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Childhood obesity treatment during the first wave of the Covid-19 pandemic : – a retrospective controlled cohort study

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Degree project, 30 ECTS January 12, 2021

Childhood obesity treatment during the first

wave of the Covid-19 pandemic

– a retrospective controlled cohort study

Version 2

Author: Malin Leoo, MB

School of Medical Sciences Örebro University Örebro Sweden

Supervisor: Sven Klaesson, MD PhD MBA

Department of Paediatrics Södertälje hospital Södertälje Sweden Word count Abstract: [250] Manuscript: [2923]

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Abstract

Introduction: Obesity amongst children is a major health problem. At the outpatient

paediatric clinic at Södertälje hospital in Region Stockholm, there is a large and

well-established treatment model against childhood obesity. During spring 2020 all elective care in Region Stockholm, including visits to the obesity team, was cancelled for 3 months due to relocation of health care professionals because of the Covid-19 pandemic.

Aim: To investigate whether the first wave of the Covid-19 pandemic affected the outcome of

childhood obesity treatment at one outpatient paediatric clinic in Region Stockholm.

Methods: A retrospective controlled cohort study comparing two groups regarding results of

first year of obesity treatment for children. One group had their first year of treatment during the first wave of the Covid-19 pandemic and the control group before the pandemic. Data was retrieved from BORIS and complemented by a review of medical records.

Results: Mean change in BMI SDS after one year of treatment in the Covid group was -0.10

units and in the control group -0.11 (ns). In the Covid group more patients quit the treatment programme and had a smaller number of visits to a nurse compared to controls.

Conclusion: This study showed no difference in outcome regarding change in BMI SDS.

However, it seems that the cancellation of visits might have affected the number of children lost to follow-up. Therefore, clinics should consider “digi-physical” care (e.g., via telephone, videocalls or other media) to secure the child and parents motivation and participation in the obesity treatment programme.

Key words: childhood obesity treatment, multidisciplinary team, outpatient paediatric clinic,

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Introduction

The last decades the prevalence of obesity in children and adolescents in developed countries have increased significantly (1). In Sweden about 11 percent of 4-year old children are obese or overweight, the corresponding number for children aged 6-9 years old is 21 percent and 15 percent for children aged 11-15 years old (2). Being overweight or obese as a child increases the risk of also becoming overweight or obese as an adult (3). Moreover, obesity can affect the children’s quality of life in a negative way (4) and is associated with increased risk of anxiety and depression (5). It may also increase the risk of mortality in early adulthood due to a higher risk of death from suicide or endogenous causes (e.g. infection or endocrine causes) (6). Childhood obesity is also associated with an increased risk of metabolic associated diseases (7,8), and a reduction of ≥0.25 BMI standard deviation score (BMI SDS) units has shown to have a clinical relevance in reducing cardiometabolic risk factors (9). Therefore, it is important to treat childhood obesity in an effective way to prevent these negative effects.

Among risk factors for developing obesity in childhood is poor diet and increased time spent on sedentary activities (10–12). At the outpatient paediatric clinic at Södertälje hospital, a suburb to Stockholm in Sweden, a treatment model regarding childhood obesity was

developed in 2005 which focuses on handling these risk factors. The treatment model includes in addition to regular visits to a paediatrician, group sessions for the child and parents

separately and visits to a multidisciplinary team for the families individually (13). Parental group sessions consists of education on obesity, the importance of good eating habits, how to increase physical activity and decrease screen time and how the parent can support the child in life style changes (14). Group sessions for the children includes age-appropriate education on the same topics as the parental group but also focuses on creating a positive experience regarding physical activity (13). The individual family sessions consists of visits to a medical doctor 1-2 times a year, visits to a nurse 1-8 times a year and, if needed, visits to a

physiotherapist and/or dietician (14). It can be said that a large part of the treatment plan is based on regular visits to the paediatric clinic.

Previous research indicates that children who undergo obesity treatment according to the treatment model have a significantly better outcome regarding decrease in obesity compared to children being treated at a centre where the action plan is not implemented (13,14). It has also earlier been described that a combination of nutritional, physical activity and behavioural

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changes have an greater effect in reducing BMI in obese children than interventions that only focuses on diet changes (15,16).

During spring of 2020 the World Health Organization classified the out brake of Covid-19 as a pandemic (17). In March 2020 all elective care in Region Stockholm got cancelled,

including obesity treatment at the outpatient paediatric clinic at Södertälje hospital, to be able to reallocate health care staff to the intensive care unit and emergency room (18). All group sessions and individual visits to the multidisciplinary obesity team was completely interrupted for about three months of time and gradually resumed in June 2020 until the second wave of the pandemic forced another close-down of the elective care in October 2020. The purpose of this study was to assess whether 3-6 months interruption of visits to the multidisciplinary team during first year of obesity treatment in children affected the outcome.

Aim

The aim was to study whether the first wave of the Covid-19-pandemic affected the outcome of childhood obesity treatment at one outpatient paediatric clinic in Region Stockholm.

Material and Methods

Subjects

All children who started their weight loss treatment programme at the outpatient paediatric clinic in Södertälje hospital between May 1, 2019 and October 31, 2019 were included. The subjects first year of treatment got affected by the first wave of Covid-19-pandemic when elective care got cancelled 3-6 months during 2020.

Comparison group

The comparison group consists of all children who started their weight loss treatment programme at the outpatient paediatric clinic in Södertälje hospital exactly one year earlier than the subjects, between May 1, 2018 and October 31, 2018. They completed their first year of treatment before the Covid-19-pandemic and their results of first year of treatment is therefore not affected by it.

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Collection of data

All patients in the study had prior to treatment agreed to participate in the National Health Care Register for Childhood Obesity (BORIS). Data was retrieved from the registry and complemented by a review of medical records. The primary outcome variable was change in degree of obesity assessed using BMI SDS. The cut-offs used in this study are recommended by the International Obesity Task Force (IOTF) (19). BMI SDS indicates how many standard deviations the weight deviates from the normal and is preferred when assessing weight status in children because it is adjusted for sex and age (20). One-year follow-up visit counted as the visit closest to one year from the first visit to the paediatric obesity team, but no more than +/- 3 months.

Other parameters that were looked upon were age, sex, BMI, weight status, screen time, physical activity in the spare time and family living situation. As secondary outcome change in weight status, number of visits each patient had to different professions such as

paediatrician and nurse or assistant nurse and participation in group sessions were analysed.

Physical activity was divided into four different categories; 1) sedentary (corresponding to physical activity for 2 hours or less per week), 2) moderate (corresponding to at least 2 hours of physical activity per week), 3) regularly moderate (defined as physical activity that made the child sweat 1-2 times a week and for at least 30 minutes at each occasion) and 4) regular (defined as physical activity that made the child sweat on an average of 3 times a week for at least 30 minutes each time).

Regarding visits to different professions the number of visits were divided into different categories. Visits to a paediatrician was divided into 0, 1 or more than 1 visit during the first year of obesity treatment. Visits to a nurse or assistant nurse was divided into 0-1 visits, 2-3 visits or more than 3 visits during the first year. When comparing the number of visits each child had to the different professions, the children who did not have a follow-up in time were also included. In cases where the child did not have a one-year follow-up in time, the number of visits up to one year was counted. Children who decided to quit the programme were excluded all together.

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Statistics

The descriptive data are presented as proportions or mean, minimum and maximum and SD. The primary outcome variable, change in BMI SDS, was evaluated using a paired-samples t-test for changes within the group and independent-samples t-t-test for changes between the two groups. To evaluate differences regarding the other parameters t-test was carried out when the variable was on a continuous scale and Chi-square test or Mann-Whitney U-test was

performed when the variable was on a categorical scale.

All analyses were performed using SPSS Statistics version 27 (IBM Corp. in Armonk, NY) and a p-value of <0.05 was considered statistically significant.

Ethical considerations

An approval for the study was obtained from the head of the Paediatric clinic at Södertälje hospital. The study was considered a quality study for the hospital and therefore no ethical approval from the Swedish Ethical Review Authority was applied for. All personal data was pseudonymized and the code key was securely kept locked in at the paediatrics clinic at Södertälje hospital. All data is presented anonymously and at a group level to prevent specific individuals to be identified.

Results

Study population

A total of 114 children who started the treatment program at Södertälje hospital between May 1, 2018 and October 21, 2019 were enrolled in the study. Study flow chart is presented in Figure 1. Twelve children in the Covid group and two in the comparison group quit the obesity treatment programme before the one-year up and were therefore lost to follow-up. Out of the 53 children left in the Covid group 42 had their one-year follow-up on time compared to 38 out of 47 in the comparison group.

There was a significant greater number of children who choose to quit the treatment programme in the Covid group than in the comparison group. There were 12 children, corresponding to 18%, in the Covid group who chose to quit the programme compared to 2 children, accounting for 4%, in the comparison group (P=0.02).

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When analysing the baseline data for each group separately regarding children lost to follow-up, there was no significant difference compared to those children who stayed in the

programme.

Figure 1. Study flow chart showing lost to up. Children who quit the programme before one-year

follow-up were excluded from all analysis. Children who were in the programme but did not have a one-year follow-follow-up on time were included in analysis regarding visits to different professions and participation in group sessions. Children who had one-year follow-up on time were included in analysis for primary outcome and change in weight status.

Descriptives

A total of 114 children were included in this study, 65 in the Covid group and 49 children in the comparison group. Descriptive data for the two groups is presented in Table 1. The distribution by gender was 47.7% boys and 52.3% girls in the Covid group and 59.2% boys and 40.8% girls in the comparison group (P = 0.22). There was no significant difference in age between the two groups, mean (SD) 8.9 (3.9) years and 9.4 (3.8) in the Covid group and comparison group respectively (P = 0.44). At the beginning of treatment there was no difference in BMI SDS between the two groups, mean (SD) 2.82 (0.48) in the Covid group and 2.83 (0.54) in the comparison group (P = 0.89). In the Covid group 1.5% were

overweight, 66.2% were obese and 32.3% were severely obese at start of treatment, in the

Total number of children enrolled

n=114

Covid group

First visit between May 1, 2019 and October 31, 2019

n=65

Comparison group

First visit between May 1, 2018 and October 31, 2018 n=49 Yes n=38 Yes n=42 Lost to follow-up Own decision to quit (n=2) Lost to follow-up

Own decision to quit (n=12)

Eligible for one-year follow-up

n=53

Eligible for one-year follow-up

n=47

One-year follow-up on time

No

n=11

No

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comparison group the corresponding numbers were 6.1%, 57.1% and 36.7% respectively (P = 0.89).

Table 1. Baseline characteristics for each group respectively at time of inclusion in study Covid group n = 65 Comparison group n = 49 P-value Sex 31 (47.7) 34 (52.3) 29 (59.2) 20 (40.8) 0.22 Boy, n (%) Girl, n (%) Age (years) 8.9 [2.2–17.0] 3.9 9.4 [3.8–16.3] 3.8 0.44 Mean [min-max] Std. deviation BMI SDS 2.82 [2.04–4.95] 0.48 2.83 [1.95–4.93] 0.54 0.89 Mean [min-max] Std. deviation Weight status 1 (1.5) 43 (66.2) 21 (32.3) 3 (6.1) 28 (57.1) 18 (36.7) 0.89 Overweight, n (%) Obese, n (%) Severely obese, n (%) Screen time 15 (23.1) 29 (44.6) 6 (9.2) 15 (23.1) 14 (28.6) 19 (38.8) 6 (12.2) 10 (20.4) 0.68 <2 h, n (%) 2–5 h, n (%) >5 h, n (%) Non-reported, n (%) Physical activity 12 (18.5) 14 (21.5) 14 (21.5) 3 (4.6) 22 (33.8) 9 (18.4) 17 (34.7) 6 (12.2) 4 (8.2) 13 (26.5) 0.73 Sedentary, n (%) Moderate, n (%) Regularly moderate, n (%) Regularly, n (%) Non-reported, n (%) Family living 37 (56.9) 15 (23.1) 13 (10.0) 33 (67.3) 16 (32.7) 0 (0) 0.68 Parents living together, n (%)

Parents not living together, n (%) Non-reported, n (%)

BMI SDS = body mass index standard deviation score. Physical activity was divided into following categories; (i) physical activity for 2 hours or less per week, (ii) physical activity for at least 2 hours per week, (iii) physical activity that made the child sweat 1-2 times a week for at least 30 minutes on each occasion and (iv) physical activity that made the child sweat on average 3 times a week for at least 30 minutes each time.

T-test was performed for continuous variables and Chi-square test or Mann-Whitney U-test for categorical variables.

Main outcome

Analysing the children that completed the one-year follow-up (n=42 in the Covid group and n=38 in the comparison group) there was no statistically significant change in BMI SDS within the groups after one year of treatment. Children in the Covid group decreased a mean

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of -0.10 units (from BMI SDS 2.88 to 2.78) and the corresponding figures for the comparison group was -0.11 units (from BMI SDS 2.74 to 2.63) (Table 2). The distribution of change in BMI SDS within each group are shown in Figure 2.

Table 2. BMI SDS and weight status at one-year follow-up for each group respectively

The presented P-value applies to differences between the two groups. T-test was carried out for continuous variables and Chi-square test for categorical variables.

When comparing the mean decrease in BMI SDS after one year between the two groups there was only a small difference (0.01 units, P=0.94) (Table 2).

Figure 2. Box plot (median, first and third quartile, minimum and maximum and outlier) of change in BMI SDS

after one year of obesity treatment for each group respectively.

Covid group n = 42 Comparison group n = 38 P-value BMI SDS 2.78 [1.73-3.90] 0.50 -0.10 2.64 [1.57-4.60] 0.60 -0.11 0.94 Mean [min-max] Std. deviation Mean change Weight status 7 (16.7) 18 (42.9) 17 (40.5) 8 (21.2) 18 (47.4) 12 (31.6) 0.76 Overweight, n (%) Obese, n (%) Severely obese, n (%)

Change in weight status

9 (21.4) 28 (66.7) 5 (11.9) 11 (28.9) 21 (55.3) 6 (15.8) 0.73 Decrease, n (%) No change, n (%) Increase, n (%)

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Secondary outcome

There were a greater number of children in the Covid group than in the comparison group who quit the programme or did not have their one-year follow-up on time. In the Covid group there were 23 children who quit or did not have a visit within time and in the comparison group there were 11 children, but the difference between the two groups was not statistically significant (P=0.15).

Weight status was analysed by dividing patients in both groups into categories based on BMI SDS; overweight, obese and severely obese (Table 2). No children in any of the two groups were classified as normal weight after one year of treatment. In the Covid group a total of 9 children had a decreased in weight status after one year of treatment; 2 children went from severely obese to obese and 7 children from obese to overweight. Five children increased their weight status, all went from obese to severely obese, and 28 children had no change in weight status. In the comparison group 11 children had a decrease in weight status; 6 children went from severely obese to obese and 8 children from obese to overweight. Six children increased their weight status; three children went from overweight to obese and three children from obese to severely obese. Twenty-one children had no change in weight status after one year of treatment.

Visits to different professions were analysed in all patients, regardless if they completed the one-year follow-up or not (Table 3). Two children in the Covid group had no visits to a medical doctor during the first year of obesity treatment, 41 children had 1 visit and 10 children had more than 1 visit. In the comparison group 5 children had no visits during first year of treatment, 30 children had 1 visit and 14 children had more than 1 visit to a medical doctor (P=0.36).

There was a difference in the number of visits each group had to a nurse or assistant nurse (P=<0.05). In the Covid group 17 children had 0-1 visits during first year of treatment

compared to the comparison group where 4 children had 0-1 visits. Thirty-four children in the Covid group and 35 children in the comparison group had 2-3 visits and 2 and 8 children from each group respectively had more than 3 visits during the first year of treatment.

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Table 3. Number of visits each child had to a paediatrician and nurse or assistant nurse and number of children

participating in group sessions

Covid group n = 53 Comparison group n = 47 P-value Paediatrician 2 (3.8) 41 (77.4) 10 (18.9) 3 (6.4) 30 (63.8) 14 (29.8) 0.36 0 visits, n (%) 1 visit, n (%) >1 visit, n (%)

Nurse and/or assistant nurse

17 (32.1) 34 (64.2) 2 (3.8) 4 (8.5) 35 (74.5) 8 (17.0) 0.001 0-1 visits, n (%) 2-3 visits, n (%) >3 visits, n (%)

Participation in group sessions

7 (13.2) 46 (86.8) 7 (14.9) 40 (85.1) 0.81 Yes, n (%) No, n (%)

Mann-Whitney U-test was carried out for visits to paediatrician and nurse or assistant nurse and Chi-square test was carried out for participation in group sessions. P-value accounts for differences between the two groups.

In both the Covid group and comparison group 7 families went to group sessions

corresponding to 13.2% and 14.9% of the families in each group respectively (P=0.81) (Table 3).

In the Covid group 13 children out of 53 went to a physiotherapist, in the comparison group the corresponding number was 11 out of 47 children. For those who went to a physiotherapist the median [IQR] number of visits for each child was 3.0 [1-5.5] in the Covid group and 7.0 [2-12] in the comparison group (P=0.85). In the Covid group 17 children went to a dietician and the median [IQR] number of visits was 2 [1.0-3.0] compared to 13 children in the comparison group where the median [IQR] number of visits was 2 [1.0-3.5].

Discussion and Conclusions

In our study, we did not find any significant difference in change in BMI SDS between the two groups after one year of treatment. Since the patients in the Covid group did not receive treatment as planned during the first wave of the pandemic one could have expected that outcome regarding decrease in weight and weight status to be poor compared to controls.

It has previously been shown that parents play an important role in changing the child’s life-style and weight loss (21,22). Even if the treatment was cancelled only for three to six months one could speculate on positive effects for children during the cancellation of elective care. For example, it is reasonable to believe in a positive effect regarding lifestyle changes if the

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child spent more time with its parents during the pandemic. There may also have been more time for regular physical activity and less time spent with friends who might have a negative impact regarding sedative behaviour and eating habits (e.g., less junk food and sodas).

On the other hand, the relatively high number of children lost to follow-up in the Covid group might have affected the results. Eighteen percent of the children during the pandemic quit the treatment compared to four percent in the control group the year before. We found no

distinctive characteristics for the children lost to follow-up but maybe when visits were cancelled a greater number of patients lost the motivation and dropped out of the treatment. The elective care was resumed in June 2020, but the Covid-19 pandemic was still ongoing. Therefore, children and their parents might have felt a resistance to visit the hospital which could explain why children in the Covid group had fewer visits to a nurse than in the comparison group.

A previous study has shown that there was no difference in outcome regarding change in BMI SDS when patients received telephone coaching instead of treatment based on physical visits (23). Interestingly there were also no patients lost to follow-up (23). This suggests that

frequent contact with the obesity team rather than physical visits to the clinic is of importance, both in terms of supporting the child and parents in lifestyle changes but also to keep them in the obesity treatment programme. During the first wave of the pandemic, when the visits to the clinic got cancelled, no other form of follow-up was implemented. If resources had been dedicated to readjusting to telephone coaching or digital follow-up the outcome regarding number of children who dropped out of the programme might have been different.

The participation in group sessions were relatively low in both groups. It has previously been shown that group sessions increases weight loss in children (24) and it might therefore be of importance to look into how to increase the participation all together. During the pandemic the group sessions were cancelled and that might be an explanation for the low attendance, but the participation was only marginally better in the comparison group. If one could increase the number of families attending group sessions it might improve the results of weight loss treatment for children.

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BMI SDS after one year of treatment. Due to the small study population, all results should be interpreted with caution. However, it seems that cancellation of visits to the obesity team might have affected the number of children lost to follow-up. Therefore, instead of just cancelling all physical visits in a similar situation, clinics should consider alternative “digi-physical” care (e.g., via telephone, videocalls or other media) to secure the child and parents motivation and participation in the obesity treatment programme. Since the pandemic is ongoing (2nd wave) we suggest a future study including more patients to analyse the full effect

of the Covid-19 pandemic when it is over.

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Populärvetenskaplig sammanfattning

Övervikt och fetma hos barn i Sverige är ett allvarligt hälsoproblem. 11% av Sveriges 4-åringar har redan utvecklat övervikt eller fetma och förekomsten ökar med åldern. Barn med fetma har tre gånger större dödlighet före trettio års ålder än normalbefolkningen. Fetma medför även ökad risk för negativ påverkan på livskvalitet och psykisk hälsa.

Vid barn- och ungdomsmedicinska mottagningen på Södertälje sjukhus finns sedan många år en etablerad behandlingsmodell för barn med fetma som erbjuds av ett multidisciplinärt team och syftar till både kost- och beteendeförändringar. Tidigare studier har visat goda resultat avseende reduktion av BMI. För växande barn anges alltid BMI-förändringen i förhållande till ett genomsnittligt normalvärde uttryckt i standarddeviationer av BMI (BMI SDS).

Under våren 2020 drabbades världen av Coronapandemins första våg. Detta medförde att all elektiv vård i Region Stockholm ställdes in. I studien har vi analyserat de barn som tvingades avbryta sitt första år av barnfetmabehandling på Södertälje sjukhus och jämfört deras resultat med barn från samma mottagning men som genomförde sitt första år i behandling innan pandemin.

Studien är liten och de preliminära resultaten visar ingen skillnad mellan grupperna gällande reduktionen av BMI SDS. Resultaten kan ha påverkats av att det var fler patienter i Covid-gruppen som valde att avsluta behandlingen eller inte följdes upp efter ett år jämfört med jämförelsegruppen. Att så många avslutade sin behandling under pandemin talar för att det är viktigt med regelbunden kontakt för att motivera till fortsatt behandling, t.ex. med ”digifysisk behandling” (telefon-, videbesök eller andra former av digitala hjälpmedel).

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Cover letter 2020-12-30 Dear editor,

Please consider our manuscript “Childhood Obesity Treatment during the first wave of the Covid-19 Pandemic” for publication in The Journal of Paediatrics.

At Södertälje hospital in Region Stockholm, Sweden a treatment model against childhood obesity has been developed which largely consists of regular visits to the outpatient paediatric clinic. During 2020 the world was affected by the Corona-pandemic and in Region Stockholm all elective care was cancelled, including the childhood obesity treatment.

In this study, we have focused on the effects of the cancelled visits on children who had their first year of treatment during the pandemic compared to children who had their first year of treatment before the pandemic. To assess this, we have compared the mean change of BMI standard deviations between the two groups after one year of treatment. Our main findings show that there was no significant difference between the two groups. We have also looked into the difference in number of visits each child had to different professions at the clinic and found that the children in the Covid group hade lesser visits to a nurse or assistant nurse than the comparison group. There was also a greater number of children who dropped out of treatment in the Covid group than in the comparison group.

This study is important because it provides information on how an interruption in childhood obesity treatment might affect the outcome in terms of weight loss and motivation to stay in the program.

Yours sincerely,

Malin Leoo, Bachelor of Medicine Örebro University

(19)

Etisk reflektion

Studien är i första hand tänkt som en kvalitetsuppföljning med hjälp av avidentifierade uppgifter från Barnobesitas registret i Sverige, BORIS. Vid behov har data kompletterats genom direkt journalgranskning, bland annat för att möjliggöra analys av antal besök varje barn hade till de olika professionerna. Genom att granska journalerna på ett systematiskt sätt och enbart inhämta eftersökt information minimerades risken att kränka patientens integritet.

I den här studien har uppgifter om patienternas hälsa behandlats vilket räknas till känsliga personuppgifter. Därför har dessa uppgifter under arbetet med projektet sparats

pseudonymiserat i ett Exceldokument med ett unikt kodnummer tilldelat för varje patient. Kodnyckeln har förvarats på ett USB-minne försett med lösenord inlåst på Barnmottagningen på Södertälje sjukhus, detta för att förhindra att den hamnar i obehöriga händer.

För att undvika att enskilda patienter ska kunna identifieras har all data bearbetats så att den presenteras anonymt och på gruppnivå, det går alltså inte att koppla ihop enskilda individer med specifika parametrar.

Det har även gjorts en riskanalys av studien. Vi kom fram till att nyttan av att utvärdera kvaliteten av barnfetmabehandling under Covid-pandemin övervägde de risker som

inhämtning av patientuppgifter utgör. Den situation som uppstått i samhället, och inte minst i vården, i samband med pandemin är någonting nytt och att se över hur olika verksamheter fungerat är av stor vikt för att kunna lära inför liknande situationer i framtiden.

References

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