Correction: Exploring the Effect of the Dynamics of Behavioral Phenotypes on Health Outcomes in an mHealth Intervention for Childhood Obesity: Longitudinal Observational Study.

[This corrects the article DOI: 10.2196/45407.].

Exploring the Effect of the Dynamics of Behavioral Phenotypes on Health Outcomes in an mHealth Intervention for Childhood Obesity: Longitudinal Observational Study.

BACKGROUND: Advancements in mobile health technologies and machine learning approaches have expanded the framework of behavioral phenotypes in obesity treatment to explore the dynamics of temporal changes. OBJECTIVE: This study aimed to investigate the dynamics of behavioral changes during obesity intervention and identify behavioral phenotypes associated with weight change using a hybrid machine learning approach. METHODS: In total, 88 children and adolescents (ages 8-16 years; 62/88, 71% male) with age- and sex-specific BMI ≥85th percentile participated in the study. Behavioral phenotypes were identified using a hybrid 2-stage procedure based on the temporal dynamics of adherence to the 5 behavioral goals during the intervention. Functional principal component analysis was used to determine behavioral phenotypes by extracting principal component factors from the functional data of each participant. Elastic net regression was used to investigate the association between behavioral phenotypes and weight change. RESULTS: Functional principal component analysis identified 2 distinctive behavioral phenotypes, which were named the high or low adherence level and late or early behavior change. The first phenotype explained 47% to 69% of each factor, whereas the second phenotype explained 11% to 17% of the total behavioral dynamics. High or low adherence level was associated with weight change for adherence to screen time (ß=-.0766, 95% CI -.1245 to -.0312), fruit and vegetable intake (ß=.1770, 95% CI .0642-.2561), exercise (ß=-.0711, 95% CI -.0892 to -.0363), drinking water (ß=-.0203, 95% CI -.0218 to -.0123), and sleep duration. Late or early behavioral changes were significantly associated with weight loss for changes in screen time (ß=.0440, 95% CI .0186-.0550), fruit and vegetable intake (ß=-.1177, 95% CI -.1441 to -.0680), and sleep duration (ß=-.0991, 95% CI -.1254 to -.0597). CONCLUSIONS: Overall level of adherence, or the high or low adherence level, and a gradual improvement or deterioration in health-related behaviors, or the late or early behavior change, were differently associated with weight loss for distinctive obesity-related lifestyle behaviors. A large proportion of health-related behaviors remained stable throughout the intervention, which indicates that health care professionals should closely monitor changes made during the early stages of the intervention. TRIAL REGISTRATION: Clinical Research Information Science KCT0004137; https://tinyurl.com/ytxr83ay.

Sedentary Time and Fast-Food Consumption Associated With Weight Gain During COVID-19 Lockdown in Children and Adolescents With Overweight or Obesity.

BACKGROUND: The coronavirus disease pandemic is predicted to have adverse health effects on children and adolescents who are overweight or obese due to restricted school activity and stay-at-home orders. The purpose of this observational study was to determine the factors associated with weight gain in children and adolescents with overweight and obesity during coronavirus disease 2019 (COVID-19) lockdown. METHODS: Ninety-seven participants (sex- and age-specific body mass index (BMI) ≥ 85th percentile) were included. A baseline examination was conducted pre-COVID-19 (August 2019 to January 2020), and re-examination was performed post-lockdown (June to September 2020) and the results were compared. Correlation and regression analyses were conducted to investigate the association among changes in cardiometabolic markers and lifestyle behaviors with changes in BMI z-score. RESULTS: During the COVID-19 pandemic, an increase in BMI z-score (2.56 [2.01-2.94] to 2.62 [2.03-3.18]) was noticed in children and adolescents with obesity. Changes in cardiometabolic markers including liver enzymes, triglycerides (r = 0.398), leptin (r = 0.578), and adiponectin (r = -0.326), as well as muscular strength (r = -0.212), were correlated with the increase in BMI z-score. According to a multivariate regression analysis, changes in sedentary time (B = 0.016; 95% confidence interval [CI], 0.001-0.032) and fast-food consumption (B = 0.067; 95% CI, 0.013-0.122) were the lifestyle variables associated with BMI z-score increase. CONCLUSION: Changes in lifestyle behaviors including fast-food consumption and sedentary time during the COVID-19 pandemic may be associated with weight gain. In order to prevent health-related risks in children and adolescents with obesity during the pandemic, it is important to maintain the level of physical activity and healthy dietary habits.

The strength of gradually accruing probabilistic evidence modulates brain activity during a categorical decision.

The evolution of neural activity during a perceptual decision is well characterized by the evidence parameter in sequential sampling models. However, it is not known whether accumulating signals in human neuroimaging are related to the integration of evidence. Our aim was to determine whether activity accumulates in a nonperceptual task by identifying brain regions tracking the strength of probabilistic evidence. fMRI was used to measure whole-brain activity as choices were informed by integrating a series of learned prior probabilities. Participants first learned the predictive relationship between a set of shape stimuli and one of two choices. During scanned testing, they made binary choices informed by the sum of the predictive strengths of individual shapes. Sequences of shapes adhered to three distinct rates of evidence (RoEs): rapid, gradual, and switch. We predicted that activity in regions informing the decision would modulate as a function of RoE prior to the choice. Activity in some regions, including premotor areas, changed as a function of RoE and response hand, indicating a role in forming an intention to respond. Regions in occipital, temporal, and parietal lobes modulated as a function of RoE only, suggesting a preresponse stage of evidence processing. In all of these regions, activity was greatest on rapid trials and least on switch trials, which is consistent with an accumulation-to-boundary account. In contrast, activity in a set of frontal and parietal regions was greatest on switch and least on rapid trials, which is consistent with an effort or time-on-task account.

Sleep continuity and total sleep time are associated with task-switching and preparation in young and older adults.

Ageing is associated with changes in sleep and decline executive functions, such as task-switching and task preparation. Given that sleep affects executive function, age-related changes in executive function may be attributable to changes in sleep. The present study used a sleep detection device to examine whether or not wake time after sleep onset and total sleep time moderated age differences in task-switching performance and participants' ability to reduce switch costs when given time to prepare. Participants were cognitively healthy [Mini Mental State Examination > 26] younger (n = 54; mean age = 22.9; 67.8% female) and older (n = 45; mean age 62.8; 71.1% female) adults. Using a task-switching paradigm, which manipulated preparation time, we found that smaller global switch costs were associated with lower wake time after sleep onset and longer total sleep time. Greater preparation effects on local switch costs and adoption of a task-set were associated with lower wake time after sleep onset, although this effect was significant only in older adults when stratified by age group. This association was independent of inhibition and working memory abilities. The lack of interactions between sleep and age group indicated that age differences in switch costs were not moderated by better sleep. Our results suggest that young and older adults may benefit similarly from lower wake time after sleep onset and longer total sleep time in overall performance, and individuals with less wake time after sleep onset are more likely to engage preparatory strategies to reduce switch costs and boost task-switching performance.

Parent and child characteristics associated with treatment non-response to a short- versus long-term lifestyle intervention in pediatric obesity.

BACKGROUND/OBJECTIVES: This study aimed to identify the factors associated with short- or long-term non-response to an obesity intervention in children and adolescents. SUBJECTS/METHODS: In this observational study, a total of 242 children and adolescents (sex- and age-specific body mass index (BMI) ≥ 85th percentile) were divided into three groups according to the BMI z-score change after 6 (n = 163) and 24 months (n = 110) of participating in an obesity intervention: responders, low responders, and non-responders if the BMI z-score decrease was ≥0.25, 0 to 0.25, and if it increased, respectively. RESULTS: Short-term non-response was associated with higher maternal psychosocial stress (OR = 2.34, 95% CI [1.07-5.11]) and adolescence (>11 years; OR = 2.40, 95% CI [1.10-5.22]). The odds of long-term non-response were reduced by an increased vegetable consumption of more than five dishes per week (OR = 0.21, 95% CI [0.07-0.69]) and an hour of increased sleep duration during weekends (OR = 0.14, 95% CI [0.04-0.53]). CONCLUSIONS: Short-term non-response was associated with child and maternal characteristics, whereas long-term non-response was associated with actual lifestyle changes such as sleep duration and vegetable consumption. Children with obesity may benefit from an hour of weekend catch-up sleep in lowering the risk of long-term treatment non-response. An individualized approach should be considered for children of older age and mothers with a higher level of stress, as they may not benefit from a conventional short-term lifestyle intervention.

Which obesity index is the most useful marker for predicting hepatic steatosis in children and adolescents with obesity? A cross-sectional study using quantitative magnetic resonance imaging.

INTRODUCTION: We aimed to evaluate the relationships between hepatic steatosis and various indices of obesity, and to identify the most useful index for the prediction of hepatic steatosis in children and adolescents with obesity. METHODS: A total of 226 children and adolescents with a mean body mass index (BMI) z-score of 2.65 and a mean age of 11.4 years were subjected to anthropometric and body composition measurements, laboratory testing, abdominal fat mass assessment, and hepatic fat accumulation by magnetic resonance imaging-derived proton density fat fraction (MRI-PDFF). The participants were divided into quartiles according to the severity of their hepatic steatosis, and the presence of hepatic steatosis was defined using an MRI-PDFF ≥ 5%. RESULTS: The multivariate ordinal regression analysis showed that the severity of hepatic steatosis was positively associated with BMI, waist circumference, waist-to-hip ratio, waist-to-height ratio, fat mass, fat-free mass, visceral adiposity, and abdominal subcutaneous adiposity. Higher activities of liver enzymes and higher concentrations of triglyceride, C-reactive protein, fasting insulin, and leptin were associated with more severe hepatic steatosis, whereas high-density lipoprotein-cholesterol and adiponectin were negatively associated with hepatic steatosis. The indices of obesity with areas under the receiver operating characteristic curves (AUCs) > 0.8 for the prediction of hepatic steatosis were liver enzymes, visceral adipose tissue area, waist-to-hip ratio, and waist-to-height ratio. CONCLUSION: The severity of hepatic steatosis significantly correlated with various indices of obesity and cardiometabolic markers in children and adolescents with obesity. The indices of abdominal obesity would be the most useful for the prediction of hepatic steatosis.

Validating the Dutch Eating Behavior Questionnaire for Children (DEBQ-C) among Korean children and adolescents with high weight.

BACKGROUND: Using reliable measurement tools is becoming increasingly important as the prevalence of obesity among children increases in Korea. The Dutch Eating Behavior Questionnaire for Children (DEBQ-C) measures three eating behaviors associated with overeating. This study aims to validate the DEBQ-C for use among Korean children and adolescents with high body weight. It examines the psychometric features of the Korean translation of the DEBQ-C and investigates the relationship between the subscale scores of the DEBQ-C and the weight status of participants (categorized into overweight, obese, and morbidly obese). METHODS: A total of 233 children and adolescents (mean age: 11.4 ± 1.6 years) completed the questionnaire. The study verified the factor structure of the DEBQ-C using confirmatory factor analysis (CFA) and estimated its internal consistency with Cronbach's alpha. For convergent validity, it employed Pearson's correlation coefficient to assess relationships between the three eating behaviors of the DEBQ-C and the number of food addiction symptoms of the Yale Food Addiction Scale for Children (YFAS-C). Lastly, it examined the relationship between DEBQ-C scores and weight status via multinomial logistic regression analysis. RESULTS: The three-factor model demonstrated goodness-of-fit (χ2 = 253, df = 167, χ2/df = 1.515, p < 0.001, CFI = 0.944; TLI = 0.937; RMSEA = 0.047). The internal consistency of the three eating behaviors was also satisfactory (Cronbach's alpha = 0.707-0.890). The emotional and external eating subscales of the DEBQ-C were positively correlated with the number of symptoms of food addiction of the YFAS-C. Emotional (OR: 2.008; 95% CI 1.973-2.043) and external (OR: 2.074; 95% CI 2.029-2.119) eating were positively associated with obesity status. CONCLUSION: The results suggest that the Korean version of the DEBQ-C is suitable for the examination of problematic eating behaviors in Korean children and adolescents with high body weight.

The proportion of children and adolescents with obesity in Korea is increasing. Thus, the availability of a tool that can reliably identify problematic eating behavior linked to obesity would assist with prevention and management efforts. The Dutch Eating Behavior Questionnaire for Children (DEBQ-C) measures three types of overeating behavior in children that influence weight gain. This study examines the suitability of the Korean translation of the DEBQ-C questionnaire for use in studies on Korean children and adolescents with high body weight. The results of a survey on 233 adolescents (average age: 11.4 ± 1.6 years) suggest that the DEBQ-C translation would be useful in investigating overeating behavior in Korean children and adolescents. In addition, the findings suggest that eating in response to emotions and external cues are likely to play a role in the development of obesity among children and adolescents.

Additive Effects of Exercise or Nutrition Intervention in a 24-Month Multidisciplinary Treatment with a Booster Intervention for Children and Adolescents with Overweight or Obesity: The ICAAN Study.

This study compared the effects of a real-world multidisciplinary intervention with additional exercise or nutritional elements and investigated the effectiveness of a booster intervention after weight regain. A total of 242 children and adolescents (age- and sex-specific body mass index [BMI] ≥ 85th percentile, mean age: 10.82 years, 60% male) were allocated to three groups: usual care, exercise, or nutrition. Six-month active treatment with 1:1 session and a maintenance stage with group activities were repeated twice to comprise a 24-month intervention. The primary outcome was change % of the BMI z-score (zBMI). A total of 110 (45.4%) participants completed the 24-month intervention. A mixed-effects model analysis indicated no significant interaction effect of the intervention group and treatment phase on the zBMI change % (p = 0.976). However, there was a significant main effect of the treatment phase on zBMI change % at 6 months (ß = -2.98, [95% CI, -5.69-0.27]), 18 months (ß = -3.99, [95% CI, -6.76-1.22]), and 24 months (ß = -3.23, [95% CI, -5.94-0.52]; p = 0.042). The improvements in zBMI, body fat %, and cardiometabolic markers were observed only among males. Whereas the additive effect of intensive exercise or nutritional feedback was not detected in the long term, a booster intervention with 1:1 counseling was effective even after weight regain during the maintenance period. It may be useful to combine individualized counseling with a less intensive form of group care for long-term maintenance in a real-world setting.

Factors associated with the perception of parents and children regarding obesity-related terminology used by healthcare professionals in a sample of Korean children and adolescents with obesity.

OBJECTIVE: This study aimed to compare how children with overweight or obesity and their parents perceive the obesity-related terms used by healthcare professionals and investigate the factors associated with these perceptions. METHODS: Children and adolescents aged 8-16 years with overweight or obesity (n = 192) and their parents participated in the cross-sectional study by responding to a 5-point Likert-scale questionnaire on 10 obesity-related terms, including "chubby," "weight problem," "weight," "overweight," "BMI," "obese," "heavy," "fleshy," "fat," and "severely obese." RESULTS: For both children and parents, "chubby" was the most desirable term (mean ± standard deviation: 3.50 ± 1.12 and 2.95 ± 0.83, respectively), and "severely obese" was the least acceptable term (2.83 ± 1.17 and 2.02 ± 1.02, respectively). Although the parents preferred all the terms less than the children did (p < 0.001), "weight problem" was considered most motivating for a child to lose weight (3.93 ± 0.94). Among children, older age and a larger self-perceived body size were associated with a more positive response towards obesity-related terms, whereas having internalized or externalized problems were negatively associated with these terms. Parents with a history of cardiovascular disease considered "severely obese" (ß = -0.419, [95% CI: -0.739, -0.099]) and "fat" (ß = -0.457, [95% CI: -0.750, -0.164]) less desirable. CONCLUSIONS: Children and adolescents had a higher preference for obesity-related terms than their parents and preferred that healthcare professionals use euphemistic terms such as "chubby," or neutral terms such as "weight problem." Children with larger self-perceived body sizes or older age had a higher preference for obesity-related words. The terms used by healthcare professionals to describe excess weight must be motivating and respectful for all family members participating in the treatment.

Vascular Alterations Preceding Arterial Wall Thickening in Overweight and Obese Children.

BACKGROUND: Childhood obesity is linked to adverse cardiovascular outcomes in adulthood. This study aimed to assess the impact of childhood obesity on the vasculature and to investigate whether vascular alteration precedes arterial wall thickening in childhood. METHODS: A total of 295 overweight (body mass index [BMI] 85th to 95th percentile, n = 30) and obese (BMI ≥ 95th percentile, n = 234) children aged 7-17 years and 31 normal-weight controls with similar age and gender were prospectively recruited. We assessed anthropometric data and laboratory findings, and measured the carotid intima-media thickness (IMT), carotid artery (CA) diameter, M-mode-derived arterial stiffness indices, and velocity vector imaging parameters, including the CA area, fractional area change, circumferential strain, and circumferential strain rate (SR). RESULTS: The mean ± standard deviation age of the participants was 10.8 ± 2.1 years; 172 (58%) children were male. Regarding structural properties, there was no difference in the IMT between the three groups. The CA diameter was significantly increased in obese children, whereas the CA area showed a significant increase beginning in the overweight stage. Regarding functional properties, contrary to ß stiffness and Young's elastic modulus, which were not different between the three groups, the circumferential SR showed a significant decrease beginning in the overweight stage and was independently associated with BMI z-scores after adjusting for covariates. CONCLUSION: We have demonstrated that arterial stiffening and arterial enlargement precede arterial wall thickening, and that these vascular alterations begin at the overweight stage in middle childhood or early adolescence.

Association of Dietary Patterns with Weight Status and Metabolic Risk Factors among Children and Adolescents.

Unhealthy dietary patterns are associated with obesity in children and adolescents. However, few studies have investigated the relationships between dietary patterns and obesity-related metabolic disorders among Asians. We identified dietary patterns in children and adolescents and examined the associations between these patterns and obesity, insulin resistance, and metabolic syndrome in South Korea. This study is a cross-sectional design. We used baseline data from an intervention study of 435 Korean children and adolescents aged 6-17 years. Insulin resistance was assessed as HOMA-IR ≥ 2.6. Metabolic syndrome was diagnosed by cardiovascular disease risk factor clustering. Dietary intakes were estimated using 3-day food records. Factor analysis was used to obtain dietary patterns, and we examined the associations between dietary patterns and obesity-related markers adjusted for potential covariates. Three dietary patterns were identified as fast food and soda (FFS), white rice and kimchi (WRK), and oil and seasoned vegetable (OSV) patterns. Compared with participants in the lower intake of FFS pattern, those in the top intake were associated with a higher waist circumference (WC) (ß = 1.55), insulin level (ß = 1.25), and body mass index (BMI) (ß = 0.53) and it was positively associated with HOMA-IR ≥ 2.6 (OR = 2.11; 95% CI: 1.227-3.638) (p < 0.05). WRK pattern was associated with lower weight and higher HDL cholesterol, and the OSV pattern was associated with a lower weight, WC, and insulin level (p < 0.05). The FFS pattern showed a positive relation with WC, serum insulin, and BMI, and the other two dietary patterns indicated a preventive effect of those parameters. The FFS pattern was associated with significantly elevated insulin resistance among children and adolescents.

Motivating Children and Adolescents in Obesity Treatment.

Enhancing motivation is a crucial issue in pediatric obesity interventions, as behavioral changes related to food intake and physical exercise are difficult to carry out with an insufficient level of motivation. In the treatment setting, low motivation towards change may lead to early termination or inadequate treatment outcomes. This paper reviews widely-used models of motivation, including the transtheoretical model of change, self-determination theory, and motivational interviewing (MI). We introduce useful strategies based on each theoretical model to enhance motivation, such as an importance and confidence scale and a decisional balance technique. A review of recent MI interventions in children and adolescents is presented to discuss the efficacy of MI-based interventions and considerations for applying MI in pediatric obesity.

Factors associated with dropout in a lifestyle modification program for weight management in children and adolescents.

BACKGROUND: Significant dropout rates remain a serious concern in pediatric weight control program, but few studies have identified predictors of dropout. AIMS: The objective of the study is to identify factors associated with dropout from a pediatric lifestyle modification weight control program at different phases. METHODS: Data on overweight and obese participants (n = 242) aged 11-18 years in the Intervention for Childhood and Adolescent Obesity via Activity and Nutrition (ICAAN) study were collected at baseline, 6-months, and 24-months through self-report and a laboratory test. Logistic regression analysis was performed for those who dropped out during the first 6-months, and multivariate generalized estimating equation analysis identified longitudinal factors associated with those who dropped out after 24 months. RESULTS: Lower family functioning (OR = 2.30, 95% CI [1.18-4.46]), exercise group (OR = 0.36, 95% CI [0.15-0.86]), lower initial attendance rate (OR = 6.09, 95% CI [2.94-12.6]), and non-self -referral pathways (OR = 2.35, 95% CI [1.05-5.27]) were significantly associated with 6-month dropouts. For late dropout, lower family functioning (OR = 1.71, 95% CI [1.06-2.77]) and lower initial attendance rates (OR = 2.06, 95% CI [1.12-3.81]) remained significant. CONCLUSION: Family function and initial attendance rate were associated with lower dropout rates. Developing a supportive family environment and focusing on the early-stage factors at the intervention's outset may reduce overall dropout rates in obesity prevention intervention.

A 24-week intervention based on nutrition care process improves diet quality, body mass index, and motivation in children and adolescents with obesity.

Higher motivation could support to lead behavioral change for obese children and adolescents. This study aimed to evaluate the effects of a nutrition care process (NCP)-based intervention targeted on diet and weight status in moderate to severe obese children and adolescents in Korea. One hundred four subjects (mean age: 10.95 years, body mass index (BMI) ≥97th percentile of age-sex) participated in the present study. Subjects were divided into a usual care group (UG) and a nutrition group (NG). All participants underwent nutrition education 6 times. The NG received individual access and continuous monitoring and setting goals with respect to nutritional problems. Consumption of high-calorie, low-nutrient (HCLN) food was significantly decreased (P < .05) and the Diet Quality Index-International (DQI-I) score also increased with respect to sodium (P < .001). The total self-efficacy score was increased from 9.15 to 10.14 points (P < .01). After 24 weeks, the BMI-z-score decreased from 2.27 to 2.19 in the NG (P < .05); however, no group difference was found. BMI-z-score was negatively associated with self-efficacy (ß = -0.03, P < .019). NCP-based intervention might be helpful to solve dietary problems by enhancing self-efficacy and lower BMI-z-score in moderately to severely obese children and adolescents.

Role of sleep continuity and total sleep time in executive function across the adult lifespan.

The importance of sleep for cognition in young adults is well established, but the role of habitual sleep behavior in cognition across the adult life span remains unknown. We examined the relationship between sleep continuity and total sleep time as assessed with a sleep-detection device, and cognitive performance using a battery of tasks in young (n = 59, mean age = 23.05) and older (n = 53, mean age = 62.68) adults. Across age groups, higher sleep continuity was associated with better cognitive performance. In the younger group, higher sleep continuity was associated with better working memory and inhibitory control. In the older group, higher sleep continuity was associated with better inhibitory control, memory recall, and verbal fluency. Very short and very long total sleep time was associated with poorer working memory and verbal fluency, specifically in the younger group. Total sleep time was not associated with cognitive performance in any domains for the older group. These findings reveal that sleep continuity is important for executive function in both young and older adults, but total sleep time may be more important for cognition in young adults.

A comprehensive protocol for manual segmentation of the medial temporal lobe structures.

The present paper describes a comprehensive protocol for manual tracing of the set of brain regions comprising the medial temporal lobe (MTL): amygdala, hippocampus, and the associated parahippocampal regions (perirhinal, entorhinal, and parahippocampal proper). Unlike most other tracing protocols available, typically focusing on certain MTL areas (e.g., amygdala and/or hippocampus), the integrative perspective adopted by the present tracing guidelines allows for clear localization of all MTL subregions. By integrating information from a variety of sources, including extant tracing protocols separately targeting various MTL structures, histological reports, and brain atlases, and with the complement of illustrative visual materials, the present protocol provides an accurate, intuitive, and convenient guide for understanding the MTL anatomy. The need for such tracing guidelines is also emphasized by illustrating possible differences between automatic and manual segmentation protocols. This knowledge can be applied toward research involving not only structural MRI investigations but also structural-functional colocalization and fMRI signal extraction from anatomically defined ROIs, in healthy and clinical groups alike.