IMPORTANCESevere childhood obesity has become a major health problem, and effective, evidence-based interventions are needed. The relative effectiveness of inpatient compared with ambulatory treatment remains unknown.OBJECTIVE To determine whether an inpatient treatment program is more effective than an ambulatory treatment program at achieving a sustained weight loss in children and adolescents with severe obesity. DESIGN, SETTING, AND PARTICIPANTSWe conducted a randomized clinical trial with a 2-year follow-up at a tertiary referral center for pediatric obesity in the Netherlands. We recruited 90 children and adolescents aged 8 to 18 years with severe obesity (body mass index [BMI] z score, Ն3.0 or >2.3 with obesity-related health problems).INTERVENTIONS Patients were randomly assigned to an inpatient (6 months of hospitalization on working days) or an ambulatory (12 days of hospital visits at increasing intervals during a 6-month period) treatment program. Both treatment programs involved an intensive, family-based, lifestyle intervention, including exercise, nutritional education, and behavior modification for the patients and their caregiver(s). MAIN OUTCOMES AND MEASURESChange in BMI z score. Secondary outcomes included fasting insulin, fasting plasma glucose, 2-hour plasma glucose, and lipid levels, insulin sensitivity, liver function test results, waist circumference, blood pressure, body composition, and aerobic fitness (peak oxygen consumption, V o 2 ). Outcomes were analyzed by intention to treat. RESULTSImmediately after treatment, reductions in the BMI z score were significantly larger for the inpatient than the ambulatory groups (mean [SE] difference, −0.26 [0.12; 95% CI, −0.59 to −0.01]; P = .04). Change from baseline for the BMI z score in the inpatient group was −18.0% (P = .001) immediately after treatment, −8.5% (P = .008) at 18 months, and −6.3% (P = .38) at 30 months; in the ambulatory group, changes from baseline were −10.5% (P = .001), −6.2% (P = .39), and −1.5% (P > .99), respectively. The favorable outcomes of the inpatient group could not be sustained at 12 and 24 months after treatment. In addition, significant differences in favor of the inpatient group immediately after treatment were found for levels of fasting insulin (−6.37 IU/L; P = .02), total cholesterol (−19.51 mg/dL; P = .01), low-density lipoprotein cholesterol (−13.48 mg/dL; P = .03), and triglycerides (−25.39 mg/dL; P = .01), and insulin sensitivity (−1.37; P = .02), fat mass (−3.31%; P = .03), and peak V o2 (378.2 mL/min; P = .01). CONCLUSIONS AND RELEVANCEIn severely obese children and adolescents, inpatient treatment was superior to ambulatory treatment immediately after treatment, but effects were not sustained at long-term follow-up. These findings stress the need to further study maintenance strategies for sustainable weight loss.

Background:Accurate prediction scores for liver steatosis are demanded to enable clinicians to noninvasively screen for nonalcoholic fatty liver disease (NAFLD). Several prediction scores have been developed, however external validation is lacking.Objective:The aim was to determine the diagnostic accuracy of four existing prediction scores in severely obese children, to develop a new prediction score using novel biomarkers and to compare these results to the performance of ultrasonography.Design and Results:Liver steatosis was measured using proton magnetic resonance spectroscopy in 119 severely obese children (mean age 14.3 ± 2.1 years, BMI z‐score 3.35 ± 0.35). Prevalence of steatosis was 47%. The four existing predictions scores (“NAFLD liver fat score,” “fatty liver index,” “hepatic steatosis index,” and the pediatric prediction score) had only moderate diagnostic accuracy in this cohort (positive predictive value (PPV): 70, 61, 61, 69% and negative predictive value (NPV) 77, 69, 68, 75%, respectively). A new prediction score was built using anthropometry, routine biochemistry and novel biomarkers (leptin, adiponectin, TNF‐alpha, IL‐6, CK‐18, FGF‐21, and adiponutrin polymorphisms). The final model included ALT, HOMA, sex, and leptin. This equation (PPV 79% and NPV 80%) did not perform substantially better than the four other equations and did not outperform ultrasonography for excluding NAFLD (NPV 82%).Conclusion:The conclusion is in severely obese children and adolescents existing prediction scores and the tested novel biomarkers have insufficient diagnostic accuracy for diagnosing or excluding NAFLD.

Lifestyle intervention for non-alcoholic fatty liver disease: prospective cohort study of its efficacy and factors related to improvement Koot, B.G.P.; van der Baan-Slootweg, O.H.; Tamminga-Smeulders, C.L.J.; Pels Rijcken, T.H.; Korevaar, J.C.; van Aalderen, W.M.; Jansen, P.L.M.; Benninga, M.A. Published in:Archives of disease in childhood : 10.1136/adc.2010.199760 Link to publication Citation for published version (APA): Koot, B. G. P., van der Baan-Slootweg, O. H., Tamminga-Smeulders, C. L. J., Pels Rijcken, T. H., Korevaar, J. C., van Aalderen, W. M., ... Benninga, M. A. (2011). Lifestyle intervention for non-alcoholic fatty liver disease: prospective cohort study of its efficacy and factors related to improvement. Archives of disease in childhood, 96(7), 669-674. https://doi.org/10.1136/adc.2010.199760 DOI General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: http://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. p<0.001) and serum p<0.002). In multivariate regression analysis, improvement in the degree of steatosis and decrease in ALT and AST were all signifi cantly related to improvement in insulin resistance. Improvement in insulin resistance only explained a small part of the observed changes in transaminases. Conclusions A lifestyle intervention of 6 months is moderately effective in improving NAFLD in severely obese children. Improvement in insulin resistance is the clinical parameter most strongly associated with improvement in NAFLD. Other factors related to the successful treatment of NAFLD need to be identifi ed so that these can be a focus for new lifestyle and drug interventions.

A 6-month intensive inpatient and ambulatory lifestyle treatment in children with severe obesity reverses NAFLD in a minority of patients. This study suggests that inpatient compared with ambulatory intensive treatment does not importantly increase treatment success. Further efforts to optimize and individualize lifestyle interventions and additional treatments options are needed particular for children with severe obesity resistant to conventional lifestyle interventions.

Weight loss in severely obese children correlated with an improvement in lung function, especially ERV. The improvement in ERV correlated with the decrease in SDS-BMI and waist circumference.