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Abstract Background Both the causes and consequences of childhood obesity can be complex. To provide healthcare that is suitably tailored to the specific needs of children with obesity integrated care is required. The objective of this study was to explore the perceived barriers and facilitators of healthcare professionals (HCPs) in providing integrated care for children with obesity, to support them in tailoring the healthcare approach. Methods In this qualitative study, semi-structured in-depth interviews were conducted with 18 healthcare professionals with experience in childhood obesity care; pediatricians, youth healthcare nurses and a youth healthcare physician. A two-phased thematic content analysis was performed: an inductive analysis with open and selective coding and a deductive analysis with axial coding using the patient-centered care model by Stewart. Results Overall, the healthcare professionals defined the etiology of obesity as complex, and experienced the integrated care as complicated. The results fit into the four theme-structure of the patient-centered care model, with the integrated care system as an additional fifth theme. The main barriers were perceived within the sub-themes of illness and healthcare experiences, and sensitivity over talking about weight-related issues. The main facilitators were perceived within the sub-themes of conducting a biomedical, psychosocial and lifestyle assessment, tailoring the approach to families’ situation and investing in a family-professional relationship. Weight stigma appeared to be an underlying barrier for healthcare professionals that impacted, both explicitly and implicitly, upon all themes. Conclusions Healthcare professionals providing integrated care for children with obesity, experience this type of care as complicated and comprising many barriers and facilitators regarding the four themes of the patient-centered care model and the fifth theme of the integrated care system. This paper demonstrates the patient-centered care model could prove helpful structuring a tailored approach within integrated care. This approach supports healthcare professionals in adopting a broad perspective towards individual and environmental factors and investing in the relationship, with respect to the sensitivity and complexity of childhood obesity.

Abstract System dynamics approaches are increasingly addressing the complexity of public health problems such as childhood overweight and obesity. These approaches often use system mapping methods, such as the construction of causal loop diagrams, to gain an understanding of the system of interest. However, there is limited practical guidance on how such a system understanding can inform the development of an action programme that can facilitate systems changes. The Lifestyle Innovations Based on Youth Knowledge and Experience (LIKE) programme combines system dynamics and participatory action research to improve obesity-related behaviours, including diet, physical activity, sleep and sedentary behaviour, in 10–14-year-old adolescents in Amsterdam, the Netherlands. This paper illustrates how we used a previously obtained understanding of the system of obesity-related behaviours in adolescents to develop an action programme to facilitate systems changes. A team of evaluation researchers guided interdisciplinary action-groups throughout the process of identifying mechanisms, applying the Intervention Level Framework to identify leverage points and arriving at action ideas with aligning theories of change. The LIKE action programme consisted of 8 mechanisms, 9 leverage points and 14 action ideas which targeted the system’s structure and function within multiple subsystems. This illustrates the feasibility of developing actions targeting higher system levels within the confines of a research project timeframe when sufficient and dedicated effort in this process is invested. Furthermore, the system dynamics action programme presented in this study contributes towards the development and implementation of public health programmes that aim to facilitate systems changes in practice.

Purpose The prevalence of overweight and obesity is continuously increasing globally and long-term weight loss intervention outcomes remain disappointing. To determine which behavioural intervention approaches improve the probability of achieving long-term weight loss, this two-year follow-up study aimed to identify distinct factors and strategies for successful long-term weight loss maintenance. Methods A cohort of 20 participants with overweight and obesity from a primary-care led weight management programme with diverse backgrounds was interviewed at baseline, after 1 and 2 years, and asked to do quantitative self-description. This study focused on the 2-year follow-up interviews from this study series. Results We found that agile, continuous self-monitoring with personalized, sustainable lifestyle habits correlated with positive outcomes. Participants reported health benefits, maintained weight loss, and found motivation in supportive peer networks. Challenges like anxiety, disappointment, and disruptions derailed progress. Long-term success relied on a strong support system of healthcare professionals, friends, and family. Conclusions The findings of this study series highlight the intricate nature of long-term weight loss maintenance. This study corroborates the persistence of overarching themes while highlighting the individual variability in their relative importance. Findings emphasize the importance of long-term support to effectively address the diverse needs of patients trying to achieve long-term weight loss maintenance.

Introduction The global prevalence of overweight and obesity is continuously increasing. Long-term weight loss results remain disappointing. This study aims to identify factors and strategies for successful long-term weight loss in a primary care-led weight-loss intervention from the perspective of participants. Materials and methods This qualitative interview study is the first follow-up study in a 2-year study series of participants with overweight or obesity. Methods utilized are semi-structured interviews (n = 20) with quantitative self-description. The data were transcribed from audio-taped interviews and analysed thematically. Results This study found that clear, continuously evolving self-monitoring strategies facilitated by strong routines and a long-term focus enhanced successful outcomes. Challenges faced included stress, disappointment and loss of routine along with external criticism and discouragement. Benefits experienced due to weight loss included improved health, self-esteem, communal support and encouragement, which continued to fuel motivation. Receiving continuous support and encouragement from healthcare practitioners was instrumental for long-term success. Conclusion This study highlighted the complex, multifaceted experiences patients encounter in the pursuit of trying to achieve long-term weight loss. Personalized treatment protocols taking into account the diverse requirements and circumstances of individuals have the potential to improve treatment outcomes. Continuous, professional support may enhance long-term outcomes.

Abstract Background Childhood obesity can affect physical as well as psychosocial wellbeing. Therefore, childhood obesity care aims to improve all dimensions of health related quality of life (HRQoL). HRQoL can be measured with the generic questionnaire PedsQL4.0 and the weight-specific IWQOL-Kids. In the Netherlands, HRQoL assessment is conducted by the coordinating professional (CP). The aim of this qualitative study was to examine how and when to implement the measurement and discussion of HRQoL using the PedsQL4.0 and IWQOL-Kids within the integrated care for children with obesity in the Netherlands. Semi-structured interviews were conducted with fourteen CPs, in which the following was discussed: a) familiarity and attributions with regard to the assessment of HRQoL; b) wishes and needs with regard to the usage of the questionnaires; c) its practical incorporation. Results Interviews revealed that most CPs gained insight into the HRQoL by talking with families. One CP used the PedsQL4.0, the remaining CPs were unfamiliar with the two questionnaires. Even though some barriers, for instance a lack of time, might hinder the implementation of the PedsQL4.0 and IWQOL-Kids, all participants think the usage of either one or both questionnaires would have additional value to the support and care for children with obesity. There was no consensus about the questionnaire of preference. Conclusions When the right preconditions are met, HRQoL questionnaires have the potential to support CPs in improving the care for children with obesity, tailored to each individual child.

Objective: To explore the perspectives of healthcare professionals (HCPs) within an integrated care approach on the facilitators, barriers and needs in children with obesity and their parents in achieving a healthier lifestyle. Methods: Semi-structured interviews were conducted with eighteen HCPs working within a Dutch integrated care approach. The interviews were analyzed by performing a thematic content analysis. Results: Main facilitators identified by HCPs were support from parents and the social network. Main barriers were first and foremost family’s lack of motivation, which was singled out as a precondition for starting the behavior change process. Other barriers were child’s socio-emotional problems, parental personal problems, lack of parenting skills, parental lack of knowledge and skills regarding a healthier lifestyle, parental lack of problem awareness and HCP’s negative attitude. To overcome these barriers, main needs that HCPs suggested were a tailored approach in healthcare and a supportive HCP. Conclusion: The HCPs identified the breadth and complexity of underlying factors of childhood obesity, of which the family’s motivation was pointed out as a critical factor to address. Innovation: Understanding the patient’s perspective is important for HCPs to provide the tailored care needed to address the complexity of childhood obesity.

Abstract Background Milk feeding type (exclusive breastfeeding [EBF], formula feeding or mixed feeding) and timing of complementary feeding (CF) have been associated with infant growth. However, studies evaluating their combined role, and the role of ethnicity, are scarce. We examined associations of feeding patterns (milk feeding type combined with timing of CF) with infant body mass index (BMI) trajectories and potential ethnic-specific associations. Methods Infant feeding and BMI data during the 1st year of life from 3524 children (Dutch n = 2880, Moroccan n = 404 and Turkish n = 240) from the Amsterdam Born Children and their Development (ABCD) cohort were used. Six feeding patterns were defined: EBF/earlyCF, EBF/lateCF (reference), formula/earlyCF, formula/lateCF, mixed/earlyCF and mixed/lateCF. A covariate adjusted latent class mixed model was applied to simultaneously model BMI trajectories and associations with feeding patterns. Potential ethnic differences in the associations were studied in a separate model where interactions between ethnicity and feeding patterns were included. Results Four distinct BMI trajectories (low, mid-low, mid-high and high) were identified. Feeding pattern of formula/earlyCF was associated with lower odds for low (OR: 0.43; 95% CI: 0.25, 0.76) or mid-high (0.28; 0.16, 0.51) (ref: high) trajectory compared with EBF/lateCF pattern (ref). An ethnic-specific model revealed that among Dutch infants, formula/earlyCF pattern was associated with lower odds for low trajectory (0.46; 0.24, 0.87), whereas among Turkish/Moroccan infants almost all feeding patterns were associated with lower odds for the low trajectory (ref: high). Conclusion Infant feeding patterns are associated with early BMI trajectories with specific ethnic differences. Future studies should take the role of ethnicity into account in the associations between infant feeding and growth.

Background: As in many other countries around the world, the Netherlands has a high prevalence of overweight and obesity in children. About 1 in 7 of children aged 2–19 years has either overweight or obesity. Summary: In this paper the national and local activities aimed at the prevention and management of obesity in children and adolescents in the Netherlands are reviewed. It is recommended to, nationally as well as locally, take an integrated-systems approach that tackles the obesogenic food environment as well as upstream and downstream determinants of obesity. Efforts should take a life course approach and be focused on promoting obesity prevention as well as improving the management of children who already have obesity. The national policies in the Netherlands rely heavily on self-regulation by stakeholders such as supermarkets, restaurants, and the food industry. Local policies and actions such as the whole-systems approach in Amsterdam are promising. Future directions include development of tools for the operationalization and evaluation of local systems approaches. Regulation by national and local governments is necessary to ensure a healthy food environment for children and their families, but health policies require intersectoral action. Key Messages: In the Netherlands many policies are in place or under development, especially at the municipal level (e.g., in Amsterdam), but more substantial action is urgently required.

IntroductionThe long-term effects of interventions aiming to achieve substantial, sustainable weight loss maintenance have been disappointing. Most people regain their lost weight over time but some seem to be able to maintain their weight loss. We are following the experiences of patients over time prospectively. This study forms the baseline to provide insights into patient experiences prior to entering a primary care-led weight management intervention and their expectations going forward.Materials and methodsWe recruited 21 adult male and female patients of varying ethnicity with a BMI between 27.7kg/m2 and 48.4kg/m2 from a cohort of patients entering a primary care-led weight management intervention. Patients were offered video and audio interview options during the COVID-19 lockdown. In total, twenty chose the audio option, while one chose the video option. The interview format was semi-structured with room for individual exploration.DiscussionWe found that participants experienced feeling unable to control their weight and encountered a multitude of internal and external barriers to weight management. Some had supportive environments, while others experienced discouraging external influences. Though personal characteristics varied, motivations, goals and expected benefits were similar across this cohort. Most participants had previously experienced transient successful weight-loss attempts with varying approaches. COVID-19 was experienced as an opportunity or barrier for change.ConclusionThis study illustrates the importance of gaining comprehensive insights into the diverse experiences patients encounter when trying to achieve weight loss. Personalized support taking into account individual experiences and circumstances may enhance long-term treatment outcomes. Future research into the complexities of weight management based on individual accounts can aid in the creation of improved treatment protocols.

Introduction: COVID-19 lockdown measures have large impact on lifestyle behaviors and wellbeing of children. The aim of this mixed-methods study was to investigate the impact of COVID-19 lockdown measures on eating styles and behaviors, physical activity (PA), screen time, and health-related quality of life (HRQoL) in children (0-18 years) with severe obesity. Methods: During the first COVID-19 wave (April 2020), validated questionnaires were completed and semi-structured telephone interviews were conducted with parents of children with severe obesity (adult BMI-equivalent ≥35kg/m2) and/or with the children themselves. Changes in pre-pandemic versus lockdown scores of the Dutch Eating Behavior Questionnaire Children (DEBQ-C), Pediatric Quality of Life Inventory (PedsQLTM), and Dutch PA Questionnaire were assessed. Qualitative analyses were performed according to the Grounded Theory. Results: Ninety families were approached of which 83 families were included. Characteristics of the included children were: mean age 11.2 ± 4.6 years, 52% female, mean BMI SD-score +3.8 ± 1.0. Emotional, restrained, and external eating styles, HRQoL, and (non-educational) screen time did not change on group level (all p>0.05). However, weekly PA decreased (mean difference -1.9 hours/week, p=0.02), mostly in adolescents. In the majority of children, mean weekly PA decreased to ≤2 hours/week. Children with high emotional and external eating scores during lockdown or pre-existent psychosocial problems had the lowest HRQoL (p

Purpose: In light of the increasing prevalence of overweight and obesity, understanding the experiences, strategies and challenges encountered when trying to achieve substantial, sustainable weight loss is an important area to investigate. We systematically evaluated qualitative studies focusing on the accounts of individuals who have achieved sustained weight loss to create a comprehensive picture of the experience of sustainable weight loss. Methods: Included studies were peer-reviewed studies that qualitatively assessed the views and experiences of adults who previously had or currently have overweight or obesity who successfully lost weight and who subsequently maintained or regained weight. The evidence was systematically synthesized, which enabled the formulation of clear themes and recommendations. Results: The 15 chosen studies included the accounts of 294 individuals. We found that continuous monitoring and goal setting, driven by sustained motivation and encouraging experiences, while resisting ever present challenges and enduring discouraging experience encapsulates the experience of sustained, substantial weight loss. Conclusions: This review aims to provide a comprehensive understanding of the experiences, strategies and challenges encountered when trying to achieve substantial, sustained weight loss. Additional research taking into account findings from this review and others of its kind will enhance the formulation of treatment protocols.

Purpose: Lifestyle interventions can be effective in the management of overweight and obesity in children. However, ineffective guidance towards interventions and high attrition rates affect health impacts and cost effectiveness. The aim of this study was to gain insight into the factors influencing participation, in particular guidance towards, adherence to and completion of an intervention. Methods: A narrative literature review was performed to identify factors related to participation, leading to the development of the “Stages towards Completion Model”. Semi-structured interviews (n = 33) and three focus group discussions (n = 25) were performed with children and parents who completed two different group lifestyle interventions, as well as with their coaches. Results: The main barrier to participating in a lifestyle intervention was the complex daily reality of the participants. The main facilitator to overcome these barriers was a personal approach by all professionals involved. Conclusions: Participation in a lifestyle intervention is not influenced by one specific factor, but by the interplay of facilitators and barriers. A promising way to stimulate participation and thereby increase the effectiveness of interventions would be an understanding of and respect for the complex circumstances of participants and to personalize guidance towards and execution of interventions.

Objective: To examine changes in generic and weight-related, health-related quality of life (HRQoL) in children and adolescents with severe obesity participating in intensive lifestyle treatment, and to examine whether changes in SDS-BMI were associated with changes in HRQoL. Methods: In this prospective observational study, a referred sample of 120 children and adolescents (8-19 years) with severe obesity (SDS-BMI ≥ 3.0, or ≥ 2.3 in combination with obesity-related comorbidity) received an intensive 1-year lifestyle treatment with an inpatient period in a specialized childhood obesity center. A weight-related (IWQOL-Kids) and three generic (KIDSCREEN-52, PedsQL 4.0, and EuroQol) HRQoL questionnaires were administered at baseline (T0), after treatment (T1), and 1 year later (T2). Generalized Linear Mixed Models and partial correlations were used to analyze changes in HRQoL and associations with changes in SDS-BMI. Results: Statistically significant improvements in generic and weight-related HRQoL overall and domain scores were observed at T1and at T2 in comparison with T0, despite partial weight regain from T1 to T2. Larger weight loss at T2 was correlated with larger improvements in physical HRQoL domains. Conclusion: Children and adolescents with severe obesity experienced long-term improvements in generic and weight-related HRQoL after participating in intensive lifestyle treatment, despite partial weight regain.