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Abstract Background Childhood and adolescent overweight and obesity are among the most serious health challenges today. Structured weight reduction programs can be helpful to reduce severe health consequences but evidence is partly scarce. The STARKIDS program aims to improve on some of these limitations and is designed to be a structured, stepwise, digitally supported intervention program for the whole family. It is divided into two intervention steps spanning over 1.5 years and aims at promoting a healthy weight development of children/adolescents with overweight/obesity and an increase in quality of life. Methods The STARKIDS intervention is evaluated in a cluster-randomized study design by comparing it with a control group receiving a one-time structured counselling in the pediatric practice. The study aims to include 1000 families with children/adolescents with overweight/obesity from 100 pediatric practices. The main outcomes are reduction in body mass index percentiles and improvements in children’s/adolescent’s quality of life, secondary outcomes refer to the contents of the intervention such as diet, physical activity, stress, and media habits. All outcomes are measured on three measurement time points: (T0) at baseline/inclusion in the study, (T1) baseline + 12 months which is the end of step 1 of the STARKIDS intervention, and (T2) baseline + 18 months which is the end of step 2 of the STARKIDS intervention. Discussion The stepwise, e-health-supported STARKIDS program is a low-threshold intervention program for families with children/adolescents with overweight/obesity. With the proof of concept, STARKIDS provides the potential to be implemented as a standard care tool for the prevention and intervention of childhood/adolescence obesity in the German health system. Trial registration German Clinical Trials Register (DRKS) DRKS00022813 (acknowledged primary register of the World Health Organization). Registered on 27 November 2020 (Universal Trial Number U1111-1254-9536).

BackgroundSchool-level infection control measures in Germany during the early Coronavirus Disease 2019 (COVID-19) pandemic differed across the 16 federal states and lacked a dependable evidence base, with available evidence limited to regional data restricted to short phases of the pandemic. This study aimed to assess the (a) infection risks in students and staff; (b) transmission risks and routes in schools; (c) effects of school-level infection control measures on school and population infection dynamics; and (d) contribution of contacts in schools to population cases.Methods and findingsFor this retrospective observational study, we used German federal state (NUTS-2) and county (NUTS-3) data from public health and education agencies from March 2020 to April 2022. We assessed (a) infection risk as cumulative risk and crude risk ratios and (b) secondary attack rates (SARs) with 95% confidence interval (CI). We used (c) multiple regression analysis for the effects of infection control measures such as reduced attendance, mask mandates, and vaccination coverage as absolute reduction in case incidence per 100,000 inhabitants per 14 days and in percentage relative to the population, and (d) infection dynamic modelling to determine the percentage contribution of school contacts to population cases. We included (a) nationwide NUTS-2 data from calendar weeks (W) 46-50/2020 and W08/2021-W15/2022 with 3,521,964 cases in students and 329,283 in teachers; (b) NUTS-3 data from W09-25/2021 with 85,788 student and 9,427 teacher cases; and (c) detailed data from 5 NUTS-3 regions from W09/2020 to W27/2021 with 12,814 cases (39% male, 37% female; median age 14, range 5 to 63), 43,238 contacts and 4,165 secondary cases for students (for teachers, 14,801 [22% male, 50% female; median age 39, range 16 to 75], 5,893 and 472). Infection risk (a) for students and teachers was higher than the population risk in all phases of normal presence class and highest in the early 2022 omicron wave with 30.6% (95% CI 30.5% to 32.6%) of students and 32.7% (95% CI 32.6% to 32.8%) of teachers infected in Germany. SARs (b) for students and staff were below 5% in schools throughout the study period, while SARs in households more than doubled from 13.8% (95% CI 10.6% to 17.6%) W21-39/2020 to 28.7% (95% CI 27% to 30.4%) in W08-23/2021 for students and 10.9% (95% CI 7% to 16.5%) to 32.7% (95% CI 28.2% to 37.6%) for staff. Most contacts were reported for schools, yet most secondary cases originated in households. In schools, staff predominantly infected staff. Mandatory surgical mask wearing during class in all schools was associated with a reduction in the case incidence of students and teachers (c), by 56/100,000 persons per 14 days (students: 95% CI 47.7 to 63.4; teachers: 95% CI 39.6 to 71.6; p < 0.001) and by 29.8% (95% CI 25% to 35%, p < 0.001) and 24.3% (95% CI 13% to 36%, p < 0.001) relative to the population, respectively, as were reduced attendance and higher vaccination coverage. The contribution of contacts in schools to population cases (d) was 2% to 20%, lowest during school closures/vacation and peaked during normal presence class intervals, with the overall peak early during the omicron wave. Limitations include underdetection, misclassification of contacts, interviewer/interviewee dependence of contact-tracing, and lack of individual-level confounding factors in aggregate data regression analysis.ConclusionIn this study, we observed that open schools under hygiene measures and testing strategies contributed up to 20% of population infections during the omicron wave early 2022, and as little as 2% during vacations/school closures; about a third of students and teachers were infected during the omicron wave in early 2022 in Germany. Mandatory mask wearing during class in all school types and reduced attendance models were associated with a reduced infection risk in schools.

Background School-level infection control measures in Germany during the early Coronavirus Disease 2019 (COVID-19) pandemic differed across the 16 federal states and lacked a dependable evidence base, with available evidence limited to regional data restricted to short phases of the pandemic. This study aimed to assess the (a) infection risks in students and staff; (b) transmission risks and routes in schools; (c) effects of school-level infection control measures on school and population infection dynamics; and (d) contribution of contacts in schools to population cases. Methods and findings For this retrospective observational study, we used German federal state (NUTS-2) and county (NUTS-3) data from public health and education agencies from March 2020 to April 2022. We assessed (a) infection risk as cumulative risk and crude risk ratios and (b) secondary attack rates (SARs) with 95% confidence interval (CI). We used (c) multiple regression analysis for the effects of infection control measures such as reduced attendance, mask mandates, and vaccination coverage as absolute reduction in case incidence per 100,000 inhabitants per 14 days and in percentage relative to the population, and (d) infection dynamic modelling to determine the percentage contribution of school contacts to population cases. We included (a) nationwide NUTS-2 data from calendar weeks (W) 46-50/2020 and W08/2021-W15/2022 with 3,521,964 cases in students and 329,283 in teachers; (b) NUTS-3 data from W09-25/2021 with 85,788 student and 9,427 teacher cases; and (c) detailed data from 5 NUTS-3 regions from W09/2020 to W27/2021 with 12,814 cases (39% male, 37% female; median age 14, range 5 to 63), 43,238 contacts and 4,165 secondary cases for students (for teachers, 14,801 [22% male, 50% female; median age 39, range 16 to 75], 5,893 and 472). Infection risk (a) for students and teachers was higher than the population risk in all phases of normal presence class and highest in the early 2022 omicron wave with 30.6% (95% CI 30.5% to 32.6%) of students and 32.7% (95% CI 32.6% to 32.8%) of teachers infected in Germany. SARs (b) for students and staff were below 5% in schools throughout the study period, while SARs in households more than doubled from 13.8% (95% CI 10.6% to 17.6%) W21-39/2020 to 28.7% (95% CI 27% to 30.4%) in W08-23/2021 for students and 10.9% (95% CI 7% to 16.5%) to 32.7% (95% CI 28.2% to 37.6%) for staff. Most contacts were reported for schools, yet most secondary cases originated in households. In schools, staff predominantly infected staff. Mandatory surgical mask wearing during class in all schools was associated with a reduction in the case incidence of students and teachers (c), by 56/100,000 persons per 14 days (students: 95% CI 47.7 to 63.4; teachers: 95% CI 39.6 to 71.6; p < 0.001) and by 29.8% (95% CI 25% to 35%, p < 0.001) and 24.3% (95% CI 13% to 36%, p < 0.001) relative to the population, respectively, as were reduced attendance and higher vaccination coverage. The contribution of contacts in schools to population cases (d) was 2% to 20%, lowest during school closures/vacation and peaked during normal presence class intervals, with the overall peak early during the omicron wave. Limitations include underdetection, misclassification of contacts, interviewer/interviewee dependence of contact-tracing, and lack of individual-level confounding factors in aggregate data regression analysis. Conclusion In this study, we observed that open schools under hygiene measures and testing strategies contributed up to 20% of population infections during the omicron wave early 2022, and as little as 2% during vacations/school closures; about a third of students and teachers were infected during the omicron wave in early 2022 in Germany. Mandatory mask wearing during class in all school types and reduced attendance models were associated with a reduced infection risk in schools. Torben Heinsohn and co-authors investigate infection and transmission risks of COVID-19 in schools, school-level infection control measures, and their contribution to population infections in Germany. Author summary Why was this study done? Infection control policy for schools in Germany is sovereignty of the 16 federal states. A lack of evidence for measures in schools resulted in varying approaches to school infection control, in particular, masking and reduced attendance measures during the first year of the pandemic and beyond. Data for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in schools was limited to small regions and short time periods. What did the researchers do and find? We gathered data collected by national and regional government agencies on Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) school infections and transmission, covering March 2020 to April 2022 and in total 3,534,778 cases in students and 340,429 in staff or teachers. The risk of getting infected was higher for students and teachers than the general population when schools were open with all students present. Strict masking and reducing student numbers were associated with a reduction in this risk. Students and teachers are more likely to pass on their infection in the household than the school. Their contacts in school were responsible for up to 20% of infections in the population during the early 2022 omicron wave and as little as 2% during school closures and vacations. What do these findings mean? When hygiene measures to reduce infections in schools are necessary including masking policies for students and teachers in all schools during class and reducing student numbers should be considered. Contribution of school contacts to overall transmission in the population is highly variable, ranging from 20% during the omicron wave with open schools to 2% during closures/vacations. Limitations include underreporting of cases, misclassification of school contacts, inaccuracies in contact tracing, and lack of data on individual person factors in grouped data analysis.

The stress response to the COVID-19 pandemic might differ between early and later stages. Longitudinal data on the development of population mental health during COVID-19 pandemic is scarce. We have investigated mental health trajectories and predictors for change in a probability sample of the general population in Germany at the beginning and after 6 months of the pandemic. We conducted a longitudinal survey in a population-based probability sample of German adults. The current study analyzed data from a first assessment in May 2020 (T1; N = 1,412) and a second in November 2020 (T2; N = 743). Mental health was assessed in terms of anxiety and depression using the Patient Health Questionnaire-4 (PHQ-4). Mental health outcomes at T1 were compared with PHQ-4 norm data. Trajectories over time were investigated based on outcome classifications of PHQ-4 scores. Predictors of mental health outcomes and change were identified using multiple regression analysis. In spring 2020, participants showed significantly higher PHQ-4 scores as compared to the norm data, however, overall anxiety and depression remained low also 6 months later. 6.6% of respondents showed a mental health deterioration in autumn 2020, entering subclinical and clinical ranges, outweighing the proportion of people with improved outcomes. Sociodemographic variables associated with mental distress at T1 were mainly not predictive for change at T2. Even under prolonged pandemic-related stress, mental health remained mainly stable in the general population. Further development of the considerable subgroup experiencing deterioration of depression and anxiety should be monitored, in order to tailor prevention and intervention efforts.

ObjectivePredictors of body weight loss (BWL) and body weight loss maintenance (BWLM) after behavioral weight loss intervention are well-investigated in adults. Less is known for children and adolescents and a systematic overview on the topic for this age group was aim of the review.MethodsA systematic research according to PRISMA guidelines using several databases was performed. The outcome was the BMI z-Score of longitudinal studies. The extracted predictors were classified in clusters (Physiology, Behavior, Psychology, Environment) and compared with a theory-driven model based on international guidelines and known predictors for adults.ResultsOut of 2,623 articles 24 met the eligibility criteria, 23 investigating BWL and 8 BWLM. The expected key predictor in research for adults “Behavior” was hardly investigated in children. The most examined cluster was “Physiology” with the most significant predictors, in particular genetics (BWL) and blood parameters (BWLM). Factors in the cluster “Psychology” also predicted BWL and BWLM. The cluster “Environment,” which was highlighted in most intervention guidelines, was neglected in studies regarding BWLM and hardly investigated in studies with BWL.ConclusionThe comparison with the theory-driven children model outlined research gaps and differences between predictors for adults and children providing further direction of research.Systematic Review Registrationhttp://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42020200505.

Overweight and obesity among children and adolescents are global problems of our time. Due to their authority and role modeling, parents play an essential part in the efficacy of prevention and intervention programs. This study assessed the barriers that parents of overweight/obese children face in preventive and interventional health care utilization. Sixteen parents were qualitatively interviewed. A content analysis was performed, and barriers to change were allocated to their stage of change according to the transtheoretical model. Among the main barriers is the underestimation of health risks caused by overweight/obesity in association with diminished problem awareness. Parents seem not necessarily in need of theoretical knowledge for prevention and interventions. They do however need support in evaluating the weight status of their child and the knowledge of whom to turn to for help as well as specific and hands-on possibilities for change. The results extend past studies by adding specific barriers to change that parents commonly experience. Possibilities to address these barriers, e.g., through trainings at the pediatric practice or adoption of conversation techniques, are discussed. Future studies might identify subgroups experiencing specific barriers and thus be able to address these in an individualized way.

Objective: The aim of this study was to identify the prevalence of eating disorder symptoms in obese adolescents participating in a lifestyle intervention for weight loss and to investigate possible relationships with weight change, general psychopathology, and health-related quality of life (HRQOL). Method: At the beginning and after completion of a 6-month lifestyle intervention, 41 participants (20 females; age: 13.7 ± 1.4 years) reported on core symptoms of eating disorders (SCOFF), self-esteem (Rosenberg Self-Esteem Scale, RSES), and HRQOL (Questionnaire for Measuring Health-Related Quality of Life in Children and Adolescents, KINDL), while parents filled in a questionnaire assessing their children's internalizing and externalizing behavioral problems (Child Behavior Checklist, CBCL). Results: Compared to age-matched normative samples, patients showed increased behavior problems and an impaired HRQOL. 43% of the patients were screened positive for an eating disorder pathology, and this subgroup showed an increased psychopathological burden compared to patients that were screened negative. The lifestyle intervention resulted in a significant weight loss which was unaffected by the presence of an eating disorder pathology. The screening rate for eating disorders remained stable after the intervention. Conclusion: The large overlap, mutual interaction, and high burden of eating and weight problems in children and adolescents underpin the need for an integrated view in both prevention and treatment approaches in pediatric obesity.

To estimate the national incidence rate and trend of type 1 diabetes (T1DM) in Germany from 1999 to 2008 and the national prevalence in 2008 in the age group 0-14 years.Data were taken from a nationwide registry for incident cases of T1DM in the ages 0-4 years and 3 regional registries (North-Rhine-Westphalia, Baden-Wuerttemberg and Saxony) for incident cases of T1DM in the ages 0-14 years covering 41% of the child population in Germany. The degree of ascertainment was ≥ 97% in all registries. Incident and prevalent cases were grouped by region, sex, age (0-4, 5-9, 10-14 years), and, for incident data, additionally by two 5-year periods (1999-2003, 2004-2008). Poisson regression models were fitted to the data to derive national estimates of incidence rate trends and prevalence in the age groups 5-9, 10-14 and 0-14 years. We used direct age-standardization.The estimated national incidence rate in 0-14-year-olds increased significantly by 18.1% (95%CI: 11.6-25.0%, p