioning and clinical outcomes.

Efficacy of Weight Reduction on Pediatric Nonalcoholic Fatty Liver Disease: Opportunities to Improve Treatment Outcomes Through Pharmacotherapy.

Obesity is the single greatest risk factor for nonalcoholic fatty liver disease (NAFLD). Without intervention, most pediatric patients with NAFLD continue to gain excessive weight, making early, effective weight loss intervention key for disease treatment and prevention of NAFLD progression. Unfortunately, outside of a closely monitored research setting, which is not representative of the real world, lifestyle modification success for weight loss in children is low. Bariatric surgery, though effective, is invasive and can worsen NAFLD postoperatively. Thus, there is an evolving and underutilized role for pharmacotherapy in children, both for weight reduction and NAFLD management. In this perspective article, we provide an overview of the efficacy of weight reduction on pediatric NAFLD treatment, discuss the pros and cons of currently approved pharmacotherapy options, as well as drugs commonly used off-label for weight reduction in children and adolescents. We also highlight gaps in, and opportunities for, streamlining obesity trials to include NAFLD assessment as a valuable, secondary, therapeutic outcome measure, which may aid drug repurposing. Finally, we describe the already available, and emerging, minimally-invasive biomarkers of NAFLD that could offer a safe and convenient alternative to liver biopsy in pediatric obesity and NAFLD trials.

Trends in prescribing anti-obesity pharmacotherapy for paediatric weight management: Data from the POWER Work Group.

INTRODUCTION: To better inform the field of obesity medicine, we set out to describe the current use of pharmacotherapy meant to improve patient weight status among a group of clinicians connected through the Paediatric Obesity Weight Evaluation Registry (POWER), as well as reasons behind clinicians' use or non-use of the medications. METHODS: Paediatric weight management (PWM) programs participating in POWER were asked to complete a program profile survey in 2014 (n = 30) and 2017 (n = 33); questions about pharmacotherapy use were included. Descriptive statistics were used to identify: (a) the proportion of PWM programs offering obesity pharmacotherapy; (b) the medications most commonly prescribed; and (c) reasons among non-prescribers for not offering pharmacotherapy. RESULTS: The 2014 and 2017 surveys were completed by 29 PWM programs (97%) and 30 PWM programs (91%), respectively. Twenty-one programs completed both surveys. In 2014, 10 (34%) programs reported offering pharmacologic agents specifically for weight control, whereas in 2017, 16 (53%) reported offering pharmacotherapy for a primary indication of weight loss. Metformin was reported as the most commonly used agent in 2014, and topiramate in 2017. Largest reported increases in use over time were for topiramate and phentermine. DISCUSSION: Our survey results demonstrate that a majority of this group of PWM programs offered pharmacotherapy to promote weight loss in patients with complications or associated medical conditions. There was a trend indicating increasing use over time, despite the significant gap regarding pharmacotherapy use in the literature. CONCLUSIONS: These data suggest the need for (a) additional robust paediatric drug trials to further develop the evidence base guiding use or non-use of pharmacotherapy in paediatric weight management, and (b) increased understanding of both facilitators and barriers to prescribing anti-obesity pharmacotherapy for youth with obesity.

Clinical approaches to minimize iatrogenic weight gain in children and adolescents.

Clinical providers may underestimate the role of management of diseases that can occur with obesity, termed co-morbid conditions, distinct from disease that arise as a result of obesity, co-morbidities. Many of these conditions are associated with iatrogenic weight gain, and can interfere with weight loss outcomes in children and adolescents with obesity. Management of co-morbid conditions, and thoughtful selection of medications associated with weight neutrality or weight loss may increase the effectiveness of obesity treatment strategies. The aim of this commentary is to summarize the literature and discuss considerations for obesity treatment in the context of the more complicated patient, which often requires strategic management of co-morbid conditions and minimizing iatrogenic weight gain.

Weight change before and after adenotonsillectomy in children: An analysis based upon pre-surgery body mass category.

OBJECTIVES: To determine the standardised body mass index (BMIz) trajectory before and after adenotonsillectomy/tonsillectomy between children in different weight classifications in a larger sample than has been studied previously, and to identify which patient factors would explain the difference in these outcomes. DESIGN: We used a retrospective chart review and leveraged data of weight status pre- and post-adenotonsillectomy/tonsillectomy from a cohort of paediatric patients seen between May 2004 and April 2017. SETTING: Data were collected from an electronic medical record at a single Midwest paediatric health system. PARTICIPANTS: The study population included a convenience sample of 1,751 paediatric patients who underwent adenotonsillectomy or tonsillectomy and had at least two height and weight measurements recorded on the same date both before and after surgery. MAIN OUTCOME MEASURES: Change in BMIz trajectories before and after surgery. RESULTS: Of 1751 paediatric patients (ages 3-11) underwent adenotonsillectomy/tonsillectomy procedures. Age at time of surgery and gender were not significant predictors. Children in different weight classifications demonstrated differences in BMIz trajectory after surgery. Children with overweight/obesity experience a decrease in BMIz, whereas children with underweight or normal weight experience an increase in BMIz. CONCLUSIONS: Improvement in weight status is seen after surgery: increased BMI for those underweight and decreased BMI for those with overweight/obesity. We advocate for behavioural strategies as a first-line treatment in children with underweight or overweight/obesity, and results suggest that coordinating these efforts alongside adenotonsillectomy/tonsillectomy when indicated for medical reasons may be warranted. However, further research is needed to confirm these findings due to the observational nature of this study.

Problematic Child Mealtime Behavior and Caregiver Mobile Phone Use.

OBJECTIVE: To evaluate the associations of caregiver mobile phone problematic use and child problematic mealtime behaviors (PMBs) to improve understanding of the possible implications of caregiver mobile phone problematic use. METHODS: Surveys were administered to caregivers of children aged 3 to 8 years. The survey included demographics, a validated measure for caregiver mobile phone problematic use (Mobile Phone Problematic Use Scale-10 [MPPUS-10]), and a validated measure for the perception of child PMB (Meals in our Household [MIOH]). The bivariate associations between child and caregiver characteristics, mobile phone problematic use, and PMBs of children were analyzed. Partial correlations examined these relations while controlling for significant (p ≤ 0.05) covariates. RESULTS: Eighty-four caregivers (mean age 32.6 years, 63% white, 21% ≤ high school completion) participated. The correlation of MIOH problematic behavior total with MPPUS-10 was significant (r = 0.33, p ≤ 0.01). Significantly correlated caregiver variables with MPPUS-10 included age (r = -0.25, p = 0.02) and female sex (p = 0.01). No significant caregiver variables were noted for PMB. Child's age was significantly correlated with PMB (r = -0.27, p = 0.01). MPPUS-10 and PMB correlation remained significant when controlling for significant covariates. CONCLUSION: A positive correlation existed between MPPUS-10 and PMB. Understanding the potential association between caregiver mobile phone problematic use and child PMB strengthens the pediatricians' ability to counsel about the implications of caregiver mobile phone problematic use when discussing child PMB.

Childhood Obesity in the State of Missouri: A Review for Providers to Counsel and Treat Patients.

Childhood obesity is a common disease both nationally and in the state of Missouri. Obesity in childhood is often under-recognized and is difficult to treat. Screening, accurate diagnosis, and counseling is imperative to proper management. Common barriers to treatment include a lack of accurate identification and a lack of awareness of needed and available treatments of this disease in the pediatric setting. This review article highlights behavioral measures as well as pharmacologic and surgical therapies for obesity in children. This review is intended as guidance for providers to properly counsel and treat patients with this disease.

Trends in Volume and Utilization Outcomes in Adolescent Metabolic and Bariatric Surgery at Children's Hospitals.

PURPOSE: As the prevalence of obesity increases in adolescents, the rate of metabolic and bariatric surgery (MBS) is also rising. Little is known about MBS rates at children's hospitals. This study describes trends in adolescent MBS volume and examines hospital resource utilization among patients undergoing MBS at children's hospitals. METHODS: We performed a retrospective cohort study using a large pediatric hospital database (Inpatient Essentials database) to identify adolescents aged 10-18 years who underwent MBS from 2012 to 2016. Procedures were identified based on the presence of diagnosis codes for obesity and bariatric surgery. Our primary outcome was annual MBS volume, and secondary outcomes included cost, length of stay (LOS), and 30-day readmission rates. RESULTS: A total of 859 adolescents from 39 children's hospitals underwent MBS during the study timeframe. Included patients were typically aged >16 years (49.7%), female (73.3%), and non-Hispanic white (50.5%). The number of bariatric surgeries increased 1.8-fold, from 126 in 2012 to 220 in 2016 (p = .004). There was considerable variation in the number of procedures by hospital, ranging from 1 to 159, with a median of 4 (interquartile range: 1-18) procedures per hospital. As the annual number of surgeries increased, LOS decreased by 1 day (p = .028) and cost decreased by 22% (p < .001), without a change in readmission rates (p = .925). CONCLUSION: MBS rates are increasing in children's hospitals, whereas LOS and cost are decreasing, without affecting readmission rates. These findings may be useful for development of quality benchmarks for developing and existing MBS programs within children's hospitals.

A Review of Modifiable Risk Factors for Severe Obesity in Children Ages 5 and Under.

Early-onset severe obesity in childhood presents a significant clinical challenge signaling an urgent need for effective and sustainable interventions. A large body of literature examines overweight and obesity, but little focuses specifically on the risk factors for severe obesity in children ages 5 and younger. This narrative review identified modifiable risk factors associated with severe obesity in children ages 5 and younger: nutrition (consuming sugar sweetened beverages and fast food), activity (low frequency of outdoor play and excessive screen time), behaviors (lower satiety responsiveness, sleeping with a bottle, lack of bedtime rules, and short sleep duration), and socio-environmental risk factors (informal child care setting, history of obesity in the mother, and gestational diabetes). The lack of literature on this topic highlights the need for additional research on potentially modifiable risk factors for early-onset severe obesity.

Factor Structure of a Spanish Translation of an Obesity-Specific Parent-Report Measure of Health-Related Quality of Life.

Objective: Latino youth are disproportionately affected by pediatric obesity and consequently experience impaired health-related quality of life (HRQOL). Although many caregivers of Latino youth do not speak English fluently, no validated Spanish translations of obesity-specific HRQOL measures exist for this population. Therefore, non-English-speaking Latino parents have typically been excluded from analyses related to HRQOL. This study assesses the factor structure of a Spanish translation of a parent-report measure of obesity-specific HRQOL, Sizing Them Up, in a treatment-seeking sample of children with obesity. Methods: Structural equation modeling was used to assess the factor structure of the 6-subscale, 22-item Sizing Them Up measure in 154 parents of treatment-seeking Latino youth (5-18 years of age). Analyses exploring internal consistency and convergent validity were also conducted. Results: Acceptable measurement fit was achieved for the six-factor solution. However, the higher-order model assessing Total HRQOL did not reach acceptable levels, as results found that the Positive Social Attributes (PSA) subscale was not representative of Total HRQOL; internal consistency and convergent validity results also supported this finding. Conclusions: The current study provides support for the utility of a modified version of Sizing Them Up, excluding the PSA Scale, as a parent-report measure of obesity-specific HRQOL in treatment-seeking Latino youth with obesity.