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Fleischman A, Hampl S, Rhodes ET, Sweeney B, Eneli I, Skelton JA. Implementation of recommended treatment for children in weight management programs: Lessons from the stay in treatment study sites. Prev Med 2024; 182:107949. [PMID: 38583602 PMCID: PMC11039354 DOI: 10.1016/j.ypmed.2024.107949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/20/2024] [Accepted: 04/04/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVES Pediatric obesity remains a public health crisis in the United States, exacerbated by the COVID-19 pandemic. There are recommended guidelines for multidisciplinary care, but they remain challenging to implement, even in tertiary care weight management programs. The aim of this analysis is to describe the implementation of these recommendations among four pediatric weight management programs in the United States. METHODS This report capitalizes on a convenience sample of programs participating in the Stay In Treatment (SIT) Study, a multicenter study to address attrition among pediatric weight management programs in tertiary care, academic institutions in diverse geographic locations. The programs were compared regarding structure, program offerings, and funding support. RESULTS The four programs were interdisciplinary, offered individual and group treatment options, and were family-based. A range of clinicians provided interventions with nutrition, physical activity, behavioral and psychosocial components. Anti-obesity pharmacotherapy and bariatric surgery were offered, when appropriate. None of the programs were self-sustaining; they required institutional and philanthropic support to provide recommended, comprehensive treatment. CONCLUSIONS Ongoing state and national advocacy are needed in the US to create consistent coverage for private and public insurance plans, so that high-risk children can have access to recommended treatment.
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Affiliation(s)
- Amy Fleischman
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States of America.
| | - Sarah Hampl
- Center for Children's Healthy Lifestyles & Nutrition, Children's Mercy-Kansas City; Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Children's, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
| | - Erinn T Rhodes
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States of America.
| | - Brooke Sweeney
- Center for Children's Healthy Lifestyles & Nutrition, Children's Mercy-Kansas City; Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Children's, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
| | - Ihuoma Eneli
- Center for Healthy Weight and Nutrition, Nationwide Children's Hospital, Columbus, OH, United States of America; Department of Pediatrics, The Ohio State University, 700 Children's Dr, Columbus, OH 43205, United States of America.
| | - Joseph A Skelton
- Department of Pediatrics, Wake Forest School of Medicine, Medical Center, Blvd., Winston-Salem, NC 27157, United States of America.
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Frim YG, Garvey KC, Gordon E, Rhodes ET. Screening for Food Insecurity in a Pediatric Diabetes Program: Provider and Parent/Guardian Perspectives. Clin Pediatr (Phila) 2024:99228231222987. [PMID: 38243651 DOI: 10.1177/00099228231222987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
Food insecurity (FI) is associated with poor health outcomes in children, and studies have shown higher FI among children with diabetes mellitus. This study assessed provider (N = 22, 35.5% response rate) and parent/guardian (N = 207, 14.6% response rate) perspectives toward FI screening in a pediatric diabetes program. Among 22 providers, most "rarely" (54.5%) or "never" (27.3%) screened for FI although all felt that screening was at least "slightly important." Barriers included lack of time (63.6%), not remembering to screen (59.1%), lack of knowledge about how to address positive screens (45.5%), and being unsure how to screen (40.9%). Among 186 parent/guardians, only 24.1% had been asked about FI at a pediatric medical appointment, but only 8.6% disliked the idea of being asked by a medical provider at endocrinology visits. To be effective and sustainable, FI screening must fit within the visit flow, and providers need education on how to address positive screens.
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Affiliation(s)
- Yonina G Frim
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Pediatrics, Mass General for Children, Boston, MA, USA
| | - Katharine C Garvey
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Erin Gordon
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Department of Clinical Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Erinn T Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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3
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Rhodes ET, Phan TLT, Earley ER, Eneli I, Haemer MA, Highfield NC, Khan S, Kim G, Kirk S, Sullivan EM, Stoll JM, Werk LN, Zeribi KA, Forrest CB, Lannon C. Patient-Reported Outcomes to Describe Global Health and Family Relationships in Pediatric Weight Management. Child Obes 2024; 20:1-10. [PMID: 36827448 PMCID: PMC10790547 DOI: 10.1089/chi.2022.0151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
Background: Patient-reported outcomes (PROs) can assess chronic health. The study aims were to pilot a survey through the PEDSnet Healthy Weight Network (HWN), collecting PROs in tertiary care pediatric weight management programs (PWMP) in the United States, and demonstrate that a 50% enrollment rate was feasible; describe PROs in this population; and explore the relationship between child/family characteristics and PROs. Methods: Participants included 12- to 18-year-old patients and parents of 5- to 18-year-olds receiving care at PWMP in eight HWN sites. Patient-Reported Outcomes Measurement Information System (PROMIS®) measures assessed global health (GH), fatigue, stress, and family relationships (FR). T-score cut points defined poor GH or FR or severe fatigue or stress. Generalized estimating equations explored relationships between patient/family characteristics and PROMIS measures. Results: Overall, 63% of eligible parents and 52% of eligible children enrolled. Seven sites achieved the goal enrollment for parents and four for children. Participants included 1447 children. By self-report, 44.6% reported poor GH, 8.6% poor FR, 9.3% severe fatigue, and 7.6% severe stress. Multiple-parent household was associated with lower odds of poor GH by parent proxy report [adjusted odds ratio (aOR) 0.69, 95% confidence interval (CI) 0.55-0.88] and poor FR by self-report (aOR 0.36, 95% CI 0.17-0.74). Parents were significantly more likely to report that the child had poor GH and poor FR when a child had multiple households. Conclusions: PROs were feasibly assessed across the HWN, although implementation varied by site. Nearly half of the children seeking care in PWMP reported poor GH, and family context may play a role. Future work may build on this pilot to show how PROs can inform clinical care in PWMP.
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Affiliation(s)
- Erinn T. Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - Thao-Ly T. Phan
- Department of General Pediatrics, Nemours Children's Health System/Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth R. Earley
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ihuoma Eneli
- Center for Healthy Weight and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Matthew A. Haemer
- Section of Nutrition, Department of Pediatrics, University of Colorado, Denver, CO, USA
| | | | - Saba Khan
- The Healthy Weight Program and Policy Lab, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Grace Kim
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Shelley Kirk
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- The Heart Institute and Center for Better Health and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Janis M. Stoll
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Lloyd N. Werk
- Department of Pediatrics, Nemours Children's Hospital, Orlando, FL, USA
| | - Karen Askov Zeribi
- Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Christopher B. Forrest
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Carole Lannon
- Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Addison J, Razzaghi H, Bailey C, Dickinson K, Corathers SD, Hartley DM, Utidjian L, Carle AC, Rhodes ET, Alonso GT, Haller MJ, Gannon AW, Indyk JA, Arbeláez AM, Shenkman E, Forrest CB, Eckrich D, Magnusen B, Davies SD, Walsh KE. Testing an Automated Approach to Identify Variation in Outcomes among Children with Type 1 Diabetes across Multiple Sites. Pediatr Qual Saf 2022; 7:e602. [PMID: 38584961 PMCID: PMC10997286 DOI: 10.1097/pq9.0000000000000602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/21/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Efficient methods to obtain and benchmark national data are needed to improve comparative quality assessment for children with type 1 diabetes (T1D). PCORnet is a network of clinical data research networks whose infrastructure includes standardization to a Common Data Model (CDM) incorporating electronic health record (EHR)-derived data across multiple clinical institutions. The study aimed to determine the feasibility of the automated use of EHR data to assess comparative quality for T1D. Methods In two PCORnet networks, PEDSnet and OneFlorida, the study assessed measures of glycemic control, diabetic ketoacidosis admissions, and clinic visits in 2016-2018 among youth 0-20 years of age. The study team developed measure EHR-based specifications, identified institution-specific rates using data stored in the CDM, and assessed agreement with manual chart review. Results Among 9,740 youth with T1D across 12 institutions, one quarter (26%) had two or more measures of A1c greater than 9% annually (min 5%, max 47%). The median A1c was 8.5% (min site 7.9, max site 10.2). Overall, 4% were hospitalized for diabetic ketoacidosis (min 2%, max 8%). The predictive value of the PCORnet CDM was >75% for all measures and >90% for three measures. Conclusions Using EHR-derived data to assess comparative quality for T1D is a valid, efficient, and reliable data collection tool for measuring T1D care and outcomes. Wide variations across institutions were observed, and even the best-performing institutions often failed to achieve the American Diabetes Association HbA1C goals (<7.5%).
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Affiliation(s)
- Jessica Addison
- From the Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, Mass
| | - Hanieh Razzaghi
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Pa
| | - Charles Bailey
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Pa
| | - Kimberley Dickinson
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Pa
| | - Sarah D. Corathers
- Division of Endocrinology, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David M. Hartley
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Levon Utidjian
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Pa
| | - Adam C. Carle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Psychology, College of Arts and Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Erinn T. Rhodes
- Division of Endocrinology, Boston Children’s Hospital, Boston, Mass
- Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - G. Todd Alonso
- University of Colorado Anschutz Medical Campus, Barbara Davis Center, Aurora, Colo
| | | | | | - Justin A. Indyk
- Section of Endocrinology, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ana Maria Arbeláez
- Washington University in St. Louis, St. Louis, Mo
- St. Louis Children’s Hospital, St. Louis, Mo
| | - Elizabeth Shenkman
- University of Florida, College of Medicine, Department of Health Outcomes and Biomedical Informatics, Gainesville, Fla
| | | | | | | | - Sara Deakyne Davies
- University of Colorado Anschutz Medical Campus, Barbara Davis Center, Aurora, Colo
| | - Kathleen E. Walsh
- Department of Pediatrics, Harvard Medical School, Boston, Mass
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Mass
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Finkelstein JB, Tremblay ES, Van Cain M, Farber-Chen A, Schumann C, Brown C, Shah AS, Rhodes ET. Pediatric Clinicians' Use of Telemedicine: Qualitative Interview Study. JMIR Hum Factors 2021; 8:e29941. [PMID: 34860669 PMCID: PMC8686477 DOI: 10.2196/29941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/05/2021] [Accepted: 08/31/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Bedside manner describes how clinicians relate to patients in person. Telemedicine allows clinicians to connect virtually with patients using digital tools. Effective virtual communication or webside manner may require modifications to traditional bedside manner. OBJECTIVE This study aims to understand the experiences of telemedicine providers with patient-to-provider virtual visits and communication with families at a single large-volume children's hospital to inform program development and training for future clinicians. METHODS A total of 2 focus groups of pediatric clinicians (N=11) performing virtual visits before the COVID-19 pandemic, with a range of experiences and specialties, were engaged to discuss experiential, implementation, and practice-related issues. Focus groups were facilitated using a semistructured guide covering general experience, preparedness, rapport strategies, and suggestions. Sessions were digitally recorded, and the corresponding transcripts were reviewed for data analysis. The transcripts were coded based on the identified main themes and subthemes. On the basis of a higher-level analysis of these codes, the study authors generated a final set of key themes to describe the collected data. RESULTS Theme consistency was identified across diverse participants, although individual clinician experiences were influenced by their specialties and practices. A total of 3 key themes emerged regarding the development of best practices, barriers to scalability, and establishing patient rapport. Issues and concerns related to privacy were salient across all themes. Clinicians felt that telemedicine required new skills for patient interaction, and not all were comfortable with their training. CONCLUSIONS Telemedicine provides benefits as well as challenges to health care delivery. In interprofessional focus groups, pediatric clinicians emphasized the importance of considering safety and privacy to promote rapport and webside manner when conducting virtual visits. The inclusion of webside manner instructions within training curricula is crucial as telemedicine becomes an established modality for providing health care.
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Affiliation(s)
- Julia B Finkelstein
- Department of Urology, Boston Children's Hospital, Boston, MA, United States
| | - Elise S Tremblay
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, United States
| | - Melissa Van Cain
- Department of Medical Informatics, School of Community Medicine, University of Oklahoma, Tulsa, OK, United States
| | - Aaron Farber-Chen
- Innovation and Digital Health Accelerator, Boston Children's Hospital, Boston, MA, United States
| | - Caitlin Schumann
- Innovation and Digital Health Accelerator, Boston Children's Hospital, Boston, MA, United States
| | - Christina Brown
- Innovation and Digital Health Accelerator, Boston Children's Hospital, Boston, MA, United States
| | - Ankoor S Shah
- Innovation and Digital Health Accelerator, Boston Children's Hospital, Boston, MA, United States.,Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Erinn T Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, United States
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6
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Danne T, Lanzinger S, de Bock M, Rhodes ET, Alonso GT, Barat P, Elhenawy Y, Kershaw M, Saboo B, Scharf Pinto M, Chobot A, Dovc K. A Worldwide Perspective on COVID-19 and Diabetes Management in 22,820 Children from the SWEET Project: Diabetic Ketoacidosis Rates Increase and Glycemic Control Is Maintained. Diabetes Technol Ther 2021; 23:632-641. [PMID: 34086503 DOI: 10.1089/dia.2021.0110] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Aims: To investigate the short-term effects of the first wave of COVID-19 on clinical parameters in children with type 1 diabetes (T1D) from 82 worldwide centers participating in the Better Control in Pediatric and Adolescent DiabeteS: Working to CrEate CEnTers of Reference (SWEET) registry. Materials and Methods: Aggregated data per person with T1D ≤21 years of age were compared between May/June 2020 (first wave), August/September 2020 (after wave), and the same periods in 2019. Hierarchic linear and logistic regression models were applied. Models were adjusted for gender, age-, and diabetes duration-groups. To distinguish the added burden of the COVID-19 pandemic, the centers were divided into quartiles of first wave COVID-19-associated mortality in their country. Results: In May/June 2019 and 2020, respectively, there were 16,735 versus 12,157 persons, 52% versus 52% male, median age 13.4 (Q1; Q3: 10.1; 16.2) versus13.5 (10.2; 16.2) years, T1D duration 4.5 (2.1; 7.8) versus 4.5 (2.0; 7.8) years, and hemoglobin A1c (HbA1c) 60.7 (53.0; 73.8) versus 59.6 (50.8; 70.5) mmol/mol [7.8 (7.0; 8.9) versus 7.6 (6.8; 8.6) %]. Across all country quartiles of COVID-19 mortality, HbA1c and rate of severe hypoglycemia remained comparable to the year before the first wave, while diabetic ketoacidosis rates increased significantly in the centers from countries with the highest mortality rate, but returned to baseline after the wave. Continuous glucose monitoring use decreased slightly during the first wave (53% vs. 51%) and increased significantly thereafter (55% vs. 63%, P < 0.001). Conclusions: Although glycemic control was maintained, a significant rise in DKA at follow-up was seen during first wave in the quartile of countries with the highest COVID mortality. Trial Registration: NCT04427189.
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Affiliation(s)
- Thomas Danne
- Diabetes Centre, Children's Hospital AUF DER BULT, Hannover, Germany
- SWEET e.V., Hannoversche Kinderheilanstalt, Hannover, Germany
| | - Stefanie Lanzinger
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany
- German Centre for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Martin de Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Erinn T Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - G Todd Alonso
- University of Colorado Denver and Barbara Davis Center for Diabetes, Aurora, Colorado, USA
| | - Pascal Barat
- Centre DiaBEA, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Yasmine Elhenawy
- Pediatric and Adolescent Diabetes Unit (PADU), Ain Shams University, Cairo, Egypt
| | - Melanie Kershaw
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | | | - Mauro Scharf Pinto
- Centro de Diabetes Curitiba and Division of Pediatric Endocrinology, Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | - Agata Chobot
- Department of Pediatrics, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Klemen Dovc
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, UMC-University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Berry DC, Rhodes ET, Hampl S, Young CB, Cohen G, Eneli I, Fleischman A, Ip E, Sweeney B, Houle TT, Skelton J. Stay in treatment: Predicting dropout from pediatric weight management study protocol. Contemp Clin Trials Commun 2021; 22:100799. [PMID: 34169176 PMCID: PMC8209185 DOI: 10.1016/j.conctc.2021.100799] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 05/18/2021] [Accepted: 06/06/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Childhood obesity is a serious public health concern. Multidisciplinary pediatric weight management programs have been deemed effective. However, effectiveness of these programs is impacted by attrition, limiting health benefits to children, and inefficiently utilizing scarce resources. Methods We have developed a model (the Outcomes Forecasting System, OFS) that isolates variables associated with attrition from pediatric weight management, with the potential to forecast participant dropout. In Aim 1, we will increase the power and precision of the OFS and then validate the model through the consistent acquisition of key patient, family, and treatment data, from three different weight management sites. In Aim 2, external validity will be established through the application of the OFS at a fourth pediatric weight management program. Aim 3 will be a pilot clinical trial, incorporating an intervention built on the results of Aims 1 and 2 and utilizing the OFS to reduce attrition. Discussion A greater understanding of the patient, family, and disease-specific factors that predict dropout from pediatric weight management can be utilized to prevent attrition. The goal of the current study is to refine the OFS to a level of precision and efficiency to be a valuable tool to any weight management program. By identifying the most pertinent factors driving attrition across weight management sites, new avenues for treatment will be identified. This study will result in a valuable forecasting tool that will be applicable for diverse programs and populations, decrease program costs, and improve patient retention, adherence, and outcomes. Clinicaltrials.gov identifier NCT04364282.
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Affiliation(s)
- Diane C Berry
- The University of North Carolina, School of Nursing, Chapel Hill, NC, USA
| | - Erinn T Rhodes
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Sarah Hampl
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Caroline Blackwell Young
- Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Gail Cohen
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Ihuoma Eneli
- Department of Pediatrics, Ohio State University, Columbus, OH, USA
| | - Amy Fleischman
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Edward Ip
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Brooke Sweeney
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Timothy T Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph Skelton
- Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
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8
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Bottino CJ, Fleegler EW, Cox JE, Rhodes ET. The Relationship Between Housing Instability and Poor Diet Quality Among Urban Families. Acad Pediatr 2019; 19:891-898. [PMID: 30986548 DOI: 10.1016/j.acap.2019.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 04/04/2019] [Accepted: 04/09/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To examine associations between housing instability and poor diet quality in a sample of urban parents and children. METHODS Cross-sectional study of 340 parent/guardian-child dyads visiting a pediatric primary care center in Boston, Massachusetts. The parent/guardian (hereafter, parent) completed 2 Harvard Service Food Frequency Questionnaires, one regarding their own dietary intake and one regarding their child's intake, and an assessment of health-related social needs. Diet quality was measured using the Healthy Eating Index-2010 (HEI-2010; score range 0-100). Housing instability was defined as: 1) homeless or in sheltered housing, 2) doubled up with another family, 3) utilities threatened or shut off, or 4) concerned about eviction. Multivariable logistic regression was used to measure associations between unstable housing and lowest-quartile HEI-2010 scores, adjusting for parent age, race/ethnicity, education, income, and child age. RESULTS Median (interquartile range) parent and child HEI-2010 scores were 63.8 (56.3-70.8) and 59.0 (54.2-64.7), respectively. Housing instability was found in 136 dyads (40%). In multivariable analysis, it was associated with increased odds of lowest-quartile total parent HEI-2010 scores (adjusted odds ratio [aOR], 1.9; 95% confidence interval [95% CI], 1.1-3.5) but not child scores (aOR, 1.4; 95% CI, 0.8-2.5). It also was associated with increased odds of lowest-quartile parent HEI-2010 dietary component scores for Total vegetables and Greens and beans (aOR, 2.0; 95% CI, 1.1-3.7 and aOR, 2.5; 95% CI, 1.3-4.8, respectively). CONCLUSIONS In this urban primary care population, housing instability is associated with lower diet quality scores for parents but not children. Lower vegetable consumption appears to drive this association.
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Affiliation(s)
- Clement J Bottino
- Divisions of General Pediatrics (CJ Bottino and JE Cox); Department of Pediatrics, Boston Children's Hospital; and Harvard Medical School (CJ Bottino, EW Fleegler, JE Cox, and ET Rhodes) Boston, Mass.
| | - Eric W Fleegler
- Emergency Medicine (EW Fleegler); Department of Pediatrics, Boston Children's Hospital; and Harvard Medical School (CJ Bottino, EW Fleegler, JE Cox, and ET Rhodes) Boston, Mass
| | - Joanne E Cox
- Divisions of General Pediatrics (CJ Bottino and JE Cox); Department of Pediatrics, Boston Children's Hospital; and Harvard Medical School (CJ Bottino, EW Fleegler, JE Cox, and ET Rhodes) Boston, Mass
| | - Erinn T Rhodes
- Endocrinology (ER Rhodes); Department of Pediatrics, Boston Children's Hospital; and Harvard Medical School (CJ Bottino, EW Fleegler, JE Cox, and ET Rhodes) Boston, Mass
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9
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Lennerz BS, Barton A, Bernstein RK, Dikeman RD, Diulus C, Hallberg S, Rhodes ET, Ebbeling CB, Westman EC, Yancy WS, Ludwig DS. Management of Type 1 Diabetes With a Very Low-Carbohydrate Diet. Pediatrics 2018; 141:peds.2017-3349. [PMID: 29735574 PMCID: PMC6034614 DOI: 10.1542/peds.2017-3349] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2018] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES To evaluate glycemic control among children and adults with type 1 diabetes mellitus (T1DM) who consume a very low-carbohydrate diet (VLCD). METHODS We conducted an online survey of an international social media group for people with T1DM who follow a VLCD. Respondents included adults and parents of children with T1DM. We assessed current hemoglobin A1c (HbA1c) (primary measure), change in HbA1c after the self-reported beginning of the VLCD, total daily insulin dose, and adverse events. We obtained confirmatory data from diabetes care providers and medical records. RESULTS Of 316 respondents, 131 (42%) were parents of children with T1DM, and 57% were of female sex. Suggestive evidence of T1DM (based on a 3-tier scoring system in which researchers took into consideration age and weight at diagnosis, pancreatic autoimmunity, insulin requirement, and clinical presentation) was obtained for 273 (86%) respondents. The mean age at diagnosis was 16 ± 14 years, the duration of diabetes was 11 ± 13 years, and the time following a VLCD was 2.2 ± 3.9 years. Participants had a mean daily carbohydrate intake of 36 ± 15 g. Reported mean HbA1c was 5.67% ± 0.66%. Only 7 (2%) respondents reported diabetes-related hospitalizations in the past year, including 4 (1%) for ketoacidosis and 2 (1%) for hypoglycemia. CONCLUSIONS Exceptional glycemic control of T1DM with low rates of adverse events was reported by a community of children and adults who consume a VLCD. The generalizability of these findings requires further studies, including high-quality randomized controlled trials.
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Affiliation(s)
- Belinda S. Lennerz
- Division of Endocrinology, and,New Balance Foundation Obesity Prevention Center, Boston Children’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Anna Barton
- Richmond Diabetes and Endocrinology, Bon Secours Medical Group, Richmond, Virginia
| | | | | | | | - Sarah Hallberg
- Virta Health and Indiana University Health, School of Medicine, Indiana University, Indianapolis, Indiana; and
| | | | - Cara B. Ebbeling
- Division of Endocrinology, and,New Balance Foundation Obesity Prevention Center, Boston Children’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | | | | | - David S. Ludwig
- Division of Endocrinology, and,New Balance Foundation Obesity Prevention Center, Boston Children’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
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10
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von Oettingen JE, Rhodes ET, Wolfsdorf JI. Resolution of ketoacidosis in children with new onset diabetes: Evaluation of various definitions. Diabetes Res Clin Pract 2018; 135:76-84. [PMID: 29111277 PMCID: PMC6013285 DOI: 10.1016/j.diabres.2017.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 08/22/2017] [Accepted: 09/18/2017] [Indexed: 01/21/2023]
Abstract
AIMS Data are sparse concerning use of serum electrolyte parameters as compared to venous blood gas (VBG) measurements to monitor acid-base status during treatment of diabetic ketoacidosis (DKA). We explored the utility of various parameters to define DKA resolution by investigating the relationship of venous pH (vpH), anion gap (AG), serum bicarbonate (HCO3), and glucose concentration during management of DKA in children with new onset diabetes mellitus (NODM). METHODS We included all patients with NODM presenting with DKA to Boston Children's Hospital from 10/1/07-7/1/13. DKA was defined as serum glucose ≥ 200 mg/dL (11.1 mmol/L) and vpH<7.30; severity as mild <7.30, moderate<7.20, severe<7.10; resolution of DKA as vpH≥7.30 and AG≤18 mmol/L. We used Cox regression to determine time to DKA resolution, and logistic regression to evaluate different serum HCO3 cut-off values as predictors of DKA resolution. RESULTS 263 patients (133F, mean age 9.9±4.4 years, 74% White) were included. DKA was mild in 134 (51%), moderate in 75 (28%) and severe in 54 (20%). In mild DKA, AG closed after normalization of vpH; in moderate and severe DKA, AG closed before normalization of vpH. HCO3>15mmol/L correlated with vpH≥7.30, and had 76% sensitivity and 85% specificity to predict DKA resolution. Median times to DKA resolution were similar using two different definitions: vpH and AG (8.4h [IQR 6.3-11.9]) vs. HCO3>15 mmol/L (7.9 h [IQR 5.0-11.8]), p=.42. CONCLUSIONS During management of pediatric DKA, HCO3 > 15 mmol/L reliably predicts resolution of DKA. In low-resource settings where VBG is unavailable, electrolyte parameters alone may be used to determine DKA resolution.
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Affiliation(s)
- Julia E von Oettingen
- Division of Endocrinology, Montreal Children's Hospital, McGill University Health Center, Montreal, QC H4A3J1, Canada; Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA.
| | - Erinn T Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
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11
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Rhodes ET, Vernacchio L, Mitchell AA, Fischer C, Giacalone P, Ludwig DS, Ebbeling CB. A telephone intervention to achieve differentiation in dietary intake: a randomized trial in paediatric primary care. Pediatr Obes 2017; 12:494-501. [PMID: 27492865 PMCID: PMC5529253 DOI: 10.1111/ijpo.12171] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 05/23/2016] [Accepted: 06/27/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Telehealth offers opportunities to extend clinical and research interventions for paediatric obesity. OBJECTIVES To assess utility of a telephone intervention, implemented through a national primary care paediatric research network, for promoting differentiation in dietary intake, consistent with either a low-glycemic load (Low GL) or Low Fat prescription, among overweight/obese school-age children. METHODS Five-week telephone dietary counselling intervention for parents of overweight/obese school-age children recruited through the Slone Center Office-based Research Network. Parent-child dyads were randomized to Low GL or Low Fat diet. Primary outcomes were dietary GL and dietary fat, adjusted for energy intake and assessed by 24-h dietary recall. RESULTS Subjects were randomized to Low GL (n = 11, 8.1 ± 1.7 years, 45.5% male) or Low Fat (n = 11, 8.2 ± 2.0 years, 36.4% male), with no baseline differences. Overall, 86% of subjects attended at least four of five counselling sessions, and study completion rate was 91% (based on completion of the final dietary recalls). Reported satisfaction was high. In adjusted analyses limited to 'recall completers,' reduction in dietary GL (g/1000 kcal) achieved within the Low GL group was significant (p = 0.01) and greater than the change in dietary GL in the Low Fat group (mean ± SE; -12.9 ± 4.4 vs. 5.1 ± 4.9, p = 0.03). Similarly, reduction in dietary fat (% of total energy) within the Low Fat group was significant (-5.6 ± 2.5, p = 0.046) but with no difference between groups (p = 0.25). CONCLUSION A telephone-based dietary intervention for overweight/obese children, implemented through a national paediatric research network, fostered prescribed dietary changes. ClinicalTrials.gov registration: NCT00620152.
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Affiliation(s)
- Erinn T. Rhodes
- Division of Endocrinology, Boston Children’s Hospital,
Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Louis Vernacchio
- Department of Pediatrics, Harvard Medical School, Boston, MA,Pediatric Physicians’ Organization at Children’s,
Boston Children’s Hospital, Boston, MA
| | - Allen A. Mitchell
- Slone Epidemiology Center, Boston University School of Medicine,
Boston, MA
| | - Corrine Fischer
- Division of Endocrinology, Boston Children’s Hospital,
Boston, MA
| | - Pamela Giacalone
- Division of Endocrinology, Boston Children’s Hospital,
Boston, MA,Harvard Longwood Psychiatry Residency Training Program, Boston
MA
| | - David S. Ludwig
- Division of Endocrinology, Boston Children’s Hospital,
Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Cara B. Ebbeling
- Division of Endocrinology, Boston Children’s Hospital,
Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
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12
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Bottino CJ, Rhodes ET, Kreatsoulas C, Cox JE, Fleegler EW. Food Insecurity Screening in Pediatric Primary Care: Can Offering Referrals Help Identify Families in Need? Acad Pediatr 2017; 17:497-503. [PMID: 28302365 DOI: 10.1016/j.acap.2016.10.006] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 09/24/2016] [Accepted: 10/10/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To describe a clinical approach for food insecurity screening incorporating a menu offering food-assistance referrals, and to examine relationships between food insecurity and referral selection. METHODS Caregivers of 3- to 10-year-old children presenting for well-child care completed a self-administered questionnaire on a laptop computer. Items included the US Household Food Security Survey Module: 6-Item Short Form (food insecurity screen) and a referral menu offering assistance with: 1) finding a food pantry, 2) getting hot meals, 3) applying for Supplemental Nutrition Assistance Program (SNAP), and 4) applying for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Referrals were offered independent of food insecurity status or eligibility. We examined associations between food insecurity and referral selection using multiple logistic regression while adjusting for covariates. RESULTS A total of 340 caregivers participated; 106 (31.2%) reported food insecurity, and 107 (31.5%) selected one or more referrals. Forty-nine caregivers (14.4%) reported food insecurity but selected no referrals; 50 caregivers (14.7%) selected one or more referrals but did not report food insecurity; and 57 caregivers (16.8%) both reported food insecurity and selected one or more referrals. After adjustment, caregivers who selected one or more referrals had greater odds of food insecurity compared to caregivers who selected no referrals (adjusted odds ratio 4.0; 95% confidence interval 2.4-7.0). CONCLUSIONS In this sample, there was incomplete overlap between food insecurity and referral selection. Offering referrals may be a helpful adjunct to standard screening for eliciting family preferences and identifying unmet social needs.
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Affiliation(s)
- Clement J Bottino
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass.
| | - Erinn T Rhodes
- Division of Endocrinology, Department of Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Catherine Kreatsoulas
- Harvard T.H. Chan School of Public Health, Department of Social and Behavioral Sciences, Boston, Mass
| | - Joanne E Cox
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Eric W Fleegler
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
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13
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Zenlea IS, Melvin P, Huh SY, Mehta N, Reidy SJ, Rhodes ET, Ma NS. Risk Factors for Fractures in Children Hospitalized in Intensive and Intermediate Care Units. Hosp Pediatr 2017; 7:395-402. [PMID: 28588070 DOI: 10.1542/hpeds.2016-0213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Fragility fractures are increasingly recognized in hospitalized children. Our study aim was to identify risk factors for fracture in children hospitalized in intensive and intermediate care units. METHODS We conducted a retrospective, case-control study comparing the clinical characteristics of children with fractures (cases) to children without fractures (controls) matched for age, sex, hospital unit, admission quarter and year, ICU length of stay, severity of illness, and resource utilization. Bivariate comparisons and matched multivariable logistic regression modeling were used to determine associations between potential risk factors and fracture. RESULTS Median age at fracture for the 35 patients was 5.0 months (interquartile range 2.0 to 10.0 months) and at a comparable interval for the 70 matched controls was 3.5 months (interquartile range 2.0 to 7.0 months). In bivariate analyses, factors associated with fracture included: primary diagnosis of tracheoesophageal fistula, esophageal atresia and stenosis; diagnosis of kidney disease; and per 5-day increase in median cumulative ICU days at risk. In the final model, a respiratory disease diagnosis (odds ratio 3.9, 95% confidence interval 1.1-13.7) and per 5-day increase in median cumulative ICU days at risk (odds ratio 1.3, 95% confidence interval 1.0-1.6) were significant independent risk factors for fracture. CONCLUSIONS Children prone to fracture in the hospital are young, medically complex patients who require extended periods of intensive level medical care and potentially life-sustaining treatment modalities. The children who would benefit most from fracture reduction efforts are those with respiratory disease and prolonged ICU stays.
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Affiliation(s)
- Ian S Zenlea
- Department of Pediatrics, and.,Division of Endocrinology
| | | | - Susanna Y Huh
- Department of Pediatrics, and.,Division of Gastroenterology, Hepatology and Nutrition
| | - Nilesh Mehta
- Division of Critical Care Medicine, and.,Department of Anesthesiology, Perioperative and Pain Medicine Harvard Medical School, Boston, Massachusetts; and
| | - Suzanne J Reidy
- Cardiovascular Program, Boston Children's Hospital, Boston, Massachusetts
| | - Erinn T Rhodes
- Department of Pediatrics, and.,Division of Endocrinology
| | - Nina S Ma
- Department of Pediatrics, and .,Division of Endocrinology
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14
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Rhodes ET, Boles RE, Chin K, Christison A, Testa EG, Guion K, Hawkins MJ, Petty CR, Sallinen Gaffka B, Santos M, Shaffer L, Tucker J, Hampl SE. Expectations for Treatment in Pediatric Weight Management and Relationship to Attrition. Child Obes 2017; 13:120-127. [PMID: 28092464 PMCID: PMC5369386 DOI: 10.1089/chi.2016.0215] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Attrition in pediatric weight management negatively impacts treatment outcomes. A potentially modifiable contributor to attrition is unmet family expectations. This study aimed to evaluate the association between adolescent and parent/guardian treatment expectations and attrition. PATIENTS AND METHODS A prospective, nonrandomized, uncontrolled, single-arm pilot trial was conducted among 12 pediatric weight management programs in the Children's Hospital Association's FOCUS on a Fitter Future collaborative. Parents/guardians and adolescents completed an expectations/goals survey at their initial visit, with categories including healthier food/drinks, physical activity/exercise, family support/behavior, and weight management goals. Attrition was assessed at 3 months. RESULTS From January to August 2013, 405 parents/guardians were recruited and reported about their children (203 adolescents, 202 children <12 years). Of the 203 adolescents, 160 also self-reported. Attrition rate was 42.2% at 3 months. For adolescents, greater interest in family support/behavior skills was associated with decreased odds of attrition at 3 months [odds ratio (OR) 0.75, 95% confidence interval (CI) 0.57-0.98, p = 0.04]. The more discordant the parent/adolescent dyad responses in this category, the higher the odds of attrition at 3 months (OR 1.36, 95% CI 1.04-1.78, p = 0.02). Weight loss was an important weight management goal for both adolescents and parents. For adolescents with this goal, the median weight-loss goal was 50 pounds. Attrition was associated with adolescent weight-loss goals above the desired median (50% above the median vs. 28% below the median, p = 0.02). CONCLUSIONS Assessing initial expectations may help tailor treatment to meet families' needs, especially through focus on family-based change and realistic goal setting. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov NCT01753063.
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Affiliation(s)
- Erinn T. Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, MA
| | | | - Kimberly Chin
- Clinical Research Center, Boston Children's Hospital, Boston, MA
| | | | | | | | | | - Carter R. Petty
- Clinical Research Center, Boston Children's Hospital, Boston, MA
| | - Bethany Sallinen Gaffka
- Pediatric Comprehensive Weight Management Center, University of Michigan Health System, Ann Arbor, MI
| | | | | | - Jared Tucker
- Helen DeVos Children's Hospital, Grand Rapids, MI
| | - Sarah E. Hampl
- Pediatrics and Center for Children's Healthy Lifestyles & Nutrition, Children's Mercy Hospital, Kansas City, MO
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15
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Zenlea IS, Milliren C, Herel S, Thomaseo Burton E, Askins N, Ludwig DS, Rhodes ET. Outcomes from an orientation model to reduce attrition in paediatric weight management. Clin Obes 2016; 6:313-20. [PMID: 27487780 PMCID: PMC5023470 DOI: 10.1111/cob.12156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/16/2016] [Accepted: 06/17/2016] [Indexed: 12/01/2022]
Abstract
We aimed to reduce attrition of newly referred patients in a paediatric weight management programme by implementing an orientation to address families' expectations and screen for and support behavioural and mental health problems and psychosocial stressors at programme outset. Orientation impact was monitored with run charts with percentages of scheduled encounters completed. Long-term impact was assessed by comparing patients in the initial 6 months of the orientation to a baseline group of referred patients during the same 6-month time interval in the prior year (Pre-Orientation Group). The outcome measure was programme attrition within 15 months. Groups were compared using Kaplan-Meier survival analysis and Cox proportional hazards regression modelling. Patients in the Orientation Group had a 23% increased odds of attrition compared to patients in the Pre-Orientation group (adjusted Hazard ratio, aHR 1.23; 95% confidence interval, CI: 1.01, 1.51) and shorter median duration of follow-up (2.0 vs. 2.9 months, P = 0.004). An increase in body mass index z-score of 1 unit resulted in a nearly fivefold increased odds of attrition (aHR 5.24; 95% CI: 2.95, 9.3). An orientation for new patients did not reduce attrition within 15 months. We suggest that ongoing retention strategies should be embedded into the treatment phase of the programme.
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Affiliation(s)
- I S Zenlea
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - C Milliren
- Clinical Research Center, Boston Children's Hospital, Boston, MA, USA
| | - S Herel
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- New Balance Obesity Prevention Center, Boston Children's Hospital, Boston, MA, USA
| | - E Thomaseo Burton
- New Balance Obesity Prevention Center, Boston Children's Hospital, Boston, MA, USA
- Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - N Askins
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - D S Ludwig
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- New Balance Obesity Prevention Center, Boston Children's Hospital, Boston, MA, USA
| | - E T Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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16
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von Oettingen JE, Wolfsdorf JI, Feldman HA, Rhodes ET. Utility of diabetes-associated autoantibodies for classification of new onset diabetes in children and adolescents. Pediatr Diabetes 2016; 17:417-25. [PMID: 26315669 PMCID: PMC5318301 DOI: 10.1111/pedi.12304] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 07/14/2015] [Accepted: 07/15/2015] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To determine whether measuring diabetes-associated autoantibodies (DAA) in pediatric new onset diabetes (NODM) can be restricted to patients with equivocal diabetes type. RESEARCH DESIGN AND METHODS Retrospective analysis of all patients with NODM admitted to Boston Children's Hospital from 1 October 2007 to 1 July 2013 who had measurement of DAA [glutamic acid decarboxylase, insulin, insulinoma-associated antigen 2 (IA-2)]. Data collection included initial diagnosis of diabetes type before DAA results and at follow-up. We used logistic regression to predict type 1 diabetes (T1D) and developed a clinical score to classify diabetes type. RESULTS Of 1089 patients (45.4% female, 76.7% White, age 10.6 ± 4.5 yr), initial diagnosis was 1021 (93.8%) T1D, 42 (3.9%) type 2 diabetes (T2D), and 26 (2.4%) other. Of 993 patients with clinical T1D, 78 (7.9%) were DAA-, and of 42 patients with clinical T2D, 12 (28.6%) were DAA+. Type of diabetes was reclassified at follow-up in less than 6% of patients. Data from a subset of 736 patients were used to develop a scoring system to predict T1D. Using weight z-score, age, and race, the scoring system had 91.7% sensitivity, 82% specificity, and a positive predictive value of 98.6%, and suggested DAA measurement was unnecessary in 85.3% of patients. Findings were similar in a validation cohort of 234 patients. CONCLUSIONS Application of a simple scoring system may reduce to ∼15% the number of DAA measurements needed to classify diabetes type, resulting in substantial cost savings. Clinical judgment should guide the decision to measure DAA.
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Affiliation(s)
- Julia E von Oettingen
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Henry A Feldman
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Clinical Research Center, Boston Children's Hospital, Boston, MA, USA
| | - Erinn T Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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17
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Bottino CJ, de Ferranti SD, Meyers AF, Rhodes ET. Massachusetts Pediatricians' Views Toward Body Mass Index Screening in Schools: Continued Controversy. Clin Pediatr (Phila) 2016; 55:844-50. [PMID: 26637404 DOI: 10.1177/0009922815618487] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective Evaluate Massachusetts pediatricians' views toward school-based body mass index screening since its implementation. Methods Survey of 286 members of the Massachusetts Chapter of the American Academy of Pediatrics on attitudes toward screening and perceived impact on clinical practice. Results Overall, 36.3% supported screening, with suburban or rural pediatricians significantly less likely (vs urban) to indicate support. Less than 10% of pediatricians agreed or strongly agreed that screening improved communication with schools (4.2%), communication with families (8.9%), or helped them care for patients (7.0%), with suburban or rural pediatricians significantly less likely to agree. Most pediatricians reported contact from patients regarding screening (59.4%) and identifying concerns from patients regarding screening during office visits (60.4%), including bullying and self-esteem. Suburban or rural pediatricians were significantly more likely to report patient contact and concerns related to screening. Conclusions Support for school-based body mass index screening is low among Massachusetts pediatricians, particularly among suburban and rural pediatricians.
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Affiliation(s)
- Clement J Bottino
- Boston Children's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - Sarah D de Ferranti
- Boston Children's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | | | - Erinn T Rhodes
- Boston Children's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
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18
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Zenlea IS, Burton ET, Askins N, Pluhar EI, Rhodes ET. The Burden of Psychosocial Stressors and Urgent Mental Health Problems in a Pediatric Weight Management Program. Clin Pediatr (Phila) 2015; 54:1247-56. [PMID: 25780257 PMCID: PMC4861055 DOI: 10.1177/0009922815574077] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To systematically screen for behavioral and mental health problems and psychosocial stressors (PS) in newly referred patients and adult caregivers (PACs) in a pediatric weight management program. METHODS We used the Strengths and Difficulties Questionnaire (SDQ), the Center for Epidemiologic Studies Depression Scale (CES-D) for caregivers and patients ≥18 years, and assessed urgent mental health concerns and psychosocial stressors. RESULTS A total of 243 PACs were screened; data were unavailable for 6. Compared with US normative data for the SDQ-Parent Proxy Version, the proportion of patients in our sample with borderline/abnormal total difficulties and conduct problems scores was greater for all age groups. Among adult caregivers with complete CES-D, 18.4% were at risk for depression. Eleven percent of patients screened positive for urgent mental health problems. Overall, 43% of patients and 57.4% of caregivers had PS. CONCLUSIONS Systematic screening identified untreated symptoms and significant PS. Addressing these complex problems likely requires collaborative approaches with community providers.
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Affiliation(s)
- Ian S. Zenlea
- Division of Endocrinology, Boston Children’s Hospital,
Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - E. Thomaseo Burton
- Division of Adolescent and Young Adult Medicine, Boston
Children’s Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Nissa Askins
- Division of Endocrinology, Boston Children’s Hospital,
Boston, MA
| | - Emily Israel Pluhar
- Department of Psychiatry, Harvard Medical School, Boston, MA,Department of Family Medicine, Tufts University School of Medicine,
Boston, MA
| | - Erinn T. Rhodes
- Division of Endocrinology, Boston Children’s Hospital,
Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
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19
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Abstract
OBJECTIVE To investigate whether serum bicarbonate (HCO3) levels can be used to accurately diagnose diabetic ketoacidosis (DKA) and classify its severity in children with new-onset diabetes mellitus (NODM). METHODS Retrospective study of all patients with NODM presenting to Boston Children's Hospital from October 1, 2007, to July 1, 2013. DKA was defined as blood glucose ≥200 mg/dL, venous pH (vpH) <7.3, and urine ketones ≥2+, and severe DKA as vpH <7.1. Linear regression was used to assess serum HCO3 as a predictor of vpH, and logistic regression to evaluate serum HCO3 as a predictor of DKA and severe DKA. RESULTS Of 690 study cohort subjects (47% girls, age 10.8 ± 4.3 years, 76.7% white), 19.4% presented with DKA. The relationship between serum HCO3 and vpH was log-linear (r = 0.87, 95% CI 0.85-0.89, P < .001). HCO3 predicted vpH (R(2) 0.75, P < .001) using the formula vpH = 6.81301 + (0.17823*ln[HCO3]) and DKA and severe DKA (c-statistic 0.97 [95% CI 0.96-0.99, P < .001] and 0.99 [95% CI 0.991-0.999, P < .001], respectively). HCO3 cutoffs of <18 and <8 mmol/L had sensitivities of 91.8% and 95.2%, and specificities of 91.7% and 96.7%, respectively, to diagnose DKA and severe DKA. Findings were similar in a validation cohort of 197 subjects. CONCLUSIONS Serum HCO3 concentration alone can substitute for vpH to diagnose DKA and classify severity in children with NODM. It is suggested as an alternative to reliance on vpH, especially in settings in which access to vpH measurement is limited.
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Affiliation(s)
| | - Joseph Wolfsdorf
- Division of Endocrinology, and ,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Henry A. Feldman
- Division of Endocrinology, and ,Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts; and
| | - Erinn T. Rhodes
- Division of Endocrinology, and ,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Affiliation(s)
- Ian S. Zenlea
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA
,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - E. Thomaseo Burton
- Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, MA
| | - Nissa Askins
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA
| | | | | | - Erinn T. Rhodes
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA
,Department of Pediatrics, Harvard Medical School, Boston, MA
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Rosenfield RL, DiMeglio LA, Mauras N, Ross J, Shaw ND, Greeley SAW, Haymond M, Rubin K, Rhodes ET. Commentary: Launch of a quality improvement network for evidence-based management of uncommon pediatric endocrine disorders: Turner syndrome as a prototype. J Clin Endocrinol Metab 2015; 100:1234-6. [PMID: 25844763 PMCID: PMC5393512 DOI: 10.1210/jc.2014-3845] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Traditional, hypothesis-oriented research approaches have thus far failed to generate sufficient evidence to achieve consensus about the management of children with many endocrine disorders, partly because of the rarity of these disorders and because of regulatory burdens unique to research in children. OBJECTIVE The Pediatric Endocrine Society is launching a quality improvement network in spring 2015 for the management of pediatric endocrine disorders that are relatively uncommon in any single practice and/or for which there is no consensus on management. DESIGN The first of the quality improvement programs to be implemented seeks to improve the care of 11- to 17-year-old girls with Turner syndrome who require initiation of estrogen replacement therapy by providing a standardized clinical assessment and management plan (SCAMP) for transdermal estradiol treatment to induce pubertal development. The SCAMP algorithm represents a starting point within current best practice that is meant to undergo refinement through an iterative process of analysis of deidentified data collected in the course of clinical care by a network of pediatric endocrinologists. CONCLUSION It is anticipated that this program will not only improve care, but will also result in actionable data that will generate new research hypotheses and changes in management of pediatric endocrine disorders.
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Affiliation(s)
- Robert L Rosenfield
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism (R.L.R., S.A.W.G.), The University of Chicago Pritzker School of Medicine, Chicago, Illinois 60637; Department of Pediatrics (L.A.D.), Indiana University School of Medicine, Indianapolis, Indiana 46202; Division of Endocrinology, Diabetes, and Metabolism (N.M.), Nemours Children's Clinic, Jacksonville, Florida 32207; Department of Pediatrics (J.R.), Jefferson University, Philadelphia, Pennsylvania 19107; Nemours/duPont Hospital for Children (J.R.), Wilmington, Delaware 19803; Reproductive Endocrine Unit (N.D.S.), Massachusetts General Hospital, Boston, Massachusetts 02114; Division of Endocrinology (N.D.S., E.T.R.), Boston Children's Hospital, Boston, Massachusetts 02115; Department of Pediatrics (M.H.), Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas 77030; Connecticut Children's Medical Center (K.R.), Hartford, Connecticut 06106; and University of Connecticut School of Medicine (K.R.), Farmington, Connecticut 06032
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22
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Rhodes ET, Gong C, Edge JA, Wolfsdorf JI, Hanas R. ISPAD Clinical Practice Consensus Guidelines 2014. Management of children and adolescents with diabetes requiring surgery. Pediatr Diabetes 2014; 15 Suppl 20:224-31. [PMID: 25182316 DOI: 10.1111/pedi.12172] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 06/09/2014] [Indexed: 11/25/2022] Open
Affiliation(s)
- Erinn T Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Zenlea IS, Mednick L, Rein J, Quinn M, Wolfsdorf J, Rhodes ET. Routine behavioral and mental health screening in young children with type 1 diabetes mellitus. Pediatr Diabetes 2014; 15:384-8. [PMID: 24274235 PMCID: PMC4033709 DOI: 10.1111/pedi.12099] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 09/30/2013] [Accepted: 10/23/2013] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The American Diabetes Association and International Society for Pediatric and Adolescent Diabetes recommend that providers of diabetes care receive training in the recognition of psychosocial problems related to diabetes. OBJECTIVE To report the results of routine behavioral/mental health screening for children with type 1 diabetes mellitus (T1D) seen in a multidisciplinary pediatric diabetes program. SUBJECTS AND METHODS This was a cross-sectional study of children with T1D ages 4-11 years, who underwent behavioral/mental health screening as part of their diabetes care. Screening utilized the Strengths and Difficulties Questionnaire (SDQ) Parent Proxy Version, and scores were reviewed by a social worker. SDQ scale and total difficulties scores were compared by gender, visit type, age, T1D duration, and HbA1c. Scores were also compared to age-appropriate normative data for children in United States of America (US). RESULTS SDQ Parent Proxy Version total difficulties and scale scores did not differ by patient or visit characteristics. Compared with normative data for US children, a greater proportion of children with T1D ages 4-7 and 8-10 years had borderline/abnormal scores on the emotional symptoms scale (p = 0.01 and p = 0.03, respectively), suggesting risk for psychological disorders, such as anxiety and depression. CONCLUSIONS Our findings suggest that children less than 11 years old with T1D may have greater emotional symptoms as compared to their age-matched healthy peers. Pediatric diabetes care providers, with access to mental health services, should consider incorporating routine behavioral/mental health screening for children less than 12 years old in their practice.
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Affiliation(s)
- Ian Spencer Zenlea
- Division of Endocrinology, Boston Children’s Hospital, 333 Longwood Avenue, 6 Floor, Boston, MA, United States, 02115
| | - Lauren Mednick
- Department of Psychology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA, United States, 02115
| | - Jennifer Rein
- Division of Endocrinology, Boston Children’s Hospital, 333 Longwood Avenue, 6 Floor, Boston, MA, United States, 02115
| | - Maryanne Quinn
- Division of Endocrinology, Boston Children’s Hospital, 333 Longwood Avenue, 6 Floor, Boston, MA, United States, 02115,Department of Pediatrics, Harvard Medical School, 250 Longwood Ave, Boston, MA, United States 02115
| | - Joseph Wolfsdorf
- Division of Endocrinology, Boston Children’s Hospital, 333 Longwood Avenue, 6 Floor, Boston, MA, United States, 02115,Department of Pediatrics, Harvard Medical School, 250 Longwood Ave, Boston, MA, United States 02115
| | - Erinn T. Rhodes
- Division of Endocrinology, Boston Children’s Hospital, 333 Longwood Avenue, 6 Floor, Boston, MA, United States, 02115,Department of Pediatrics, Harvard Medical School, 250 Longwood Ave, Boston, MA, United States 02115
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Haemer MA, Grow HM, Fernandez C, Lukasiewicz GJ, Rhodes ET, Shaffer LA, Sweeney B, Woolford SJ, Estrada E. Addressing prediabetes in childhood obesity treatment programs: support from research and current practice. Child Obes 2014; 10:292-303. [PMID: 25055134 PMCID: PMC4120814 DOI: 10.1089/chi.2013.0158] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) and prediabetes have increased in prevalence among overweight and obese children, with significant implications for long-term health. There is little published evidence on the best approaches to care of prediabetes among overweight youth or the current practices used across pediatric weight management programs. METHODS This article reviews the literature and summarizes current practices for screening, diagnosis, and treatment of prediabetes at childhood obesity treatment centers. Findings regarding current practice were based on responses to an online survey from 28 pediatric weight management programs at 25 children's hospitals in 2012. Based on the literature reviewed, and empiric data, consensus support statements on prediabetes care and T2DM prevention were developed among representatives of these 25 children's hospitals' obesity clinics. RESULTS The evidence reviewed demonstrates that current T2DM and prediabetes diagnostic parameters are derived from adult-based studies with little understanding of clinical outcomes among youth. Very limited evidence exists on preventing progression of prediabetes. Some evidence suggests that a significant proportion of obese youth with prediabetes will revert to normoglycemia without pharmacological management. Evidence supports lifestyle modification for children with prediabetes, but further study of specific lifestyle changes and pharmacological treatments is needed. CONCLUSION Evidence to guide management of prediabetes in children is limited. Current practice patterns of pediatric weight management programs show areas of variability in practice, reflecting the limited evidence base. More research is needed to guide clinical care for overweight youth with prediabetes.
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Affiliation(s)
- Matthew A. Haemer
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, CO
| | - H. Mollie Grow
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Cristina Fernandez
- Department of Pediatrics, Creighton University School of Medicine, Omaha, NE
| | | | - Erinn T. Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, MA
| | - Laura A. Shaffer
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY
| | - Brooke Sweeney
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY
| | | | - Elizabeth Estrada
- Division of Endocrinology, Connecticut Children's Medical Center, Hartford, CT
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Garvey KC, Wolpert HA, Laffel LM, Rhodes ET, Wolfsdorf JI, Finkelstein JA. Health care transition in young adults with type 1 diabetes: barriers to timely establishment of adult diabetes care. Endocr Pract 2014; 19:946-52. [PMID: 23807526 DOI: 10.4158/ep13109.or] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine barriers to health care transition reported by young adults with type 1 diabetes and associations between barriers and prolonged gaps between pediatric and adult diabetes care. METHODS We surveyed young adults aged 22 to 30 years with type 1 diabetes about their transition experiences, including barriers to timely establishment of adult diabetes care. We evaluated relationships between barriers and gaps in care using multivariate logistic regression. RESULTS The response rate was 53% (258 of 484 eligible subjects). Respondents (62% female) were 26.7 ± 2.4 years old and transitioned to adult diabetes care at 19.5 ± 2.9 years. Reported barriers included lack of specific adult provider referral name (47%) or contact information (27%), competing life priorities (43%), difficulty getting an appointment (41%), feeling upset about leaving pediatrics (24%), and insurance problems (10%). In multivariate analysis, barriers most strongly associated with gaps in care >6 months were lack of adult provider name (odds ratio [OR], 6.1; 95% confidence interval [CI], 3.0-12.7) or contact information (OR, 5.3; 95% CI, 2.0-13.9), competing life priorities (OR, 5.2; 95% CI, 2.7-10.3), and insurance problems (OR, 3.5; 95% CI, 1.2-10.3). Overall, respondents reporting ≥1 moderate/major barrier (48%) had 4.7-fold greater adjusted odds of a gap in care >6 months (95% CI, 2.8-8.7). CONCLUSION Significant barriers to transition, such as a lack of specific adult provider referrals, may be addressed with more robust preparation by pediatric providers and care coordination. Further study is needed to evaluate strategies to improve young adult self-care in the setting of competing life priorities.
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Abstract
BACKGROUND One of the most frequently cited challenges faced by pediatric weight management programs/clinics is attrition, with many studies reporting rates greater than 50%. Few studies have evaluated parental perspectives on recommendations for weight-management treatment enhancement. The aim of this study was to elicit perspectives on areas for improvement, discussions with staff about discontinuation, and potentially modifiable aspects of attrition from parents who prematurely discontinued stage 3 pediatric weight management treatment. METHODS This study was performed as a semistructured interview as part of a telephone survey assessing reasons for attrition. RESULTS Interviews were performed with 147 parents of children who attended programs/clinics at 13 children's hospitals participating in the National Association of Children's Hospitals and Related Institutions (now Children's Hospital Association) FOCUS on a Fitter Future II collaborative. The majority of parents (65%) denied talking to staff about their decisions to stop coming. When describing what could have been done to retain families, parents most frequently discussed changing logistics (e.g., hours and locations). Parents described changes in logistics and components (i.e., nutrition education, exercise, and behavior education/support) when asked what would work best for their family for pediatric weight management. CONCLUSIONS Parental responses appeared to express frustration about flexibility with appointment times and treatment locations. The most frequently desired components were those traditionally offered by stage 3 pediatric weight management programs/clinics, and this may suggest a need for treatment delivery of these components to be more individualized. Additional discussion with families about their desire to discontinue treatment may provide a timely opportunity to address this need.
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Affiliation(s)
- Bethany J Sallinen Gaffka
- 1 Pediatric Comprehensive Weight Management Center, Department of Pediatrics, Division of Child Behavioral Health, University of Michigan C.S. Mott Children's and Von Voigtlander Women's Hospital , Ann Arbor, MI
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27
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Shah RV, Abbasi SA, Neilan TG, Hulten E, Coelho-Filho O, Hoppin A, Levitsky L, de Ferranti S, Rhodes ET, Traum A, Goodman E, Feng H, Heydari B, Harris WS, Hoefner DM, McConnell JP, Seethamraju R, Rickers C, Kwong RY, Jerosch-Herold M. Myocardial tissue remodeling in adolescent obesity. J Am Heart Assoc 2013; 2:e000279. [PMID: 23963758 PMCID: PMC3828806 DOI: 10.1161/jaha.113.000279] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Childhood obesity is a significant risk factor for cardiovascular disease in adulthood. Although ventricular remodeling has been reported in obese youth, early tissue-level markers within the myocardium that precede organ-level alterations have not been described. METHODS AND RESULTS We studied 21 obese adolescents (mean age, 17.7±2.6 years; mean body mass index [BMI], 41.9±9.5 kg/m(2), including 11 patients with type 2 diabetes [T2D]) and 12 healthy volunteers (age, 15.1±4.5 years; BMI, 20.1±3.5 kg/m(2)) using biomarkers of cardiometabolic risk and cardiac magnetic resonance imaging (CMR) to phenotype cardiac structure, function, and interstitial matrix remodeling by standard techniques. Although left ventricular ejection fraction and left atrial volumes were similar in healthy volunteers and obese patients (and within normal body size-adjusted limits), interstitial matrix expansion by CMR extracellular volume fraction (ECV) was significantly different between healthy volunteers (median, 0.264; interquartile range [IQR], 0.253 to 0.271), obese adolescents without T2D (median, 0.328; IQR, 0.278 to 0.345), and obese adolescents with T2D (median, 0.376; IQR, 0.336 to 0.407; P=0.0001). ECV was associated with BMI for the entire population (r=0.58, P<0.001) and with high-sensitivity C-reactive protein (r=0.47, P<0.05), serum triglycerides (r=0.51, P<0.05), and hemoglobin A1c (r=0.76, P<0.0001) in the obese stratum. CONCLUSIONS Obese adolescents (particularly those with T2D) have subclinical alterations in myocardial tissue architecture associated with inflammation and insulin resistance. These alterations precede significant left ventricular hypertrophy or decreased cardiac function.
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Affiliation(s)
- Ravi V Shah
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Garvey KC, Finkelstein JA, Laffel LM, Ochoa V, Wolfsdorf JI, Rhodes ET. Transition experiences and health care utilization among young adults with type 1 diabetes. Patient Prefer Adherence 2013; 7:761-9. [PMID: 23990711 PMCID: PMC3749062 DOI: 10.2147/ppa.s45823] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The purpose of this study was to describe the current status of adult diabetes care in young adults with type 1 diabetes and examine associations between health care transition experiences and care utilization. METHODS We developed a survey to assess transition characteristics and current care in young adults with type 1 diabetes. We mailed the survey to the last known address of young adults who had previously received diabetes care at a tertiary pediatric center. RESULTS Of 291 surveys sent, 83 (29%) were undeliverable and three (1%) were ineligible. Of 205 surveys delivered, 65 were returned (response rate 32%). Respondents (mean age 26.6 ± 3.0 years, 54% male, 91% Caucasian) transitioned to adult diabetes care at a mean age of 19.2 ± 2.8 years. Although 71% felt mostly/completely prepared for transition, only half received recommendations for a specific adult provider. Twenty-six percent reported gaps exceeding six months between pediatric and adult diabetes care. Respondents who made fewer than three diabetes visits in the year prior to transition (odds ratio [OR] 4.5, 95% confidence interval [CI] 1.2-16.5) or cited moving/relocation as the most important reason for transition (OR 6.3, 95% CI 1.3-31.5) were more likely to report gaps in care exceeding six months. Patients receiving current care from an adult endocrinologist (79%) were more likely to report at least two diabetes visits in the past year (OR 6.0, 95% CI 1.5-24.0) compared with those receiving diabetes care from a general internist/adult primary care doctor (17%). Two-thirds (66%) reported receiving all recommended diabetes screening tests in the previous year, with no difference according to provider type. CONCLUSION In this sample, transition preparation was variable and one quarter reported gaps in obtaining adult diabetes care. Nevertheless, the majority endorsed currently receiving regular diabetes care, although visit frequency differed by provider type. Because locating patients after transition was incomplete, our findings suggest the need for standardized methods to track transitioning patients.
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Affiliation(s)
- Katharine C Garvey
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA, USA
- Correspondence: Katharine C Garvey, Division of Endocrinology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA, Tel +1 617 919 3045, Email
| | - Jonathan A Finkelstein
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Lori M Laffel
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA, USA
- Pediatric, Adolescent and Young Adult Section, Joslin Diabetes Center, Boston, MA, USA
| | - Victoria Ochoa
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA, USA
| | | | - Erinn T Rhodes
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA, USA
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Garvey KC, Wolpert HA, Rhodes ET, Laffel LM, Kleinman K, Beste MG, Wolfsdorf JI, Finkelstein JA. Health care transition in patients with type 1 diabetes: young adult experiences and relationship to glycemic control. Diabetes Care 2012; 35:1716-22. [PMID: 22699289 PMCID: PMC3402251 DOI: 10.2337/dc11-2434] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine characteristics of the transition from pediatric to adult care in emerging adults with type 1 diabetes and evaluate associations between transition characteristics and glycemic control. RESEARCH DESIGN AND METHODS We developed and mailed a survey to evaluate the transition process in emerging adults with type 1 diabetes, aged 22 to 30 years, receiving adult diabetes care at a single center. Current A1C data were obtained from the medical record. RESULTS The response rate was 53% (258 of 484 eligible). The mean transition age was 19.5 ± 2.9 years, and 34% reported a gap >6 months in establishing adult care. Common reasons for transition included feeling too old (44%), pediatric provider suggestion (41%), and college (33%). Less than half received an adult provider recommendation and <15% reported having a transition preparation visit or receiving written transition materials. The most recent A1C was 8.1 ± 1.3%. Respondents who felt mostly/completely prepared for transition had lower likelihood of a gap >6 months between pediatric and adult care (adjusted odds ratio 0.47 [95% CI 0.25-0.88]). In multivariate analysis, pretransition A1C (β = 0.49, P < 0.0001), current age (β = -0.07, P = 0.03), and education (β = -0.55, P = 0.01) significantly influenced current posttransition A1C. There was no independent association of transition preparation with posttransition A1C (β = -0.17, P = 0.28). CONCLUSIONS Contemporary transition practices may help prevent gaps between pediatric and adult care but do not appear to promote improvements in A1C. More robust preparation strategies and handoffs between pediatric and adult care should be evaluated.
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Affiliation(s)
- Katharine C Garvey
- Division of Endocrinology, Children’s Hospital Boston, Boston, Massachusetts, USA.
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Rhodes ET, Goran MI, Lieu TA, Lustig RH, Prosser LA, Songer TJ, Weigensberg MJ, Weinstock RS, Gonzalez T, Rawluk K, Zoghbi RM, Ludwig DS, Laffel LM. Health-related quality of life in adolescents with or at risk for type 2 diabetes mellitus. J Pediatr 2012; 160:911-7. [PMID: 22217471 PMCID: PMC4793715 DOI: 10.1016/j.jpeds.2011.11.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 10/04/2011] [Accepted: 11/10/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate how adolescents with or at risk for type 2 diabetes mellitus (T2DM) and their parent/guardians (parents) perceive adolescents' health-related quality of life. STUDY DESIGN We interviewed overweight/obese, 12- to 18-year-old youth with T2DM, prediabetes, or insulin resistance and one parent from 5 US sites. Assessments included Pediatric Quality of Life Inventory (PedsQL), Health Utilities Index, family conflict, and diabetes burden. RESULTS In 108 adolescents, diagnoses included 40.7% with T2DM, 25.0% with prediabetes, and 34.3% with insulin resistance. PedsQL summary score (SS) was higher in adolescents than parents (P=.02). Parents rated physical functioning lower than adolescents (P<.0001), but there were no differences in psychosocial health. Adolescent PedsQL SS did not differ with diagnosis, but was inversely associated with adolescent body mass index z-score (P=.0004) and family conflict (P<.0001) and associated with race/ethnicity (P<.0001). Number of adolescent co-morbidities (P=.007) and burden of diabetes care (P<.05) were inversely associated with parent PedsQL SS. There were no differences in the Health Utilities Index-Mark 3 multi-attribute utility score. CONCLUSIONS Parents perceive their adolescents' physical functioning as more impaired than adolescents themselves. Contextual factors including severity of obesity, race/ethnicity, family conflict, and burden of diabetes care influence health-related quality of life. Family-based approaches to treatment and prevention of T2DM may benefit from increased attention to the biopsychosocial context.
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Affiliation(s)
- Erinn T. Rhodes
- Division of Endocrinology, Children’s Hospital Boston, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Michael I. Goran
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Tracy A. Lieu
- Center for Child Health Care Studies, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA,Division of General Pediatrics, Children’s Hospital Boston, Boston, MA
| | - Robert H. Lustig
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Lisa A. Prosser
- Center for Child Health Care Studies, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA,Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, MI
| | - Thomas J. Songer
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - Marc J. Weigensberg
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ruth S. Weinstock
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY
| | - Tessa Gonzalez
- Division of Endocrinology, Children’s Hospital Boston, Boston, MA
| | - Kaitlin Rawluk
- Division of Endocrinology, Children’s Hospital Boston, Boston, MA
| | - Roula M. Zoghbi
- Division of Endocrinology, Children’s Hospital Boston, Boston, MA
| | - David S. Ludwig
- Division of Endocrinology, Children’s Hospital Boston, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lori M. Laffel
- Department of Pediatrics, Harvard Medical School, Boston, MA,Pediatric, Adolescent and Young Adult Section, Joslin Diabetes Center, Boston
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Abstract
AIMS To estimate remaining life expectancy (RLE), quality-adjusted life expectancy (QALE), causes of death and lifetime cumulative incidence of microvascular/macrovascular complications of diabetes for youths diagnosed with Type 2 diabetes. METHODS A Markov-like computer model simulated the life course for a hypothetical cohort of adolescents/young adults in the USA, aged 15-24 years, newly diagnosed with Type 2 diabetes following either conventional or intensive treatment based on the UK Prospective Diabetes Study. Outcomes included RLE, discounted QALE in quality-adjusted life years (QALYs), cumulative incidence of microvascular/macrovascular complications and causes of death. RESULTS Compared with a mean RLE of 58.6 years for a 20-year-old in the USA without diabetes, conventional treatment produced an average RLE of 43.09 years and 22.44 discounted QALYs. Intensive treatment afforded an incremental 0.98 years and 0.44 discounted QALYs. Intensive treatment led to lower lifetime cumulative incidence of all microvascular complications and lower mortality from microvascular complications (e.g. end-stage renal disease (ESRD) death 19.4% vs. 25.2%). Approximately 5% with both treatments had ESRD within 25 years. Lifetime cumulative incidence of coronary heart disease (CHD) increased with longer RLE and greater severity of CHD risk factors. Incorporating disutility (loss in health-related quality of life) of intensive treatment resulted in net loss of QALYs. CONCLUSIONS Adolescents/young adults with Type 2 diabetes lose approximately 15 years from average RLE and may experience severe, chronic complications of Type 2 diabetes by their 40s. The net clinical benefit of intensive treatment may be sensitive to preferences for treatment. A comprehensive management plan that includes early and aggressive control of cardiovascular risk factors is likely needed to reduce lifetime risk of CHD.
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Affiliation(s)
- E T Rhodes
- Division of Endocrinology, Children's Hospital Boston, Boston, MA 02115, USA.
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32
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Keller N, Bhatia S, Braden JN, Gildengorin G, Johnson J, Yedlin R, Tseng T, Knapp J, Glaser N, Jossan P, Teran S, Rhodes ET, Noble JA. Distinguishing type 2 diabetes from type 1 diabetes in African American and Hispanic American pediatric patients. PLoS One 2012; 7:e32773. [PMID: 22412923 PMCID: PMC3296728 DOI: 10.1371/journal.pone.0032773] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 01/30/2012] [Indexed: 11/22/2022] Open
Abstract
Objective To test the hypothesis that clinical observations made at patient presentation can distinguish type 2 diabetes (T2D) from type 1 diabetes (T1D) in pediatric patients aged 2 to 18. Subjects and Methods Medical records of 227 African American and 112 Hispanic American pediatric patients diagnosed as T1D or T2D were examined to compare parameters in the two diseases. Age at presentation, BMI z-score, and gender were the variables used in logistic regression analysis to create models for T2D prediction. Results The regression-based model created from African American data had a sensitivity of 92% and a specificity of 89%; testing of a replication cohort showed 91% sensitivity and 93% specificity. A model based on the Hispanic American data showed 92% sensitivity and 90% specificity. Similarities between African American and Hispanic American patients include: (1) age at onset for both T1D and T2D decreased from the 1980s to the 2000s; (2) risk of T2D increased markedly with obesity. Racial/ethnic-specific observations included: (1) in African American patients, the proportion of females was significantly higher than that of males for T2D compared to T1D (p<0.0001); (2) in Hispanic Americans, the level of glycated hemoglobin (HbA1c) was significantly higher in T1D than in T2D (p<0.002) at presentation; (3) the strongest contributor to T2D risk was female gender in African Americans, while the strongest contributor to T2D risk was BMI z-score in Hispanic Americans. Conclusions Distinction of T2D from T1D at patient presentation was possible with good sensitivity and specificity using only three easily-assessed variables: age, gender, and BMI z-score. In African American pediatric diabetes patients, gender was the strongest predictor of T2D, while in Hispanic patients, BMI z-score was the strongest predictor. This suggests that race/ethnic specific models may be useful to optimize distinction of T1D from T2D at presentation.
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Affiliation(s)
- Nancy Keller
- Children's Hospital and Research Center Oakland, Oakland, California, United States of America.
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Pietras SA, Rhodes ET, Meyers A, Goodman E. Understanding pediatricians' views toward school-based BMI screening in Massachusetts: a pilot study. J Sch Health 2012; 82:107-114. [PMID: 22320334 DOI: 10.1111/j.1746-1561.2011.00673.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Massachusetts (MA) mandated body mass index (BMI) screening in schools in 2010. However, little is known about pediatricians' views on school-based screening or how the pediatricians' perspectives might affect the school-based screening process. We assessed MA pediatricians' knowledge, attitudes, beliefs, and practices concerning BMI screening. METHODS An anonymous Web-based survey was completed by 286 members of the MA Chapter of the American Academy of Pediatrics who provided primary care (40% response rate). RESULTS Support for school-based BMI screening was mixed. While 16.1% strongly supported it, 12.2% strongly opposed it. About one fifth (20.2%) believed school-based screening would improve communication between schools and pediatricians; 23.0% believed school-based screening would help with patient care. More (32.2%) believed screening in schools would facilitate communication with families. In contrast, pediatricians embraced BMI screening in practice: 91.6% calculated and 85.7% plotted BMI at every well child visit. Pediatricians in urban practices, particularly inner city, had more positive attitudes toward BMI screening in schools, even when adjusting for respondent demographics, practice setting, and proportion of patients in the practice who were overweight/obese (p < .001). CONCLUSION These data suggest MA pediatricians use BMI screening and support its clinical utility. However, support for school-based BMI screening was mixed. Urban-based pediatricians in this sample held more positive beliefs about screening in schools. Although active collaboration between schools and pediatricians would likely help to ensure that the screenings have a positive impact on child health regardless of location, it may be easier for urban-based schools and pediatricians to be successful in developing partnerships.
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Affiliation(s)
- Stefanie A Pietras
- Center for Child and Adolescent Health Policy, Massachusetts General Hospital for Children, Boston, MA 02114, USA.
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Rhodes ET, Prosser LA, Lieu TA, Songer TJ, Ludwig DS, Laffel LM. Preferences for type 2 diabetes health states among adolescents with or at risk of type 2 diabetes mellitus. Pediatr Diabetes 2011; 12:724-32. [PMID: 21489091 PMCID: PMC4793716 DOI: 10.1111/j.1399-5448.2011.00772.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE We evaluated how adolescents with or at risk of type 2 diabetes (T2DM) and their parent/guardians (parents) value health states associated with T2DM. METHODS We interviewed overweight/obese [Body Mass Index (BMI) ≥ 85th percentile], 12-18-yr old adolescents with T2DM, prediabetes, or insulin resistance (IR) and a parent. The standard gamble (SG) method elicited preferences (utilities) for seven hypothetical T2DM health states reported on a scale from 0 (dead) to 1 (perfect health). Adolescent's current health was evaluated with the SG and Health Utilities Index (HUI). RESULTS There were 70 adolescents and 69 parents. Adolescents were 67.1% female and 15.5 ± 2.2 yr old; 30% had T2DM, 30% prediabetes, and 40% IR. Almost half (48.6%) had a BMI > 99th percentile. Parents (83% mothers) were 45.1 ± 7.3 yr old and 75% had at least some college/technical school education. Adolescents and parents rated T2DM with no complications treated with diet as most desirable [median (IQR); adolescent 0.72 (0.54, 0.98); parent 1.0 (0.88, 1.0)] and end-stage renal disease as least desirable [adolescent 0.51 (0.31, 0.70); parent 0.80 (0.65, 0.94)]. However, adolescents' utilities were significantly lower (p ≤ 0.001) than parents for all health states assessed. Adolescents' assessments of their current health with the SG and HUI were not correlated. CONCLUSIONS Adolescents with or at risk of T2DM rated treatments and sequelae of diabetes as significantly worse than their parents. These adolescent utilities should be considered in the evaluation of treatment strategies for youth with T2DM. Family-based programs for T2DM must also be prepared to address conflicting preferences in order to promote shared decision-making.
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Affiliation(s)
- Erinn T. Rhodes
- Division of Endocrinology, Children’s Hospital Boston, Boston, MA, USA, 02115,Department of Pediatrics, Harvard Medical School, Boston, MA, USA, 02115
| | - Lisa A. Prosser
- Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, MI, USA, 48109,Center for Child Health Care Studies, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA, 02215
| | - Tracy A. Lieu
- Center for Child Health Care Studies, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA, 02215,Division of General Pediatrics, Children’s Hospital Boston, Boston, MA, USA, 02115
| | - Thomas J. Songer
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA, 15261
| | - David S. Ludwig
- Division of Endocrinology, Children’s Hospital Boston, Boston, MA, USA, 02115,Department of Pediatrics, Harvard Medical School, Boston, MA, USA, 02115
| | - Lori M. Laffel
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA, 02115,Pediatric, Adolescent and Young Adult Section, Joslin Diabetes Center, Boston, MA, USA, 02215
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Rhodes ET, Pawlak DB, Takoudes TC, Ebbeling CB, Feldman HA, Lovesky MM, Cooke EA, Leidig MM, Ludwig DS. Effects of a low-glycemic load diet in overweight and obese pregnant women: a pilot randomized controlled trial. Am J Clin Nutr 2010; 92:1306-15. [PMID: 20962162 PMCID: PMC2980957 DOI: 10.3945/ajcn.2010.30130] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The optimal diet for pregnancy that is complicated by excessive weight is unknown. OBJECTIVE We aimed to examine the effects of a low-glycemic load (low-GL) diet in overweight and obese pregnant women. DESIGN We randomly assigned 46 overweight or obese pregnant women to receive a low-GL or a low-fat diet. Participants received carbohydrate-rich foods, fats, and snack foods through home delivery or study visits. The primary outcome was birth weight z score. Other endpoints included infant anthropometric measurements, gestational duration, maternal weight gain, and maternal metabolic parameters. RESULTS There were no significant differences in birth weight z score or other measures of infant adiposity between groups. However, in the low-GL compared with the low-fat group, gestational duration was longer (mean ± SD: 39.3 ± 1.1 compared with 37.9 ± 3.1 wk; P = 0.05) and fewer deliveries occurred at ≤ 38.0 wk (13% compared with 48%, P = 0.02; with exclusion of planned cesarean deliveries: 5% compared with 53%; P = 0.002). Adjusted head circumference was greater in the low-GL group (35.0 ± 0.8 compared with 34.2 ± 1.3 cm, P = 0.01). Women in the low-GL group had smaller increases in triglycerides [median (interquartile range): 49 (19, 70) compared with 93 (34, 129) mg/dL; P = 0.03] and total cholesterol [13 (0, 36) compared with 33 (22, 56) mg/dL, P = 0.04] and a greater decrease in C-reactive protein [-2.5 (-5.5, -0.7) compared with -0.4 (-1.4, 1.5) mg/dL, P = 0.007]. CONCLUSIONS A low-GL diet resulted in longer pregnancy duration, greater infant head circumference, and improved maternal cardiovascular risk factors. Large-scale studies are warranted to evaluate whether dietary intervention during pregnancy aimed at lowering GL may be useful in the prevention of prematurity and other adverse maternal and infant outcomes. This trial is registered at clinicaltrials.gov as NCT00364403.
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Affiliation(s)
- Erinn T Rhodes
- Division of Endocrinology, Children's Hospital Boston, Boston, MA, USA
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Wolff MS, Rhodes ET, Ludwig DS. Training in childhood obesity management in the United States: a survey of pediatric, internal medicine-pediatrics and family medicine residency program directors. BMC Med Educ 2010; 10:18. [PMID: 20163732 PMCID: PMC2839969 DOI: 10.1186/1472-6920-10-18] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 02/17/2010] [Indexed: 05/16/2023]
Abstract
BACKGROUND Information about the availability and effectiveness of childhood obesity training during residency is limited. METHODS We surveyed residency program directors from pediatric, internal medicine-pediatrics (IM-Peds), and family medicine residency programs between September 2007 and January 2008 about childhood obesity training offered in their programs. RESULTS The response rate was 42.2% (299/709) and ranged by specialty from 40.1% to 45.4%. Overall, 52.5% of respondents felt that childhood obesity training in residency was extremely important, and the majority of programs offered training in aspects of childhood obesity management including prevention (N = 240, 80.3%), diagnosis (N = 282, 94.3%), diagnosis of complications (N = 249, 83.3%), and treatment (N = 242, 80.9%). However, only 18.1% (N = 54) of programs had a formal childhood obesity curriculum with variability across specialties. Specifically, 35.5% of IM-Peds programs had a formal curriculum compared to only 22.6% of pediatric and 13.9% of family medicine programs (p < 0.01). Didactic instruction was the most commonly used training method but was rated as only somewhat effective by 67.9% of respondents using this method. The most frequently cited significant barrier to implementing childhood obesity training was competing curricular demands (58.5%). CONCLUSIONS While most residents receive training in aspects of childhood obesity management, deficits may exist in training quality with a minority of programs offering a formal childhood obesity curriculum. Given the high prevalence of childhood obesity, a greater emphasis should be placed on development and use of effective training strategies suitable for all specialties training physicians to care for children.
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Affiliation(s)
- Margaret S Wolff
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erinn T Rhodes
- Division of Endocrinology, Children's Hospital Boston, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - David S Ludwig
- Division of Endocrinology, Children's Hospital Boston, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Fleischman A, Rhodes ET. Management of obesity, insulin resistance and type 2 diabetes in children: consensus and controversy. Diabetes Metab Syndr Obes 2009; 2:185-202. [PMID: 21437133 PMCID: PMC3048003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Childhood obesity has become a national and international epidemic. The prevalence and incidence of type 2 diabetes in youth have been increasing, and type 2 diabetes is one of the most challenging complications of obesity in childhood. Comprehensive lifestyle interventions that include attention to dietary change, increased physical activity and behavior change appear to be required for the successful treatment of pediatric obesity. In particular, aspects of behavioral interventions that have been identified as contributing to effectiveness have included intensity, parent/family participation, addressing healthy dietary change, promoting physical activity, and involving behavioral management principles such as goal setting. A multidisciplinary team approach is required for successful management of type 2 diabetes in youth as well. As with many therapies in pediatrics, clinical trials and support for treatments of obesity and type 2 diabetes in youth lag behind adult data. Pediatric recommendations may be extrapolated from adult data and are often based on consensus guidelines. Type 2 diabetes in children is most commonly managed with lifestyle modification and medications, metformin and/or insulin, the only medications currently approved for use in children. However, many opportunities exist for ongoing research to clarify optimal management for obesity and type 2 diabetes in youth.
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Affiliation(s)
| | - Erinn T Rhodes
- Correspondence: Erinn T Rhodes, Division of Endocrinology, Children’s, Hospital Boston, 333 Longwood Ave., 6th Floor, Boston, MA, 02115, USA, Tel + 617-355-3209, Fax + 617-730-0183, Email
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Rhodes ET, Ludwig DS. Obesity: Guiding the management of pediatric obesity. Nat Rev Endocrinol 2009; 5:247-9. [PMID: 19444255 DOI: 10.1038/nrendo.2009.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pediatric obesity is a global phenomenon in danger of spiraling out of control. New guidelines from the Endocrine Society offer expert opinion on the prevention and management of this challenging health-care problem.
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Rhodes ET, Ebbeling CB, Meyers AF, Bayerl CT, Ooi WL, Bettencourt MF, Ludwig DS. Pediatric obesity management: variation by specialty and awareness of guidelines. Clin Pediatr (Phila) 2007; 46:491-504. [PMID: 17579101 DOI: 10.1177/0009922806298704] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A survey of 2727 pediatric clinicians evaluated pediatric overweight management and awareness of Expert Committee recommendations (ECR) on obesity. Adjusted response rate was 45%. ECR awareness was reported by 24.6%. Family practice specialists (FPS) were less likely than pediatric specialists (PS) to be aware of ECR (OR, 0.46; 95% CI, 0.30-0.71). Body mass index (BMI) was never used by 25.6% to identify overweight; 35.4% did not obtain laboratory tests. Among PS but not FPS, ECR awareness was associated with BMI use (OR, 2.70; 95% CI, 1.56-4.65) and frequent follow-up (OR, 2.48; 95% CI, 1.58-3.90). FPS were more likely than PS to use BMI (OR, 1.78; 95% CI, 1.15-2.75) and obtain thyroid function tests (OR, 2.58; 95% CI, 1.53-4.37), but less likely to obtain fasting lipids (OR, 0.47; 95% CI, 0.30-0.73). Specialty differences in dietary recommendations, referrals, and barriers to treatment were identified. Pediatric overweight management guidelines should consider specialty differences and be accessible to all pediatric care providers.
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Affiliation(s)
- Erinn T Rhodes
- Division of Endocrinology, Children's Hospital Boston, Boston, Massachusetts 02115, USA.
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Affiliation(s)
- Erinn T Rhodes
- Division of Endocrinology, Children's Hospital Boston, 300 Longwood Ave., Boston, MA 02115, USA.
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Rhodes ET, Finkelstein JA, Marshall R, Allen C, Gillman MW, Ludwig DS. Screening for Type 2 Diabetes Mellitus in Children and Adolescents: Attitudes, Barriers, and Practices Among Pediatric Clinicians. ACTA ACUST UNITED AC 2006; 6:110-4. [PMID: 16530149 DOI: 10.1016/j.ambp.2005.10.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2005] [Revised: 10/17/2005] [Accepted: 10/28/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The American Diabetes Association (ADA) recommends screening children at risk for type 2 diabetes with a fasting plasma glucose test or an oral glucose tolerance test. The purpose of this study was to describe attitudes, barriers, and practices related to type 2 diabetes screening in children among pediatric clinicians. METHODS Pediatricians, nurse practitioners and physician assistants from a multispecialty, group practice in Eastern Massachusetts completed a mailed survey. To assess screening practice, three vignettes were presented representing pediatric patients with low, moderately high, and high risk for type 2 diabetes. The moderately high-risk and high-risk patients met ADA criteria for screening. ADA-consistent practice was defined as only screening the moderately high-risk and high-risk patients; lower-threshold practice was defined as also screening the low-risk patient; and higher threshold practice was screening only the high-risk patient. RESULTS Sixty-two of 90 clinicians responded (69%). Based on intent to screen in the 3 vignettes, 21% of respondents reported ADA-consistent screening practice, 39% lower-threshold, and 35% higher-threshold screening practice. Five percent had incomplete or nonclassifiable responses. Many clinicians ordered screening tests other than those recommended by the ADA; few (< or =8% in any vignette) ordered only an ADA-recommended test. Preferences for nonfasting tests were influenced by nonmedical factors such as access to or cost of transportation. Inadequate patient education materials and unclear recommendations for appropriate screening methods were the most frequently reported moderate/strong barriers to screening. CONCLUSIONS Most respondents reported type 2 diabetes screening practices that differed from current ADA recommendations. Our findings suggest that type 2 diabetes screening tests must be practical for clinicians and patients if they are to be used in pediatric practice. Further study of the benefits and cost-effectiveness of type 2 diabetes screening in children is warranted to clarify the role and optimal methods for screening in pediatric primary care.
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Affiliation(s)
- Erinn T Rhodes
- Division of Endocrinology, Children's Hospital Boston, MA 02115, USA.
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Abstract
UNLABELLED Pediatric patients with diabetes are managed with increasingly complex regimens. To optimally manage these patients during the perioperative period, pediatric anesthesiologists must carefully consider the pathophysiology of the disease, patient-specific methods of treatment, status of glycemic control, and the type of surgery proposed. Important pediatric issues, including body size, pubertal development, and ability to tolerate nil per os status, must be considered. To keep pace with the array of options for treating diabetes in children, the perioperative plan should be developed in consultation with a pediatric endocrinologist. We present an algorithm that was developed at Children's Hospital Boston for the management of pediatric patients with either type 1 or type 2 diabetes mellitus presenting for surgery and general anesthesia. This collaborative effort between the pediatric anesthesia and endocrine services represents one example of a standardized approach to these patients that should facilitate care and improve management. Differences from previously published recommendations are highlighted, as are expected changes caused by the continued evolution of pediatric diabetes care. IMPLICATIONS The evolution of diabetes care for children has made the management of perioperative blood glucose levels a greater challenge for pediatric anesthesiologists. A standardized algorithm for the perioperative management of pediatric patients with type 1 or type 2 diabetes mellitus os presented.
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Affiliation(s)
- Erinn T Rhodes
- *Division of Endocrinology and †Department of Anesthesiology, Perioperative, and Pain Medicine, Children's Hospital Boston; ‡Departments of Pediatrics and §Anesthesia, Harvard Medical School, Boston, Massachusetts
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Rhodes ET, Wolfsdorf JI, Cuthbertson DD, Feldman HA, Ludwig DS. Effect of low-dose insulin treatment on body weight and physical development in children and adolescents at risk for type 1 diabetes. Diabetes Care 2005; 28:1948-53. [PMID: 16043737 DOI: 10.2337/diacare.28.8.1948] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Insulin's role in body weight regulation is controversial. We evaluated the effect of parenteral insulin on body weight and physical development in children and adolescents at risk for type 1 diabetes. RESEARCH DESIGN AND METHODS We performed a secondary analysis of the parenteral arm of the Diabetes Prevention Trial-Type 1 Diabetes (DPT-1), a randomized controlled trial of low-dose parenteral insulin (human ultralente insulin at 0.25 units x kg(-1) x day(-1)) in subjects with a >50% 5-year risk of diabetes. Analysis was limited to 100 subjects (55 intervention, 45 closely monitored) aged <19 years at randomization whose weight was followed for at least 2 years by study end after excluding subjects who were noncompliant within 2 years or developed diabetes within 36 months of randomization. RESULTS Subjects ranged in age from 4.07 to 18.98 years. There were no significant differences at randomization between subjects in each group with respect to sex, age, weight, height, BMI, Tanner stage, or glucose tolerance. We found no differences over 2 years between the intervention and closely monitored groups in the change in weight (median 6.8 vs. 6.0 kg, P = 0.65), height (median 10.7 vs. 10.1 cm, P = 0.66), BMI (median 0.9 vs. 1.0 kg/m2, P = 0.79), or Tanner stage (median 0 vs. 0, P = 0.35). Multiple regression showed no effect of insulin on change in weight (P = 0.53) or BMI (P = 0.95) over 2 years after adjustment for relevant covariates. CONCLUSIONS Low-dose insulin treatment for 2 years did not affect the weight, BMI, or physical development of nondiabetic children and adolescents.
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Affiliation(s)
- Erinn T Rhodes
- Division of Endocrinology, Children's Hospital Boston, 300 Longwood Ave., Boston, MA 02115, USA
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Abstract
At the optimum temperature for its growth (37 degrees C), Escherichia coli tends to accumulate heterologous proteins in insoluble form. Fusion protein technology has been used to increase the solubility of overexpressed proteins in this organism, but with variable degrees of success. Fusion to a mutant form of DsbA (DsbAmut) confers higher levels of solubility to heterologous proteins in a reproducible way, even when E. coli is grown at 37 degrees C. We have shown this to be true with a diverse sample of eukaryotic proteins: IGF-I, IGFBP-3, 3C proteinase, TGF beta-2, sTGF beta-RII, BDNF, GDNF, mEGFBP, leptin, and GFP. In addition, we have investigated the effects of charge average and proline content on the solubility of DsbAmut fusions. Coexpression of a protein prolyl isomerase [cyclophilin (L-)] and modification of selected asparagine residues to aspartic acid appear to have beneficial effects on the accumulation of soluble heterologous proteins.
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Affiliation(s)
- Y Zhang
- Department of Molecular and Cell Biology, Celtrix Pharmaceuticals, Inc., Santa Clara, California 95054, USA
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