Health care providers' weight management practices for adolescent obesity and alignment with clinical practice guidelines: a multi-centre, qualitative study.

BACKGROUND: Clinical practice guidelines (CPGs) include evidence-based recommendations for managing obesity in adolescents. However, information on how health care providers (HCPs) implement these recommendations in day-to-day practice is limited. Our objectives were to explore how HCPs deliver weight management health services to adolescents with obesity and describe the extent to which their reported practices align with recent CPGs for managing pediatric obesity. METHODS: From July 2017 to January 2018, we conducted a qualitative study that used purposeful sampling to recruit HCPs with experience in adolescent weight management from multidisciplinary, pediatric weight management clinics in Edmonton and Ottawa, Canada. Data were collected using audio-recorded focus groups (4-6 participants/group; 60-90 min in length). We applied inductive, semantic thematic analysis and the congruent methodological approach to analyze our data, which included transcripts, field notes, and memos. Qualitative data were compared to recent CPGs for pediatric obesity that were published by the Endocrine Society in 2017. Of the 12 obesity 'treatment-related' recommendations, four were directly relevant to the current study. RESULTS: Data were collected through three focus groups with 16 HCPs (n = 10 Edmonton; n = 6 Ottawa; 94% female; 100% Caucasian), including dietitians, exercise specialists, nurses, pediatricians, psychologists, and social workers. We identified three main themes that we later compared with CPG recommendations, including: (i) discuss realistic expectations regarding weight management (e.g., shift focus from weight to health; explore family cohesiveness; foster delayed vs instant gratification), (ii) personalize weight management (e.g., address personal barriers to change; consider developmental readiness), and (iii) exhibit non-biased attitudes and practices (e.g., de-emphasize individual causes of obesity; avoid making assumptions about lifestyle behaviors based on weight). Based on these qualitative findings, HCPs applied all four CPG recommendations in their practices. CONCLUSIONS: HCPs provided practical insights into what and how they delivered weight management for adolescents, which included operationalizing relevant CPG recommendations in their practices.

End-user perspectives to inform policy and program decisions: a qualitative and quantitative content analysis of lifestyle treatment recommendations by adolescents with obesity.

BACKGROUND: Lifestyle modifications represent the first line of treatment in obesity management; however, many adolescents with obesity do not meet lifestyle recommendations. Given that adolescents are rarely consulted during health policy development and in the design of lifestyle interventions, their first-hand experiences, preferences, and priorities may not be represented. Accordingly, our purpose was to explore adolescents' lifestyle treatment recommendations to inform policy and program decisions. METHODS: Conducted from July 2017 to January 2018, this study adhered to a qualitative, crosslanguage, patient-oriented design. We recruited 19 13-17-year-old adolescents (body mass index [BMI] ≥85th percentile) seeking multidisciplinary treatment for obesity in geographically and culturally diverse regions of Canada. Adolescents participated in one-on-one, in-person, semi-structured interviews in English or French. Interviews were audio-recorded, transcribed verbatim, managed using NVivo 11, and analyzed using quantitative and qualitative content analysis by two independent researchers. RESULTS: Adolescents' recommendations were organized into five categories, each of which denotes health as a collective responsibility: (i) establish parental support within limits, (ii) improve accessibility and availability of 'healthy foods', (iii) limit deceptive practices in food marketing, (iv) improve accessibility and availability of varied physical activity opportunities, and (v) delay school start times. Respect for individual autonomy and decision-making capacity were identified as particularly important, however these were confronted with adolescents' partial knowledge on nutrition and food literacy. CONCLUSIONS: Adolescents' recommendations highlighted multi-level, multi-component factors that influenced their ability to lead healthy lifestyles. Uptake of these recommendations by policy-makers and program developers may be of added value for lifestyle treatment targeting adolescents with obesity.

Feasibility, user experiences, and preliminary effect of Conversation Cards for Adolescents© on collaborative goal-setting and behavior change: protocol for a pilot randomized controlled trial.

BACKGROUND: Adolescents and providers can benefit from practical tools targeting lifestyle modification for obesity prevention and management. We created Conversation Cards for Adolescents© (CCAs), a patient-centered communication and behavior change tool for adolescents and providers to use in clinical practice. The purpose of our study is to (i) assess the feasibility of CCAs in a real-world, practice setting to inform full-scale trial procedures, (ii) assess user experiences of CCAs, and (iii) determine the preliminary effect of CCAs on changing behavioral and affective-cognitive outcomes among adolescents. METHODS: Starting in early 2019, this prospective study is a nested mixed-methods, theory-driven, and pragmatic pilot randomized controlled trial with a goal to enroll 50 adolescents (13-17 years old) and 9 physicians practicing at the Northeast Community Health Centre in Edmonton, Alberta, Canada. Adolescents will collaboratively set one S.M.A.R.T. (specific, measurable, attainable, realistic, timely) goal with their physician to implement over a 3-week period; however, only those randomized to the experimental group will use CCAs to inform their goal. Outcome assessments at baseline and follow-up (3 weeks post-baseline) will include behavioral, affective-cognitive, and process-related outcomes. DISCUSSION: In examining the feasibility, user experiences, and preliminary effect of CCAs, our study will add contributions to the obesity literature on lifestyle modifications among adolescents in a real-world, practice setting as well as inform the scalability of our approach for a full-scale effectiveness randomized controlled trial on behavior change. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03821896.

Defining metabolically healthy obesity in children: a scoping review.

We conducted a scoping review to identify definitions of metabolically healthy obesity (MHO), describe gaps in the literature, and establish a universal definition of MHO in children. We searched electronic databases from January 1980 to June 2017 and grey literature. Experimental, quasi-experimental, or observational studies were eligible for inclusion if they (i) included a definition of MHO that identified risk factors, cut-off values, and the number of criteria used to define MHO, and (ii) classified 2-18 year olds as overweight or obese. Two reviewers independently screened 1,711 papers for relevance and quality; we extracted data from 39 individual reports that met inclusion criteria. Most (31/39; 79%) definitions of MHO included an absence of cardiometabolic risk factors. Heterogeneity across MHO definitions, obesity criteria, and sample sizes/characteristics resulted in variable prevalence estimates (3-80%). Finally, we convened an international panel of 46 experts to complete a 4-round Delphi process to generate a consensus-based definition of MHO. Based on consensus (≥ 80% agreement), our definition of MHO included: high density lipoprotein-cholesterol > 40 mg/dl (or > 1.03 mmol/l), triglycerides ≤ 150 mg/dl (or ≤ 1.7 mmol/l), systolic and diastolic blood pressure ≤ 90th percentile, and a measure of glycemia. This definition of MHO holds potential universal value to enable comparisons between studies and inform clinical decision-making for children with obesity.

"Fat is really a four-letter word": Exploring weight-related communication best practices in children with and without disabilities and their caregivers.

BACKGROUND: Health care professionals play a critical role in preventing and managing childhood obesity, but the American Academy of Pediatrics recently stressed the importance of using sensitive and nonstigmatizing language when discussing weight with children and families. Although barriers to weight-related discussions are well known, there are few evidence-based recommendations around communication best practices. Disability populations in particular have previously been excluded from work in this area. The objectives were to present the findings of a recent scoping review to children with and without disabilities and their caregivers for their reactions; and to explore the experiences and perceptions of the children and their caregivers regarding weight-related communication best practices. METHODS: Focus group and individual interviews were conducted with 7-18-year olds with and without disabilities and their caregivers. The interview guide was created using findings from a recent scoping review of weight-related communication best practices. Inductive thematic analysis was employed. RESULTS: Eighteen children (9 boys; 7 children with disabilities) and 21 caregivers (17 mothers, 1 step-father, 3 other caregivers) participated in 8 focus group and 7 individual interviews. Preferred communication strategies were similar across those with and without disabilities, although caregivers of children with autism spectrum disorder endorsed more concrete approaches. Discussions emphasizing growth and health were preferred over weight and size. Strengths-based, solution-focused approaches for weight conversations were endorsed, although had not been widely experienced. CONCLUSION: Perceptions of weight-related communication were similar across stakeholder groups, regardless of children's disability or weight status. Participants generally agreed with the scoping review recommendations, suggesting that they apply broadly across different settings and populations; however, tailoring them to specific circumstances is critical. Empirical evaluations are still required to examine the influence of weight-related communication on clinically important outcomes, including behaviour change and family engagement in care.

A brief eHealth tool delivered in primary care to help parents prevent childhood obesity: a randomized controlled trial.

OBJECTIVES: To determine the feasibility and preliminary impact of an electronic health (eHealth) screening, brief intervention and referral to treatment (SBIRT) delivered in primary care to help parents prevent childhood obesity. METHODS: Parents of children (5-17 years) were recruited from a primary care clinic. Children's measured height and weight were entered into the SBIRT on a study-designated tablet. The SBIRT screened for children's weight status, block randomized parents to one of four brief interventions or an eHealth control and provided parents with a menu of optional obesity prevention resources. Feasibility was determined by parents' interest in, and uptake of, the SBIRT. Preliminary impact was based on parents' concern about children's weight status and intention to change lifestyle behaviours post-SBIRT. RESULTS: Parents (n = 226) of children (9.9 ± 3.4 years) were primarily biological mothers (87.6%) and Caucasian (70.4%). The proportion of participants recruited (84.3%) along with parents who selected optional resources within the SBIRT (85.8%) supported feasibility. Secondary outcomes did not vary across groups, but non-Caucasian parents classified as inaccurate estimators of children's weight status reported higher levels of concern and intention to change post-SBIRT. CONCLUSIONS: Our innovative, eHealth SBIRT was feasible in primary care and has the potential to encourage parents of unhealthy weight children towards preventative action.

Barriers to and enablers of healthy lifestyle behaviours in adolescents with obesity: a scoping review and stakeholder consultation.

Healthy lifestyle behaviours are key to successful weight management, but have proven to be challenging to attain for adolescents with obesity. The purpose of our scoping review was to (i) describe barriers and enablers that adolescents with obesity encounter for healthy nutrition, physical activity, sedentary behaviour and sleep habits and (ii) identify gaps in the literature. We adhered to established methodology for scoping reviews. Six databases were searched (1980-June 2016) for original articles published in English or French that focused on lifestyle behaviours of 13- to 17-year-olds in paediatric weight management. Following screening and data extraction, findings of selected articles were synthesized thematically using a social ecological framework. Stakeholder consultation (n = 20) with adolescents with obesity and health professionals was completed to enhance methodological rigour. Our search yielded 17 articles for inclusion, including 546 unique participants. Barriers to healthy nutrition and physical activity were more consistently related to individual-level and interpersonal-level factors; enablers tended to be linked with interpersonal-level factors. Knowledge gaps identified related to sedentary behaviour and sleep as well as environmental and policy levels of influence. Our review revealed that some barriers and enablers were unique to adolescents with obesity, which were either within or beyond their control. These findings highlight the importance of multilevel interventions to enable healthy lifestyle behaviours for weight management.

Communicating with children and families about obesity and weight-related topics: a scoping review of best practices.

BACKGROUND: Healthcare professionals have called for direction on how best to communicate about weight-related topics with children and families. Established scoping review methodology was used to answer the question: 'How can healthcare professionals best communicate with children and their families about obesity and weight-related topics?' METHODS: We searched four scientific databases, two grey literature repositories and 14 key journals (2005-2016). Inclusion criteria were (i) children up to and including 18 years of age and/or their parents; (ii) communication about healthy weight, overweight, obesity or healthy/active living; and (iii) healthcare setting. RESULTS: Thirty-two articles were included. Evidence-based best practices were largely absent from the literature, although the following guiding principles were identified: (i) include all stakeholders in discussions; (ii) raise the topic of weight and health early and regularly; (iii) use strengths-based language emphasizing health over weight; (iv) use collaborative goal-setting to engage children and parents and (v) augment discussions with appropriate tools and resources. Guidance on how to implement these principles and how to negotiate relevant contextual factors (e.g. age, culture and disability) is still needed. CONCLUSION: Despite agreement on a number of guiding principles, evidence-based weight-related communication best practices are lacking. Rigorous, empirical evaluations of communication approaches are urgently required, especially those that include children's perspectives.

Weight bias reduction in health professionals: a systematic review.

Innovative and coordinated strategies to address weight bias among health professionals are urgently needed. We conducted a systematic literature review of empirical peer-reviewed published studies to assess the impact of interventions designed to reduce weight bias in students or professionals in a health-related field. Combination sets of keywords based on three themes (1: weight bias/stigma; 2: obesity/overweight; 3: health professional) were searched within nine databases. Our search yielded 1447 individual records, of which 17 intervention studies satisfied the inclusion criteria. Most studies (n = 15) included medical, dietetic, health promotion, psychology and kinesiology students, while the minority included practicing health professionals (n = 2). Studies utilized various bias-reduction strategies. Many studies had methodological weaknesses, including short assessment periods, lack of randomization, lack of control group and small sample sizes. Although many studies reported changes in health professionals' beliefs and knowledge about obesity aetiology, evidence of effectiveness is poor, and long-term effects of intervention strategies on weight bias reduction remain unknown. The findings highlight the lack of experimental research to reduce weight bias among health professionals. Although changes in practice will likely require multiple strategies in various sectors, well-designed trials are needed to test the impact of interventions to decrease weight bias in healthcare settings.

Why do families enrol in paediatric weight management? A parental perspective of reasons and facilitators.

BACKGROUND: Few children with obesity who are referred for weight management end up enroled in treatment. Factors enabling enrolment are poorly understood. Our purpose was to explore reasons for and facilitators of enrolment in paediatric weight management from the parental perspective. METHODS: Semi-structured interviews were conducted with parents of 10- to 17-year-olds who were referred to one of four Canadian weight management clinics and enroled in treatment. Interviews were audio-recorded and transcribed verbatim. Manifest/inductive content analysis was used to analyse the data, which included the frequency with which parents referred to reasons for and facilitators of enrolment. RESULTS: In total, 65 parents were interviewed. Most had a child with a BMI ≥95th percentile (n = 59; 91%), were mothers (n = 55; 85%) and had completed some post-secondary education (n = 43; 66%). Reasons for enrolment were related to concerns about the child, recommended care and expected benefits. Most common reasons included weight concern, weight loss expectation, lifestyle improvement, health concern and need for external support. Facilitators concerned the referral initiator, treatment motivation and barrier control. Most common facilitators included the absence of major barriers, parental control over the decision to enrol, referring physicians stressing the need for specialized care and parents' ability to overcome enrolment challenges. CONCLUSIONS: Healthcare providers might optimize enrolment in paediatric weight management by being proactive in referring families, discussing the advantages of the recommended care to meet treatment expectations and providing support to overcome enrolment barriers.

Variations in the prevalence and predictors of prevalent metabolically healthy obesity in adolescents.

BACKGROUND: Obesity is a heterogeneous condition, which includes a subset of individuals that can be classified as having metabolically healthy obesity (MHO), but there is no consensus on what constitutes MHO. Thus, the objective of the study is to examine the prevalence and predictors of prevalent MHO in adolescents using various definitions of MHO. METHODS: Cross-sectional data from the 1999-2010 National Health and Nutrition Examination Surveys were used. Participants included 316 male and 316 female adolescents aged 12-19 years with a BMI ≥ 95th percentile. Two definitions were used to define MHO. First, MHO was defined as having ≤1 metabolic syndrome criteria (excluding waist) and being free of type 2 diabetes, hypertension and dyslipidemia. Second, MHO was defined as being free of all metabolic syndrome criteria, insulin resistance and inflammation. RESULTS: The prevalence of MHO was 42% (male) and 74% (female) using the first definition and 7% (male) and 12% (female) using the second more conservative definition. Lower abdominal obesity (waist circumference) and lower insulin resistance predicted prevalent MHO in male and female adolescents for both definitions (p < 0.01). Associations between dietary components and MHO were weak and inconsistent, while physical activity and inflammation were not associated with MHO in male and female adolescents for both definitions (p > 0.05). CONCLUSIONS: The prevalence of MHO in adolescents varied across definitions, with lower levels of abdominal obesity and insulin resistance as the most consistent predictors of prevalent MHO status.

Ready, set, go! Motivation and lifestyle habits in parents of children referred for obesity management.

BACKGROUND: Parents play a fundamental role in helping children with obesity to make and maintain healthy lifestyle changes. OBJECTIVE: This study aimed to characterize stages of engagement to change nutrition and physical activity habits among parents whose children with obesity were enrolled in obesity management and examine differences in parents' own nutrition and physical activity habits according to their stage of engagement. METHODS: Medical records of 113 children (body mass index [BMI] ≥95th percentile) enrolled in an outpatient weight management clinic were reviewed for baseline (cross-sectional) data. Parents completed the Weight Loss Behavior-Stage of Change Scale to assess the degree of engagement in making healthy changes to their lifestyle behaviours. Latent class analysis was used to classify parents into distinct clusters by grouping individuals with similar ratings of stages of engagement regarding nutrition- and physical activity-related behaviours. RESULTS: Parents' engagement in healthy lifestyle behaviours varied (more engaged [n = 43]; less engaged [n = 70]). A greater proportion of parents in the more engaged group was in action and/or maintenance stages of changing their lifestyle habits. The more engaged group was less overweight than the less engaged group (BMI = 28.5 vs. 33.3 kg m(-2); P < 0.05). Further, the more engaged group consumed fewer total calories, calories from fat, trans fat and carbohydrates vs. their less engaged peers (P < 0.05). Compared with the less engaged group, the more engaged group consumed more daily servings of vegetables and fruits (4.9 vs. 3.9, P < 0.05) and accumulated more steps per day (9130 vs. 7225; P < 0.05). The more engaged group was also more likely to meet daily recommendations for vegetable and fruit intake (48.8 vs. 24.3%; P < 0.05) and physical activity (42.9 vs. 22.9%, P < 0.05). CONCLUSIONS: Parents of children with obesity varied in their degree of engagement in making healthy changes to their lifestyle behaviours, and those categorized as more engaged already demonstrated positive lifestyle behaviours. Information regarding parents' degree of engagement in healthy behaviours can inform clinical recommendations, especially when parents represent the primary agents of change in families trying to manage paediatric obesity.

Vigorous physical activity and longitudinal associations with cardiometabolic risk factors in youth.

OBJECTIVE: To examine the longitudinal associations between different physical activity (PA) intensities and cardiometabolic risk factors among a sample of Canadian youth. METHODS: The findings are based on a 2-year prospective cohort study in a convenience sample of 315 youth aged 9-15 years at baseline from rural and urban schools in Alberta, Canada. Different intensities (light, moderate and vigorous) of PA were objectively assessed with Actical accelerometers. The main outcome measures were body mass index (BMI) z-score, waist circumference, cardiorespiratory fitness and systolic blood pressure at 2-year-follow-up and conditional BMI z-score velocity. A series of linear regression models were conducted to investigate the associations after adjusting for potential confounders. RESULTS: At follow-up, cardiorespiratory fitness increased (quartile 1 vs quartile 4=43.3 vs 50.2; P(trend)<0.01) and waist circumference decreased (quartile 1 vs quartile 4=79.0 vs 72.6; P(trend)=0.04; boys only) in a dose-response manner across quartiles of baseline vigorous-intensity PA. A similar trend was observed for systolic blood pressure (quartile 1 vs quartile 4=121.8 vs 115.3; P(trend)=0.07; boys only). Compared with quartile 1 of vigorous-intensity PA, BMI z-score at follow-up and conditional BMI z-score velocity were significantly lower in the quartile 2 and 3 (P<0.05). Waist circumference at follow-up also decreased (quartile 1 vs quartile 4=75.3 vs 73.8; P(trend)=0.04) across quartiles of baseline moderate-intensity PA. CONCLUSIONS: Time spent in vigorous-intensity PA was associated with several positive health outcomes 2 years later. These findings suggest that high-intensity activities in youth help to reduce the risk for several chronic diseases.

Elevated remnant lipoproteins may increase subclinical CVD risk in pre-pubertal children with obesity: a case-control study.

OBJECTIVES: Current clinical guidelines to assess paediatric cardiovascular disease (CVD) risk heavily rely on cholesterol parameters that are generally normal for obese children. Remnant lipoproteins have emerged as a critical CVD risk factor particularly in adults with normolipidemia. We assessed remnant lipoprotein concentration (measured by apolipoprotein [apo] B48) and its relationship with other traditional CVD risk biomarkers in pre-pubertal children with obesity. METHODS: Pre-pubertal children (n = 78) with obesity (n = 39, 9.9 ± 0.3 years old) as well as sex-matched normal-weight controls (n = 39, 9.8 ± 0.3 years) were assessed for anthropometry, blood pressure and fasting plasma biochemical parameters for remnant lipoprotein, lipid and glucose/insulin metabolism, and inflammatory status. RESULTS: Children with obesity had striking 2-fold higher apoB48-containing remnant lipoproteins concentrations relative to normal-weight peers; the magnitude of elevation in the remnant lipoproteins is comparable to the levels previously reported for adults with established CVD and type-2 diabetes. Fasting apoB48 was positively correlated with fasting triglyceride concentration in children with obesity (r = 0.51, P < 0.001) and their normal-weight peers (r = 0.45, P < 0.01). Traditional CVD biomarkers including low-density lipoprotein cholesterol showed no difference between groups and remained within the normal range for a paediatric population. CONCLUSION: Elevated apoB48-containing remnant lipoprotein is a stronger biomarker for paediatric CVD risk compared to traditional cholesterol parameters and may be associated with early adaptation of the intestine during obesity. Further investigation of abnormalities associated with the secretion and/or clearance of atherogenic remnant lipoproteins during the postprandial state may yield insight into our understanding of and therapeutic targets for managing risk for CVD in children with obesity.

Family-health professional relations in pediatric weight management: an integrative review.

In this integrative review, we examined contemporary literature in pediatric weight management to identify characteristics that contribute to the relationship between families and health professionals and describe how these qualities can inform healthcare practices for obese children and families receiving weight management care. We searched literature published from 1980 to 2010 in three electronic databases (MEDLINE, PsycINFO and CINAHL). Twenty-four articles identified family-health professional relationships were influenced by the following: health professionals' weight-related discussions and approaches to care; and parents' preferences regarding weight-related terminology and expectations of healthcare delivery. There was considerable methodological heterogeneity in the types of reports (i.e. qualitative studies, review articles, commentaries) included in this review. Overall, the findings have implications for establishing a positive clinical relationship between families and health professionals, which include being sensitive when discussing weight-related issues, using euphemisms when talking about obesity, demonstrating a non-judgmental and supportive attitude and including the family (children and parents) in healthcare interactions. Experimental research, clinical interventions and longitudinal studies are needed to build on the current evidence to determine how best to establish a collaborative partnership between families and health professionals and whether such a partnership improves treatment adherence, reduces intervention attrition and enhances pediatric weight management success.

Apolipoprotein B48: a novel marker of metabolic risk in overweight children?

Clinical studies in adults indicate there is a positive and significant association between insulin resistance, dyslipidaemia, fasting intestinally derived lipoproteins [via apoB48 (apolipoprotein B48)] and visceral fat. All of these factors contribute to increased risk of CVD (cardiovascular disease). Since little is known about postprandial dyslipidaemia in overweight children, we sought to compare fasting levels of apoB48 with the HOMA-IR (homoeostasis model assessment of insulin resistance) score, classic lipid profile and VAT (visceral adipose tissue). Pre-pubertal, overweight boys and girls were recruited from the wider-Edmonton area (Alberta). Body composition was determined using both dual-energy X-ray absorptiometry and MRI (magnetic resonance imaging). Fasting apoB48 was quantified in plasma using an adapted SDS/PAGE immunoblotting technique, and insulin, glucose, TC (total cholesterol), TAG (triacylglycerol), LDL (low-density lipoprotein) and HDL (high-density lipoprotein) were determined by calorimetric assay. In this overweight sample, we observed elevated fasting apoB48 concentrations, greater than the normal adult range. In addition, apoB48 was significantly related to HOMA-IR and TAG levels. Although apoB48 was positively correlated with TC and LDL and negatively associated with HDL, these relationships did not achieve significance. Our ongoing MRI analysis reveals a positive relationship between apoB48 and VAT volume. To our knowledge, this is the first study to report apoB48 concentrations in overweight pre-pubertal children. Thus this article will provide a brief rationale for our study and its methodology.