Lifestyle intervention for children and adolescents with severe obesity - results after one year. / Livsstilsbehandling av barn og ungdom med alvorlig fedme ­ resultater etter ett år.

BACKGROUND: Lifestyle interventions for children and adolescents with severe obesity show moderate short-term effects on weight reduction internationally. We evaluated treatment results at two Norwegian specialist outpatient clinics. MATERIAL AND METHOD: We performed a retrospective analysis of data from children and adolescents between 3 and 18 years of age collected in 2012-2016. Children and adolescents with severe obesity who attended their one-year follow-up were included. We included in the analyses the following body weight measures: percentage overweight as defined by the International Obesity Task Force cut-off (% IOTF-25); BMI standard deviation score; waist circumference standard deviation score; and body fat percentage at the start of treatment and at one-year follow-up. RESULTS: Of 568 children and adolescents who started treatment, 416 (73 %) attended the one-year check-up. A total of 271 (65 %) patients achieved a reduction in %IOTF-25, while 228 patients (55 %) reduced their BMI standard deviation score. There was a statistically significant mean reduction of all four registered body weight measurements. Altogether 54 of 325 children (17 %) changed category from severe obesity to obesity, 8 (2 %) went from severe obesity to overweight, and 8 of 91 children (9 %) changed category from obesity to overweight or normal weight. The proportion of participants with a reduction of more than 5 % in %IOTF-25 was 43 % (177/416), and a reduction in BMI standard deviation score of more than 0.25 was observed in 23 % (95/416) of participants. Girls responded on average more poorly to the intervention than boys. There was no clinically significant difference in results between the treatment centres. INTERPRETATION: After one year of treatment of children and adolescents with severe obesity in two specialist healthcare centres, we found a moderate mean reduction in weight, waist circumference and body fat percentage, but with large interindividual variation.

Monitoring children and adolescents with severe obesity: body mass index (BMI), BMI z-score or percentage above the International Obesity Task Force overweight cut-off?

AIM: Body mass index (BMI) metrics are widely used as a proxy for adiposity in children with severe obesity. The BMI expressed as the percentage of a cut-off percentile for overweight or obesity has been proposed as a better alternative than BMI z-scores when monitoring children and adolescents with severe obesity. METHODS: Annual changes in BMI, BMI z-score and the percentage above the International Obesity Task Force overweight cut-off (%IOTF-25) were compared with dual-energy X-ray absorptiometry (DXA) derived body fat (%BF-DXA) in 59 children and adolescents with severe obesity. RESULTS: The change in %BF-DXA was correlated with the change in %IOTF-25 (r = 0.68) and BMI (r = 0.70), and somewhat less with the BMI z-score (r = 0.57). Cohen's Kappa statistic to detect an increase or decrease in %BF-DXA was fair for %IOTF-25 (κ = 0.25; p = 0.04) and BMI (κ = 0.33; p = 0.01), but not for the BMI z-score (κ = 0.08; p = 0.5). The change in BMI was positively biased due to a natural increase with age. CONCLUSION: Changes in the BMI metrics included in the study are associated differently with changes in %BF-DXA. The BMI z-score is widely used to monitor changes in adiposity in children and adolescents with severe obesity, but the %IOTF-25 might be a better alternative.

Study Protocol: A randomized controlled trial evaluating the effect of family-based behavioral treatment of childhood and adolescent obesity-The FABO-study.

BACKGROUND: The purpose of the FABO-study is to evaluate the effect of family-based behavioral social facilitation treatment (FBSFT), designed to target children's family and social support networks to enhance weight loss outcomes, compared to the standard treatment (treatment as usual, TAU) given to children and adolescents with obesity in a routine clinical practice. METHODS: Randomized controlled trial (RCT), in which families (n = 120) are recruited from the children and adolescents (ages 6-18 years) referred to the Obesity Outpatient Clinic (OOC), Haukeland University Hospital, Norway. Criteria for admission to the OOC are BMI above the International Obesity Task Force (IOTF) cut-off ≥ 35, or IOTF ≥ 30 with obesity related co-morbidity. Families are randomized to receive FBSFT immediately or following one year of TAU. All participants receive a multidisciplinary assessment. For TAU this assessment results in a plan and a contract for chancing specific lifestyle behaviors. Thereafter each family participates in monthly counselling sessions with their primary health care nurse to work on implementing these goals, including measuring their weight change, and also meet every third month for sessions at the OOC. In FBSFT, following assessment, families participate in 17 weekly sessions at the OOC, in which each family works on changing lifestyle behaviors using a structured cognitive-behavioral, socio-ecological approach targeting both parents and children with strategies for behavioral maintenance and sustainable weight change. Outcome variables include body mass index (BMI; kg/m2), BMI standard deviation score (SDS) and percentage above the IOTF definition of overweight, waist-circumference, body composition (bioelectric impedance (BIA) and dual-X-ray-absorptiometry (DXA)), blood tests, blood pressure, activity/inactivity and sleep pattern (measured by accelerometer), as well as questionnaires measuring depression, general psychological symptomatology, self-esteem, disturbed eating and eating disorder symptoms. Finally, barriers to treatment and parenting styles are measured via questionnaires. DISCUSSION: This is the first systematic application of FBSFT in the treatment of obesity among youth in Norway. The study gives an opportunity to evaluate the effect of FBSFT implemented in routine clinical practice across a range of youth with severe obesity. TRIAL REGISTRATION: ClinicalTrails.gov NCT02687516 . Registered 16th of February, 2016.

Differences in sleep patterns between patients with anorexia nervosa and healthy controls: a cross-sectional study.

BACKGROUND: Sleep difficulties are common in patients with anorexia nervosa (AN), but objective assessments have mostly been performed in hospital and laboratory settings. We aimed to identify differences in sleep patterns between patients with AN and healthy controls (HC) in their free-living environments, and potential associations between sleep patterns and clinical symptoms in patients with AN. METHODS: This cross-sectional study analyzed 20 patients with AN prior to them starting outpatient treatment and 23 HC. Sleep patterns were measured objectively using an accelerometer (Philips Actiwatch 2) for 7 consecutive days. Average sleep onset, sleep offset, total sleep time, sleep efficiency, wake after sleep onset (WASO) and mid-sleep awakenings lasting ≥ 5 min were compared between patients with AN and HC using nonparametric statistical analyses. Associations of sleep patterns with body mass index, eating-disorder symptoms, eating-disorder-associated impairment, and symptoms of depression were assessed in the patient group. RESULTS: Compared with HC, patients with AN had shorter WASO [median (interquartile range(IQR)): 33 vs. 42 min], but a longer average duration of mid-sleep awakenings lasting ≥ 5 min [median (IQR): 9 vs. 6 min, p = 0.006] and had more nights with no sleep (six nights in four patients with AN vs. zero nights in HC). There were no differences between patients with AN and HC regarding other sleep parameters and no significant correlations between sleep patterns and clinical parameters in patients with AN. However, HC presented a Intraindividual variability pattern that was closer to a normal distribution, whereas patients with AN tended to either have very regular or large variability in sleep onset time (AN; n = 7 < 25th percentile and n = 8 > 75th percentile vs. HC; n = 4 < 25 percentile and n = 3 > 75th percentile) during the week of sleep recordings. CONCLUSION: Patients with AN seem to spend more time awake during the night and have more nights without sleep than do HC, even though their average weekly sleep duration did not differ from that in HC. The intraindividual variability in sleep pattern seems to be an important parameter that should be assessed when studying sleep in patients with AN. Trial registration ClinicalTroals.gov. Identifier: NCT02745067. Registered: April 20, 2016.

Sleep disturbances are common in patients with anorexia nervosa. However, most studies that have assessed sleep patterns in this patient group have used either sleep questionnaires or sleep-measuring instruments in surroundings different from where they usually sleep. This study compared sleep patterns between patients with anorexia nervosa and healthy individuals without an eating disorder in their home environments using an accelerometer over 1 week. The accelerometer used was a sleep-monitoring instrument that looks similar to a wristwatch and records sleep patterns using movement and light sensors, and is easy to use in the home environment. We observed that patients with anorexia nervosa on average had longer periods awake during the night, as well as more awake nights compared with healthy individuals. Nevertheless, the average sleep duration during the week of sleep recordings was similar in the two groups. However, we also observed considerable variations in sleep patterns among the patients with anorexia nervosa, ranging from very regular to very irregular sleep patterns. We therefore believe that variability in the sleep patterns among patients with anorexia nervosa is an important parameter that should be included when studying sleep in these patients.

Perceived barriers in family-based behavioural treatment of paediatric obesity - Results from the FABO study.

BACKGROUND: To date, few studies have investigated perceived barriers among those who participate in and drop out of family-based behavioural treatment (FBT) for paediatric obesity. Examining experienced barriers during treatment, and their role in participation and completion of treatment has important implications for clinical practice. OBJECTIVES: To compare perceived barriers to participating in a family-based behavioural social facilitation treatment (FBSFT) for obesity among families who completed and did not complete treatment. METHODS: Data were analysed from 90 families of children and adolescents (mean (M) age = 12.8 years, standard deviation (SD) = 3.05) with severe obesity enrolled in a 17-session FBSFT program. After completing 12 sessions or at the time of dropout, parents and therapists completed the Barriers to Treatment Participation Scale (BTPS), a 5-point Likert scale (1 = never a problem, 5 = very often a problem) which includes four subscales: 1. Stressors and obstacles that compete with treatment, 2. Treatment demands and issues, 3. Perceived relevance of treatment, 4. Relationship with the therapist. RESULTS: Families who did not complete treatment scored significantly higher on the BTPS subscales stressors and obstacles that compete with treatment (M = 2.03, SD = 0.53 vs. M = 1.70, SD = 0.42), p = 0.010 and perceived relevance of treatment (M = 2.27, SD = 0.48 vs. M = 1.80, SD = 0.50), p < 0.001 than families who completed treatment. No other significant differences between groups were observed. CONCLUSION: Families are more likely to drop out of FBSFT when experiencing a high burden from life stressors or when treatment is not meeting the expectations and perceived needs of the family.

Polysomnographic comparison of sleep in children with obesity and normal weight without suspected sleep-related breathing disorder.

Short sleep and obstructive apneas/hypopneas have been shown to be associated with childhood obesity. Still, few studies have compared sleep in children with obesity, without suspected sleep disordered breathing and normal weight peers by objective sleep measures and compared results with subjective parent assessment of sleep. Children with obesity aged 7-13 years (N = 44) and a matched group of normal weight children (N = 42) completed clinical polysomnography (Embla A10 Recording System). Parents scored their children's sleep on the Children's Sleep Habits Questionnaire (CSHQ). Mann-Whitney U tests were used to compare groups. There was a higher obstructive apnea/hypopnea index (AHI) (median obesity = 1.20 vs. median normal  = 0.66; z = -1.33, U = 560.50, p = 0.002) and number of oxygen desaturation events per hour (median obesity = 0.7 vs. median normal  = 0.2; z = -3.45, U = 402.50, p = 0.001) in the children with obesity compared to children with normal weight. The children with obesity had a significantly longer sleep duration (median obesity 8:50 h = vs. median normal = 8:32 h; z = -2.05, U = 687.00, p = 0.041), longer stage N2 sleep (median obesity = 87 min vs. median normal = 52 min; z = -2.87, U = 576.50, p = 0. 004) and shorter REM sleep (median obesity = 94 min vs. median normal = 121 min; z = 5.05, U = 1477.00, p ≤ .001). No differences were observed for time in sleep stage N1 and N3, wake time after sleep onset or the total arousal index . Further, no group differences were found on the CSHQ sleep-disordered breathing sub-scale (p = 0.399). The children with obesity demonstrated significantly more mild to moderate sleep disordered breathing than children with normal weight, although this was not corroborated by parent report.

Objectively measured physical activity among treatment seeking children and adolescents with severe obesity and normal weight peers.

Background: Treatment seeking children and adolescents with severe obesity often experience barriers to physical activity. Studies objectively measuring physical activity in this group and investigating explanatory factors for physical activity levels could inform clinical practice. Objectives: This study aimed to compare objectively measured physical activity levels among treatment seeking children and adolescents with severe obesity and normal weight peers, and to investigate explanatory factors for time spent in moderate physical activity and vigorous physical activity among children and adolescents with severe obesity. Methods: Children with severe obesity (n = 85) were matched 1:1 by age, gender, and the season for accelerometer measurements with normal weight peers (n = 85). Children wore accelerometers for seven consecutive days, yielding measures of physical activity, sleep duration and timing. Parents reported on screen time, parental body mass index and participation in organized sports. Results: Children and adolescents with severe obesity spent significantly less time in moderate physical activity (12 min, p < 0.001) and vigorous physical activity (21 min, p < 0.001) per day compared to normal weight peers. No difference for time spent in sedentary activity was found between groups. For participants with severe obesity, age ≤12 years (p = 0.009) and participation in organized sports (p = 0.023) were related to more moderate physical activity, while age ≤12 years (p = 0.038) and early sleep timing (p = 0.019) were related to more vigorous physical activity. Conclusion: Children and adolescents with severe obesity were less physically active than their normal weight peers. Factors related to more moderate and vigorous physical activity in children with severe obesity were lower age, participation in organized sports and earlier sleep timing.

Family-based treatment of children with severe obesity in a public healthcare setting: Results from a randomized controlled trial.

To compare the effectiveness of family-based behavioural social facilitation treatment (FBSFT) versus treatment as usual (TAU) in children with severe obesity. Parallel-design, nonblinded, randomized controlled trial conducted at a Norwegian obesity outpatient clinic. Children aged 6-18 years referred to the clinic between 2014 and 2018 were invited to participate. Participants were randomly allocated using sequentially numbered, opaqued, sealed envelopes. FBSFT (n = 59) entailed 17 sessions of structured cognitive behavioural treatment, TAU (n = 55) entailed standard lifestyle counselling sessions every third month for 1 year. Primary outcomes included changes in body mass index standard deviation score (BMI SDS) and percentage above the International Obesity Task Force cut-off for overweight (%IOTF-25). Secondary outcomes included changes in sleep, physical activity, and eating behaviour. From pre- to posttreatment there was a statistically significant difference in change in both BMI SDS (0.19 units, 95% confidence interval [CI]: 0.10-0.28, p < .001) and %IOTF-25 (5.48%, 95%CI: 2.74-8.22, p < .001) between FBSFT and TAU groups. FBSFT participants achieved significant reductions in mean BMI SDS (0.16 units, (95%CI: -0.22 to -0.10, p < .001) and %IOTF-25 (6.53%, 95% CI: -8.45 to -4.60, p < .001), whereas in TAU nonsignificant changes were observed in BMI SDS (0.03 units, 95% CI: -0.03 to 0.09, p = .30) and %IOTF-25 (-1.04%, 95% CI: -2.99 to -0.90, p = .29). More FBSFT participants (31.5%) had clinically meaningful BMI SDS reductions of ≥0.25 from pre- to posttreatment than in TAU (13.0%, p = .021). Regarding secondary outcomes, only changes in sleep timing differed significantly between groups. FBSFT improved weight-related outcomes compared to TAU.

Beyond sleep duration: Sleep timing as a risk factor for childhood obesity.

BACKGROUND: Ample evidence attests to the relationship between short sleep duration, sleep problems and childhood obesity. However, few studies have examined the association between sleep timing and obesity in children. OBJECTIVES: To investigate how sleep duration, problems and timing relate to obesity and obesogenic behaviours in children. METHODS: Eighty-five children (58.8% girls) with severe obesity and mean (SD) age of 12.1 (2.9) years, were matched by age and sex with peers with normal weight (n = 85,12.0 [2.8] years). Sleep and moderate-to-vigorous physical activity (MVPA) were measured via accelerometer for seven consecutive days. Children self-reported emotional eating on the Dutch eating behavior questionnaire. Parents reported children's screen time and sleep problems. RESULTS: Children with severe obesity had significantly later mean mid-sleep time, overall (36 minutes later, P < .001), on school nights (36 minutes later, P < .001) and weekend nights (39 minutes later, P = .002) compared to children with normal weight. Children with obesity had more sleep problems (P = .030), but no differences emerged in sleep duration or social jetlag. After adjusting for demographic factors, mid-sleep time was positively related to screen time (P = .030). Mid-sleep time and sleep duration were inversely related to time in MVPA (Ps ≤ .041). There were no other significant associations between the sleep variables and the obesogenic behaviours. CONCLUSIONS: Later sleep timing was related to obesogenic behaviours in children and may represent an obesity risk factor.