Impact of short-term refeeding on appetite and meal experiences in new onset adolescent eating disorders.

Restrictive eating disorders (ED) are increasing and represent a serious risk to the health of adolescent females. Restrictive ED in youth are often treated through aggressive short-term refeeding. Although evidence supports that this intervention is the "gold standard" for improving ED outcomes in youth, little research has specifically probed appetite and meal-related responses to this type of intensive, short-term refeeding in newly diagnosed individuals. Information about appetite and meal-related dysfunction could provide valuable insights regarding treatment-interfering features of ED in both acute inpatient and longer-term outpatient treatment. The purpose of this study was to evaluate the hunger, fullness, olfactory, and gustatory responses of adolescents with newly-diagnosed restrictive ED and to probe how and when these responses are altered by refeeding. Using a quasi-experimental ecologically valid methodology, this study described and compared profiles of hunger, fullness, olfactory, and gustatory responses in adolescent females (n = 15) with newly diagnosed restrictive ED at hospital admission (i.e., severe malnutrition) and after medical refeeding, in comparison to healthy controls (n = 15). Results showed that newly diagnosed (i.e., malnourished) adolescents with ED showed significantly different meal-related experiences than controls. Refeeding improved some of these differences, but not all. Following refeeding, females with ED continued to show lower hunger, greater fullness, and lower pleasantness of smell ratings compared to controls. Unpleasantness of taste ratings maladaptively increased, such that females who were re-fed reported more aversive scents than pre-treatment. Profiles of meal-related responses were also identified and compared between groups. The applicability of these findings are discussed within the context of critical periods of change during refeeding treatment and potentially promising intervention targets that might enhance treatment outcomes for adolescents with newly onset, restrictive ED.

Nutritional strategy for adolescents undergoing bariatric surgery: report of a working group of the Nutrition Committee of NASPGHAN/NACHRI.

Surgical options for the treatment of adolescent obesity have been gaining popularity. Adolescent patients present a particular challenge to clinicians, secondary to age-related issues, revolving around both mental and physical growth. These age-related issues require a unique approach to nutritional intervention for adolescents undergoing bariatric surgery as opposed to standardized approaches for adults. Despite the increasing numbers of adolescents undergoing obesity surgery, evidence-based nutritional guidelines have yet to be published. The goal of this document is to provide the clinician with recommendations on how to assess, educate, nourish, and monitor the adolescent who has undergone obesity surgery. A multidisciplinary panel composed of 3 pediatric gastroenterologists, 1 psychologist, and 3 registered dietitians from the Nutrition Committee for the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition and National Association of Children's Hospitals and Related Institutions, with experience in nutrition and adolescent weight loss surgery, reviewed the medical literature for evidence-based practice for nutritional strategies for patients undergoing bariatric surgery. In addition to this group, an adolescent medicine physician was consulted for matters related to reproductive health. The present article presents a consensus of recommendations based on a review of the literature. In areas for which there was a lack of evidence to support the recommendations, best-practice guidelines were used. The present article provides the clinician with an overview of the nutritional concerns for adolescent patients undergoing obesity surgery. These guidelines address the preoperative educational pathway, the postoperative diet progression, recognition of disordered eating, guidelines for female reproductive issues, and assistance for the adolescent in a school/college environment.

Pediatricians and screening for obesity with body mass index: does level of training matter?

OBJECTIVES: Pediatric obesity is increasing at epidemic rates in industrialized nations. It is recommended that pediatricians screen all children annually with the use of body mass index (BMI). However, it is unclear whether this recommendation is followed. This study sought to (1) determine the proportion of children screened for obesity with BMI, and (2) test whether attending physicians are more likely than resident physicians to document and plot BMI. METHODS: We conducted a systematic review of medical records in an urban academic pediatric practice. Participants were children aged 5 to 11 years presenting for health care in 2004. We measured the proportion of subjects with documented and plotted BMI and compared results for attending and resident physicians. We used logistic regression analysis to determine factors associated with documentation of BMI. RESULTS: Of 397 medical records reviewed, 59.7% contained the 2000 Centers for Disease Control and Prevention growth curve with BMI for age; 5.5% documented BMI, and 4.3% plotted BMI. Resident physicians were more likely to document (13.0% vs. 3.0%, p = 0.0008) and plot (9.0% vs. 2.7%, p = 0.0260) BMI compared with attending physicians. Children with a BMI--95% for age were more likely to have their BMI documented (odds ratio [OR] = 10.7, 95% confidence interval [CI] 3.7, 31.5) and plotted (OR = 7.1, 95% CI 2.3, 21.6). CONCLUSION: We found the use of BMI to screen for childhood obesity very poor in this academic pediatric practice. Resident physicians were more likely to document and plot BMI than attending physicians.

Differences in the management of adolescents with polycystic ovary syndrome across pediatric specialties.

STUDY OBJECTIVE: Evaluate for differences in the management of adolescents with polycystic ovarian syndrome (PCOS) across 3 pediatric specialties. DESIGN: Retrospective review of medical records. SETTING: Academic children's hospital. PARTICIPANTS: 181 adolescents seen between July 2008 and June 2010 by providers in Pediatric Endocrinology (PEndo), Adolescent Medicine (AMed), or Pediatric and Adolescent Gynecology (PGyn) identified via billing data (ICD-9 code for PCOS, 256.4). INTERVENTIONS: None. MAIN OUTCOME MEASURES: (1) Percentage of adolescents with a billing diagnosis of PCOS who met diagnostic criteria; (2) Percentage of individuals screened for comorbidities and differences across specialties; (3) Differences in treatment recommendations across specialties; (4) Factors associated with recommendation for metformin and hormonal contraceptives. RESULTS: Thirteen percent of PEndo patients did not meet diagnostic criteria for PCOS; 20% of AMed and PGyn patients did not meet criteria. There were significant differences in rates of screening for obesity, insulin resistance, and Type 2 diabetes. There were significant differences in treatment recommendations for lifestyle changes, metformin, and anti-androgen therapy across specialties. Specialty and obesity were significant predictors of metformin recommendation; specifically PEndo predicted metformin recommendation. PGyn and AMed specialties predicted hormonal contraceptive recommendation. CONCLUSIONS: The variability observed among specialties may be due to differences in training, accounting for a range of comfort with aspects of PCOS. Formulation of consensus guidelines for diagnosis and management of PCOS are needed, along with broad educational efforts. By correctly diagnosing, screening for comorbidities, and managing PCOS appropriately during adolescence, providers may reduce the risk for long-term consequences.

Early pubertal development and insulin sensitivity among school-aged girls: mediation via adiposity.

STUDY OBJECTIVE: To examine whether the known association between early pubertal breast maturation and insulin sensitivity (SI) is mediated by adiposity. DESIGN: Cross-sectional analyses. SETTING: Observational study examining the roles of environment, diet, and obesity on puberty. PARTICIPANTS: 379 girls with a mean age, 7.03 years; 62% were white and 29% black. MAIN OUTCOME MEASURES: Pubertal development was assessed via physical examination and adiposity by body mass index Z score (BMI Z) and waist-to-height ratio. Fasting blood samples were obtained for insulin and glucose concentrations. SI was calculated with the quantitative insulin sensitivity check index (QUICKI). Analysis of variance and Sobel's test was used to assess mediation. RESULTS: Fifty-five girls were pubertal (Tanner 2 breast). Breast maturation was inversely associated with SI (P = .005) and positively associated with BMI Z (P < .001) and waist-to-height ratio (P < .001). The effect of breast maturation on SI was no longer significant (P = .41) after adjusting for the effect of BMI Z, which remained significant (P < .001). Similar results were obtained when waist-to-height ratio replaced BMI Z in the models. Mediation analyses demonstrated that 75% of the association between breast maturation and SI is mediated by adiposity. CONCLUSIONS: In girls, decreased SI during early puberty is largely mediated by total and visceral adiposity.

Obesity and the hypothalamic-pituitary-adrenal axis in adolescent girls.

Stress and stress-related concomitants, including hypothalamic-pituitary-adrenal (HPA) axis activation, are implicated in obesity and its attendant comorbidities. Little is known about this relationship in adolescents. To begin to address this important knowledge gap, we studied HPA axis activity in 262 healthy adolescent girls aged 11, 13, 15, and 17 years. We hypothesized that obesity would be correlated with increased HPA axis activity and reactivity. Measures of HPA axis activity included 3 blood samples obtained midday (between 1:00 and 2:00 pm) over the course of 40 minutes; overnight urine free cortisol; and cortisol levels 0, 20, and 40 minutes after venipuncture (cortisol reactivity). Measures of adiposity included body mass index (BMI), BMI z score (BMI-Z), percentage body fat, and fat distribution (central adiposity) assessed by dual-energy x-ray absorptiometry. Daytime levels of serum cortisol were inversely associated with BMI-Z and central adiposity (P < .05). The urine free cortisol excretion rate was positively correlated with BMI, BMI-Z, and central adiposity. There was blunting of cortisol response to venipuncture with increasing adiposity. Our results suggest that there may be reduced cortisol levels during the day and increased levels at night with increasing degree of adiposity. This study provides preliminary findings indicating an alteration of the circadian rhythm of cortisol with obesity. We conclude that obesity is associated with altered HPA activity in adolescent girls. The clinical implications of our findings require further investigation.

Ghrelin biology and its role in weight-related disorders.

The discovery of ghrelin and its role in human metabolism has promoted significant research and advances in the study of obesity and other weight-related disorders. Ghrelin is relevant to many disorders of metabolism and weight such as obesity, cachexia, Prader-Willi Syndrome (PWS), and Anorexia Nervosa (AN), and its role in the pathophysiology differs. The changes observed in ghrelin physiology in these disorders shed light on the overall role of ghrelin in human metabolism and growth. The purpose of this review is to summarize the existing literature on ghrelin and some disorders of metabolism and growth. The disorders that will be discussed include obesity, cachexia, PWS, and AN. Within each disorder we will review relevant ghrelin physiology, recent studies, and potential modes of intervention with ghrelin analogues.

Menstrual concerns and intrauterine contraception among adolescent bariatric surgery patients.

OBJECTIVE: Adolescent obesity has dramatically increased in recent decades, and along with that so have other medical comorbidities, such as hypertension, diabetes, hyperlipidemia, nonalcoholic steatohepatitis, polycystic ovary syndrome (PCOS), and pseudotumor cerebri. Obesity and related comorbidites may be contraindications to hormonal contraception, making contraception counseling of morbidly obese adolescents more challenging. Obese adolescent females seeking bariatric surgery need effective contraception in the postoperative period. This study is designed to determine the acceptance rate of the levonorgestrel-releasing intrauterine device (IUD) and describe common menstrual problems in obese adolescent bariatric surgery patients. METHODS: This is a historic cohort study of adolescent females who underwent bariatric surgery over a 2-year period at a tertiary referral center for pediatric obesity. Data were systematically abstracted. The percent of patients with menstrual problems and the acceptance rate for the levonorgestrel-releasing IUD were determined. RESULTS: Twenty-five adolescents met inclusion criteria. The mean age was 17.4 years (standard deviation [SD] 2.6), and the mean body mass index (BMI) was 51.4 (SD 6.3) kg/m(2). Eighty-four percent were white. Twenty-eight percent had menorrhagia, 32% had oligomenorrhea, 40% had dysmenorrhea, and 36% had PCOS. Ninety-two percent (23 of 25) underwent IUD placement. CONCLUSIONS: There was a high prevalence of menstrual problems among this sample of severely obese adolescent females. The majority accepted the IUD, indicating it is a viable option among this population.

Does competence mediate the associations between puberty and internalizing or externalizing problems in adolescent girls?

PURPOSE: To examine separate mediational models linking (a) menarcheal status or (b) pubertal timing to internalizing and externalizing problems through competence. METHOD: This study involved cross-sectional analyses of 262 adolescent girls (age: 11-17 years; mean = 14.93, standard deviation = 2.17) enrolled in a longitudinal study examining the association of psychological functioning and smoking with reproductive and bone health. Measures of menarcheal status (pre/post), pubertal timing (early, on-time, or late), internalizing and externalizing behavior, and perceived competence (parent and adolescent report) were obtained. Structural equation modeling was used for analyses. RESULTS: Perceived competence was found to fully mediate the association between menarcheal status and parent report of internalizing and externalizing problems. For adolescent report, there was a full mediation effect for internalizing problems but a partial mediation effect for externalizing problems. Being menarcheal was related to lower competence, which was in turn related to higher internalizing and externalizing problems. Models including pubertal timing were not significant. CONCLUSIONS: Perceived competence is important in understanding the associations between menarcheal status and internalizing and externalizing problems. Interventions targeting competence, particularly in postmenarcheal girls, may reduce or prevent problem behaviors.

Bone mass, depressive, and anxiety symptoms in adolescent girls: variation by smoking and alcohol use.

PURPOSE: The purpose of the study was to examine (a) the association between depressive and anxiety symptoms with bone health, (b) the association of smoking or alcohol use with bone health, and, in turn (c) whether the association between depressive and anxiety symptoms with bone health varied by smoking or alcohol use individually or by combined use. Bone health included total body bone mineral content (TB BMC) and bone mineral density (BMD) of the lumbar spine, total hip, and femoral neck. Previously published data have not examined these issues in adolescence, a period when more than 50% of bone mass is accrued. METHODS: An observational study enrolled 262 healthy adolescent girls by age cohort (11, 13, 15, and 17 years). Participants completed questionnaires and interviews on substance use, depressive symptoms, and anxiety. BMC and BMD were measured by dual-energy X-ray absorptiometry. RESULTS: Higher depressive symptoms were associated with lower TB BMC and BMD (total hip, femoral neck). Those with the lowest level of smoking had higher BMD of the hip and femoral neck, whereas no main effect differences were noted by alcohol use. Regular users of both cigarettes and alcohol demonstrated a stronger negative association between depressive symptoms and TB BMC as compared with nonusers/experimental users and regular alcohol users. Findings were parallel for anxiety symptoms. CONCLUSION: Depressive and anxiety symptoms may negatively influence bone health in adolescent girls. Consideration of multiple substances, rather than cigarettes or alcohol separately, may be particularly informative with respect to the association of depression with bone health.

Association of anxiety and depressive symptoms and adiposity among adolescent females, using dual energy X-ray absorptiometry.

The purpose of this study is to evaluate the association between anxiety and depressive symptoms and obesity among adolescent females using objective measures of adiposity and evaluate for moderating effects of race and age. This is a cross-sectional analysis of 198 females aged 11, 13, 15, and 17 years (mean = 14.6, standard deviation = 2.2). Adiposity measures include BMI, BMI Z score, percentage body fat from dual energy X-ray absorptiometry (DXA), and fat distribution (fat mass upper vs lower body regions from DXA). Symptoms of anxiety are measured with the State-Trait Anxiety Inventory and depressive symptoms with the Children's Depression Inventory. Trait anxiety and depressive symptoms are positively associated with BMI and percentage body fat. No interaction of anxiety/ depressive symptoms with race or age on measures of adiposity was detected. Symptoms of anxiety and depression are associated with percentage body fat among adolescent females, linking psychological distress with a physiological measure of adiposity.

Perceived competence and contraceptive use during adolescence.

BACKGROUND: Little is known about psychosocial correlates of different contraceptive methods in adolescence. STUDY DESIGN: Cross-sectional analyses of 209 postmenarcheal girls [mean age (years)+/-SD=15.68+/-1.74], primarily Caucasian (62.8%) or African American (32.8%). Competence (activities and social) and rule-breaking behavior were assessed by the Youth Self Report (YSR; adolescent) and the Child Behavior Checklist (CBCL; parent). Three contraceptive-use groups were created: no hormonal contraceptive (n=142), combined oral contraceptives or the transdermal patch (COCs/patch, n=41), and depot medroxyprogesterone acetate (DMPA, n=20). RESULTS: There was a significant effect of contraceptive-use group on competence (p=.003). The DMPA group had lower competence (CBCL activities and social; YSR social) than the no-hormonal-contraceptive and COCs/patch groups. The COCs/patch group scored lower than the no-hormonal-contraceptive group on YSR activities competence, but was not different from the DMPA group. Lastly, there was an effect of contraceptive-use group on CBCL (but not YSR) rule-breaking behavior (p=.029) with the DMPA group having higher rule-breaking behavior than the other groups. CONCLUSIONS: Type of contraceptive method was associated with parent and adolescent's perceived competence. For rule-breaking behavior, parental perception may be more relevant to contraceptive use.

The measurement of menstrual symptoms: factor structure of the menstrual symptom questionnaire in adolescent girls.

This study examined the factor structure of the Menstrual Symptom Questionnaire (MSQ) in a sample of 210 adolescent girls (11-17 years). Such an examination has not been carried out with an adolescent sample. In addition, the definitions of menstrual disorders have evolved since the creation of the MSQ. Exploratory factor analysis supported a three factor structure indicating abdominal pain, negative affect/somatic complaints, and back pain. Partial correlations indicated all three MSQ factors were correlated with depressive symptoms, but only the negative affect factor was correlated with trait anxiety. Future research should explore potential associations in multiple areas of functioning as menstrual symptoms may alter healthy developmental processes during adolescence.