eHealth, family-based interventions, and multilevel approaches to pediatric weight management: a scoping review.

OBJECTIVE: This scoping review examines the current literature on technology-based, eHealth interventions that integrate community and clinical approaches for family-based pediatric weight management. BACKGROUND: Telehealth and eHealth interventions for weight management are increasingly commonplace; however, it is unclear in the current literature how family-based, pediatric, healthy-weight interventions integrate technology. Additionally, multilevel approaches to address childhood obesity, including working with clinical and community partners, are currently considered best practice and within the socioecological framework for sustainability of outcomes. Little is known how current family based pediatric healthy weight interventions integrate eHealth and multi-level approaches. METHODS: Guided by Arksey and O'Malley's scoping review framework, a scoping literature review was conducted. Four databases were searched to identify studies conducted between 2010 and 2022 that addressed multilevel, family-based, pediatric weight management interventions that also integrated technology. Studies were excluded that did not include at least 2 of the 4 components and that did not include technology to some degree. RESULTS: A total of 15 articles were included in the scoping review. All articles included some type of technology in the intervention. Twelve articles included a family-based approach, and only 1 article fully used a holistic approach to family-based, pediatric weight management that included technology and integrated clinical and community approaches to address the complexity of childhood obesity. CONCLUSIONS: There are several family-based, pediatric weight management interventions that incorporate an eHealth component. There is a gap in the literature about programs that use both technology and integrate multilevel clinical and community approaches for treatment. Additionally, gaps exist in information about adolescent, family-based, weight management interventions, and there are opportunities for nutrition and dietetic professionals to become more involved with technological and multilevel approaches in family-based pediatric weight management.

Sensory-Informed Evaluation Method for Use With Peer Educators of Nutrition Education Programs.

OBJECTIVE: Determine acceptance of unfamiliar recipes and investigate the practicality of a hybrid (remote and in-office) method of evaluating recipes. METHODS: Peer educators from the University of Georgia's Expanded Food and Nutrition Education Program and Supplemental Nutrition Assistance Program-Education programs used a hybrid home-use test method to evaluate 8 recipes before and after preparation and tasting. We collected perceived and actual measures of recipe acceptance. The main outcomes included overall liking and preparation behaviors, analyzed using nonparametric approaches. RESULTS: No significant differences (P > 0.05) were found between prepreparation and postpreparation overall liking or preparation behaviors for each recipe, supporting the practicality of the method. Liking of recipe preparation exceeded 7 out of 9 for all recipes, but ratings for recipe preparation willingness and perceived program participant ratings decreased after tasting. CONCLUSIONS AND IMPLICATIONS: Although tasting new recipes is necessary to determine specific modifications, a hybrid recipe evaluation format is practical for introducing new recipes to peer educators when resources are limited.

Design and Implementation of a Nutrition and Breastfeeding Education Program for Black Expecting Mothers and Fathers.

OBJECTIVE: To describe the intervention and research methods of Project Dads in Nutrition Education, an intervention that adds nutrition and breastfeeding education to the existing Healthy Start program in Georgia for Black expecting mothers and fathers to improve nutrition literacy, health outcomes, and breastfeeding rates. DESIGN: This 2-year community-based participatory research study employs a cluster randomization factorial design. SETTING: Six Healthy Start program sites (3 intervention and 3 control sites) in Georgia counties with high infant and maternal mortality rates. PARTICIPANTS: Approximately 480 Black, expecting, Healthy Start program participants (20 couples [mother and father] and 40 single mothers from each site) will be enrolled over the study period. INTERVENTION(S): Project Dads in Nutrition Education will strengthen the capacity of the Georgia Healthy Start program to integrate an evidence-based nutrition education program, breastfeeding education, and father engagement into its routine services. MAIN OUTCOME MEASURE(S): Changes in prepost survey assessment of participants' nutrition literacy and eating behaviors; changes in prepost survey assessment of participants' breastfeeding knowledge, attitudes, intent, initiation, and duration; and health and food diary collected 3 times (ie, at baseline, 3 months, and 6 months after enrollment). ANALYSIS: Process evaluation throughout the study to document implementation. Generalized linear mixed modeling will be used to determine the impact of the intervention.

Large neutral amino acid status in association with P:T ratio and diet in adult and pediatric patients with phenylketonuria.

BACKGROUND: Intake of large neutral amino acids (LNAA) may inhibit phenylalanine (PHE) transport across the blood brain barrier and assist with blood PHE control in patients with phenylketonuria (PKU). We evaluated the interrelationship between LNAA in plasma and diet on Phe:Tyr (P:T) ratio in patients with PKU and the influence of dietary factors on plasma LNAA markers. METHODS: Plasma amino acid values and 3-day food record analysis from two studies (34 male/30 female; age 4.6-47 years) were examined. For pediatrics (<18 years) and adults (≥18 years) the relationship between P:T ratio, plasma LNAA, and dietary intake patterns were investigated. RESULTS: Dietary factors influencing P:T ratio included intake of total protein (g/kg), medical food (MF) protein (g/kg, % below Rx), and LNAA (g) in the full cohort (P < .05). Associations were found between plasma valine and other dietary and plasma LNAA in pediatrics (P < .05) and plasma LNAA with dietary LNAA intake in adults (P = .019). Plasma P:T ratio was inversely associated with plasma LNAA concentrations in both age groups (P < .05). Aside from histidine in pediatrics (P = .024), plasma LNAA did not differ by having plasma PHE levels within or above the therapeutic range (120-360 µmol/L). Plasma LNAA in both age groups was similar to reported healthy control values. CONCLUSION: P:T ratio is significantly tied to dietary LNAA, adherence to MF Rx, and plasma LNAA concentrations. Additionally, P:T ratio and valine may be effective clinical proxies for determining LNAA metabolic balance and LNAA quality of the diet in patients with PKU.

Determining the Accuracy and Reliability of Indirect Calorimeters Utilizing the Methanol Combustion Technique.

BACKGROUND: Several indirect calorimetry (IC) instruments are commercially available, but comparative validity and reliability data are lacking. Existing data are limited by inconsistencies in protocols, subject characteristics, or single-instrument validation comparisons. The aim of this study was to compare accuracy and reliability of metabolic carts using methanol combustion as the cross-laboratory criterion. METHODS: Eight 20-minute methanol burn trials were completed on 12 metabolic carts. Respiratory exchange ratio (RER) and percent O2 and CO2 recovery were calculated. RESULTS: For accuracy, 1 Omnical, Cosmed Quark CPET (Cosmed), and both Parvos (Parvo Medics trueOne 2400) measured all 3 variables within 2% of the true value; both DeltaTracs and the Vmax Encore System (Vmax) showed similar accuracy in measuring 1 or 2, but not all, variables. For reliability, 8 instruments were shown to be reliable, with the 2 Omnicals ranking best (coefficient of variation [CV] < 1.26%). Both Cosmeds, Parvos, DeltaTracs, 1 Jaeger Oxycon Pro (Oxycon), Max-II Metabolic Systems (Max-II), and Vmax were reliable for at least 1 variable (CV ≤ 3%). For multiple regression, humidity and amount of combusted methanol were significant predictors of RER (R2 = 0.33, P < .001). Temperature and amount of burned methanol were significant predictors of O2 recovery (R2 = 0.18, P < .001); only humidity was a predictor for CO2 recovery (R2 = 0.15, P < .001). CONCLUSIONS: Omnical, Parvo, Cosmed, and DeltaTrac had greater accuracy and reliability. The small number of instruments tested and expected differences in gas calibration variability limits the generalizability of conclusions. Finally, humidity and temperature could be modified in the laboratory to optimize IC conditions.

Assessing Resting Metabolic Rate in Overweight and Obese Adolescents With a Portable Indirect Calorimeter: A Pilot Study for Validation and Reliability.

BACKGROUND: Indirect calorimetry measured via the traditional indirect calorimeter is considered the "gold standard" for determining resting metabolic rate (RMR). Portable devices for assessing RMR are a less expensive option for measuring RMR in the clinical setting. This pilot study tested the reliability and validity of a portable device for measuring RMR, specifically in overweight and obese adolescents. MATERIALS AND METHODS: Participants aged 17-19 years (n = 19) and ≥85th percentile on the Centers for Disease Control and Prevention body mass index growth curves for age and sex were recruited from a university campus. Participants completed testing on a traditional indirect calorimeter and a portable indirect calorimeter in a randomized order on 2 separate testing days. RESULTS: A paired samples t test comparing the means of the portable device and the traditional indirect calorimeter found no significant difference (P = .22). The test-retest intraclass correlation coefficient for assessing RMR was 0.91, indicating reliability of the portable indirect calorimeter. Compared with measured RMR, the Mifflin-St Jeor equation demonstrated 37% accuracy, and the Molnar equation demonstrated 57% accuracy. CONCLUSION: This pilot study found portable indirect calorimetry to be reliable and valid for assessing RMR in an overweight and obese adolescent population. In addition, this study indicates that portable indirect calorimetry may be an acceptable option for assessing RMR in this population compared with the traditional indirect calorimeter or predictive equations.

Camp-based immersion treatment for obese, low socioeconomic status, multi-ethnic adolescents.

BACKGROUND: Immersion treatment (IT) provided in a camp setting has been shown to promote short-term improvements in weight and health status in obese adolescents. However, evidence of IT's long-term efficacy and efficacy for multi-ethnic and lower socioeconomic status (SES) adolescents is limited. METHODS: This was a cohort study with a pre/post design and longitudinal follow-up. The intervention was a 19-day camp-based IT program comprising (1) a nutrition curriculum and ad-lib access to a nutritious diet, (2) several hours of physical activity daily, (3) group therapy, and (4) cognitive-behavioral therapy (CBT). This analysis included 52 low-SES adolescents that participated in 2009 and 2010. A subgroup of 33 campers and their families was offered follow-up monthly for 10 months. Primary outcome measures were change in weight-related parameters immediately postcamp and after 10 months of follow-up. RESULTS: Campers had significant short-term improvements in mean waist circumference (mean [M], 2.6; standard deviation [SD], 3.2 cm), weight (M, 2.6; SD, 1.9 kg), BMI (M, 1.1; SD, 0.9 kg/m2), BMI z-score (M, 0.06; SD, 0.07), and percent overweight (M, 6.1; SD, 4.7). Campers offered follow-up had a modest increase in mean percent overweight (M, 2.0; SD, 8.4) during 10 months of follow-up. However, 33% experienced continuing decline in percent overweight during follow-up, and long-term follow-up was associated with significant overall (precamp vs. end of follow-up) improvements in percent overweight (M, 4.9; SD, 7.2). CONCLUSIONS: Camp-based IT with CBT is a promising intervention for improving short- and long-term weight status of low-SES adolescents. Additional research is needed to increase long-term efficacy.

Comparison of predictive equations and measured resting energy expenditure among obese youth attending a pediatric healthy weight clinic: one size does not fit all.

BACKGROUND: The Academy of Nutrition and Dietetics recommends the use of indirect calorimetry for calculating caloric targets for weight loss in obese youth. Practitioners typically use predictive equations since indirect calorimetry is often not available. The objective of this study was to compare measured resting energy expenditure (MREE) with that estimated using published predictive equations in obese pediatric patients. MATERIAL AND METHODS: Youth aged 7 to 18 years (n = 80) who were referred to a university-based healthy weight clinic and who were greater than the 95th percentile BMI for age and gender participated. MREE was measured via a portable indirect calorimeter. Predicted energy expenditure (pEE) was estimated using published equations including those commonly used in children. pEE was compared to the MREE for each subject. Absolute mean difference between MREE and pEE, mean percentage accuracy, and mean error were determined. RESULTS: Mean percentage accuracy of pEE compared with MREE varied widely, with the Harris-Benedict, Lazzer, and Molnar equations providing the greatest accuracy (65%, 61%, and 60%, respectively). Mean differences between MREE and equation-estimated caloric targets varied from 197.9 kcal/day to 307.7 kcal/day. CONCLUSIONS: The potential to either overestimate or underestimate calorie needs in the clinical setting is significant when comparing EE derived from predictive equations with that measured using portable indirect calorimetry. While our findings suggest that the Harris-Benedict equation has improved accuracy relative to other equations in severely obese youth, the potential for error remains sufficiently great to suggest that indirect calorimetry is preferred.

Exercise effects on lipids in persons with varying dietary patterns-does diet matter if they exercise? Responses in Studies of a Targeted Risk Reduction Intervention through Defined Exercise I.

BACKGROUND: The standard clinical approach for reducing cardiovascular disease risk due to dyslipidemia is to prescribe changes in diet and physical activity. The purpose of the current study was to determine if, across a range of dietary patterns, there were variable lipoprotein responses to an aerobic exercise training intervention. METHODS: Subjects were participants in the STRRIDE I, a supervised exercise program in sedentary, overweight subjects randomized to 6 months of inactivity or 1 of 3 aerobic exercise programs. To characterize diet patterns observed during the study, we calculated a modified z-score that included intakes of total fat, saturated fat, trans fatty acids, cholesterol, omega-3 fatty acids, and fiber as compared with the 2006 American Heart Association diet recommendations. Linear models were used to evaluate relationships between diet patterns and exercise effects on lipoproteins/lipids. RESULTS: Independent of diet, exercise had beneficial effects on low-density lipoprotein cholesterol particle number, low-density lipoprotein cholesterol size, high-density lipoprotein cholesterol, high-density lipoprotein cholesterol size, and triglycerides (P < .05 for all). However, having a diet pattern that closely adhered to American Heart Association recommendations was not related to changes in these or any other serum lipids or lipoproteins in any of the exercise groups. CONCLUSIONS: We found that even in sedentary individuals whose habitual diets vary in the extent of adherence to AHA dietary recommendations, a rigorous, supervised exercise intervention can achieve significant beneficial lipid effects.

Medical nutrition therapy for overweight youth in their medical home: the KIDPOWER experience.

OBJECTIVE: To determine the feasibility and impact of implementing a standardized medical nutrition therapy (MNT) protocol to treat overweight children in their medical home. Primary outcomes evaluated were changes in eating behaviors, television habits, and weight status. METHODS: A MNT protocol with handouts (known as KIDPOWER) was delivered by a registered dietitian (RD) to overweight children (2-20 years) in 9 primary care practices in a rural community. A medical record review yielded height, weight and selected patient/parent reported eating and TV behaviors from each MNT visit. Mean values were compared by paired samples t-tests. Changes in behaviors and BMI z score were compared using repeated measures ANOVA. RESULTS: For patients with at least three MNT visits (n=109) significant improvements in eating and TV viewing habits were seen by the third visit. Weight status, as determined by a significant decline in mean BMI z score, was improved. CONCLUSION: The KIDPOWER protocol delivered by a RD in the pediatric medical home aided overweight youth in making behavior changes that positively impacted their weight status. PRACTICE IMPLICATIONS: Reimbursement to RDs for treating childhood obesity is improving and KIDPOWER provides a model and tools for community practice.

Insulin resistance status: predicting weight response in overweight children.

OBJECTIVE: To assess the relationship between insulin resistance and body mass index (BMI) z score associated with dietary modification that focuses on limiting sweetened beverage consumption in overweight children. DESIGN: A retrospective cohort study conducted between July 1, 2004, and April 28, 2006. SETTING: Community-based primary care practices treating children. PATIENTS: Forty-five children (aged < or =18 years) at or above the 95th percentile of BMI for age and sex. Intervention Children and parents were instructed by a dietitian regarding caloric reduction and modification of sweetened beverage intake. MAIN OUTCOME MEASURES: Insulin resistance at baseline was calculated from fasting insulin and glucose levels (ie, homeostatic model assessment [HOMA]) and change in BMI z score from baseline to 12-week follow-up. RESULTS: Change in BMI z score in response to a decrease in sweetened beverages correlated (Pearson product moment correlation coefficient = 0.42; P < .01) with baseline insulin resistance. Those with a decrease in or an unchanged BMI z score had significantly greater insulin resistance than those whose BMI z score increased (mean [SD] HOMA, 6.2 [4.2] vs 2.6 [2.0], P < .01). Linear regression confirmed that HOMA was a significant predictor of change in BMI z score when controlling for age, race, and sex. CONCLUSIONS: Among overweight children in primary care practices, a significant relationship was found between insulin resistance and the change in BMI z score associated with a dietitian-mediated intervention that includes a focus on decreasing sweetened beverage consumption. Estimating insulin resistance may inform dietary recommendations for overweight children.

Artificial selection for high-capacity endurance running is protective against high-fat diet-induced insulin resistance.

Elevated oxidative capacity, such as occurs via endurance exercise training, is believed to protect against the development of obesity and diabetes. Rats bred both for low (LCR)- and high (HCR)-capacity endurance running provide a genetic model with inherent differences in aerobic capacity that allows for the testing of this supposition without the confounding effects of a training stimulus. The purpose of this investigation was to determine the effects of a high-fat diet (HFD) on weight gain patterns, insulin sensitivity, and fatty acid oxidative capacity in LCR and HCR male rats in the untrained state. Results indicate chow-fed LCR rats were heavier, hypertriglyceridemic, less insulin sensitive, and had lower skeletal muscle oxidative capacity compared with HCR rats. Upon exposure to an HFD, LCR rats gained more weight and fat mass, and their insulin resistant condition was exacerbated, despite consuming similar amounts of metabolizable energy as chow-fed controls. These metabolic variables remained unaltered in HCR rats. The HFD increased skeletal muscle oxidative capacity similarly in both strains, whereas hepatic oxidative capacity was diminished only in LCR rats. These results suggest that LCR rats are predisposed to obesity and that expansion of skeletal muscle oxidative capacity does not prevent excess weight gain or the exacerbation of insulin resistance on an HFD. Elevated basal skeletal muscle oxidative capacity and the ability to preserve liver oxidative capacity may protect HCR rats from HFD-induced obesity and insulin resistance.

Subsarcolemmal and intermyofibrillar mitochondria play distinct roles in regulating skeletal muscle fatty acid metabolism.

Skeletal muscle contains two populations of mitochondria that appear to be differentially affected by disease and exercise training. It remains unclear how these mitochondrial subpopulations contribute to fiber type-related and/or training-induced changes in fatty acid oxidation and regulation of carnitine palmitoyltransferase-1beta (CPT1beta), the enzyme that controls mitochondrial fatty acid uptake in skeletal muscle. To this end, we found that fatty acid oxidation rates were 8.9-fold higher in subsarcolemmal mitochondria (SS) and 5.3-fold higher in intermyofibrillar mitochondria (IMF) that were isolated from red gastrocnemius (RG) compared with white gastrocnemius (WG) muscle, respectively. Malonyl-CoA (10 muM), a potent inhibitor of CPT1beta, completely abolished fatty acid oxidation in SS and IMF mitochondria from WG, whereas oxidation rates in the corresponding fractions from RG were inhibited only 89% and 60%, respectively. Endurance training also elicited mitochondrial adaptations that resulted in enhanced fatty acid oxidation capacity. Ten weeks of treadmill running differentially increased palmitate oxidation rates 100% and 46% in SS and IMF mitochondria, respectively. In SS mitochondria, elevated fatty acid oxidation rates were accompanied by a 48% increase in citrate synthase activity but no change in CPT1 activity. Nonlinear regression analyses of mitochondrial fatty acid oxidation rates in the presence of 0-100 muM malonyl-CoA indicated that IC(50) values were neither dependent on mitochondrial subpopulation nor affected by exercise training. However, in IMF mitochondria, training reduced the Hill coefficient (P < 0.05), suggesting altered CPT1beta kinetics. These results demonstrate that endurance exercise provokes subpopulation-specific changes in mitochondrial function that are characterized by enhanced fatty acid oxidation and modified CPT1beta-malonyl-CoA dynamics.

Effects of the amount and intensity of exercise on plasma lipoproteins.

BACKGROUND: Increased physical activity is related to reduced risk of cardiovascular disease, possibly because it leads to improvement in the lipoprotein profile. However, the amount of exercise training required for optimal benefit is unknown. In a prospective, randomized study, we investigated the effects of the amount and intensity of exercise on lipoproteins. METHODS: A total of 111 sedentary, overweight men and women with mild-to-moderate dyslipidemia were randomly assigned to participate for six months in a control group or for approximately eight months in one of three exercise groups: high-amount-high-intensity exercise, the caloric equivalent of jogging 20 mi (32.0 km) per week at 65 to 80 percent of peak oxygen consumption; low-amount-high-intensity exercise, the equivalent of jogging 12 mi (19.2 km) per week at 65 to 80 percent of peak oxygen consumption; or low-amount-moderate-intensity exercise, the equivalent of walking 12 mi per week at 40 to 55 percent of peak oxygen consumption. Subjects were encouraged to maintain their base-line body weight. The 84 subjects who complied with these guidelines served as the basis for the main analysis. Detailed lipoprotein profiling was performed by nuclear magnetic resonance spectroscopy with verification by measurement of cholesterol in lipoprotein subfractions. RESULTS: There was a beneficial effect of exercise on a variety of lipid and lipoprotein variables, seen most clearly with the high amount of high-intensity exercise. The high amount of exercise resulted in greater improvements than did the lower amounts of exercise (in 10 of 11 lipoprotein variables) and was always superior to the control condition (11 of 11 variables). Both lower-amount exercise groups always had better responses than the control group (22 of 22 comparisons). CONCLUSIONS: The highest amount of weekly exercise, with minimal weight change, had widespread beneficial effects on the lipoprotein profile. The improvements were related to the amount of activity and not to the intensity of exercise or improvement in fitness.