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ABSTRACTBackgroundObesity is a complex, chronic, stigmatized disease whereby abnormal or excess body fat may impair health or increase the risk of medical complications, and can reduce quality of life and shorten lifespan in children and families. We developed this guideline to provide evidence-based recommendations on options for managing pediatric obesity that support shared decision-making among children living with obesity, their families, and their health care providers. MethodsWe followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We used the Guidelines International Network principles to manage competing interests. Caregivers, health care providers, and people living with obesity participated throughout the guideline development process, which optimized relevance. We surveyed end users (caregivers, health care providers) to prioritize health outcomes, completed 3 scoping reviews (2 on minimal important difference estimates; 1 on clinical assessment), performed 1 systematic review to characterize families’ values and preferences, and conducted 3 systematic reviews and meta-analyses to examine the benefits and harms of behavioural and psychological, pharmacologic, and surgical interventions for managing obesity in children. Guideline panellists developed recommendations focused on an individualized approach to care by using the GRADE evidence-to-decision framework, incorporating values and preferences of children living with obesity and their caregivers. RecommendationsOur guideline includes 10 recommendations and 9 good practice statements for managing obesity in children. Managing pediatric obesity should be guided by a comprehensive child and family assessment based on our good practice statements. Behavioural and psychological interventions, particularly multicomponent interventions (strong recommendation, very low to moderate certainty), should form the foundation of care, with tailored therapy and support using shared decision-making based on the potential benefits, harms, certainty of evidence, and values and preferences of children and families. Pharmacologic and surgical interventions should be considered (conditional recommendation, low to moderate certainty) as therapeutic options based on availability, feasibility, and acceptability, and guided by shared decision-making between health care providers and families. InterpretationThis guideline will support children, families, and health care providers to have informed discussions about the balance of benefits and harms for available obesity management interventions to support value- and preference-sensitive decision-making.

Decreased β-Cell Function in Overweight Latino Children With Impaired Fasting Glucose Marc J. Weigensberg , MD 1 , Geoff D.C. Ball , PHD 2 , Gabriel Q. Shaibi , BA 2 , Martha L. Cruz , PHD 2 and Michael I. Goran , PHD 2 3 1 Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California 2 Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California 3 Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California Address correspondence and reprint requests to Michael I. Goran, PhD, 1540 Alcazar St., Room 208-D, Department of Preventive Medicine, University of Southern California, Los Angeles, California 90033. E-mail: goran{at}usc.edu Abstract OBJECTIVE —To determine whether overweight Latino children with impaired fasting glucose (IFG) (≥100 mg/dl) have increased insulin resistance or decreased β-cell function compared with those with normal fasting glucose (NFG). RESEARCH DESIGN AND METHODS —We studied 207 healthy overweight Latino children, aged 8–13 years, with a family history of type 2 diabetes. Fasting and 2-h glucose and insulin were assessed by oral glucose tolerance test. Insulin sensitivity ( S i ), the acute insulin response to glucose (AIRg), and the disposition index (DI; an index of β-cell function) were determined using the insulin-modified intravenous glucose tolerance test and minimal modeling. Body composition was determined by dual-energy X-ray absorptiometry. RESULTS —There were no differences in body composition between NFG ( n = 182) and IFG ( n = 25) children. Compared with children with NFG, children with IFG had higher fasting and 2-h glucose values and higher fasting insulin. After adjusting for covariates, children with IFG had no difference in S i but 15% lower DI than NFG children (2,224 ± 210 vs. 2,613 ± 76, P < 0.05). Multivariate linear regression showed that AIRg and DI, but not S i , were significant predictors of fasting blood glucose. CONCLUSIONS —In overweight Latino adolescents with a family history of type 2 diabetes, IFG is associated with impaired β-cell function and therefore may identify children likely to be at risk for progression to type 2 diabetes. The actual risk of progression of IFG to type 2 diabetes remains to be determined by prospective longitudinal studies. ADA, American Diabetes Association AIRg, acute insulin response to glucose DI, disposition index HOMA-IR, homeostasis model assessment of insulin resistance IFG, impaired fasting glucose IGT, impaired glucose tolerance NFG, normal fasting glucose USC, University of Southern California Footnotes A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Accepted July 7, 2005. Received April 13, 2005. DIABETES CARE

Relation Between Acanthosis Nigricans and Insulin Sensitivity in Overweight Hispanic Children at Risk for Type 2 Diabetes Hassan A. Kobaissi , DPM 1 , Marc J. Weigensberg , MD 2 , Geoff D.C. Ball , PHD 1 , Martha L. Cruz , DVM, PHD 1 , Gabriel Q. Shaibi , BS 3 and Michael I. Goran , PHD 1 4 1 Department of Preventive Medicine, University of Southern California, Health Sciences Campus, Los Angeles, California 2 Department of Pediatrics, University of Southern California, Health Sciences Campus, Los Angeles, California 3 Department of Biokinesiology and Physical Therapy, University of Southern California, Health Sciences Campus, Los Angeles, California 4 Department of Physiology and Biophysics, University of Southern California, Health Sciences Campus, Los Angeles, California Address correspondence and reprint requests to Michael I. Goran, PhD, Associate Director, Institute for Prevention Research, Professor of Preventive Medicine and Physiology & Biophysics, Keck School of Medicine, University of Southern California, 1540 Alcazar St., Rm. 208-D, Los Angeles, CA 90033. E-mail: goran{at}usc.edu Abstract OBJECTIVE —To investigate in a population of Hispanic children if 1 ) the presence of acanthosis nigricans (AN) is related to insulin sensitivity ( S i ) independent of adiposity and 2 ) scale scoring AN severity adds to the clinical estimation of insulin sensitivity, above and beyond the presence or absence AN alone. RESEARCH DESIGN AND METHODS —The study population, 131 Hispanic overweight children (mean BMI percentile 97.0 ± 3.1, 72 boys, 59 girls, ages 8–13 years, mean Tanner stage 2.4 ± 1.5) with a family history of type 2 diabetes, underwent a physical examination of the neck to determine AN absence or presence (0–1), AN extent score (0–4 scale), AN texture score (0–3 scale), and an AN combined score (extent + texture; 0–7 scale). S i was measured by the frequently sampled intravenous glucose tolerance test and minimal modeling. Multivariate linear regression analysis was used to determine the role of BMI and AN in predicting S i . RESULTS —BMI was the main predictor of S i , explaining ∼41% of the variance. The presence of AN explained an additional 4% of the variability in S i ; scale scoring of AN extent or texture did not significantly improve the prediction. CONCLU S IONS —Although AN is an independent risk factor for insulin resistance in overweight Hispanic children at risk for type 2 diabetes, body adiposity is the primary determinant of insulin sensitivity. In addition, scale scoring AN seems of minimal usefulness in clinically estimating the severity of insulin resistance over and above assessing the presence or absence of AN and calculating BMI. AN, acanthosis nigricans DEXA, dual-energy X-ray absorptiometry Footnotes A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Accepted March 8, 2004. Received December 3, 2003. DIABETES CARE

Social determinants of health (SDH) may influence children's weight status. Our objective was to examine relationships between SDH and preschoolers' weight status. This retrospective cohort study included 169 465 children (aged 4-6 years) with anthropometric measurements taken at immunization visits from 2009 to 2017 in Edmonton and Calgary, Canada. Children were categorized by weight status based on WHO criteria. Maternal data were linked to child data. The Pampalon Material and Social Deprivation Indexes were used to assess deprivation. We used multinomial logistic regression to generate relative risk ratios (RRRs) to examine associations between ethnicity, maternal immigrant status, neighbourhood-level household income, urban/ rural residence and material and social deprivation with child weight status. Children of Chinese ethnicity were less likely than those in the General Population to have overweight (RRR = 0.64, 95% CI: 0.61-0.69) and obesity (RRR = 0.51, 0.42-0.62). Children of South Asian ethnicity were more likely than those in the General Population to have underweight (RRR = 4.14, 3.54-4.84) and more likely to have obesity (RRR = 1.39, 1.22-1.60). Children with maternal immigrant status were less likely than those without maternal immigrant status to have underweight (RRR = 0.72, 0.63-0.82) and obesity (RRR = 0.71, 0.66-0.77). Children were less likely to have overweight (RRR = 0.95, 0.94-0.95) and obesity (RRR = 0.88, 0.86-0.90) for every CAD 10 000 increase in income. Relative to the least deprived quintile, children in the most materially deprived quintile were more likely to have underweight (RRR = 1.36, 1.13-1.62), overweight (RRR = 1.52, 1.46-1.58) and obesity (RRR = 2.83, 2.54-3.15). Relative to the least deprived quintile, children in the most socially deprived quintile were more likely to have overweight (RRR = 1.21, 1.17-1.26) and obesity (RRR = 1.40, 1.26-1.56). All results are significant to p < 0.001. Our findings suggest the need for interventions and policies to address SDH in preschoolers to optimize their weight and health.

Abstract Many children and their families do not benefit from multidisciplinary clinical care (MCC) for paediatric weight management because they do not enrol in (initiate) treatment. The purpose of this report was to highlight practical recommendations to enhance the enrolment of Canadian children in MCC, which were drawn from multisite Canadian studies (quantitative and qualitative) that we completed recently. Recommendations to stakeholders, including primary care providers, MCC providers and decisions makers, were organized according to opportunities, motivation and barriers to enrol. Findings from our research suggested that enrolment in MCC can be improved by increasing opportunities and motivation to enrol as well as reducing the impact of enrolment barriers.

Enrollment of international post-secondary students is increasing across Canadian campuses. International post-secondary students may experience challenges in accessing nutritious foods that meet their dietary needs and food preferences. These challenges can pose negative impacts on their health, well-being, and academic achievement. Our aim was to describe international post-secondary students' perceptions of (1) challenges to attaining food security and (2) consequences of food insecurity on the university experience. We conducted individual semi-structured interviews with 11 international post-secondary students who had food insecurity, were enrolled at a public university in Canada, and who had requested emergency food hampers from the on-campus food bank. Interviews were audio-recorded, transcribed verbatim, and analyzed using manifest, inductive content analysis. International post-secondary students reported several logistical issues related to obtaining sufficient food, including a lack of time, limited family support, modest food preparation skills, and low knowledge about supportive services and resources. Students also faced challenges in sourcing culturally appropriate foods, including issues related to food availability, accessibility, acceptability, and affordability. Further, they perceived food insecurity to negatively influence their academic performance through compromised concentration, reduced class and exam attendance, and adverse impacts on physical, mental, and social well-being. Some students reported extreme food deprivation, resulting in hunger. Our results revealed the negative impacts that food insecurity can have on international post-secondary students. Findings underscore the imperative to minimize the occurrence of food insecurity while studying in Canada by introducing and enhancing support systems on campus and in the community to enable food security.

We compared food insecurity status, coping strategies, demographic characteristics, and self-rated health of international and domestic postsecondary students requesting emergency food hampers from a campus food bank (CFB). We collected data from a cross-sectional convenience sample of domestic and international students who accessed the CFB at the University of Alberta. Food insecurity was prevalent (international students: n = 26/27 (96.2%), domestic students: n = 31/31 (100%)). Compared with their domestic peers, international students were less likely to rate their mental health negatively (14.8% vs 38.7%, P = 0.04). The primary income source was government loans (54.8%) for domestic students and research assistantships (33.3%) for international students. To cope with not having enough money for food, the majority of both student groups delayed bill payments or buying university supplies, applied for loans or bursaries, purchased food on credit, or worked more. International students were less likely to ask friends or relatives for food (48.1% vs 77.4%, P = 0.02). Domestic and international students mostly used similar coping strategies to address food insecurity; however, they paid for their education using different income sources. Distinct strategies for international and domestic students are required to allow more students to cover their educational and living expenses.

Purpose: To describe the food security status, food insecurity coping strategies, characteristics, and experiences of student clients of the Campus Food Bank (CFB) at the University of Alberta in Edmonton, Alberta, Canada. Methods: A convenience sample of 58 students completed a survey from April 2013 to April 2014. Food security status was determined using the “Adult Food Security Survey Module”. Results: Ninety percent of CFB student clients who participated in this study were food insecure, which included both moderately and severely food insecure groups. The most prevalent coping strategies for food insecurity included applying for a loan or bursary (86.2%), seeking employment or working more hours (84.5%), and purchasing food using a credit card (77.6%). Participants were a diverse mix of students, including graduate students (50.0%), international students (46.6%), and caregivers of children (24.1%). The most common primary sources of income were government student loans (29.3%) and research assistantships (20.7%). Most participants (82.8%) liked the food they received from the food bank. Conclusions: Food insecurity is highly prevalent among student clients of this university-based food bank. Students used a variety of coping strategies to increase their disposable income, highlighting the need for additional strategies to alleviate food insecurity among vulnerable students.

Purpose: School-based interventions may increase children's preferences for vegetables and fruit (V&F). This Canadian study measured changes in Indigenous First Nations schoolchildren's V&F knowledge, preferences, and home consumption following the implementation of a gardening and V&F snack program. Methods: At baseline, 7 months, and 18 months, children in grades 1–6 (i) listed at least 5 V&F they knew, (ii) tasted and indicated their preferences towards 9 vegetables and 8 fruit using a 6-point Likert scale, and (iii) indicated their home consumption of 17 V&F. Results: At all 3 time points, 56.8% (n = 66/116) of children provided data. Children listed a greater number of V&F at 18 months (4.9 ± 0.1) than at baseline (4.5 ± 1.0) or 7 months (4.7 ± .07) (F (1.6,105.6) = 6.225, P < 0.05). Vegetable preferences became more positive between baseline (37.9 ± 9.3) and 7 months (39.9 ± 9.2), but returned to baseline levels at 18 months (37.3 ± 8.7) (F (1.6,105.8) = 4.581, P < 0.05). Fruit preferences at 18 months (42.7 ± 3.0) were greater than at baseline (41.1 ± 4.3) and at 7 months (41.9 ± 5.1) (F (1.7,113.3) = 3.409, P < 0.05). No change in V&F consumption occurred at home. Conclusions: Despite improvements in V&F knowledge and preferences, home consumption of V&F did not occur. Complementing school-based programs with home-based components may be needed to influence V&F intake of children.