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Summary: Background and Objective: The aim was assessing a short training for healthcare providers on patient‐focused counselling to treat childhood obesity in primary care, along with dietitian‐led workshops and educational materials. Methods: Randomized clustered trial conducted with paediatrician‐nurse pairs (Basic Care Units [BCU]) in primary care centres from Tarragona (Spain). BCUs were randomized to intervention (MI) (motivational interview, dietitian‐led education, and educational materials) or control group (SC, standard care). Participants were 8–14‐year‐old children with obesity, undergoing 1–11 monthly treatment visits during 1 year at primary care centres. The primary outcome was BMI z‐score reduction. Results: The study included 44 clusters (23 MI). Out of 303 allocated children, 201 (n = 106 MI) completed baseline, final visits, and at least one treatment visit and were included in the analysis. BMI z‐score reduction was −0.27 (±0.31) in SC, versus −0.36 (±0.35) in MI (p = 0.036). Mixed models with centres as random effects showed greater reductions in BMI in MI than SC; differences were B = −0.11 (95% CI: −0.20, −0.01, p = 0.025) for BMI z‐score, and B = −2.06 (95% CI: −3.89, −0.23, p = 0.028) for BMI %. No severe adverse events related to the study were notified. Conclusion: Training primary care professionals on motivational interviewing supported by dietitians and educational materials, enhanced the efficacy of childhood obesity therapy. [ABSTRACT FROM AUTHOR]

Background Most body composition techniques assume constant properties of fat free mass (FFM) (hydration and density) regardless of nutritional status, which may lead to biased values. Aim To evaluate the interactive associations of age and body mass index (BMI) with hydration and density of FFM. Methods Data from subjects aged between 4 and 22 years old from several studies conducted in London, UK were assessed. Hydration (H.sub.FFM) and density (D.sub.FFM) of FFM obtained from the four-component model in 936 and 905 individuals, respectively, were assessed. BMI was converted in to z-scores, and categorised into five groups using z-score cut-offs (thin, normal weight, overweight, obese, and severely obese). Linear regression models for H.sub.FFM and D.sub.FFM were developed using age, sex, and BMI group as predictors. Results Nearly 30% of the variability in H.sub.FFM was explained by models including age and BMI groups, showing increasing H.sub.FFM values in heavier BMI groups. On the other hand, ~40% of variability in D.sub.FFM was explained by age, sex, and BMI groups, with D.sub.FFM values decreasing in association with higher BMI group. Conclusion Nutritional status should be considered when assessing body composition using two-component methods, and reference data for H.sub.FFM and D.sub.FFM is needed for higher BMI groups to avoid bias. Further research is needed to explain intra-individual variability in FFM properties., Author(s): Desirée Gutiérrez-Marín [sup.1] , Veronica Luque [sup.1] , Natàlia Ferré [sup.1] , Mary S. Fewtrell [sup.2] , Jane E. Williams [sup.2] , Jonathan C. K. Wells [sup.2] Author Affiliations: [...]

We aimed to investigate the eating frequency (EF) in children over age, and examined the influence of country, sex, feeding mode and weight status on EF. We used the dietary data of the Childhood Obesity Project, which comprised European children from five countries. Dietary data of 3-days weighed and estimated records were available monthly from 1 to 9 and at 12-, 24-, 36-, 48-, 60-, 72- and 96-months old. Generalized additive mixed effects models were used to estimate EF trajectories with EF as outcome and applying age splines. Additionally, the models were further adjusted for country, feeding mode, sex or weight status. Data from 1244 children were analysed. EF was highest at 1 month with on average 7.3 ± 1.9 feeds per day, and fell to 5.1 ± 1.1 eating occasions at the age 96 months. Night feeding was similarly often than day feeding at 1 month but declined thereafter. Significant differences in EF were observed between countries (p < 0.05), with the highest EF in Poland, and between infant feeding modes, with a higher EF in breastfed than non-breastfed infants (p < 0.05). Sex and body weight were not associated with EF. Despite the importance of EF towards total energy intake, no association with weight status was found. [ABSTRACT FROM AUTHOR]

High protein intake has been associated with kidney hypertrophy, which is usually reversible; however, when it occurs early in life, it could lead to cell programming with a long-lasting effect. This study aimed to assess whether higher protein ingestion early in life has a persistent effect on kidney volume at 11 years of age, as well as its influence on blood pressure. This is a secondary analysis of a randomized control trial that compared the growth of infants fed with a higher-protein formula versus those fed with a lower-protein formula, with a control group of breastfed infants. Renal ultrasound and anthropometric measurements were assessed at 6 months and 11 years of age. At 11 years, urinary protein, albumin and creatinine, and blood pressure were measured in 232 children. Feeding with a higher-protein formula was associated with a larger kidney volume (β = 8.71, 95%CI 0.09–17.33, p = 0.048) and higher systolic blood pressure (β = 3.43, 95%CI 0.78–6.08, p = 0.011) at 11 years of age. Microalbuminuria was detected in 7% of the patients, with no differences among groups (p = 0.56). The effect of increased protein ingestion early in life may condition kidney volume and blood pressure in later childhood. [ABSTRACT FROM AUTHOR]

Summary: Background and Objectives: Infant feeding affects child growth and later obesity risk. We examined whether protein supply in infancy affects the adiposity rebound, body mass index (BMI) and overweight and obesity up to 11 years of age. Methods: We enrolled healthy term infants from five European countries in a double blind randomized trial, with anticipated 16 examinations within 11 years follow‐up. Formula‐fed infants (n = 1090) were randomized to isoenergetic formula with higher or lower protein content within the range stipulated by EU legislation in 2001. A breastfed reference group (n = 588) was included. Adiposity rebound and BMI trajectories were estimated by generalized additive mixed models in 917 children, with 712 participating in the 11 year follow‐up. Results: BMI trajectories were elevated in the higher compared to the lower protein group, with significantly different BMI at adiposity rebound (0.24 kg/m2, 0.01–0.47, p = 0.040), and an increased risk for overweight at 11 years (adjusted Odds Ratio 1.70; 1.06–2.73; p = 0.027) but no significant difference for obesity (adjusted Odds Ratio 1.47; 0.66–3.27). The two formula groups did not differ in the timing of adiposity rebound, but all children with obesity at 11 years had an early adiposity rebound before four years. Conclusions: Compared to conventional high protein formula, feeding lower protein formula in infancy lowers BMI trajectories up to 11 years and achieves similar BMI values at adiposity rebound as observed in breastfed infants. [ABSTRACT FROM AUTHOR]

Meal timing is suggested to influence the obesity risk in children. Our aim was to analyse the effect of energy and nutrient distributions at eating occasions (EO), including breakfast, lunch, supper, and snacks, on the BMI z-score (zBMI) during childhood in 729 healthy children. BMI and three-day dietary protocols were obtained at 3, 4, 5, 6, and 8 years of age, and dietary data were analysed as the percentage of the mean total energy intake (TEI; %E). Intakes at EOs were transformed via an isometric log–ratio transformation and added as exposure variables to linear mixed-effects models. Stratified analyses by country and recategorization of EOs by adding intake from snacks to respective meals for further analyses were performed. The exclusion of subjects with less than three observations and the exclusion of subjects who skipped one EO or consumed 5% energy or less at one EO were examined in sensitivity analyses. Around 23% of the children were overweight at a given time point. Overweight and normal-weight children showed different distributions of dietary intakes over the day; overweight children consumed higher intakes at lunch and lower intakes of snacks. However, no significant effects of timing of EOs on zBMI were found in regression analyses. [ABSTRACT FROM AUTHOR]

it has previously been described that dietary patterns established early in life tracked to late childhood. The aim of the present work was to analyse the association of dietary patterns that tracked from 2 to 8y with cardiometabolic markers at 8y of age. The 3 identified patterns at 2y (that previous analyses showed to track to age 8y) were: "Core DP ", loaded for vegetables, fruits, fish, olive oil, etc.; "F&S DP ", loaded by poor-quality fats and sugars; and "Protein DP ", mainly loaded by animal protein sources. Cardiometabolic markers at 8y were systolic blood pressure (SBP), insulin resistance (HOMA-IR), and triglycerides, and BMI z-score. To examine whether the association of diet with the outcomes was the result of a direct effect of diet at either two or 8y, or synergy between them, we used structural equation models. the associations between the patterns and the health outcomes were: Core DP was inversely associated with SBP and HOMA-IR; Protein DP was directly associated with HOMA-IR and SBP; and adherence to F&S DP was directly associated with triglycerides and SBP. The associations between the patterns and the health outcomes were independent of BMI and were the result of a direct effect of diet at 2y, an indirect effect of diet at 2y through diet at 8y or a combination between both pathways. dietary patterns acquired in early life, persisting to later childhood, were associated with cardiometabolic markers at school age independently of BMI. [ABSTRACT FROM AUTHOR]

The aim was to generate a predictive equation to assess body composition (BC) in children with obesity using bioimpedance (BIA), and avoid bias produced by different density levels of fat free mass (FFM) in this population. This was a cross-sectional validation study using baseline data from a randomized intervention trial to treat childhood obesity. Participants were 8 to 14y (n = 315), underwent assessments on anthropometry and BC through Air Displacement Plethysmography (ADP), Dual X-Ray Absorptiometry and BIA. They were divided into a training (n = 249) and a testing subset (n = 66). In addition, the testing subset underwent a total body water assessment using deuterium dilution, and thus obtained results for the 4-compartment model (4C). A new equation to estimate FFM was created from the BIA outputs by comparison to a validated model of ADP adjusted by FFM density in the training subset. The equation was validated against 4C in the testing subset. As reference, the outputs from the BIA device were also compared to 4C. The predictive equation reduced the bias from the BIA outputs from 14.1% (95%CI: 12.7, 15.4) to 4.6% (95%CI: 3.8, 5.4) for FFM and from 18.4% (95%CI: 16.9, 19.9) to 6.4% (95% CI: 5.3, 7.4) for FM. Bland–Altman plots revealed that the new equation significantly improved the agreement with 4C; furthermore, the observed trend to increase the degree of bias with increasing FM and FFM also disappeared. The new predictive equation increases the precision of BC assessment using BIA in children with obesity. [ABSTRACT FROM AUTHOR]

Abstract Background Previous studies have reported postpartum depression to be associated with both positive and negative effects on early infant growth. This study examined the hypothesis that maternal postnatal depression may be a risk factor for later child growth faltering or overweight. Methods A total of 929 women and their children participating in a European multicenter study were included at a median age of 14 days. Mothers completed the Edinburgh postnatal depression scale (EPDS) at 2, 3 and 6 months after delivery. EPDS scores of 13 and above at any time were defined as maternal depression. Weight, length, triceps and subscapular skinfold thicknesses were measured, and body mass index (BMI) were calculated when the children were two years old and converted to standard deviation scores based on the WHO Multicentre Growth Reference Study (MGRS). Results Z-scores for weight-for-length at inclusion of infants of mothers with high EPDS scores (-0.55, SD 0.74) were lower than of those with normal scores (-0.36, SD 0.74; p = 0.013). BMI at age 24 months did not differ in the high (16.3 kg/m2, SD 1.3) and in the normal EPDS groups (16.2 kg/m2, SD 1.3; p = 0.48). All other anthropometric indices also did not differ between groups, with no change by multivariate adjustment. Conclusions We conclude that a high maternal postnatal depression score does not have any major effects on offspring growth in high income countries.

Assessment of Fat Mass (FM) and fat-free mass (FFM) using Air-displacement plethysmography (ADP) technique assumes constant density of FFM (D FFM) by age and sex. It has been recently shown that D FFM further varies according to body mass index (BMI), meaning that ADP body composition assessments of children with obesity could be biased if D FFM is assumed to be constant. The aim of this study was to validate the use of the calculations of D FFM (rather than constant density of the FFM) to improve accuracy of body composition assessment in children with obesity. cross-sectional validation study in 66 children with obesity (aged 8–14 years) where ADP assessments of body composition assuming constant density (FFM BODPOD and FM BODPOD) were compared to those where D FFM was adjusted in relation to BMI (FFM adjusted and FM adjusted), and both compared to the gold standard reference, the 4-component model (FFM 4C and FM 4C). FFM BODPOD was overestimated by 1.50 kg (95%CI -0.68 kg, 3.63 kg) while FFM adjusted was 0.71 kg (−1.08 kg, 2.51 kg) (percentage differences compared to FFM 4C were 4.9% (±2.9%) and 2.8% (±2.1%), respectively (p < 0.001)). Consistently, FM was underestimated by both methods, representing a mean difference between methods of 4.0% (±2.9%) and 6.8% (±3.8%), respectively, when compared to the reference method. The agreement and reliability of body composition assessments were improved when adjusted using calculations (adjusted models) rather than assuming constant D FFM. The use of constant values for fat-free mass properties may increase bias when assessing body composition (FM and FFM) in children with obesity by two-component techniques such as ADP. Using adjusted corrections as proposed in the present work may reduce the bias by half. [ABSTRACT FROM AUTHOR]

Objective: In view of the current obesity epidemic, studies focusing on the interplay of playing outside (PO), screen time (ST) and anthropometric measures in preschool age are necessary to guide evidence-based public health planning. We therefore investigated the relationship between average time spent PO and ST from the ages 3 to 6 years and anthropometric measures at 6 years of age. Methods: PO and ST of 526 children of the European Childhood Obesity Project (CHOP) were annually assessed by questionnaire from 3 until 6 years of age. Body weight, waist circumference and height were measured at 3 and 6 years of age to calculate Body-Mass-Index z-Scores (zBMI) and waist-to-height ratio (WTH). Linear, logistic and quantile regressions were used to test whether average time spent PO and ST in the 4 year period had an effect on anthropometric measures at age 6 years. Results: Longer daily ST was associated with a higher zBMI (P = 0.002) and WTH (P = 0.001) at 6 years of age. No significant associations were found for time spent PO. Each additional hour of average ST during the 4 year period resulted in a 66% higher risk of having a zBMI score over 1 (P < 0.001) and almost twice the risk (94% higher risk) of having an zBMI score over 2 (P < 0.001) at 6 years. Conclusions: Excessive ST during preschool age is a risk factor for increased zBMI at 6 years, regardless of time spent PO. Reducing high levels of ST during preschool age, for e.g. at least 1h per week, could help preventing childhood obesity. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to investigate the effect of lower protein (LP) versus higher protein (HP) content in infant formula on body composition from 3 months to 6 years.Methods: In a multicenter, double-blind European trial, healthy infants (N = 1,090) were randomly assigned to different protein content formulas (upper [HP] and lower [LP] limits of the European Union regulations in 2001) during the first year; breastfed infants (N = 588) were recruited for reference values. Weight, height, and triceps and subscapular skinfold (SF) thickness were measured repeatedly (N = 650 at 6 years), and body composition was estimated (Slaughter). The 99th percentile of fat mass index reference data were used to assess excess body fat at 6 years.Results: At 2 and 6 years, the study observed greater sum of SFs (Δ 2 years: 0.5 mm, P = 0.026, Δ 6 years: 0.6 mm, P = 0.045), fat mass index (Δ 2 years: 0.12 kg/m², P = 0.008, Δ 6 years: 0.15 kg/m², P = 0.011), and fat-free mass index (Δ 2 years: 0.17 kg/m², P = 0.003, Δ 6 years: 0.18 kg/m², P = 0.010) in the HP group compared with the LP group. At 6 years, the HP group had a twofold higher risk than the LP group for excess body fat (adjusted odds ratio: 2.13, P = 0.019).Conclusions: Infant formula with HP levels induced greater fat mass in children from 2 to 6 years. Lowering the protein content of infant formula may result in a healthier body composition in early childhood. [ABSTRACT FROM AUTHOR]

Background: Dietary habits established in infancy may persist into adulthood and determine long-term health.Objectives: The aims of this work were to describe dietary patterns, predictors of adherence to them, and their tracking from ages 1 to 8 y in European children.Methods: Three-day food diaries were prospectively collected at ages 1, 2, 3, 4, 5, 6 and 8 y. Foods were allocated to 1 of 29 food groups, which were included in exploratory factor analyses at each children's age. The tracking of patterns through childhood was assessed by an estimated general equation model.Results: At age 1 y (n = 633), 2 patterns were identified. One was labeled "core foods" (CORE), since it was positively loaded for vegetables, fish, olive oil, and white and red meat, and negatively loaded for ready-to-eat infant products, sugar, and confectioneries. The other was positively loaded for saturated spreads, sugar, fruit juices, and confectioneries, and negatively loaded for olive oil, fish, and cow milk; this was labeled as the "poor-quality fats and added sugars" (F&S) pattern. From ages 2 to 8 y, 3 patterns were repeatedly identified: CORE, F&S, and a "high protein sources" (PROT) pattern that was positively loaded for milk, flavored milks, fish, eggs, white and processed meat, chips, and olive oil, and negatively loaded for fresh fruits at almost all time points. Of those children in the highest quartiles of the CORE, F&S, and PROT patterns at 2 y, 45%, 72%, and 36%, respectively, remained in the highest quartile at 8 y [OR = 2.01 (1.08, 3.8), OR = 3.6 (1.5, 8.4) and OR = 0.80 (0.4,1.6), respectively; P = 0.510].Conclusions: Dietary patterns are established between 1 and 2 y of age and track into mid-childhood. A dietary pattern characterized by added sugars, unhealthy fats, and poor consumption of fish and olive oil was the most stable throughout childhood. Further analyses will reveal whether those dietary patterns are associated with metabolic disease risk. [ABSTRACT FROM AUTHOR]

Summary Background In European countries, suboptimal intake has been reported for several micronutrients (as calcium, iron, zinc, vitamin B12, D and folate) in both adulthood and childhood. No studies to date have prospectively compiled nutrient intake from healthy children in different European countries using the same methodology. Aim To describe the adequacy of micronutrient intake during the first eight years of life in children from 5 European countries. Methods Prospective observational trial analyzing data from the EU Childhood Obesity Project. Infants were enrolled within the first two months of life and were followed regularly to age 8 years. Dietary intake was collected periodically with 3-day food records. Nutrient intake adequacy was estimated for calcium, phosphorus, iron, zinc, magnesium, iodine, folate and vitamins B12, A and D, following the American Institute of Medicine (IOM) guidelines at group (prevalence of adequacy >80%) and individual (high probability of adequate intake >80% of the children) level; the assessment was based on the Estimated Average Requirements of nutrients of the FAO, WHO and United Nations University (FAO/WHO/UNU) or the IOM if FAO/WHO/UNU data were not available. Results Intake data were available for a decreasing number of children, from 904 at 3 months to 396 at 8 years. Iron, iodine, folate and vitamin D were inadequately consumed when assessing adequacy at group level; at individual-level less than 80% of the children showed high probability of adequate intake for iron, iodine, folate and zinc at all ages, and calcium from 12 months onwards. Conclusions Accurate dietary intake and adequacy assessment methodology in this prospective cohort of European children found iron, calcium, vitamin D, folate, iodine and zinc to be inadequately consumed in childhood, as described previously by epidemiologic studies. Further studies are needed to elucidate health consequences of these deficiencies. CHOP trial was registered at clinicaltrials.gov as NCT00338689 . [ABSTRACT FROM AUTHOR]

Background: Constipation is a common disorder in children.Objective: The objective of this study is to assess the beneficial effects of a daily supplementation with Orafti® inulin-type fructans in 2-5 year old constipated children.Methods: Double-blind, randomised, placebo-controlled parallel group trial where constipated children received two doses of 2 g Orafti® inulin-type fructans (OF:IN) or placebo (maltodextrin) for 6 weeks. Primary outcome was stool consistency. Secondary outcomes were stool frequency and gastrointestinal symptoms.Results: Twenty-two children were included, 17 completed the study protocol (nine and eight for the control and the OF:IN group, respectively). Results showed that Orafti® inulin-type fructans supplemented children had softer stools (p = .003). The longitudinal analysis showed no significant changes in controls, whereas supplemented children increased their stool consistency from 2.2 to 2.6 on the modified Bristol scale for children (five items instead of seven) (p = .040).Conclusions: Prebiotic inulin-type fructans supplementation improves stool consistency in constipated 2-5-year old children. Clinicaltrials.gov, with number NCT02863848. [ABSTRACT FROM AUTHOR]

Background: Physical activity (PA) and its health benefits are a continuous point of discussion. Recommendations for children's daily PA vary between guidelines. To better define the amount of PA necessary to prevent overweight and obesity in children, further research is needed. The present study investigates children's compliance to physical activity guidelines (PAGs) and the association between objectively measured PA and body mass index (BMI).Methods: Participating children were 11 years old (n = 419) and part of the European CHOP trial, which was conducted in Germany, Belgium, Poland, Spain, Italy. At least 2 days of PA measurements were collected from each child using a SenseWear™ armband. BMI was calculated from children's height and weight. Thresholds of min·day-1 in PA needed to differentiate between normal and excess weight (overweight/obesity) were determined with Receiver Operator Characteristics (ROC) analysis. Additionally, adjusted linear and logistic regressions models were calculated for group differences and effects of a 5, 15 and 60 min·day-1 increases in PA on BMI.Results: Median time spent in total PA was 462 min·day-1 (25th percentile; 75th percentile: 389; 534) and 75 min·day-1 (41; 115) in moderate to vigorous PA (MVPA). Girls spent 36 min·day-1 less in MVPA than boys and overweight/obese children 24 min·day-1 less than normal weight children (linear regression, p < 0.001). 63.2% of the children met PAGs of 60 min·day-1 in MVPA. The optimal threshold for min·day-1 in MVPA determined with ROC analysis was 46 min·day-1. Comparing 5, 15 and 60 min·day-1 increases in PA revealed that an additional 15 min·day-1 of vigorous PA had the same effect as 60 min·day-1 of MVPA. Sedentary time and light PA showed contrary associations to one another, with light PA being negatively and sedentary time being positively associated with excessive weight.Conclusions: Current PAGs are met by 2/3 of children and seem appropriate to prevent excess weight in children. An official recommendation of daily 15-20 min of vigorous PA and further reduction of sedentary time could help to fight youth overweight and thus be of potential public health importance.Trial Registration: ClinicalTrials.gov Identifier: NCT00338689 . Registered: June 19, 2006 (retrospectively registered). [ABSTRACT FROM AUTHOR]

This article reviews the role of protein intake on metabolic programming early in life. The observations that breastfeeding in infancy reduces the risk of being overweight and obese later in life and the differences in the protein content between formula milk and human milk have generated the early protein hypothesis. The present review focuses on a mechanistic approach to programmed adiposity and the growth and development of other organs by protein intake in infancy, which may be mediated by branched-chain amino acids, insulin, and insulin-like growth factor 1 via the mammalian target of rapamycin. Observational studies and clinical trials have shown that lowering the protein content in infant and follow-on formulas may reduce the risk of becoming obese later in life. The recent body of evidence is currently being translated into new policies. Therefore, the evolution of European regulatory laws and recommendations by expert panels on the protein content of infant and follow-on formulas are also reviewed. Research gaps, such as the critical window for programming adiposity by protein intake, testing formulas with modified amino acids, and the long-term consequences of differences in protein intake on organ functionality among well-nourished infants, have been identified. [ABSTRACT FROM AUTHOR]