Use of the socio-ecological model to explore trusted sources of COVID-19 information in Black and Latinx communities in Michigan

BACKGROUND

Identifying trusted sources of health information and exploring what makes these sources trustworthy is an important aspect of public health. This exploration requires embracing the cultural differences in minoritized communities, which are often treated as homogeneous. This qualitative study identifies and analyze the sources of trusted COVID-19 information among Black and Latinx communities in Michigan and assesses the rationale underlying this trust.

METHODS

Interviews were conducted with 24 Black and 16 Latinx participants (n = 40) in four Michigan counties significantly impacted by COVID-19. The socio-ecological model was applied as an analytical framework for understanding the entities considered trusted sources of information. Within each level of the model, the dimensions of trustworthiness most salient for participants were identified.

RESULTS

We found that sources of information came from all levels of the model, including interpersonal (COVID-19 survivors, church representatives, friends, relatives), organizational (employers, healthcare providers, traditional news reports), social media (hybrid source), community (members and groups), and public policy (county health department, federal and state government). Furthermore, participants determined whether they could trust information about COVID-19 by cross-referencing multiple resources. We identified competence, confidence, communication, and system trust as the dimensions of trustworthiness most often reported by participants.

CONCLUSIONS

Our research suggests public health communications should engage in cross-referencing practices, providing information from sources at all levels of interaction, cultural competency, and awareness of historical/structural inequities. These efforts would be further strengthened by attending to needs for both factual information as well as care and personal connection.

MICEAL Black and Latinx Perspectives on COVID-19 Vaccination: A Mixed-Methods Examination

OBJECTIVES

To describe the differences and similarities in perceptions and attitudes regarding COVID-19 vaccination among Black and Latinx Michiganders.

METHODS

Utilizing a convergent mixed-methods approach, forty interviews were conducted with 24 Black and 16 Latinx community members between December 2020 and June 2021 across four Michigan counties disproportionately affected by COVID-19. Survey data were collected from a representative sample of 1598 individuals living in Detroit between January and March 2021.

RESULTS

Vaccine hesitancy was a more prevalent theme among Black interview participants than Latinx participants. Trust in experts and vaccine access were significantly more influential in the decision to vaccinate for Latinx residents compared to Black residents. Latinx individuals reported greater intention to receive a COVID-19 vaccine compared to Black respondents. Multinomial logit models revealed that 30% of Black participants expressed hesitancy about the COVID-19 vaccine compared to 10% of Latinx respondents.

CONCLUSIONS AND IMPLICATIONS

This study provides a deeper understanding of key differences and similarities in vaccine acceptance/hesitancy across race/ethnicity. The findings can enhance health interventions and outcomes by informing the development of culturally responsive practices tailored to specific communities.

Conceptualizing Trust and Distrust as Alternative Stable States: Lessons from the Flint Water Crisis

Despite the universally recognized importance of fostering trust and avoiding distrust in governance relationships, there remains considerable debate on core questions like the relation between (dis)trust and the evaluations of the characteristics that make a governance agent appear (un)worthy of trust. In particular, it remains unclear whether levels of (dis)trust simply follow levels of (dis)trustworthiness-such that building trust is primarily a question of increasing evidence of trustworthiness and avoiding evidence of distrustworthiness, or if their dynamics are more complicated. The current paper adds novel theory for thinking about the management of trust and distrust in the governance context through the application of principles borrowed from resilience theory. Specifically, we argue that trust and distrust exist as distinct, self-reinforcing (i.e., stable) states separated by a threshold. We then theorize as to the nature of the self-reinforcing processes and use qualitative data collected from and inductively coded in collaboration with Flint residents as part of a participatory process to look for evidence of our argument in a well-documented governance failure. We conclude by explaining how this novel perspective allows for clearer insight into the experience of this and other communities and speculate as to how it may help to better position governance actors to respond to future crises.

Association of High Normal Body Weight in Youths With Risk of Hypertension

IMPORTANCE

Ample evidence links obesity to hypertension in youths. However, the association of high normal body mass index (BMI) with obesity and the interaction with different weight trajectories are not well understood.

OBJECTIVE

To examine the hypertension risk associated with high normal BMI for age and different weight trajectories in youths.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study assessed 801 019 youths aged 3 to 17 years in an integrated health care system in Southern California from January 1, 2008, to February 28, 2015, with a maximum follow-up of 5 years from January 1, 2008, to February 28, 2020. Data analysis was performed from 2018 to 2022.

EXPOSURES

Youths were compared by first available (baseline) sex-specific BMI for age and change in the distance to the median BMI for age during the 5-year follow-up.

MAIN OUTCOMES AND MEASURES

Cox proportional hazards regression models with age as a time scale to assess hypertension risk (based on 2017 Blood Pressure Guidelines by the American Academy of Pediatrics from 3 consecutive independent visits), adjusted for sex, race and ethnicity, socioeconomic status, baseline year, and birth year.

RESULTS

A total of 801 019 youths (mean [SD] age, 9.4 [4.6] years; 409 167 [51.1%] female]; 59 399 [7.4%] Asian and Pacific Islanders, 65 712 [8.2%] Black, and 427 492 [53.4%] Hispanic) were studied. Compared with youths with a baseline BMI for age in the 40th to 59th percentiles, the adjusted hazard ratio (aHR) for hypertension within a maximum of 5 years was 1.26 (95% CI, 1.20-1.33) for youths between the 60th and 84th percentiles if they maintained their BMI for age. With every 1-unit annual increase in the distance to the median BMI for age, the aHR increased by 1.04 (95% CI, 1.04-1.05). The aHR was 4.94 (95% CI, 4.72-5.18) in youths with a baseline BMI for age in the 97th percentile or higher who maintained their body weight. Weight gain increased the risk associated with baseline BMI for age in the 97th percentile or higher with an aHR of 1.04 (95% CI, 1.04-1.05) per 1-unit annual increase in the distance to the median BMI for age. The risk associated with weight change was higher in youths living with low to high normal weight and overweight than in youths living with severe obesity.

CONCLUSIONS AND RELEVANCE

In this cohort study of youths, high normal body weight above the 60th percentile of BMI for age was associated with increased risk of hypertension. Weight gain was associated with further increases in hypertension risk. Further research is needed to evaluate the wide range of body weight considered normal in youths and the health risks associated with high normal weight.

Disparities in weight changes during the COVID-19 pandemic-related lockdown in youths

OBJECTIVE

This study evaluates whether changes in weight among school-aged youth in California due to the COVID-19 lockdown vary by social constructs of race/ethnicity and associated social factors.

METHODS

Including 160,472 youth aged 5 to 17 years enrolled at Kaiser Permanente Southern California, mixed effects models stratified by age group were fitted to estimate changes in distance from the median BMI-for-age from March 2020 to January 2021 (lockdown) compared with the same period before the pandemic.

RESULTS

Excess pandemic weight gain was higher among Black and Hispanic youth aged 5 to 17 years than among White and Asian youth; this difference was most pronounced in those aged 5 to 11 years. In youth aged 5 to 11 years, the distance from the median BMI-for-age increased by 1.72 kg/m2 (95% CI: 1.61-1.84) in Hispanic and 1.70 kg/m2 (95% CI: 1.47-1.94) in Black youth during the lockdown compared with 1.16 kg/m2 (95% CI: 1.02-1.29) in non-Hispanic White youth. The excess weight gain was also higher in youth with fewer neighborhood parks and those with state-subsidized health insurance.

CONCLUSIONS

The COVID-19 pandemic lockdown led to a gain of excess body weight, particularly for Black and Hispanic youth; this weight gain varied by social factors associated with race and ethnicity.

Parental Perspectives Regarding the Impact of the COVID-19 Pandemic on Their Children

Background: The COVID-19 pandemic has brought profound changes to the health of families worldwide. Yet, there is limited research regarding its impact on children. The pandemic may exacerbate factors associated with excess weight, which is particularly concerning due to the potential association between excess weight and severity of COVID-19 infection. This study investigates parental perspectives of changes in fruit/vegetable (FV) intake, processed food (PF) intake, outdoor playtime (OP), physical activity (PA) levels, and recreational screen time (RST) among children living in Michigan during the pandemic. Methods: The study team and community partners developed and distributed a survey using snowball sampling to reach families living largely in Central and Southeastern Michigan. Nonlinear mixed-effects proportional odds models were used to examine associations between child weight status along with demographic/household factors and changes in five weight-related behaviors. Results: Parents (n = 1313; representing 2469 children) reported a decrease in OP, FV, and PA levels, while there was an increase in RST and PF intake among their children. Household income was protective against a decrease in OP, PA, and FV but was associated with increased RST. Children's weight status was associated with decreased FV. Age was negatively associated with OP and PA, and positively associated with RST. Conclusions: These findings suggest an adverse influence of the pandemic on weight-related behaviors, particularly among adolescents in families with lower incomes and those with excess weight. Further work is needed to measure any impact on BMI trajectory and to identify interventions to reverse negative effects.

Cost-effectiveness of a motivational interviewing obesity intervention versus usual care in pediatric primary care offices

OBJECTIVE

This study aimed to assess the incremental cost-effectiveness ratio (ICER) of a 2-year motivational interviewing (MI) intervention versus usual primary care.

METHODS

A national trial was implemented in the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics to evaluate MI versus usual care for children (2-8 years old; baseline BMI 85th-97th percentiles). Health care use, food costs, provider fees, and training costs were assessed, and sensitivity analyses were conducted. Primary outcome was the ICER, calculated as cost per unit change in BMI percentile for intervention versus usual care.

RESULTS

At 2 years, 72% of enrolled parent/child dyads were retained; 312 children were included in the analysis. Mean BMI percentile point change was -4.9 and -1.8 for the intervention and control, respectively, yielding an incremental reduction of 3.1 BMI percentile points (95% CI: 1.2-5.0). The intervention cost $1051 per dyad ($658 for training DVD development). Incorporating health care and non-health care costs, the intervention ICER was $363 (range from sensitivity analyses: cost saving, $3159) per BMI percentile point decrease per participant over 2 years.

CONCLUSIONS

Training pediatricians, nurse practitioners, and registered dietitians to deliver MI-based interventions for childhood obesity in primary care is clinically effective and acceptably cost-effective. Future work should explore this approach in broader dissemination.

Employing Smartphone Health Apps in Weight Management for Adolescents: Analysis on Experiences and Perspectives From Pediatric Providers

The rising popularity of smartphone health applications (apps) offers great potential for facilitating pediatric weight management. Pediatric providers can determine health interventions for young patients with excess weight. We surveyed 51 pediatric providers at a Midwest academic medical institution and found that 78% thought currently available resources were not sufficient for pediatric weight management. In all, 76% of respondents reported use of at least one smartphone health app for their personal health. The quality of pediatric providers' experiences with their favorite app was strongly associated with their willingness to recommend the app to their patients (P < .001), but few of them have made such a recommendation in practice, mainly due to the lack of either personal knowledge about health apps or about evidence-based health apps for pediatric weight management. Moreover, respondents shared ideas about qualities for an effective health app, which shed new light on developing apps specifically for adolescents with excess weight.

776 INTRODUCING TREATMENT ESCALATION PLANS (TEP) FOR OLDER PERSONS: RESPONSE TO THE COVID-19 PANDEMIC

Introduction

TEP detail appropriate ceilings of care and guide treatment of patients based on shared decision making. TEP documentation was not standard within our trust up to 2018. We aimed to design and introduce a standardised TEP proforma and evaluate its use in older persons aged ≥80.

Methods

Data was obtained from patient notes and questionnaires within the Medicine for Older Persons department (MOP) from four PDSA cycles between 2018–2020. Cycle 1 was a service evaluation. Based on this data, a TEP form was created and approved for use in all adult patients. Cycles 2, 3 and 4 evaluated TEP after introduction of the proforma.

Results

There was a 239% increase in TEP after introduction of the proforma, compared to baseline (cycle 1: n = 14/47 [29.8%], cycle 2: n = 17/112 [15.2%], cycle 3: n = 30/97 [30.9%], cycle 4: n = 42/59 [71.2%]). The increase in TEP between cycles 3 and 4 coincided with the COVID-19 epidemic. Clinicians were more confident in actioning TEP based on the proforma, compared to those written in the notes (cycle 2: 83% confidence vs 54%, cycle 3: 100% vs 35%, Cycle 4: 98% vs none written in the notes). An improvement in understanding the purpose, comprehensiveness and location of TEP forms was observed. Feedback suggested TEP provided clear guidance for 1. ceilings of care; especially useful out of hours 2. discussions with critical care and 3. patient handover between staff and successive shifts.

Conclusion

TEP forms offer clear guidance on ceilings of care. Introduction of the TEP proforma has led to more frequent and proactive discussions with patients on ceilings of care and have facilitated a culture change in the management of older persons. Use of the forms increased during the COVID-19 pandemic but are now viewed as an essential component of patient safety and have been successfully implemented trustwide.

Changes in Body Mass Index Among Children and Adolescents During the COVID-19 Pandemic

This study compares body mass index (BMI) of youths during the COVID-19 pandemic with BMI during the same period in 2019 to determine whether they experienced pandemic-related weight gain.

84 COVID-19 and Associations with Frailty and Multimorbidity: A Prospective Analysis of UK Biobank Participants

Introduction

Frailty and multimorbidity have been suggested as risk factors for severe COVID-19 disease. We therefore investigated whether frailty and multimorbidity were associated with risk of hospitalisation with COVID-19 in the UK Biobank. Method 502,640 participants aged 40–69 years at baseline (54–79 years at COVID-19 testing) were recruited across UK 2006–10. A modified assessment of frailty using Fried’s classification was generated from baseline data. COVID-19 test results (England) were available 16/03/2020–01/06/2020, mostly taken in hospital settings. Logistic regression was used to discern associations between frailty, multimorbidity and COVID-19 diagnoses, adjusting for sex, age, BMI, ethnicity, education, smoking and number of comorbidity groupings, comparing COVID-19 positive, COVID-19 negative and non-tested groups.

Results

4,510 participants were tested for COVID-19 (positive = 1,326, negative = 3,184). 497,996 participants were not tested. Compared to the non-tested group, after adjustment, COVID-19 positive participants were more likely to be frail (OR = 1.4 [95%CI = 1.1, 1.8]), report slow walking speed (OR = 1.3 [1.1, 1.6]), report two or more falls in the past year (OR = 1.3 [1.0, 1.5]) and be multimorbid (≥4 comorbidity groupings vs 0–1: OR = 1.9 [1.5, 2.3]). However, similar strength of associations were apparent when comparing COVID-19 negative and non-tested groups. Furthermore, frailty and multimorbidity were not associated with COVID-19 diagnoses, when comparing COVID-19 positive and COVID-19 negative participants.

Conclusions

Frailty and multimorbidity do not appear to aid risk stratification, in terms of a positive versus negative results of COVID-19 testing. Investigation of the prognostic value of these markers for adverse clinical sequelae following COVID-19 disease is urgently needed.

Placental volume at 11 weeks is associated with offspring bone mass at birth and in later childhood: Findings from the Southampton Women's Survey

OBJECTIVES

To investigate associations between placental volume (PV) at 11 weeks' gestation and offspring bone outcomes at birth, 6 years and 8 years.

METHODS

3D ultrasound scanning was used to assess 11 week PV in a subset (n = 236) of the Southampton Women's Survey (a prospective mother-offspring cohort). Maternal anthropometric measures and lifestyle information were obtained pre-pregnancy and at 11 weeks' gestation. Offspring dual-energy x-ray absorptiometry scanning was performed within 2 weeks postnatally and at 6 and 8 years. Linear regression was used to assess associations between PV and bone outcomes, adjusting for offspring age at DXA and sex, and maternal age, height, smoking status, walking speed and triceps skinfold thickness. β are SD change in bone outcome per SD change in PV.

RESULTS

In adjusted models, 11 week PV was positively associated with bone area (BA) at all time points, with evidence of persisting associations with increasing childhood age (birth: n = 80, β = 0.23 [95%CI = 0.03, 0.42], 6 years: n = 110, β = 0.17 [-0.01, 0.36], 8 years: n = 85, β = 0.13 [-0.09, 0.36]). Similar associations between 11 week PV and bone mineral content (BMC) were observed. Associations with size-corrected bone mineral content were weaker at birth but strengthened in later childhood (birth: n = 78, β = 0.07 [-0.21, 0.35], 6 years: n = 107, β = 0.13 [-0.08, 0.34], 8 years: n = 71, β = 0.19 [-0.05, 0.43]).

CONCLUSIONS

11 week PV is associated with DXA bone measures at birth, with evidence of persisting associations into later childhood. Further work is required to elucidate the contributions of placental morphology and function to gestational influences on skeletal development.

COVID-19 and associations with frailty and multimorbidity: a prospective analysis of UK Biobank participants

BACKGROUND

Frailty and multimorbidity have been suggested as risk factors for severe COVID-19 disease.

AIMS

We investigated, in the UK Biobank, whether frailty and multimorbidity were associated with risk of hospitalisation with COVID-19.

METHODS

502,640 participants aged 40-69 years at baseline (54-79 years at COVID-19 testing) were recruited across UK during 2006-10. A modified assessment of frailty using Fried's classification was generated from baseline data. COVID-19 test results (England) were available for 16/03/2020-01/06/2020, mostly taken in hospital settings. Logistic regression was used to discern associations between frailty, multimorbidity and COVID-19 diagnoses, after adjusting for sex, age, BMI, ethnicity, education, smoking and number of comorbidity groupings, comparing COVID-19 positive, COVID-19 negative and non-tested groups.

RESULTS

4510 participants were tested for COVID-19 (positive = 1326, negative = 3184). 497,996 participants were not tested. Compared to the non-tested group, after adjustment, COVID-19 positive participants were more likely to be frail (OR = 1.4 [95%CI = 1.1, 1.8]), report slow walking speed (OR = 1.3 [1.1, 1.6]), report two or more falls in the past year (OR = 1.3 [1.0, 1.5]) and be multimorbid (≥ 4 comorbidity groupings vs 0-1: OR = 1.9 [1.5, 2.3]). However, similar strength of associations were apparent when comparing COVID-19 negative and non-tested groups. However, frailty and multimorbidity were not associated with COVID-19 diagnoses, when comparing COVID-19 positive and COVID-19 negative participants.

DISCUSSION AND CONCLUSIONS

Frailty and multimorbidity do not appear to aid risk stratification, in terms of positive versus negative results of COVID-19 testing. Investigation of the prognostic value of these markers for adverse clinical sequelae following COVID-19 disease is urgently needed.

Enhanced Myeloid Leukocytes in Obese Children and Adolescents at Risk for Metabolic Impairment

Objective: We aimed to examine if myeloid leukocyte profiles are associated with metabolic impairment in children and adolescents with obesity, and if sex, age, or race influence this relationship. Methods: 282 children ages 8-17 were evaluated. Predictor measures were absolute neutrophil counts (ANC), absolute monocyte count, monocyte subtypes and C reactive protein (CRP). Outcome variables were waist circumference, fasting glucose and insulin, HOMA-IR, HbA1c (%) and lipid profiles. Pearson correlation coefficients were used to determine associations between predictor and outcome variables. Wilcoxon two-sample tests were used to evaluate differences by sex. Results: CRP (p < 0.0001), ANC (p < 0.0018), and classical monocytes (p = 0.05) were significantly higher in children with obesity. CRP, ANC and classical monocytes showed positive correlations with waist circumference, insulin, HOMA-IR and triglycerides. CRP was positively associated with ANC overall (p = 0.05). ANC demonstrated positive correlation with monocytes (p < 0.001). The associations between predictor and outcome variables were influenced by sex, race, and age. Conclusions: CRP and myeloid leukocyte populations, specifically classical monocytes and neutrophils associate with both body composition and metabolic parameters in children with obesity suggesting that these cells may play a critical role in metabolic impairment. Race, gender and age interactions between monocytes and metabolic parameters were significant.

Community Healthcare and Technology to Enhance Communication in Pediatric Obesity Care

Childhood obesity continues to be a critical healthcare issue and a paradigm of a pervasive chronic disease affecting even our youngest children. When considered within the context of the socioecological model, the factors that influence weight status, including the social determinants of health, limit the impact of multidisciplinary care that occurs solely within the medical setting. Coordinated care that incorporates communication between the healthcare and community sectors is necessary to more effectively prevent and treat obesity. In this article, the Expert Exchange authors, with input from providers convened at an international pediatric meeting, provide recommendations to address this critical issue. These recommendations draw upon examples from the management of other chronic conditions that might be applied to the treatment of obesity, such as the use of care plans and health assessment forms to allow weight management specialists and community personnel (e.g., school counselors) to communicate about treatment recommendations and responses. To facilitate communication across the healthcare and community sectors, practical considerations regarding the development and/or evaluation of communication tools are presented. In addition, the use of technology to enhance healthcare-community communication is explored as a means to decrease the barriers to collaboration and to create a web of connection between the community and healthcare providers that promote wellness and a healthy weight status.

Lessons for Physicians from Flint's Water Crisis

Physicians form a vital front in recognizing unusual clinical presentations that could herald a health threat. In the Flint water crisis, physicians can be credited with playing critical roles in both uncovering the crisis and providing leadership when government failed to respond effectively. Yet most physicians in Flint were not formally trained in advocacy or leadership and might have recognized the health implications of the crisis more quickly had they received formal environmental health training. Furthermore, connections to other professional disciplines-and to the community-are vital for effective responses to environmental health threats. We explore some lessons learned in Flint that might help expedite resolution of future environmental health crises, particularly those involving aging infrastructure and diminished or dysfunctional regulation or oversight.

An Evaluation of a Smartphone-Assisted Behavioral Weight Control Intervention for Adolescents: Pilot Study

Background

The efficacy of adolescent weight control treatments is modest, and effective treatments are costly and are not widely available. Smartphones may be an effective method for delivering critical components of behavioral weight control treatment including behavioral self-monitoring.

Objective

To examine the efficacy and acceptability of a smartphone assisted adolescent behavioral weight control intervention.

Methods

A total of 16 overweight or obese adolescents (mean age=14.29 years, standard deviation=1.12) received 12 weeks of combined treatment that consisted of weekly in-person group behavioral weight control treatment sessions plus smartphone self-monitoring and daily text messaging. Subsequently they received 12 weeks of electronic-only intervention, totaling 24 weeks of intervention.

Results

On average, participants attained modest but significant reductions in body mass index standard score (zBMI: 0.08 standard deviation units, t (13)=2.22, P=.04, d=0.63) over the in-person plus electronic-only intervention period but did not maintain treatment gains over the electronic-only intervention period. Participants self-monitored on approximately half of combined intervention days but less than 20% of electronic-only intervention days.

Conclusions

Smartphones likely hold promise as a component of adolescent weight control interventions but they may be less effective in helping adolescents maintain treatment gains after intensive interventions.

No sweat: African American adolescent girls' opinions of hairstyle choices and physical activity

Background

Obesity prevalence is higher among African American adolescent (AAA) girls than among non-black girls. Lower levels of physical activity (PA) likely contribute to this disparity; this may be impacted by hairstyle concerns.

Methods

In 2011, focus groups were conducted with AAA girls 14-17 years old (n = 36) in Michigan (n = 9), California (n = 11), and Georgia (n = 16). Groups addressed perceptions of hairstyles, exercise, and relationships between the two. Groups were recorded, transcripts reviewed, and themes identified. Adolescents completed a standardized ethnic identity (EI) measure and a survey addressing demographics and PA. Linear regression was used to examine associations between self-reported activity and participants’ characteristics.

Results

Four themes emerged: 1) between ages 8 and 15, when concerns about hairstyles began, participants changed from “juvenile” (natural) styles to “adult” (straightened) styles; 2) participants avoided getting wet or sweating during exercise because their straightened hair became “nappy;” 3) braids with extensions and natural styles were viewed as better for exercise but not very attractive; 4) participants almost universally selected long, straight hairstyles as most attractive. In Michigan and California, EI was positively associated with levels of PA (p < 0.05) and overall having extensions was also positively associated with levels of PA.

Conclusions

A preference for straight hair may contribute to AAA girls avoiding certain activities due to concerns about sweat affecting their hair. Furthermore, EI and hairstyle choice appear to be associated with levels of PA for some participants. Efforts to increase AAA girls’ PA may benefit from approaches that address hairstyle choices and EI.

Predictors of medication adherence and persistence in Medicaid enrollees with developmental disabilities and type 2 diabetes

BACKGROUND

The prevalence of diabetes mellitus is high among patients with developmental disabilities (cerebral palsy, autism, Down's syndrome and cognitive disabilities).

OBJECTIVES

The purpose of this study was to examine the racial health disparities in medication adherence and medication persistence in developmentally disabled adults with type 2 diabetes enrolled in Medicaid.

METHODS

This was a retrospective cohort study using the MarketScan(®) Multi-State Medicaid Database. Adults aged 18-64 years with a prior diagnosis of a developmental disability (cerebral palsy/autism/down's/cognitive disabilities) and a new diagnosis of type 2 diabetes enrolled in Medicaid from January 1, 2004 and December 31, 2006, were included. Adults were included if they had a continuous enrollment for at least 12 months and were excluded if they were dual eligible. Anti-diabetes medication adherence and diabetes medication persistence were measured using multivariate logistic regression and the Cox-proportional hazard regression, respectively.

RESULTS

The study population comprised of 1529 patients. Although overall diabetes medication adherence in this population was optimal, African Americans had significantly lower odds (25%) of adhering to anti-diabetes medications compared to Caucasians (OR = 0.75, 95% CI = 0.58-0.97, P < 0.05). Also, after controlling for other covariates, the rate of discontinuation was higher in African Americans compared to Caucasians (hazard ratio = 1.03, 95% CI = 0.91-1.18, P < 0.629).

CONCLUSION

In this study, racial disparities were found in anti-diabetes medication adherence among Medicaid enrollees with developmental disabilities (DD). Studies conducted in the future should examine predictors that impact access to care, availability of primary and specialized care, social support as well as beliefs of racial minority populations with developmental disabilities and chronic conditions like diabetes to optimize medication use outcomes in this especially vulnerable population.

Social/Electronic Media Use of Children and Adolescents Who Attend the Pediatric Weight Management Programs of the COMPASS Network

BACKGROUND

Obesity is a major healthcare problem in youth and their social/electronic media (SEM) use has been described as a risk factor. Though much is known about the newer technologies youth use to communicate, little is known about what is used by those in weight management programs. The aim of this study was to determine what types of SEM, including sedentary and active video games, youth in weight management programs use and which they prefer for communicating with healthcare providers.

METHODS/DESIGN

This was a multisite study using a 24-question online SurveyMonkey® questionnaire. Youth, 12-17 years old, attending pediatric weight management programs at seven participating centers in the Childhood Obesity Multi Program Analysis and Study System network were eligible.

RESULTS

There were 292 responders with a mean age of 14.2 years. Fifty-four percent were female, 36% Caucasian, 35% African American, and 33% were Hispanic. Ninety-four percent had access to a computer, 71% had Internet access, and 63% had smartphones. Whereas 87% had at least one gaming system at home, 50% reported they never played sedentary video games (71% of females vs. 25% males; p < 0.0001) and 63% never played exercise video games during the week. The preferred method of communication with a healthcare provider was face to face (60%), with few indicating a preference for communication by texting (13%), phone (12%), or social media (6%).

CONCLUSIONS

Face-to-face communication with healthcare providers is the preferred method for youth in pediatric weight management programs. They self-reported video game use less than previously described.

Characteristics of Youth Presenting for Weight Management: Retrospective National Data from the POWER Study Group

BACKGROUND

There are no existing multisite national data on obese youth presenting for pediatric weight management. The primary aim was to describe BMI status and comorbidities among youth with obesity presenting for pediatric weight management (PWM) at programs within the Pediatric Obesity Weight Evaluation Registry (POWER).

METHODS

Data were collected from 2009-2010 among 6737 obese patients ages 2-17. Patients were classified in three groups by BMI (kg/m(2)) cutoffs and percent of the 95th percentile for BMI: (1) obesity; (2) severe obesity class 2; and (3) severe obesity class 3. Weighted percentages are presented for baseline laboratory tests, blood pressure, and demographics. Generalized logistic regression with clustering was used to examine the relationships between BMI status and comorbidities.

RESULTS

Study youth were 11.6 ± 3.4 years of age, 56% female, 31% black, 17% Hispanic, and 53% publicly insured. Twenty-five percent of patients had obesity (n = 1674), 34% (2337) had severe obesity class 2, and 41% (2726) had severe obesity class 3. Logistic regression revealed that males (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5-2.0), blacks (OR, 1.7; 95% CI, 1.5-2.0), age <6 years (OR, 2.0; 95% CI, 1.5-2.6), and public insurance (OR, 1.8; 95% CI, 1.5-2.0) had a higher odds of severe obesity class 3. Severe obesity class 3 was associated with higher odds of laboratory abnormalities for hemoglobin A1c (OR, 1.7; 95% CI, 1.3-2.2), alanine aminotransferase ≥40 U/L (OR, 1.9; 95% CI, 1.3-2.6), and elevated systolic blood pressure (OR, 2.5; 95% CI, 2.0-3.0).

CONCLUSIONS

Youth with obesity need earlier access to PWM given that they are presenting when they have severe obesity with significant comorbidities.

Addressing prediabetes in childhood obesity treatment programs: support from research and current practice

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.

Children's Hospital Association consensus statements for comorbidities of childhood obesity

BACKGROUND

Childhood obesity and overweight affect approximately 30% of US children. Many of these children have obesity-related comorbidities, such as hypertension, dyslipidemia, fatty liver disease, diabetes, polycystic ovary syndrome (PCOS), sleep apnea, psychosocial problems, and others. These children need routine screening and, in many cases, treatment for these conditions. However, because primary care pediatric providers (PCPs) often are underequipped to deal with these comorbidities, they frequently refer these patients to subspecialists. However, as a result of the US pediatric subspecialist shortage and considering that 12.5 million children are obese, access to care by subspecialists is limited. The aim of this article is to provide accessible, user-friendly clinical consensus statements to facilitate the screening, interpretation of results, and early treatment for some of the most common childhood obesity comorbidities.

METHODS

Members of the Children's Hospital Association (formerly NACHRI) FOCUS on a Fitter Future II (FFFII), a collaboration of 25 US pediatric obesity centers, used a combination of the best available evidence and collective clinical experience to develop consensus statements for pediatric obesity-related comorbidities. FFFII also surveyed the participating pediatric obesity centers regarding their current practices.

RESULTS

The work group developed consensus statements for use in the evaluation and treatment of lipids, liver enzymes, and blood pressure abnormalities and PCOS in the child with overweight and obesity. The results of the FFFII survey illustrated the variability in the approach for initial evaluation and treatment as well as pattern of referrals to subspecialists among programs.

CONCLUSIONS

The consensus statements presented in this article can be a useful tool for PCPs in the management and overall care of children with overweight and obesity.

Sleep duration predicts cardiometabolic risk in obese adolescents

OBJECTIVE

To examine the independent contributions of objectively measured sleep duration and fragmentation on cardiometabolic risk accumulation in free-living obese adolescents.

STUDY DESIGN

Characteristics of metabolic syndrome (waist circumference, mean arterial pressure, fasting high-density lipoprotein cholesterol, triglycerides, glucose) were measured in obese adolescents and standardized residuals (z-scores) were summed (inverse high-density lipoprotein cholesterol) to create a continuous cardiometabolic risk score (cMetScore), adjusted for age, sex, and race. Sleep and physical activity were objectively measured in habitual, free-living conditions for 7 days (SenseWear Pro3, BodyMedia, Pittsburgh, Pennsylvania; n = 37; 54% female, ages 11-17 years). Associations between sleep duration and cMetScore were assessed via multiple linear regression.

RESULTS

Body mass index, total sleep time, and sleep session length were each correlated with cMetScore (P < .05 all). Total sleep time was inversely and independently associated with cMetScore (r = -0.535, P = .001) and was the best independent predictor of metabolic risk.

CONCLUSIONS

Sleep duration inversely predicts cardiometabolic risk in obese adolescents, even when we controlled for various measures of physical activity, anthropometry, and adiposity. Further research should investigate the biological mechanism of this relationship and the potential treatment effect of sleep intervention in decreasing cardiometabolic risk in this population.

To pay or not to pay: public perception regarding insurance coverage of obesity treatment

OBJECTIVE

To explore public opinion regarding insurance coverage for obesity treatment among severely obese adolescents.

DESIGN AND METHODS

The National Poll on Children's Health was fielded to a nationally representative sample of US adults, January 2011. Respondents (n = 2150) indicated whether insurance should cover specific weight management services for obese adolescents and whether private insurance and Medicaid should cover bariatric surgery. Sampling weights were applied to generate nationally representative results. Linear and logistic regression analyses were performed to assess associations.

RESULTS

More respondents endorsed insurance coverage for traditional healthcare services (mental health 86%, dietitian 84%) than for services generally viewed as outside the healthcare arena (exercise programs 65%, group programs 60%). For bariatric surgery, 81% endorsed private insurance coverage; 55% endorsed Medicaid coverage. Medicaid enrollees, black, Hispanic, and low-income respondents had greater odds (P < 0.05) of endorsing bariatric surgery coverage by Medicaid, compared to the referent groups (non-Hispanic white, income ≥$60K, private insurance).

CONCLUSION

Although public support for insurance coverage of traditional weight management services appears high, support for Medicaid coverage for bariatric surgery is lower and varies by demographics. If public opinion is a harbinger of future coverage, low-income adolescents could experience disparities in access to treatments like bariatric surgery.

The role of social media in online weight management: systematic review

BACKGROUND

Social media applications are promising adjuncts to online weight management interventions through facilitating education, engagement, and peer support. However, the precise impact of social media on weight management is unclear.

OBJECTIVE

The objective of this study was to systematically describe the use and impact of social media in online weight management interventions.

METHODS

PubMed, PsycINFO, EMBASE, Web of Science, and Scopus were searched for English-language studies published through March 25, 2013. Additional studies were identified by searching bibliographies of electronically retrieved articles. Randomized controlled trials of online weight management interventions that included a social media component for individuals of all ages were selected. Studies were evaluated using 2 systematic scales to assess risk of bias and study quality.

RESULTS

Of 517 citations identified, 20 studies met eligibility criteria. All study participants were adults. Because the included studies varied greatly in study design and reported outcomes, meta-analysis of interventions was not attempted. Although message boards and chat rooms were the most common social media component included, their effect on weight outcomes was not reported in most studies. Only one study measured the isolated effect of social media. It found greater engagement of participants, but no difference in weight-related outcomes. In all, 65% of studies were of high quality; 15% of studies were at low risk of bias.

CONCLUSIONS

Despite the widespread use of social media, few studies have quantified the effect of social media in online weight management interventions; thus, its impact is still unknown. Although social media may play a role in retaining and engaging participants, studies that are designed to measure its effect are needed to understand whether and how social media may meaningfully improve weight management.

Let's face it: patient and parent perspectives on incorporating a Facebook group into a multidisciplinary weight management program

BACKGROUND

Social media may have the potential to enhance weight management efforts. However, the acceptability of incorporating this entity into pediatrics is unknown. The objective of this project was to explore patients' and parents' perspectives about developing a Facebook group as a component of a pediatric weight management program.

METHODS

Semistructured interviews were performed between September, 2011, and February, 2012, with patients and parents in a multidisciplinary weight management program. Interviews explored participants' perceptions of potential benefits, concerns, and preferences related to a program-specific Facebook group. Transcripts were reviewed and themes identified. The study concluded when thematic saturation was achieved.

RESULTS

Participants (n=32) were largely enthusiastic about the idea of a program-specific Facebook group for adolescents. Most preferred a secret group, where only participants would know of the group's existence or group members' identity. No parents expressed concern about security or privacy related to a program-specific Facebook group; one parent expressed concern about undesirable advertisements. Participants endorsed a variety of ideas for inclusion on the page, including weight loss tips, live chats with providers, quizzes, and an incentive system where participants could gain points for making healthy choices. Many parents requested a separate parent-focused page, an idea that was supported by the adolescents.

CONCLUSIONS

This study suggests that participants perceive potential benefits from incorporating social media interventions into pediatric weight management efforts. Privacy and security issues do not appear to be major parental concerns. Future work should explore the impact of program-specific social media interventions on outcomes for patients in weight management programs.

Slow and steady: readiness, pretreatment weekly strengthening activity, and pediatric weight management program completion

BACKGROUND

Pediatric weight management programs have substantial attrition rates, which have led to recommendations to assess readiness prior to enrollment. Both pretreatment readiness scales and behaviors, such as exercise, have been theorized to predict subsequent program completion. The purpose of this study was to explore the role of self-reported pretreatment exercise in adolescents on completion of a pediatric weight management program and to explore the predictive ability of standard readiness scales.

METHODS

A total of 146 obese (BMI≥95(th) percentile) pediatric (ages 11-18) participants joined a 6-month multidisciplinary weight management program between March, 2007, and July, 2010. Completers were compared retrospectively to noncompleters on demographic, readiness, and pretreatment exercise practices from clinic-developed intake questionnaires using univariate analyses. Regression analyses specified the degree to which these variables predicted program completion.

RESULTS

The 6-month completion rate was 53%. There was no relationship between self-reported readiness and program completion. Self-reported pretreatment weekly strengthening activity (SA) was significantly associated with program completion, compared to those who performed SA either never [univariate odds ratio (OR) 3.18, 95% confidence interval (CI) 1.51-6.68, p=0.002; multivariate OR 2.43, 95% CI 1.06-5.58, p=0.036] or daily (univariate OR 4.90, 95% CI 1.74-13.77, p=0.002; multivariate OR 4.69, 95% CI 1.45-15.14, p=0.010). No relationship was found between other forms of exercise and program completion.

CONCLUSIONS

Self-reported pretreatment weekly SA, but not standard readiness scales, predicted pediatric weight management program completion.

In their own words: learning from families attending a multidisciplinary pediatric weight management program at the YMCA

BACKGROUND

A family-based multidisciplinary weight management program for obese children 7-11 years old was implemented by a pediatric weight management center and local YMCA. The purpose of this study was to explore parents' and children's perceptions of the program to gain insight about factors that may enhance engagement and retention of families in weight management treatment.

METHODS

Families were invited to participate in a telephone interview after their participation in the program. The interviews assessed satisfaction with program components, acceptability of the intervention, barriers to treatment participation, and suggestions for improvement.

RESULTS

A total of 34 semistructured telephone interviews were performed, including 19 parents and 15 children. The majority of children (mean age=9.2±1.5 years) interviewed were female (74%) and recipients of Medicaid (79%). The population was racially diverse (63% black, 26% white, 11% other). Results suggest families were generally very positive about the program and viewed the major components of the program as helpful (i.e., nutrition, exercise, behavior). Families particularly enjoyed exercise and cooking demonstrations, whereas self-monitoring activities and learning about behavior change strategies were less enjoyable. Parents noted that increasing the length of individual sessions would likely be beneficial. Families who did not complete the program cited factors such as transportation barriers (e.g., gas money, distance), scheduling conflicts, and unmet expectations as contributing to their decision to discontinue participation.

CONCLUSIONS

This study may have implications for how to enhance family-based pediatric weight management programs for children ages 7-11 years.

Longer weekly sleep duration predicts greater 3-month BMI reduction among obese adolescents attending a clinical multidisciplinary weight management program

AIMS

To determine whether baseline levels of self-reported sleep and sleep problems among obese adolescents referred to an outpatient multidisciplinary family-based weight management program predict reduction in BMI 3 months later.

METHODS

A retrospective medical chart review was conducted for 83 obese adolescents. The following baseline variables were extracted: self-reported sleep duration (weekdays and weekends), and presence of snoring, daytime fatigue, suspected sleep apnea, and physician-diagnosed sleep apnea. Anthropometric data at baseline and 3 months were also collected.

RESULTS

On average, adolescents reported significantly less sleeping on weeknights (7.7 ± 1.3 h) compared to weekend nights (10.0 ± 1.8 h), t(82) = 10.5, p = 0.0001. Reduction in BMI after 3 months of treatment was predicted by more weekly sleep at baseline (R² = 0.113, F(1, 80) = 10.2, p = 0.002). Adolescents who reduced their BMI by ≥1 kg/m² reported greater weekly sleep at baseline compared to adolescents who experienced <1 kg/m² reduction (60.7 ± 7.5 h vs. 56.4 ± 8.6 h; F(1, 80) = 5.7, p = 0.02).

CONCLUSION

Findings from this study, though correlational, raise the possibility that increased duration of sleep may be associated with weight loss among obese adolescents enrolled in a weight management program. Evidence-based behavioral techniques to improve sleep hygiene and increase sleep duration should be explored in pediatric weight management settings.

A risk score for identifying overweight adolescents with dysglycemia in primary care settings

OBJECTIVE

To develop a clinical risk scoring system for identifying adolescents with dysglycemia (prediabetes or diabetes) who need further confirmatory testing and to determine whether the addition of non-fasting tests would improve the prediction of dysglycemia.

STUDY DESIGN

A sample of 176 overweight and obese adolescents (10-17 years) had a history/physical exam, a 2-h oral glucose tolerance test, and non-fasting tests [hemoglobin A1c, 1-h glucose challenge test (GCT), and random glucose test] performed. Given the low number of children with diabetes, we created several risk scoring systems combining the clinical characteristics with non-fasting tests for identifying adolescents with dysglycemia and compared the test performance.

RESULTS

Sixty percent of participants were white and 32% were black; 39.2% had prediabetes and 1.1% had diabetes. A basic model including demographics, body mass index percentile, family history of diabetes, and acanthosis nigricans had reasonable test performance [area under the curve (AUC), 0.75; 95% confidence interval (95% CI), 0.68-0.82]. The addition of random glucose (AUC, 0.81; 95% CI, 0.75-0.87) or 1-h GCT (AUC, 0.82; 95% CI, 0.75-0.88) to the basic model significantly improved the predictive capacity, but the addition of hemoglobin A1c did not (AUC, 0.76; 95% CI, 0.68-0.83). The clinical score thresholds to consider for the basic plus random glucose model are total score cutoffs of 60 or 65 (sensitivity 86% and 65% and specificity 60% and 78%, respectively) and for the basic plus 1-h GCT model are total score cutoffs of 50 or 55 (sensitivity 87% and 73% and specificity 59% and 76%, respectively).

CONCLUSIONS

Pending a validation in additional populations, a risk score combining the clinical characteristics with non-fasting test results may be a useful tool for identifying children with dysglycemia in the primary care setting.

Eat, play, love: adolescent and parent perceptions of the components of a multidisciplinary weight management program

BACKGROUND

Participants' perceptions may be associated with the high attrition rates reported by weight management programs.

OBJECTIVE

To explore participants' perceptions of a weight management program.

METHODS

Semistructured interviews were performed (spring 2010) with past participants of the Michigan Pediatric Outpatient Weight Evaluation and Reduction program. Transcripts were reviewed and themes identified.

RESULTS

Parents (38) and adolescents (25) were interviewed separately; similar themes emerged. Theme 1: Support/encouragement-Participants emphasized the importance of a supportive environment with a positive, compassionate approach from providers. Theme 2: Exercise-Fun, achievable activities were a valued means of making exercise enjoyable and building self-efficacy. Theme 3: Nutrition-Hands on demonstrations and tangible suggestions were preferred over activities such as self-monitoring. Theme 4: Behavioral factors-Participants valued the opportunity to hear their peers' experiences. However, individual/family sessions addressing their personal concerns were also viewed as important.

CONCLUSION

Beyond program content, participants valued a supportive environment emphasizing health over habitus.

A picture may be worth a thousand texts: obese adolescents' perspectives on a modified photovoice activity to aid weight loss

BACKGROUND

In an effort to enhance the vividness and personal relevance of a text messaging intervention to promote weight loss among obese adolescents, a modified Photovoice process was evaluated with adolescents in a weight management program.

METHODS

Photovoice is a method using photography to generate relevant images and stories from users. Participants were recruited from the Michigan Pediatric Outpatient Weight Evaluation and Reduction (MPOWER) program, a multidisciplinary weight management program for obese adolescents and their parents. Twenty-three adolescents with a mean BMI of 40 were asked to take pictures on three to five randomly assigned weight-related topics, such as “something that reminds you to exercise,” and to text them to a research assistant. Adolescents then engaged in semistructured interviews about the experience. Detailed notes of the interviews were analyzed to identify themes.

RESULTS

Participants generally provided high ratings of the process, indicating that (1) deciding what pictures to take caused them to reflect on their weight loss experience, and (2) a mobile intervention incorporating personally relevant images (e.g., basketball as their favorite sport rather than sports in general) would increase treatment adherence. The submitted photographs frequently featured family members and friends, and participants indicated that family and friends played a major role in motivating and supporting them.

CONCLUSIONS

This study suggests that a Photovoice component has the potential to enhance weight management programs for teens as part of a text messaging intervention and as an independent entity. Further work should evaluate the effect of this promising intervention on weight loss.

Bariatric surgery decision making challenges: the stability of teens' decisions and the treatment failure paradox

PURPOSE

Criteria for adolescent bariatric surgery include failure of ≥6 months of organized weight loss attempts. We wished to explore whether adolescents, initially wanting surgery, change their mind during a 6-month weight loss program and how many meet the treatment failure criterion.

METHODS

A retrospective chart review of adolescents enrolled in a weight loss program between 3/2007 and 2/2009.

RESULTS

Twenty-one (13 % of total patients) initially wanted bariatric surgery. Most were Medicaid enrollees (70 %), female (85 %), and white (60 %). The mean age was 15 years and mean BMI was 51 (range 36-71). Five did not meet BMI, comorbidity, or psychological criteria for surgery. Eight lost weight and therefore did not meet the treatment failure criterion. Of these, seven no longer wanted surgery. Eight did not lose weight and therefore met the treatment failure criterion; five of these decided against surgery due to difficulty in making recommended lifestyle changes.

CONCLUSION

Most patients initially wanting bariatric surgery changed their minds. The treatment failure criterion presented a paradox, because most patients who met the criterion exhibited difficulty in making the lifestyle changes. To aid provider/patient decisions about bariatric surgery, further work should explore the criteria for surgery and stability of adolescents' decisions regarding bariatric surgery.

Association Between Physician Recommendation for Adolescents to Join a Weight Loss Program and BMI Change

OBJECTIVE

To explore whether reasons for enrollment in a pediatric multidisciplinary weight management program (PMWMP) are associated with subsequent weight loss.

METHOD

A retrospective analysis of obese adolescents (12-18 years old, body mass index [BMI] > 95th percentile) who enrolled in a PMWMP from April 2007 to March 2009, and had BMI measurements at weeks 1 and 12. Reasons for enrollment were obtained from parents' responses to an enrollment questionnaire (which allowed selection of more than one reason). The most common reasons for enrollment were computed. Linear regression was used to explore associations between mean change in BMI and reasons for enrollment, controlling for demographic and anthropometric factors.

RESULTS

Most of the 90 adolescents who met the inclusion criteria were female (70%) and white (57%). Mean age was 14.5 years and mean initial BMI was 42 kg/m(2). The most common reasons for enrolling in the PMWMP were due to concerns about adolescents' physical health (96%), concerns about adolescents' mental health (76%), and because of a physician recommendation (73%). The mean 12-week change in BMI showed a greater decrease for those who enrolled due to a physicians' recommendation versus those who did not (-1.5 vs -0.5 kg/m(2): P < .05). This finding remained significant even when controlling for the covariates of interest.

CONCLUSIONS

A physician's recommendation to join a PMWMP appears to be associated with greater weight loss among obese adolescents than other reasons for enrollment. Further research should explore how physician involvement affects long-term weight loss.

OMG do not say LOL: obese adolescents' perspectives on the content of text messages to enhance weight loss efforts

Adolescents participating in weight loss programs experience difficulty adhering to behavior change recommendations. Communications technology provides a low cost means to increase the frequency of contact with adolescents which can improve their engagement and also lead to behavior change. Within a larger project on the development of tailored text messages for adolescents enrolled in an existing multidisciplinary weight management program, this study explored participants' perspectives about message content. A library of messages was developed focused on topics central to weight management. Four focus groups were conducted with a total of 24 participants from the weight management program to gage their reactions to the messages. Detailed notes from the focus groups were analyzed to assess the acceptability of individual messages and to identify overriding themes. Results indicate that participants were very enthusiastic about receiving text messages. They preferred messages that provided recipe ideas, included successful weight loss strategies used by peers, and requested feedback regarding their progress. They preferred positive, encouraging, and direct messages. They were unanimous that messages should include encouraging symbols (e.g., exclamation points and "smiley faces") as often as possible. They emphasized that any mention of unhealthy foods or behaviors would trigger them to eat those foods or engage in those behaviors. Text messaging acronyms (e.g., LOL) were considered too informal for messages from healthcare providers. This study suggests that including text messages in obesity interventions is acceptable to obese adolescents as a means of supporting their weight loss efforts, and it highlights the need for such messages to be carefully constructed.

Results from a clinical multidisciplinary weight management program

BACKGROUND/OBJECTIVE

Published data regarding outcomes of pediatric behavioral weight management are mainly from research interventions. The authors wished to explore outcomes from a clinical program.

METHODS

A retrospective analysis of data from obese adolescents enrolled in the Michigan Pediatric Outpatient Weight Evaluation and Reduction program (April 2007 to June 2008). The multidisciplinary program included group sessions, individual visits, and exercise classes. Linear regression was used to explore associations between change in body mass index (BMI) and age, sex, race, and insurance.

RESULTS

N = 67. Mean age was 14.5 years; 71% female, 50% Medicaid enrollees, and 30% African American. Mean initial BMI was 40. Mean change in BMI was -2.3 for those completing the 24-week program (n = 48; P < .01). Reduction in BMI was not associated with participants' demographic characteristics.

CONCLUSIONS

A clinical multidisciplinary weight loss program for adolescents can lead to decreases in BMI after 24 weeks. Further work is needed to assess long-term outcomes.

Tailored mobile phone text messages as an adjunct to obesity treatment for adolescents

We examined the use of tailored messages sent to the mobile phones of obese adolescents enrolled in a weight-management programme, as a means of increasing adherence. The feasibility study was conducted in three phases: (1) a library of 90 messages was developed about five weight-related behaviours; (2) a computer application was developed to tailor these messages to participants' characteristics; the SMS messages (text and images) were sent to mobile phones daily; (3) a three-month trial of the intervention was performed with 20 adolescents. Semi-structured interviews were conducted to assess the participants' perceptions of the intervention and the participants', providers' and computer consultants' reports about technology performance. These interviews revealed that participants were enthusiastic about the intervention and most found the messages to be personally relevant. The favourite messages were meal suggestions and recipe ideas. The computer tailoring application performed faultlessly and messages were delivered on schedule and in the desired sequence. Computerized tailored text messaging is a feasible adjunct to multidisciplinary obesity treatment and is acceptable to adolescents as an enjoyable means of improving their adherence to healthy lifestyle practices.

Physicians' perspectives on referring obese adolescents to pediatric multidisciplinary weight management programs

OBJECTIVE

To identify factors that might influence physicians' referrals of obese adolescents to pediatric multidisciplinary weight management (PMWM) programs.

DESIGN/METHODS

Survey of a national sample of 375 pediatricians (PDs) and 375 family physicians (FPs) explored program availability, referral history, desired services, and when in the course of treatment physicians would refer. Differences were examined via chi(2) tests.

RESULTS

Response rate was 67%. More PDs than FPs reported having a PMWM program available (46% vs 10%, P < .01). More PDs (PD 83% vs FP 53%, P < .01) and female physicians (88% vs 65%, P < .01) reported having made a referral. Most physicians wanted coordinated diet, activity, and behavioral therapy (79%). Almost all physicians indicated they would refer when unsure of what else to do, or if requested by the patient/parent.

CONCLUSIONS

PMWM program referrals appear limited by availability. These data also suggest physicians may be reticent to refer. Further work should examine whether this affects patient outcomes.

Feasibility and acceptability of a 1-page tool to help physicians assess and discuss obesity with parents of preschoolers

OBJECTIVE

To assess the feasibility and acceptability of a brief tool to help pediatricians communicate with parents of preschoolers about obesity risk, prevention, and treatment.

METHODS

The 2-sided Assessment and Targeted Messages (ATM) tool developed by the investigators included sections to assess nutrition and physical activity, self-efficacy and readiness-to-change, obesity-related family history, and treatment/prevention recommendations. Twenty-five pediatricians were recruited to use the ATM and then surveyed regarding their opinions of its feasibility and acceptability.

RESULTS

Response rate was 60%. Most ATM features were considered somewhat or very useful by the majority of respondents. The majority of physicians (62%) indicated that they were somewhat likely to use the ATM in the future, with only 23% indicating that they were very likely to use it. The greatest barrier to its use was time.

CONCLUSION

Pediatricians considered the ATM tool moderately feasible and acceptable. Time-efficient methods to help physicians address obesity should be explored.

Waist circumference percentile thresholds for identifying adolescents with insulin resistance in clinical practice

We formally evaluated waist circumference (WC) percentile cutoffs for predicting insulin resistance (IR) and whether different cutoffs should be used for adolescents of different race/ethnicities. Analysis was performed for 1575 adolescents aged 12-18 yr from the National Health and Nutrition Examination Survey 1999-2002. Adolescents were classified as having IR if they had a homeostasis model assessment-insulin resistance level, a validated measure of IR, of >4.39, and WC percentile was classified according to previously published universal (all races combined) and race/ethnicity-specific WC percentile cutoffs. Receiver operating characteristic curves for predicting IR were constructed comparing the race/ethnicity-specific vs. universal WC percentile cutoffs, and area under the curve (AUC) was calculated. Comparing universal with race/ethnicity-specific WC percentiles, there were no significant differences in AUC for Black, Mexican-American, or White adolescents. Because race/ethnicity-specific thresholds did not discriminate better than universal WC thresholds, universal WC thresholds may be used effectively to identify adolescents with IR in primary care practices. A WC > or =75th or > or =90th percentile for all race/ethnicities combined would be appropriate to apply in clinical practice for identification of adolescents with IR, a risk factor for development of type 2 diabetes.

Persistent gap of incremental charges for obesity as a secondary diagnosis in common pediatric hospitalizations

OBJECTIVE

To use hospitalization data from 2003 to determine whether prior findings, showing higher charges and longer lengths-of-stay (LOSs) for children with obesity versus those without, were stable over time and whether the magnitude of differences was consistent over a 4-year period.

METHODS

Using the 2000 and 2003 Agency for Healthcare Research and Quality (AHRQ) Kids Inpatient Database (KID), we examined discharges for the top 4 nonpregnancy-related principal discharge diagnoses for children aged 2-18 years (asthma, pneumonia, affective disorders, and appendicitis), classified as with or without obesity based on the presence of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 278.0x as a secondary diagnosis. We compared mean charges for hospitalizations with obesity listed as secondary diagnosis versus those without. Results are presented in 2003 dollars.

RESULTS

Among children's discharges in 2000 and 2003, 1.1% and 1.6%, respectively, listed obesity as a secondary diagnosis. In 2003, for all 4 diagnoses, adjusted mean hospital charges were statistically significantly higher and adjusted mean LOS was statistically significantly longer for discharges with obesity as a secondary diagnosis versus those without. Additionally, the magnitude of the differences for both charges and LOS was generally somewhat greater in 2003 than in 2000 (asthma 9%, pneumonia 17%, affective disorders 121%, and appendicitis 3%) although it did not achieve statistical significance (P > 0.05).

CONCLUSIONS

These findings suggest a widening gap of incremental charges and LOS associated with obesity as a comorbidity. This implies a financial imperative for further research to evaluate factors that contribute to greater resource utilization among obese children.