key: cord-0840084-xwmiwifw authors: Appelhans, Bradley M.; French, Simone A.; Martin, Molly A.; Lui, Karen; Janssen, Imke title: Attenuated efficacy of pediatric obesity treatment during the COVID‐19 pandemic date: 2021-11-23 journal: Obesity (Silver Spring) DOI: 10.1002/oby.23313 sha: 01f7c2e296d26c20bb953634de82a446bd3620a7 doc_id: 840084 cord_uid: xwmiwifw OBJECTIVE: This study examined whether the efficacy of a standard‐of‐care pediatric obesity treatment was affected by the COVID‐19 pandemic. METHODS: Analyses leveraged data from an ongoing pediatric obesity treatment trial involving 230 lower‐income, urban children aged 6 to 12 years. Mixed‐effects regression models compared children who participated in a 12‐month weight‐management intervention before versus during the COVID‐19 pandemic on change from baseline in BMI z score (ΔzBMI) at 3, 6, 9, and 12 months. RESULTS: The observed pattern of ΔzBMI was significantly different before versus during the pandemic (χ(2) = 22.73, p < 0.0001). Children treated before the pandemic maintained an average weight loss of −0.06 ΔzBMI at 12 months, whereas children treated during the pandemic steadily gained weight over time, averaging a net gain of 0.11 ΔzBMI at 12 months (χ(2) = 34.99, p < 0.0001). Treatment session completion did not differ before versus during the pandemic (60.4% vs. 55.7%, respectively; p = 0.30) or account for differences in ΔzBMI. CONCLUSIONS: Similar reductions in intervention efficacy may be anticipated in other pediatric obesity treatment trials conducted during the COVID‐19 pandemic. Many families that have struggled with managing their child’s weight during this period may need encouragement to continue engaging in structured weight management as society renormalizes. Data for this analysis originated from an ongoing trial comparing home-based and clinic-based pediatric obesity treatment in lowerincome families (Clini calTr ials.gov: NCT03195790). Both trial arms received the same 12-month, family-based pediatric obesity treatment and differed only in the location of treatment. This analysis pooled data across arms to examine changes in treatment efficacy related to the COVID-19 pandemic. The trial's design paper includes methodological details and a description of the intervention (10) . The Creating Healthy Environments for Chicago Kids (CHECK) intervention is a standard-of-care pediatric obesity treatment program with 18 in-person sessions and 12 monthly telephone support calls (10) . Following the issuance of public health guidelines in March 2020, in-person intervention visits were held via videoconference or telephone. As restrictions eased, in-person visits resumed, with close adherence to COVID-19 transmission precautions (e.g., masking, social distancing, meeting outdoors when feasible). Monthly telephone support calls continued according to protocol throughout the pandemic. Change from baseline in BMI z score (ΔzBMI) was derived from objective height and weight measurements collected at baseline and at 3-, 6-, 9-, and 12-months post-randomization. In-person contact with participants was severely limited between March and mid-June 2020 because of stringent stay-at-home orders, including social distancing requirements and a prohibition against indoor gatherings. Research staff used various strategies to continue to collect objective height and weight measurements during this time, including collecting measurements outdoors or bringing sanitized, research-grade scales and stadiometers to participants' homes and witnessing measurements taken by caregivers (either in-person or via videoconferencing) while maintaining social distancing. The proportion of scheduled in-person intervention visits completed (of those due given their point in the intervention) was determined for each participant. What is already known? ► Greater weight gain and engagement in obesogenic behaviors have been reported among children during the COVID-19 pandemic lockdown. ► There is limited data on how the pandemic has affected the efficacy of pediatric weight-management interventions. ► Data from this clinical trial shows that the efficacy of a standard-of-care pediatric weight-management intervention was substantially reduced during the COVID-19 pandemic. ► Many children who received the intervention during the pandemic demonstrated significant weight gain despite receiving a 12-month weight-loss intervention. ► Children's weight loss progress during the pandemic may not reflect their true potential for benefit, and families should be encouraged to continue structured weight-management efforts as society renormalizes. ► Other pediatric obesity treatment trials should report analyses characterizing change in intervention efficacy during the COVID-19 pandemic. Child age (derived from date of birth), gender, and ethnicity/race were reported by caregivers at baseline. Mixed-effects regression was used to model multiple observations of ΔzBMI, nested within children, from the fixed effects of COVID-19 time period, assessment point (3, 6, 9, Characteristics of the analytic sample are shown in Table 1 The efficacy of structured, family-based pediatric obesity treatment was significantly attenuated during the COVID-19 pandemic among low-income, urban, racially diverse children. Children who received treatment prior to the pandemic demonstrated an initial weight loss that was largely maintained across 12 months, whereas children treated during the pandemic showed similar initial weight loss but subsequently gained weight until reaching a net ΔzBMI gain well above baseline. The reduction in treatment efficacy was not attributable to decreased intervention session completion. Considering reports of COVID-19-related weight gain in nontreated adults and children (3, 8, 11, 12) , the attenuation in treatment efficacy likely reflects the broader influence of COVID-19 pandemic stay-at-home orders on TA B L E 1 Characteristics of children whose participation in pediatric obesity treatment occurred before or during the COVID-19 pandemic A key takeaway from this study is that a family's (lack of) success in managing their child's weight during the pandemic does not necessarily represent their true potential to be successful within a structured intervention. It may be important to normalize the experience of families who struggled to lose weight during the pandemic and encourage continued engagement in structured weight-loss programs. The present findings also suggest that normalization of society (school reopenings, resumption of youth sports and activities) may be a necessary condition for successful weight management in children. The present findings also have implications for the interpretation of ongoing pediatric obesity treatment trials. As of July 2021, there were over 120 active clinical trials focused on pediatric obesity listed in Clini calTr ials.gov. In addition to other statistical procedures (16) , investigators should conduct and report supplementary analyses that characterize changes in treatment efficacy associated with the pandemic. Several strengths and limitations of the study are noteworthy. Given its timeline, the parent trial was uniquely positioned to examine changes in pediatric obesity treatment efficacy following the COVID-19 lockdown. The study focused on low-income children aged 6 to 12 who were predominantly of a racial minority, a group with a high burden of pediatric obesity (17) and poorer engagement and outcomes in weight-management interventions (18, 19) . However, findings may not generalize to other populations, and the sample's composition did not enable comparisons with highersocioeconomic status or nonminority children. The efficacy of pediatric obesity treatment was markedly attenu- Avery, Dan Lindich, and Alyssa Cho. The authors declared no conflict of interest. Clini calTr ials.gov identifier NCT03195790. Bradley M. Appelhans https://orcid.org/0000-0002-5195-802X Simone A. French https://orcid.org/0000-0003-3413-5985 F I G U R E 1 Change in BMI z score (ΔzBMI) among children whose participation in pediatric obesity treatment occurred before versus during the COVID-19 pandemic. 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