Relationship between youth cardiometabolic health and physical activity in medical records.

BACKGROUND: Thers is limited research examining modifiable cardiometabolic risk factors with a single-item health behavior question obtained during a clinic visit. Such information could support clinicians in identifying patients at risk for adverse cardiometabolic health. We investigated if children meeting physical activity or screen time recommendations, collected during clinic visits, have better cardiometabolic health than children not meeting recommendations. We hypothesized that children meeting either recommendation would have fewer cardiometabolic risk factors. METHODS AND FINDINGS: This cross-sectional study used data from electronic medical records (EMRs) between January 1, 2013 through December 30, 2017 from children (2-18 years) with a well child visits and data for ≥1 cardiometabolic risk factor (i.e., systolic and diastolic blood pressure, glycated hemoglobin, alanine transaminase, high-density and low-density lipoprotein, total cholesterol, and/or triglycerides). Physical activity and screen time were patient/caregiver-reported. Analyses included EMRs from 63,676 well child visits by 30,698 unique patients (49.3% female; 41.7% Black, 31.5% Hispanic). Models that included data from all visits indicated children meeting physical activity recommendations had reduced risk for abnormal blood pressure (odds ratio [OR] = 0.91, 95%CI 0.86, 0.97; p = 0.002), glycated hemoglobin (OR = 0.83, 95%CI 0.75, 0.91; p = 0.00006), alanine transaminase (OR = 0.85, 95%CI 0.79, 0.92; p = 0.00001), high-density lipoprotein (OR = 0.88, 95%CI 0.82, 0.95; p = 0.0009), and triglyceride values (OR = 0.89, 95%CI 0.83, 0.96; p = 0.002). Meeting screen time recommendations was not associated with abnormal cardiometabolic risk factors. CONCLUSION: Collecting information on reported adherence to meeting physical activity recommendations can provide clinicians with additional information to identify patients with a higher risk of adverse cardiometabolic health.

Implementation of recommended treatment for children in weight management programs: Lessons from the stay in treatment study sites.

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.

Neighborhood park access and park characteristics are associated with weight status in youth.

This study investigated park access and park quality in the context of childhood obesity. Participants were 20,638 children ages 6-17y from a large primary care health system. Analyses tested associations of park access and park characteristics with children's weight status, and sociodemographic interactions. Both park access and the quality of nearest park were associated with a lower odds of having obesity. Park quality interacted with age, sex, and income. Findings suggest park access is important for supporting a healthy weight in children. Park quality may be most important among 12-14-year-olds, girls, and higher income groups.

Prospective associations of neighborhood healthy food access and walkability with weight status in a regional pediatric health system.

BACKGROUND: Most neighborhood food and activity related environment research in children has been cross-sectional. A better understanding of prospective associations between these neighborhood environment factors and children's weight status can provide stronger evidence for informing interventions and policy. This study examined associations of baseline and changes in neighborhood healthy food access and walkability with changes in children's weight status over 5 years. METHODS: Height, weight, and home address were obtained for 4,493 children (> 75% were Black or Latinx) from primary care visits within a large pediatric health system. Eligible participants were those who had measures collected during two time periods (2012-2014 [Time 1] and 2017-2019 [Time 2]). Data were integrated with census tract-level healthy food access and walkability data. Children who moved residences between the time periods were considered 'movers' (N = 1052; 23.4%). Mixed-effects models, accounting for nesting of children within census tracts, were conducted to model associations of baseline and changes in the neighborhood environment variables with Time 2 weight status (BMIz and overweight or obese vs. healthy weight). Models adjusted for weight status and child and neighborhood sociodemographics at baseline. RESULTS: Children living in a neighborhood with [ample] healthy food access at Time 1 had a lower BMIz at Time 2, regardless of mover status. A decrease in healthy food access was not significantly associated with children's weight status at Time 2. Baseline walkability and improvements in walkability were associated with a lower BMIz at Time 2, regardless of mover status. CONCLUSIONS: Findings provide evidence that residing in a neighborhood with healthy food access and walkability may support a healthy weight trajectory in children. Findings on changes in the neighborhood environment suggested that improved walkability in the neighborhood may support children's healthy weight. The greater and more consistent findings among movers may be due to movers experiencing greater changes in neighborhood features than the changes that typically occur within a neighborhood over a short period of time. Future research is needed to investigate more robust environmental changes to neighborhoods.

Medicaid Expenditures among Children with Documented Obesity.

Background: Obesity rates continue to rise among children, but knowledge regarding medical expenditures of Medicaid enrollees with documented obesity is lacking. We aim to describe Medicaid expenditure patterns among children with documented obesity and determine the degree to which specific clinical characteristics and conditions contribute to high expenditures. Methods: We performed a retrospective cross-sectional analysis of children aged 2-17 years with a diagnosis code of obesity continuously enrolled in the 2017 Medicaid MarketScan database. Children were grouped based on annual expenditure percentiles: <80th, 80 to <95th, 95 to <99th, and ≥99th. Inpatient, outpatient, and pharmacy expenditures were analyzed. Covariates included demographics, common obesity comorbid conditions (e.g., hypertension), complex chronic conditions (CCCs), and mental health conditions (MHCs). Logistic regression assessed demographic and clinical characteristics associated with high-spending groups (≥95th%). Results: We identified 300,286 children with a diagnosis of obesity. The 1% of children with the highest spending accounted for 25.4% of annual expenditures among children with documented obesity. Annual expenditures in the highest spending groups were driven primarily by inpatient and outpatient mental health services. Characteristics associated with high-spending groups included the following: age 12-17 years, obesity comorbid conditions, and having ≥1 CCC or MHC. These associations increased with increasing number of CCCs or MHCs. Conclusions: Inpatient and outpatient mental health expenditures made up a large proportion of spending among Medicaid-enrolled children with documented obesity. Important drivers of cost in this population were medical complexity and comorbid MHCs. Future research is needed to determine if some of these costs are avoidable in children with obesity.

A Longitudinal Effectiveness Study of a Child Obesity Electronic Health Record Tool.

BACKGROUND: Primary-care providers, clinic staff, and nurses play an important role in reducing child obesity; yet time restraints and clinical demands compete with effective pediatric weight management and prevention. METHODS: To investigate the potential impact of an electronic health record (EHR) enabled tool to assist primary care teams in addressing child obesity, we conducted a controlled effectiveness study of FitTastic compared with usual care on the BMI pattern of 291 children (2 to 17 years) up to 4 years later. RESULTS: Per χ2 analysis, a greater proportion of children with baseline overweight/obesity in the EHR tool group than the control group had a favorable BMI pattern (32% vs 13%, P = .03). In logistic regression, FitTastic children were more likely than control children to have a favorable BMI pattern at follow-up (OR 3.8, 95% CI 1.1 to 13.2), adjusted for age, gender, race, and parental education. CONCLUSION: Study findings suggest that EHR-enabled tools to assist primary care teams in managing child obesity may be useful for helping to address the weight in children with overweight/obesity, especially in younger children (2 to 5 years). Digital and EHR-enabled technologies may prove useful for partnering health care teams and families in the important tasks of setting positive, family-centered healthy lifestyle behavioral goals and managing child overweight and obesity.

Elevated blood pressure in youth in pediatric weight management programs in the Pediatric Obesity Weight Evaluation Registry (POWER).

Blood pressure (BP) assessment and management are important aspects of care for youth with obesity. This study evaluates data of youth with obesity seeking care at 35 pediatric weight management (PWM) programs enrolled in the Pediatric Obesity Weight Evaluation Registry (POWER). Data obtained at a first clinical visit for youth aged 3-17 years were evaluated to: (1) assess prevalence of BP above the normal range (high BP); and (2) identify characteristics associated with having high BP status. Weight status was evaluated using percentage of the 95th percentile for body mass index (%BMIp95); %BMIp95 was used to group youth by obesity class (class 1, 100% to < 120% %BMIp95; class 2, 120% to < 140% %BMIp95; class 3, ≥140% %BMIp95; class 2 and class 3 are considered severe obesity). Logistic regression evaluated associations with high BP. Data of 7943 patients were analyzed. Patients were: mean 11.7 (SD 3.3) years; 54% female; 19% Black non-Hispanic, 32% Hispanic, 39% White non-Hispanic; mean %BMIp95 137% (SD 25). Overall, 48.9% had high BP at the baseline visit, including 60.0% of youth with class 3 obesity, 45.9% with class 2 obesity, and 37.7% with class 1 obesity. Having high BP was positively associated with severe obesity, older age (15-17 years), and being male. Nearly half of treatment-seeking youth with obesity presented for PWM care with high BP making assessment and management of BP a key area of focus for PWM programs.

Incorporating Yoga into a Pediatric Weight Management Program: A Pilot Study.

Purpose: To assess the feasibility and acceptability of yoga incorporated into a pediatric weight management program (promoting health in teens; PHIT Yoga) to racially diverse caregivers and youth and to compare this program with a cohort that received a program that did not include yoga (PHIT Kids). Methods: Thirty children with obesity were enrolled in a 12-week pediatric weight management intervention (PHIT Kids, n = 17; PHIT Yoga, n = 13). Weight, BMI z-score (BMIz), BMI percent of the 95th percentile, and health habits assessment were obtained from both cohorts pre- and post intervention. Acceptability was assessed in the yoga cohort. Results: Fifty-four percent of children in the PHIT Yoga cohort and 65% of children in the PHIT Kids cohort attended ≥75% of the intervention sessions. Survey results support that the PHIT Yoga was acceptable to both caregivers and children. Improvements in BMIz were observed in 50% of children in each cohort and both groups improved on five of seven health habits; cohorts overlapped on three habits (breakfast, screen time, and sugar-sweetened drinks). Conclusion: Findings support that yoga classes added to a pediatric weight management program are feasible and acceptable in racially diverse children with severe obesity and their caregivers.

Implementation of a Scalable Family-Based Behavioral Treatment for Childhood Obesity Delivered through Primary Care Clinics: Description of the Missouri Childhood Obesity Research Demonstration Study Protocol.

Background: Significant gaps exist in access to evidence-based pediatric weight management interventions, especially for low-income families who are disproportionately affected by obesity. As a part of the Centers for Disease Control and Prevention's Childhood Obesity Research Demonstration project (CORD 3.0), the Missouri team (MO-CORD) aims to increase access to and dissemination of an efficacious pediatric obesity treatment, specifically family-based behavioral treatment (FBT), for low-income families. Methods/Design: The implementation pilot study is a multisite matched-comparison group pilot of packaged FBT in pediatric clinics for low-income children with obesity, of ages 5 to 12 years old. The study is implemented in two Missouri pediatric primary care clinical sites, Freeman Health System Pediatric Clinics (rural Joplin) and Children's Mercy Hospital Pediatric Clinics (urban Kansas City). The design focuses on pragmatism through utilization of PRECIS (Pragmatic Explanatory Continuum Indicator Summary) domains, such as open eligibility criteria, limited follow-up intensity, reliance on medical records for creating a usual care comparison group data, and unobtrusive measurement of participant and provider adherence. The evaluation focuses on effectiveness as well as implementation outcomes and barriers to inform implementation scale up. Conclusions: Findings from this study will advance both science and practice by providing novel and immediately useful information to families, health care providers, health care organizations, payers, and other state Medicaid plans by developing and optimizing evidence-based pediatric weight management treatment for implementation and dissemination in health systems to address health disparities among low-income populations most affected by overweight and obesity.

Translating Family-Based Behavioral Treatment for Childhood Obesity into a User-Friendly Digital Package for Delivery to Low-Income Families through Primary Care Partnerships: The MO-CORD Study.

Background: Significant gaps exist in access to evidence-based pediatric weight management interventions, especially for low-income families. As a part of the Centers for Disease Control and Prevention's Childhood Obesity Research Demonstration project 3.0 (CORD), the Missouri CORD (MO-CORD) team aims to increase access to and dissemination of an efficacious pediatric obesity treatment, family-based behavioral treatment (FBT), among low-income families. This article describes the MO-CORD team's approach to translating FBT into a digital package for delivery to low-income families through primary care practices. Methods: Using digital technology, the primary care setting, and existing reimbursement mechanisms, the MO-CORD team is developing a scalable user-centered design informed treatment package of FBT. This package will be implemented in primary care clinics and delivered to children (5-12 years) with obesity from low-income households in rural and urban communities. The digital platform includes three main components: (1) provider and interventionist training, (2) interventionist-facing materials, and (3) family-facing treatment materials. User-centered design techniques and continuous iterative stakeholder feedback are utilized to emphasize tailoring to a low-income population, along with scalability and sustainability of the digital package. Conclusions: The MO-CORD project addresses the critical need to increase access to obesity treatment for children from low-income households and establishes a platform for future large-scale (i.e., nation-wide) dissemination of evidence-based pediatric weight-management interventions. This study determines whether the digital FBT package can be implemented within real-world settings to create a system by which children with obesity and their families can be effectively treated in primary care settings.

Stay in treatment: Predicting dropout from pediatric weight management study protocol.

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. CLINICALTRIALSGOV IDENTIFIER: NCT04364282.

Health-Related Quality of Life across Recent Pediatric Obesity Classification Recommendations.

Extreme body mass index (BMI) values (i.e., above the 97th and below the 3rd percentiles) are inaccurately represented on the Centers for Disease Control and Prevention's growth curves, which may limit the utility of BMI percentile and BMI z-score for capturing changes in clinical outcomes for patients at extreme weights. Modeling child obesity severity based upon the percentage of BMI in excess of the 95th percentile (BMI95pct) has been proposed as an improved metric to better capture variability in weight at extreme ends of growth curves, which may improve our understanding of relationships between weight status and changes in clinical outcomes. However, few studies have evaluated whether the use of BMI95pct would refine our understanding of differences in clinical psychosocial constructs compared to previous methods for categorization. This cross-sectional study evaluated child obesity severity based on BMI95pct to examine potential group differences in a validated, obesity-specific measure of Health-Related Quality of Life (HRQoL). Four hundred and sixty-five children with obesity completed Sizing Me Up, a self-report measure of HRQoL. Children were classified into categories based on BMI95pct (i.e., class I: ≥100% and <120%; class II: ≥120% and <140%; class III: ≥140%). The results indicate that children with class III obesity reported lower HRQoL than children with class I and class II obesity; however, there were no differences between Class II and Class I. In much of the previous literature, children with class II and class III obesity are often combined under the category "Severe Obesity" based upon BMI above the 99th percentile. This study suggests that grouping children from various classes together would neglect to capture critical differences in HRQoL. Future research including children with severe obesity should consider obesity classes to best account for functioning and clinical outcomes.

Investigating associations between physical activity-related neighborhood built environment features and child weight status to inform local practice.

Despite evidence of the importance of neighborhood built environment features in relation to physical activity and obesity, research has been limited in informing localized practice due to small sample sizes and limited geographic coverage. This demonstration study integrated data from a local pediatric health system with nationally available neighborhood built environment data to inform local decision making around neighborhood environments and childhood obesity. Height/weight from clinic visits and home neighborhood measures from the U.S. Environmental Protections Agency and WalkScore were obtained for 15,989 6-17 year olds. Multilevel models accounted for the nested data structure and were adjusted for neighborhood income and child sociodemographics. In 9-17 year olds, greater street connectivity and walkability were associated with a 0.01-0.04 lower BMIz (Ps = .009-.017) and greater residential density, street connectivity, and walkability were associated 5-7% lower odds of being overweight/obese (Ps = .004-.044) per standard deviation increase in environment variable. 45.9% of children in the lowest walkability tertile were overweight or obese, whereas 43.1% of children in the highest walkability tertile were overweight or obese. Maps revealed areas with low walkability and a high income-adjusted percent of children overweight/obese. In the Kansas City area, data showed that fewer children were overweight/obese in more walkable neighborhoods. Integrating electronic health records with neighborhood environment data is a replicable process that can inform local practice by highlighting the importance of neighborhood environment features locally and pointing to areas most in need of interventions.

Readiness to Change and Prospective Effects of Weight Management Programs in Pediatric Nonalcoholic Fatty Liver Disease.

Non-alcoholic fatty liver disease (NAFLD) is an increasing problem in pediatrics with limited treatment options. We prospectively assessed outcomes in patients managed in a hepatology clinic (HC) alone vs. those managed in combination with a multidisciplinary weight management program (MWMP). We describe each group's readiness to change at the time of NAFLD diagnosis. Patients diagnosed with NAFLD were given a modified Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) at enrollment (T1) to assess readiness to change. They were then followed at 3-9 months (T2) and at 10-15 months (T3). Linear mixed models were used to evaluate changes in body mass index (BMI), BMI z-score, and transaminases over time and between the two groups. There were no significant treatment group main effects or treatment × time interactions for our primary end points for HC alone (n = 75) or with MWMP (n = 18). There was a significant main effect for time for BMI z-score, with BMI z-scores declining on average by 0.0568 (P = 0.004) from visit to visit. Low SOCRATES subscales scores in HC alone (n = 33) or with MWMP (n = 4) suggested a patient population with low recognition of disease and likelihood of taking steps for change. Patients with obesity and NAFLD had low scores on all three SOCRATES subscales. Despite this, both groups had improvement in BMI z-score without significant difference between the two treatment groups in other primary end points. Further study is needed to identify the most effective patient selection and treatment strategies for pediatric patients with NAFLD, including pharmacotherapy and surgery.

Adoption of an Electronic Medical Record Tool for Childhood Obesity by Primary Care Providers.

BACKGROUND: Primary care providers are tasked with the increasingly difficult job of addressing childhood obesity during clinic visits. Electronic medical record (EMR)-enabled decision-support tools may aid providers in this task; however, information is needed regarding whether providers perceive such tools to be useful for addressing nutrition and physical activity lifestyle behaviors. OBJECTIVES: This study aimed to evaluate the usefulness and usability of FitTastic, an EMR-enabled tool to support prevention and management of childhood obesity in primary care. METHODS: In this mixed-method study, we implemented the FitTastic tool in two primary-care clinics, then surveyed and conducted focused interviews with providers. Validated Technology Acceptance Model perceived usefulness and National Aeronautics and Space Administration (NASA) perceived usability survey questions were e-mailed to 60 providers. In-depth provider interviews with family medicine and pediatric physicians (n = 12) were used to further probe adoption of FitTastic. RESULTS: Surveys were completed by 73% of providers (n = 44). The mean score for FitTastic's usefulness was 3.3 (standard deviation [SD] = 0.54, scale 1-5, where 5 is strongly agree) and usability, 4.8 (SD = 0.86, scale 1-7, where 7 is strongly agree). Usefulness and usability scores were associated with intention to use FitTastic (correlation for both, p < 0.05). Data from provider interviews indicated that useful features of FitTastic included: standardizing the approach to childhood obesity, and facilitating conversations about weight management, without increasing cognitive workload. However, use of FitTastic required more time from nurses to input lifestyle data. CONCLUSION: FitTastic is perceived as a useful and usable EMR-based lifestyle behavior tool that standardizes, facilitates, and streamlines healthy lifestyle conversations with families. Perceived usability and usefulness scores correlated with provider intention-to-use the technology. These data suggest that EMR-based child obesity prevention and management tools can be feasible to use in the clinic setting, with potential for scalability. Usefulness can be optimized by limiting amount of time needed by staff to input data.

Prevalence and Trends in Obesity Among Hospitalized Children.

OBJECTIVES: As obesity rates rise in children, it is likely that the number of hospitalized children with obesity is also increasing. However, characterization of the inpatient population with obesity as a whole has not been reported. We aimed to examine trends in the annual prevalence of obesity in hospitalized children and to identify demographic and clinical characteristics associated with higher obesity prevalence in children who are hospitalized. METHODS: We completed a retrospective cohort analysis of children aged 2 to 19 years admitted to a single tertiary children's hospital system for any reason in 2009-2016. Body mass index was calculated from documented height and weight. Children with obesity were defined by using age- and sex-specific body mass index percentile guidelines established by the Centers for Disease Control and Prevention. Annual obesity prevalence was calculated on the encounter level for service line and All Patients Refined Diagnosis-Related Groups (diagnosis groups). χ2 tests were used to determine statistical differences between groups, and the Cochran-Armitage test of trend was used to describe changes in obesity over time. RESULTS: Of 83 329 children who were hospitalized, 17.0% had obesity, increasing from 16.5% of hospitalizations in 2009-2010 to 17.3% in 2015-2016 (P = .002). Service lines with the highest obesity prevalence included orthopedics (22.1%), infectious disease (20.6%), and neuroscience (18.7%). Diagnosis groups with the highest obesity prevalence included cellulitis (22.5%), tonsil/adenoid procedures (22.0%), and some orthopedic procedures (28.7%). CONCLUSIONS: Some groups of children who were hospitalized experience higher obesity prevalence, including children hospitalized with orthopedic, infectious disease, and neurologic problems. In future research, investigators should target disproportionately affected groups by examining health outcomes, patient safety, and satisfaction issues.