Maintenance Following a Randomized Trial of a Clinic and Home-based Behavioral Intervention of Obesity in Preschoolers.

OBJECTIVE: To assess maintenance of improved weight outcomes in preschoolers with obesity 6 and 12 months following a randomized clinical trial comparing a home- and clinic-based behavioral intervention (Learning about Activity and Understanding Nutrition for Child Health [LAUNCH]) to motivational interviewing and standard care. STUDY DESIGN: Randomized controlled trial with children between the ages of 2 and 5 years above the 95th percentile for body mass index for age and sex recruited from 27 pediatrician offices across 10 recruitment cycles between March 12, 2012, and June 8, 2015, were followed 6 and 12 months post-treatment. Child and caregiver weight, height, and caloric intake, child physical activity, and home environment were assessed. The primary outcome was maintenance of greater reduction of percent over the 50th percentile body mass index (BMI%50th) by LAUNCH compared with motivational interviewing and standard care at the 6- and 12-month follow-up. RESULTS: Significantly lower child BMI%50th was maintained for LAUNCH compared with motivational interviewing at 12-month follow-up and to standard care at the 6-month follow-up; however, the effect sizes were maintained for comparison with standard care at 12-month follow-up. LAUNCH had significantly lower daily caloric intake compared with motivational interviewing and standard care at both follow-ups and maintained significantly fewer high-calorie foods in the home compared with standard care at 6 and 12 months and compared with motivational interviewing at 12 months. However, caloric intake increased by 12% from post-treatment. LAUNCH caregivers did not maintain improved BMI at follow-up. CONCLUSIONS: LAUNCH showed success in reducing weight in preschoolers. However, maintaining treatment gains post-treatment is more difficult. Treatment may need to last longer than 6 months to achieve optimal results. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01546727.

Predictors of Preoperative Program Non-Completion in Adolescents Referred for Bariatric Surgery.

BACKGROUND: Factors contributing to adolescents' non-completion of bariatric surgery, defined as self-withdrawal during the preoperative phase of care, independent of program or insurance denial, are largely unknown. Recent adolescent and adult bariatric surgery literature indicate that psychological factors and treatment withdrawal play a role; however, for adolescents, additional age-salient (family/caregiver) variables might also influence progression to surgery. OBJECTIVES: The present study examined demographic, psychological, and family/caregiver variables as predictors of whether adolescents completed surgery ("completers") or withdrew from treatment ("non-completers"). SETTING: Adolescents were from a bariatric surgery program within a pediatric tertiary care hospital. METHODS: A retrospective chart review was conducted of consecutive patients who completed bariatric surgery psychological intake evaluations from September 2009 to April 2013. Data involving completer (n = 61) versus non-completer (n = 65) status were analyzed using two-tailed independent t tests, Chi-squared tests, and logistic regressions. RESULTS: Forty-three percent of adolescents completed surgery, similar to adult bariatric samples. Significantly more males were non-completers (p < .05), and there was a trend towards non-completion for older adolescents (p = 0.06). No other demographic, psychological, or caregiver/family variables were significant predictors of non-completion. CONCLUSIONS: These findings indicate that demographic variables, rather than psychological or family factors, were associated with the progression to or withdrawal from surgery. Further assessment is needed to determine specific reasons for completing or withdrawing from treatment, particularly for males and older adolescents, to improve clinical care and reduce attrition.

Psychosocial Screening Among Youth Seeking Weight Management Treatment.

The objectives of this study were to identify rates of, and factors associated with, "at-risk" scores on a brief psychosocial screener among overweight/obese youth seeking weight management treatment, as well as concordance between youth and caregiver reports. A retrospective chart review of 1443 consecutive patients ages 4 to 18 years and their caregivers was conducted. Almost 1 in 4 youth with overweight/obesity presented with psychosocial symptoms in the at-risk range for significant mental health issues based on caregiver report on the Pediatric Symptom Checklist (PSC) and 1 in 6 based on youth self-report on the Youth Pediatric Symptom Checklist (Y-PSC). Concordance between caregiver and youth was fair (agreement 24% to 40%). Higher scores were associated with male sex and older age on the PSC and with indication of depressive disorder in the electronic medical record on the Y-PSC. Conducting a brief psychosocial screen in comprehensive weight management programs is feasible and clinically indicated.

Clinic and Home-Based Behavioral Intervention for Obesity in Preschoolers: A Randomized Trial.

OBJECTIVE: To test the hypotheses that an innovative skills-based behavioral family clinic and home-based intervention (LAUNCH) would reduce body mass index z score (BMIz) compared with motivational interviewing and to standard care in preschool-aged children with obesity. STUDY DESIGN: Randomized controlled trial with children between the ages of 2 and 5 years above the 95th percentile for body mass index for age and sex recruited from 27 pediatrician offices across 10 recruitment cycles between March 12, 2012 and June 8, 2015. Children were randomized to LAUNCH (an 18-session clinic and home-based behavioral intervention), motivational interviewing (delivered at the same frequency as LAUNCH), or standard care (no formal intervention). Weight and height were measured by assessors blinded to participant assignment. The primary outcome, BMIz at month 6 after adjusting for baseline BMIz, was tested separately comparing LAUNCH with motivational interviewing and LAUNCH with standard care using regression-based analysis of covariance models. RESULTS: A total of 151 of the 167 children randomized met intent-to-treat criteria and 92% completed the study. Children were 76% White and 57% female, with an average age of 55 months and BMI percentile of 98.57, with no demographic differences between the groups. LAUNCH participants demonstrated a significantly greater decrease in BMIz (mean = -0.32, SD = ±0.33) compared with motivational interviewing (mean = -0.05, SD = ±0.27), P < .001, ω2 = 0.74 and compared with standard care (mean = -0.13, SD = ±0.31), P < .004, ω2 = 0.75. CONCLUSIONS: In preschool-age children, an intensive 6-month behavioral skills-based intervention is necessary to reduce obesity. TRIAL REGISTRATION: Clinicaltrials.gov NCT01546727.

Weight loss surgery improves quality of life in pediatric patients with osteogenesis imperfecta.

BACKGROUND: Osteogenesis imperfecta (OI) is an inherited disorder, which causes brittle bones resulting in recurrent fractures. The associated poor mobility of children with OI increases susceptibility to obesity, and obesity further dramatically limits mobility and increases fracture risk. OBJECTIVES: The aim of this report is to describe outcomes of weight loss surgery (WLS) in 2 adolescents with severe obesity and OI. SETTING: Two University Hospitals (in the United Kingdom and in the United States). METHODS: Two cases of OI treated with WLS were identified. Pre- and postoperative anthropometric and biochemical data and clinical course were reviewed. RESULTS: In these 2 cases, preoperative Body Mass Index (BMI) values were 38 and 46 kg/m2. Following laparoscopic sleeve gastrectomy (LSG), BMI decreased by 55% and 60% by 26 and 24 months, respectively. There were no surgical complications, and both patients experienced improvement in their mobility and ability to perform activities of daily living. CONCLUSION: WLS effectively treated severe obesity in 2 OI patients and substantially improved mobility and quality of life, theoretically reducing fracture risk.

Learning about Activity and Understanding Nutrition for Child Health (LAUNCH): Rationale, design, and implementation of a randomized clinical trial of a family-based pediatric weight management program for preschoolers.

Obesity affects nearly 2 million preschool age children in the United States and is not abating. However, research on interventions for already obese preschoolers is limited. To address this significant gap in the literature, we developed an intervention targeting obesity reduction in 2 to 5year olds, Learning about Activity and Understanding Nutrition for Child Health (LAUNCH). This paper describes the rationale, design, participant enrollment, and implementation of a 3-arm randomized, parallel-group clinical trial comparing LAUNCH to a motivational-interviewing intervention (MI) and standard care (STC), respectively. Whereas LAUNCH was designed as a skills based intervention, MI focused on addressing the guardian's motivation to make changes in diet and activity and providing tools to do so at the guardian's level of readiness to implement changes. Child body mass index z-score was the primary outcome, assessed at pretreatment, posttreatment (Month 6), and 6 and 12month follow-ups (Months 12 and 18). Mechanisms of weight change (e.g., dietary intake, physical activity) and environmental factors associated with weight (e.g., foods available in the home, caregiver diet) were also assessed. This study is unique because it is one of the few randomized controlled trials to examine a developmentally informed, clinic and home skills based behavioral family intervention for preschoolers who are already obese. Being obese during the preschool years increases the likelihood of remaining obese as an adult and is associated with serious health conditions; if this intervention is successful, it has the potential to change the health trajectories for young children with obesity.

Feasibility of ecological momentary assessment to characterize adolescent postoperative diet and activity patterns after weight loss surgery.

BACKGROUND: Adherence to postoperative lifestyle recommendations may be associated with weight outcomes among weight loss surgery (WLS) patients, but it is difficult to objectively assess and has not been reported among adolescents. Methods of assessment that are ecologically valid and provide important contextual information related to adherence are needed. The objective of this pilot study was to demonstrate the feasibility of using a form of ecological momentary assessment (i.e., daily phone diaries; DPD) to assess postoperative diet and activity patterns among a sample of adolescent WLS patients to determine adherence to best-practice lifestyle recommendations. SETTING: University Hospital. METHODS: Eight adolescent WLS patients completed 3 consecutive DPDs at 12 and 18 months postsurgery. RESULTS: Ninety-four percent of DPD's were completed with an average 20.9 ± 5.0 activities/day. Although adolescents engaged in recommended lifestyle behaviors (e.g.,≥ 30 min moderate physical activity/d; duration of meals/snacks ≥ 20 min) some of the time, few were adherent to postoperative physical activity and dietary recommendations the majority of the time. CONCLUSION: The DPD provides a feasible and informative methodology for assessing adherence behaviors among adolescent WLS patients. It is a relatively low burden method that may be useful in identifying behavioral targets for postoperative intervention. Adherence to postoperative lifestyle recommendations may be a serious concern among this cohort. These preliminary data shed light on potential targets for postoperative intervention. Targeting nonadherence is essential in not only improving health outcomes but in deciphering the true potential effectiveness of WLS in this at-risk population.

Strategies for Recruitment and Retention of Families from Low-Income, Ethnic Minority Backgrounds in a Longitudinal Study of Caregiver Feeding and Child Weight.

BACKGROUND: Children from low-SES and ethnic minority backgrounds are at heightened risk for overweight, yet are underrepresented in the pediatric obesity literature. METHODS: The current paper describes strategies employed to minimize barriers to recruitment and retention of African-American families receiving WIC services in a longitudinal study examining caregiver feeding and child weight. RESULTS: Seventy-six families enrolled in the study over 3.5 years, and 50% of the families completed the study. IMPLICATIONS FOR PRACTICE: Despite effortful planning, unanticipated barriers likely contributed to lengthy recruitment and a modest retention rate. Future research should incorporate lessons learned to modify and develop effective strategies for increasing engagement of low-SES and ethnic minority families in research.

Adolescent suicidal behavior across the excess weight status spectrum.

OBJECTIVE: Relative suicidal behavioral risks (ideation, attempts) for overweight, obese, and extremely obese adolescents (vs. healthy weight) and who did/did not accurately perceive themselves as overweight were examined in this study. DESIGN AND METHODS: A new variable (weight status/accuracy) was computed that combined actual weight status (based on BMI) with weight perception accuracy. To evaluate the effect of weight status/accuracy on each suicidal risk behavior, logistic regression was performed to calculate odds-ratios and 95% confidence intervals (CI). Potential model covariates included gender, age, race, survey year, and whether they had felt sad/hopeless. RESULTS: Weight perception accuracy increased as the degree of excess weight increased. Relative to healthy weight, being obese or extremely obese (but not overweight) was associated with significantly greater risk for adolescent engagement in suicidal ideation, but was unrelated to suicide attempts. Adolescents in all excess weight categories who were accurate in their weight perception were at significantly greater odds of suicidal ideation, whereas those who were inaccurate were of no greater odds of suicidal ideation than healthy weight youth who accurately perceived their weight. Findings regarding suicide attempts varied based on actual weight/weight perception accuracy and race/ethnicity. CONCLUSION: The present findings are both important and clinically relevant. While widely accepted that there are multiple pathways to suicide, our understanding of adolescent suicidal behavior risks and accordingly, prevention efforts, will be informed by comprehensive prospective studies that should also, from here forward, consider categorization of the entire weight spectrum (e.g., extreme obesity).

Prospective changes in body image dissatisfaction among adolescent bariatric patients: the importance of body size estimation.

BACKGROUND: Body image dissatisfaction (BID) is pervasive among patients presenting for bariatric surgery but improves significantly postoperatively. These findings have been determined primarily from studies of adults. The objective of the present study was to examine the changes in BID among adolescents with extreme obesity from baseline/preoperatively to 6 and 12 months after receiving bariatric surgery at a pediatric medical center using body size estimation. METHODS: BID was prospectively assessed among 16 adolescent bariatric patients (mean age 16.3 ± 1.2 years, mean body mass index [BMI] 66.2 ± 12.0, 67% female) using a standard visual/perceptual measure (i.e., Stunkard Figure Rating Scale). Participants identified their current and ideal body size, with a discrepancy score (current minus ideal) indicating BID. The body size estimation ratings were compared with attitudinal (i.e., Impact of Weight on Quality Of Life-Kids: Body Esteem and Self-Perception Profile for Adolescents: Physical Appearance) body image scores, BMI, and total weight-related quality of life. RESULTS: A significant reduction occurred in the current body size (from 7.9 to 6.4, P <.001) from baseline to 6 months but not from 6 to 12 months. The current body size was related to BMI and percentage of excess weight loss but not attitudinal body image at each follow-up point. A smaller discrepancy (current minus ideal) was associated with greater total weight-related quality of life (r = -.68), with a trend toward significance for body esteem (r = -.65) at 12 months. CONCLUSION: Adolescents undergoing bariatric surgery experience a significantly decreased BID within the first 12 months after surgery, with the most substantial change occurring from baseline to 6 months. The postoperative weight-related quality of life is more closely associated with the body size discrepancy than with the current body size.

Risk-taking behaviors of adolescents with extreme obesity: normative or not?

OBJECTIVE: Present first published data detailing high-risk behaviors of adolescent high school students (HSS) with extreme obesity (BMI ≥ 99th percentile for age and gender) compared with healthy weight peers (5th-84th percentile). METHODS: The 2007 Youth Risk Behavior Survey was used to compare HSS with extreme obesity (N = 410) and healthy weight peers (N = 8669) in their engagement in (1) tobacco use, (2) alcohol/other drug use, (3) high-risk sexual behaviors, and (4) suicidal behaviors. Logistic regression was used to calculate gender-stratified odds ratios (OR) and 95% confidence intervals (CI), controlling for age and race. RESULTS: HSS with extreme obesity were similar to healthy weight peers in the prevalence of most behaviors related to alcohol/drug use, high-risk sexual activities, and suicide, with the following exceptions: relative to healthy weight HSS, both male and female students with extreme obesity more frequently reported ever trying cigarettes (female students, adjusted OR: 2.0 [95% CI: 1.3-3.2]; male students, OR: 1.5 [CI: 1.2-2.0]). Compared with healthy weight female students, female students with extreme obesity had lower odds of ever having sex (OR: 0.5 [CI: 0.3-0.9]), but greater odds of drinking alcohol/using drugs before their last sexual encounter (OR: 4.6 [CI: 1.2-17.6]), currently smoking (OR: 2.3 [CI: 1.2-4.4]), and using smokeless tobacco (OR: 4.6 [CI: 1.2-17.2]). Compared with healthy weight male students, male students with extreme obesity had greater odds of smoking before age 13 (OR: 1.4 [CI: 1.0-2.0]). CONCLUSIONS: With few exceptions, HSS with extreme obesity engage in high-risk behaviors at rates comparable with healthy weight peers, sometimes in even more dangerous ways. Health care providers should assess risk-taking behaviors in this cohort.

Two-year trends in psychosocial functioning after adolescent Roux-en-Y gastric bypass.

BACKGROUND: Comprehensive studies of adolescent bariatric surgery outcomes are in their infancy and are critically needed. The present study examined the rate of change in the body mass index (BMI), health-related quality of life (HRQOL), depressive symptoms, and self-concept in adolescents undergoing Roux-en-Y gastric bypass (RYGB) during the first 24 postoperative months using a prospective longitudinal design at a pediatric medical center. METHODS: A total of 16 adolescents (mean age 16.2 yr; 62.5% female, mean BMI 59.9 kg/m2; 97% of eligible, consecutive patients) completed the Impact of Weight on Quality of Life-Kids, Pediatric Quality of Life Inventory, Beck Depression Inventory, Self-Perception Profile for Adolescents, and height and weight measurements at baseline and 6, 12, 18, and 24 months after RYGB. A total of 75% participated at all follow-up points. RESULTS: Before RYGB, global psychosocial impairments were documented. Hierarchical linear modeling was used to examine the growth trajectories. Several quadratic (nonlinear) trends were revealed. A substantial reduction in weight and depressive symptoms, as well as improved HRQOL and self-concept were identified across the first postoperative year, followed by decelerations in year 2, including weight regain (P < .0001) and slight increases in depressive symptoms (P = .004) and decreases in HRQOL (Social, P = .002; Body Esteem, P = .0007; Physical Comfort, P < .0001; and Total, P < .0001), and self-concept (Social, P = .02; Appearance, P = .002; and Close Friendship, P = .008). CONCLUSION: During the first 24 months after RYGB, preliminary evidence suggests adolescents experience significant weight loss as well as psychosocial and HRQOL improvements. A deceleration in these gains occurred in the second postoperative year. Longer term follow-up with larger samples is critical to determine the weight and psychosocial trajectories, and what role psychosocial status plays in adolescents' weight change and maintenance.

Adolescent bariatric surgery: caregiver and family functioning across the first postoperative year.

BACKGROUND: The present study examined the psychological distress, parenting stress, and family functioning in female caregivers of adolescents undergoing bariatric surgery compared to that of caregivers of adolescents with extreme obesity not undergoing surgery across the first postoperative year. METHODS: The female caregivers of 16 adolescents undergoing Roux-en-Y gastric bypass (mean age 16.6 years, mean body mass index 66.2 kg/m(2); 94% recruitment) and those of 28 comparison adolescents who had sought behavioral weight management (mean age 16.2 years, mean body mass index 46.3 kg/m(2); 90% recruitment) were included in the study. The caregivers completed measures of psychological distress (Symptom Checklist-90-Revised), parenting stress (Stress Index for Parents of Adolescents), and family functioning (Family Assessment Device) at baseline (before surgery) and at 6 and 12 months after surgery. Caregiver and adolescent anthropometric data were also obtained. RESULTS: At baseline, clinical cutoffs were exceeded by 29.5% of the caregivers for psychological distress, 31.8% for family dysfunction, and 13.2% for parenting stress. Linear mixed modeling indicated that bariatric adolescents had a significantly greater body mass index at baseline than the comparison adolescents (t = -7.79, P <.001), with a substantial reduction by 12 months relative to the near-flat trajectory of the comparison group (t = 20.32, P <.001). No significant group differences at baseline or group trajectory differences were identified for any caregiver or family variable. CONCLUSION: Our initial findings suggest that caregivers of adolescents with extreme obesity present with limited dysfunction and that bariatric surgery has no effect on caregiver distress, parenting stress, or family functioning across the first postoperative year. Larger samples and longer term follow-up will allow examination of what role caregiver/family factors play in the adolescent postoperative outcomes.

A pilot randomized controlled trial of a clinic and home-based behavioral intervention to decrease obesity in preschoolers.

We evaluated the efficacy of a 6-month clinic and home-based behavioral intervention (Learning about Activity and Understanding Nutrition for Child Health; LAUNCH) to reduce obesity in preschool children ≥95th BMI percentile compared to enhanced standard of care (Pediatrician Counseling; PC). LAUNCH was a family-based behavioral intervention that taught parents to use child behavior management strategies to increase healthy eating and activity for their children and themselves. PC presented the same diet and activity recommendations, but was delivered in a one-time PC session. Eighteen children aged 2-5 years (mean 4.71 ± 1.01) with an average BMI percentile of 98 (±1.60) and an overweight parent were randomized to LAUNCH or PC. Assessments were conducted at baseline, 6 months (end of LAUNCH treatment) and 12 months (6 months following LAUNCH treatment). LAUNCH showed a significantly greater decrease on the primary outcomes of child at month 6 (post-treatment) BMI z (-0.59 ± 0.17), BMI percentile (-2.4 ± 1.0), and weight gain (-2.7 kg ± 1.2) than PC and this difference was maintained at follow-up (month 12). LAUNCH parents also had a significantly greater weight loss (-5.5 kg ± 0.9) at month 6 and 12 (-8.0 kg ± 3.5) than PC parents. Based on the data from this small sample, an intensive intervention that includes child behavior management strategies to improve healthy eating and activity appears more promising in reducing preschool obesity than a low intensity intervention that is typical of treatment that could be delivered in primary care.

Racial differences in obese youth's perception of health care and weight loss.

Within the United States, minority youth are at greater risk of becoming overweight/obese and are less likely to receive preventive health care. The authors examined several domains of preventive health care perceptions among persistently overweight/obese white and black adolescents. A total of 55 youth (29 white, 26 black) who had previously sought weight management treatment participated in a follow-up study 4 years later (M (years) = 4.2 ± 0.8). All participants remained overweight (5% at the 85th- 94th BMI percentiles) or obese (95% ≥ 95th BMI percentile), with no significant difference in weight by race. Relative to whites, blacks perceived greater physician concern about and counseling regarding weight (P (concern) < .01; P (counsel) < .01), eating habits(P (concern) < .001; P (counsel) < .01), and physical activity (P (concern) < .001; P (counsel) < .05). Although whites reported knowing more weight-related comorbidities than blacks, there were no group differences in number of weight loss methods attempted (M (methods) = 7.5 ± 2.7). Overall, there were no group differences in perceptions of risk. Physicians may be appropriately focusing efforts on educating black youth, but knowledge and behavior gaps persist.

Changes in depressive symptoms among adolescent bariatric candidates from preoperative psychological evaluation to immediately before surgery.

BACKGROUND: The preoperative psychological evaluation (including the assessment of depressive symptoms) is an important component in determining adolescent bariatric candidacy. The adult bariatric data have suggested that candidates can engage in "impression management" and underreport depressive symptoms during their preoperative evaluation. The present study examined whether adolescent depressive symptoms among bariatric candidates change during preoperative preparation compared with adolescents with extreme obesity who were not seeking surgery. METHODS: Adolescent candidates for bariatric surgery (n = 30; 60% female; mean age 16.5 ± 1.4 years) completed the Beck Depression Inventory-II (BDI-II) at initial consultation (time 1, mean body mass index [BMI] 64.5 ± 11.5 kg/m(2)) and again immediately preoperatively (time 2, mean interval 4.7 ± 2.9 months; mean BMI 64.4 ± 10.4 kg/m(2)). Comparators (n = 25; 64% female; mean age 16.2 ± 1.2 years; mean BMI 46.5 ± 4.8 kg/m(2)) were studied at enrollment in a research protocol and again 6 months later (mean interval 6.2 ± 0.4 months; mean BMI 46.8 ± 5.0 kg/m(2)). The height and weight were also taken. RESULTS: We found a small, but statistically significant, difference in the BDI-II scores at time 1, with bariatric candidates reporting greater depressive symptoms (mean 16.6 ± 12.9) than the comparators (mean 10.6 ± 9.0; P < .05). No difference was seen in the BDI-II scores between the bariatric candidates (mean 14.4 ± 12.1) and the comparators (mean 10.4 ± 8.2) at time 2 (P = .17). The change in BDI-II scores for the bariatric candidates showed a trend toward significance (P = .09). CONCLUSION: These results reinforce the position that the adult bariatric literature does not necessarily generalize to the adolescent bariatric population. They further suggest that impression management might not be a significant concern in the assessment of adolescent bariatric candidates. Future research should examine whether preoperative changes in psychological functioning predict the postoperative outcomes.

The relationship between adolescent renal transplant recipients' perceived adversity, coping, and medical adherence.

The aim of the present study was to assess adolescent renal transplant recipients' perceived adversity (PA) for various aspects of living with a transplant, including its association with coping and medication non-adherence, from a theoretical perspective. Thirty-three adolescent renal transplant recipients were interviewed using structured questionnaires and medical record reviews. Health care provider ratings of adversity were also collected. Participants reported moderate levels of PA, with those who received a transplant at an older age reporting more adversity on several domains and girls reporting more adversity for missing school. Ratings of adversity for specific aspects of living with a transplant differed depending on age and medical factors and were related to specific coping strategies and measures of non-adherence. Consistent with the Self-Regulation Model, perceived consequences (represented as PA) appears to be related to coping and illness outcomes. Assessing PA and teaching appropriate coping strategies may yield better medical outcomes among this at-risk population.