Incidence of pediatric narcolepsy diagnosis and management: evidence from claims data.

STUDY OBJECTIVES: To characterize the incidence of pediatric narcolepsy diagnosis, subsequent care, and potential sociodemographic disparities in a large US claims database. METHODS: Merative MarketScan insurance claims (n=12,394,902) were used to identify youth (6-17 years) newly diagnosed with narcolepsy (ICD-10 codes). Narcolepsy diagnosis and care 1-year post-diagnosis included polysomnography (PSG) with Multiple Sleep Latency Test (MSLT), pharmacological care, and clinical visits. Potential disparities were examined by insurance coverage and child race and ethnicity (Medicaid-insured only). RESULTS: The incidence of narcolepsy diagnosis was 10:100,000, primarily type 2 (69.9%). Most diagnoses occurred in adolescents with no sex differences, but higher rates in Black versus White youth with Medicaid. Two-thirds had a prior sleep disorder diagnosis and 21-36% had other co-occurring diagnoses. Only half (46.6%) had a PSG with MSLT (± 1-year post-diagnosis). Specialty care (18.9% pulmonary, 26.9% neurology) and behavioral health visits were rare (34.4%), although half were prescribed stimulant medications (51.0%). Medicaid-insured were 86% less likely than commercially insured youth to have any clinical care and 33% less likely to have a PSG with MSLT. CONCLUSIONS: Narcolepsy diagnoses occurred in 0.01% of youth, primarily during adolescence, and at higher rates for Black versus White children with Medicaid. Only half had evidence of a diagnostically required PSG with MSLT, underscoring potential misdiagnosis. Many patients had co-occurring conditions, but specialty and behavioral health care were limited. Results suggest misdiagnosis, underdiagnosis, and limited narcolepsy treatment, as well as possible insurance-related disparities. Results highlight the need to identify determinants of evidence-based pediatric narcolepsy diagnosis and management.

Geospatial Disparities in Youth Sexually Transmitted Infections During COVID-19.

INTRODUCTION: Early in the COVID-19 pandemic, routine sexually transmitted infection (STI) screenings decreased, and test positivity rates increased due to limited screening appointments, national-level STI testing supply shortages, and social distancing mandates. It is unclear if adolescent preventive STI screening has returned to pre-pandemic levels and if pre-existing disparities worsened in late-pandemic. METHODS: This cross-sectional study examined 22,974 primary care visits by 13-19-year-olds in the Philadelphia metropolitan area undergoing screening for gonorrhea and chlamydia in a 31-clinic pediatric primary care network during 2018-2022. Using interrupted-time-series analysis and logistic regression, pandemic-related changes in the asymptomatic STI screening rate and test positivity were tracked across patient demographics. Neighborhood moderation was investigated by census-tract-level Child Opportunity Index in 2023. RESULTS: The asymptomatic STI screening rate dropped by 27.8 percentage points (pp) and 13.5pp when the pandemic and national STI test supply shortage began, respectively, but returned to pre-pandemic levels after supply availability was restored in early 2021. Non-Hispanic-Black adolescents had a significant pandemic drop in STI screening rate, and it did not return to prep-andemic levels (-3.6 pp in the late-pandemic period, p<0.01). This decrease was more pronounced in socioeconomically and educationally disadvantaged neighborhoods (7.5 pp and 9.9 pp lower, respectively) than in advantaged neighborhoods (both p<0.001), controlling for sex, age, insurance type and clinic characteristics. CONCLUSIONS: Neighborhood socioeconomic and educational disadvantage amplified racial-ethnic disparities in STI screening during the pandemic. Future interventions should focus on improving primary care utilization of non-Hispanic-Black adolescents to increase routine STI screening and preventive care utilization.

Pediatric obesity during COVID-19: the role of neighborhood social vulnerability and collective efficacy.

INTRODUCTION: Childhood obesity increased in the first year of COVID-19 with significant disparities across race, ethnicity, and socioeconomic status. Social distancing led to fewer physical activity opportunities but increased screen time and high-calorie food consumption, all co-determined by neighborhood environments. This study aimed to test the moderation effects of neighborhood socioeconomic and built environments on obesity change during COVID-19. METHODS: Using electronic health records from a large pediatric primary care network in 2018-2022, we cross-sectionally examined 163,042 well visits of 2-17-year-olds living in Philadelphia County in order to examine (1) the pandemic's effect on obesity prevalence and (2) moderation by census-tract-level neighborhood socioeconomic disadvantage, crime, food and physical activity-related environments using interrupted-time-series analysis, Poisson regression, and logistic regression. RESULTS: Weekly obesity prevalence increased by 4.9 percent points (pp) during the pandemic (January 2021-August 2022) compared to pre-pandemic (March 2018-March 2020) levels. This increase was pronounced across all age groups, racially/ethnically minoritized groups, and insurance types (ranging from 2.0 to 6.4 pp) except the Non-Hispanic-white group. The increase in obesity among children racially/ethnically minoritized groups was significantly larger in the neighborhoods with high social vulnerability (3.3 pp difference between high and low groups), and low collective efficacy (2.0 pp difference between high and low groups) after adjusting for age, sex, and insurance type. CONCLUSIONS: Racially/ethnically minoritized children experienced larger obesity increases during the pandemic, especially those in socioeconomically disadvantaged neighborhoods. However, the buffering effect of community collective efficacy on the disparities underscores the importance of environments in pediatric health.

Disparities in pediatric obesity during COVID-19: The role of neighborhood social vulnerability and collective efficacy.

Introduction: Childhood obesity increased in the first year of Covid-19 with significant disparities across race, ethnicity, and socioeconomic status. Social distancing led to fewer physical activity opportunities but increased screen time and high-calorie food consumption, all co-determined by neighborhood environments. This study aimed to test the moderation effects of neighborhood socioeconomic and built environments on racial/ethnic disparities in obesity change during Covid-19. Methods: Using electronic health records from a large pediatric primary care network in 2018-2022, we cross-sectionally examined 163,042 well visits of 2-17 year-olds living in Philadelphia county in order to examine (1) the pandemic's effect on obesity prevalence and (2) moderation by census-tract-level neighborhood socioeconomic disadvantage, crime, food and physical activity-related environments using interrupted-time-series analysis, Poisson regression, and logistic regression. Results: Weekly obesity prevalence increased by 4.9 percent points (pp) during the pandemic (Jan 2021-Aug 2022) compared to pre-pandemic (Mar 2018-Mar 2020) levels. This increase was pronounced across all age groups, racially/ethnically-minoritized groups, and insurance types (ranging from 2.0 to 6.4 pp) except the Non-Hispanic-white group. The increase in obesity among children racially/ethnically-minoritized groups was significantly larger in the neighborhoods with high social vulnerability (3.3 pp difference between high and low groups), and low collective efficacy (2.0 pp difference between high and low groups) after adjusting for age, sex, and insurance type. Conclusions: Racially/ethnically-minoritized children experienced larger obesity increases during the pandemic, especially those in socioeconomically disadvantaged neighborhoods. However, the buffering effect of community collective efficacy on the disparities underscores the importance of environments in pediatric health.

Expanding Contraceptive Access for Teens-Leveraging the Pediatric Emergency Department.

PURPOSE: Adolescents have limited access to sexual healthcare services, and the emergency department (ED) may be the only place some will seek care. We implemented an ED-based contraception counseling intervention to assess intervention feasibility, and adolescent intention to initiate contraception, contraception initiation, and follow-up visit completion. METHODS: This prospective cohort study trained advanced practice providers in the EDs of two pediatric urban academic medical centers to deliver brief contraception counseling. A convenience sample of patients enrolled from 2019 to 2021 included females aged 15-18 not pregnant/desiring pregnancy and/or using hormonal contraception/an intrauterine device. Participants completed surveys to assess demographics and intention to initiate contraception (yes/no). Sessions were audiotaped and reviewed for fidelity. We ascertained contraception initiation and follow-up visit completion via medical record review and participant survey at 8 weeks. RESULTS: Twenty-seven advanced practice providers were trained, and 96 adolescents were counseled/responded to surveys (mean age 16.7 years; 19% non-Hispanic White, 56% non-Hispanic Black; 18% Hispanic). Mean counseling duration was 12 minutes and >90% of reviewed sessions maintained fidelity to content/style. Most participants (61%) reported intention to initiate contraception, and these participants were older and more likely to report prior contraceptive use, compared to those without intention. One-third (33%) initiated contraception in the ED or after the follow-up visit. DISCUSSION: Contraceptive counseling was feasible to integrate in the ED visit. Intention to initiate contraception was common and many adolescents initiated contraception. Future work should increase the pool of trained providers and supports for same-day contraception initiation for those desiring in this novel setting.

Racial Inequities in Adolescent Contraceptive Care Delivery: A Reproductive Justice Issue.

STUDY OBJECTIVE: The objective of this study was to examine racial/ethnic disparities in contraceptive delivery for adolescent patients within an adolescent medicine subspecialty clinical system before and during the COVID-19 pandemic. Secondarily, we aimed to assess the relationship between race and contraceptive delivery by telehealth. DESIGN: Retrospective cohort study using electronic health record data SETTING: Three adolescent medicine subspecialty clinics in a large academic hospital system, including an urban location and 2 suburban locations PARTICIPANTS: Patients assigned female sex at birth prescribed hormonal contraception between January 1st, 2018, and May 31st, 2021. MAIN OUTCOME MEASURES: Method and type of contraceptive prescribed (short-acting, medium-acting, long-acting reversible contraception [LARC]) RESULTS: There were 2453 patients in the study; 47.5% were White, 36.0% were Black, and 8.1% identified as Hispanic. After controlling for insurance and age, Black patients, compared with non-Black patients, had twofold higher odds of receiving LARC compared with a short-acting method across the study period (aOR = 2.0; 95% CI, 1.52-2.62). We identified effect modification with significant interaction between Black race and the pandemic period, with evidence of a higher marginal probability of Black patients receiving LARCs during the pandemic. Additionally, during the pandemic, patients receiving new contraceptive prescriptions via telehealth were less likely to be Black (aOR = 0.63; 95% CI, 0.41-0.94) or publicly insured (aOR = 0.56; 95% CI, 0.38-0.81). CONCLUSION: Our data show significantly higher prescribing of LARCs to Black adolescents by clinicians, which could suggest differences in physician contraceptive counseling with a bias toward preferentially counseling Black patients toward LARCs. Our data also show that Black and publicly insured patients had decreased utilization of contraceptive care by telehealth during the pandemic.

Racial-Ethnic Disparities in Obesity and Biological, Behavioral, and Sociocultural Influences in the United States: A Systematic Review.

For a comprehensive understanding of high-level obesity in the USA, we studied the trends of obesity prevalence since 2007, and related biological, behavioral, and sociocultural factors in obesity racial/ethnic disparities. We searched PubMed, Embase, and national data archives for the studies using national survey data and published in English from January 1, 2007 to September 11, 2020. Forty-seven studies met the inclusion criteria and were systematically reviewed. After a short leveling-off during 2009-2012, the US national prevalence of obesity has steadily increased. Although women had higher racial/ethnic disparities in obesity and severe obesity than men, it decreased due to the significant drop in non-Hispanic black (NHB) women in the last 10 y. However, obesity and severe obesity prevalence increased in Mexican-American (MA) men, MA boys, and MA girls and became similar to or surpassing NHB groups. Substantial racial/ethnic disparities remained in the past decade. Even at the same level of BMI, MAs and non-Hispanic Asians had a higher percent of body fat and metabolic syndrome than other ethnic/racial groups. NHB's cultural preference for a large body significantly associated weight misperception and lower weight control practices. In addition to socioeconomic status, health behaviors, neighborhood environments, and early childhood health factors explained substantial racial/ethnic differences in obesity. Differences in biological, behavioral, and sociocultural characteristics should be considered in future public health intervention efforts to combat obesity in the USA.

Racial/Ethnic Disparities in Female Sexual Health from Adolescence to Young Adulthood: How Adolescent Characteristics Matter?

STUDY OBJECTIVE: To describe sexual initiation patterns in female adolescents and examine their association with adolescent characteristics and racial disparities in adverse sexual health across adolescence into early adulthood. DESIGN: A prospective, longitudinal, observational study from adolescence to adulthood. SETTING: Nationally representative, the National Longitudinal Study of Adolescent to Adult Health data, in the range of 24-32 years old at final assessment. PARTICIPANTS: Data from 43,577 US women from 1994 to 2008. INTERVENTIONS AND MAIN OUTCOME MEASURES: Adolescent sex-related characteristics at the individual-, family-, and school peer-level were assessed, and multiple sex partners, sexually transmitted infections (STIs)/HIV, and intimate partner violence (IPV) were longitudinally tracked. The sexual initiation pattern and its longitudinal association with sexual health were analyzed using latent class analysis and mixed effects Poisson regression models. RESULTS: Of the 43,577 subjects, the sexual initiation patterns were determined as normative (n = 28,712, 65.9%), late (n = 10,799, 24.8%), and early but unempowered (n = 4,066, 9.3%). The highest rate of the early-unempowered group was shown in Hispanic individuals (1,054/7,307 = 14.4%); they were more likely to be depressed, unsatisfied with their bodies, receiving welfare, and have less educated/permissive parents to their sexual initiation than others. The late group had a higher body mass index and greater satisfaction with their bodies. The highest number of STIs/HIV and IPV victimization was shown in non-Hispanic Black (NHB) and Hispanic individuals, respectively. However, NHB females' higher number of STIs/HIV was shown in the late/normative groups, not in the early-unempowered group. Among Hispanic females, adolescent sexual initiation patterns were not directly associated with their frequent IPV victimization. CONCLUSION: NHB females' higher STI/HIV in late/normative groups and Hispanic females' frequent IPV victimization regardless of their sexual initiation patterns might indicate that racial/ethnic disparities in female sexual health was not directly determined by adolescent risk behaviors.

Has the prevalence of overweight, obesity and central obesity levelled off in the United States? Trends, patterns, disparities, and future projections for the obesity epidemic.

BACKGROUND: Obesity (OB) is a serious epidemic in the United States. METHODS: We examined OB patterns and time trends across socio-economic and geographic parameters and projected the future situation. Large national databases were used. Overweight (OW), OB and severe obesity (SOB) were defined using body mass index cut-points/percentiles; central obesity (CO), waist circumference cut-point in adults and waist:height ratio cutoff in youth. Various meta-regression analysis models were fit for projection analyses. RESULTS: OB prevalence had consistently risen since 1999 and considerable differences existed across groups and regions. Among adults, men's OB (33.7%) and OW (71.6%) levelled off in 2009-2012, resuming the increase to 38.0 and 74.7% in 2015-2016, respectively. Women showed an uninterrupted increase in OB/OW prevalence since 1999, reaching 41.5% (OB) and 68.9% (OW) in 2015-2016. SOB levelled off in 2013-2016 (men: 5.5-5.6%; women: 9.7-9.5%), after annual increases of 0.2% between 1999 and 2012. Non-Hispanic Blacks had the highest prevalence in women's OB/SOB and men's SOB. OB prevalence in boys rose continuously to 20.6% and SOB to 7.5% in 2015-2016, but not in girls. By 2030, most Americans will be OB/OW and nearly 50% of adults OB, whereas ∼33% of children aged 6-11 and ∼50% of adolescents aged 12-19 will be OB/OW. Since 1999, CO has risen steadily, and by 2030 is projected to reach 55.6% in men, 80.0% in women, 47.6% among girls and 38.9% among boys. Regional differences exist in adult OB prevalence (2011-2016) and across ethnicities; South (32.0%) and Midwest (31.4%) had the highest rates. CONCLUSIONS: US obesity prevalence has been rising, despite a temporary pause in 2009-2012. Wide disparities across groups and geographical regions persist. Effective, sustainable, culturally-tailored interventions are needed.

Disease Burdens and Risk Factors for Diabetes, Hypertension, and Hyperlipidemia among Refugees in Buffalo, New York, 2004-2014.

INTRODUCTION: Limited is known about prevalence and risk factors for diabetes, hypertension, and hyperlipidemia among refugees. METHODS: At a refugee clinic in Buffalo, N.Y. (2004-2014), 1,570 adults were studied using multivariate logistic regression. RESULTS: Prevalences of diabetes, hypertension, and hyperlipidemia were 7.8%, 24.1%, and 27.1%, respectively. Among refugees, 49.2% of diabetes and 46.7% of hypertension were uncontrolled. Obesity (odds ratio [OR]=2.49; 95% confidence interval [CI]=1.61-3.85) and length of stay (OR=1.25; 95%CI=1.16-1.35) were risk factors for diabetes. Eastern European origin (OR=4.09; 95%CI=2.00-8.38), obesity (OR=2.62; 95%CI=1.92-3.58), length of follow-up (OR=1.06; 95%CI=1.00-1.12), gender (OR=0.59; 95%CI=0.44-0.78) and tobacco use (OR=1.54; 95%CI=1.00-2.38) were associated with hypertension. Age (OR=1.02; 95%CI=1.01-1.04) was associated with hyperlipidemia. CONCLUSIONS: Refugees had comparable burden of non-communicable diseases, but a greaterleast once during the study period proportion of refugees than of the U.S. population had uncontrolled conditions. Duration of follow-up, obesity, tobacco use, gender, age, and region of origin were risk factors for diagnosis. Culturally-tailored chronic disease management strategies are needed.

Burden of Mental Illness and Non-communicable Diseases and Risk Factors for Mental Illness Among Refugees in Buffalo, NY, 2004-2014.

INTRODUCTION: Limited is known about mental illness and non-communicable diseases (NCDs) and their risk factors among refugees. These were studied using data collected from a refugee population in Buffalo, NY. METHODS: Longitudinal data collected on 1055 adults (> 18 years) at a large refugee health center in Buffalo, NY, during 2004-2014 were used. Main outcomes were hypertension, diabetes, tobacco use, obesity, overweight/obesity, and mental illness. Risk factors were assessed using multivariate regression models. RESULTS: Compared to those without mental illness, refugees with mental illness had higher rates of hypertension (16.9 vs 28.4%, P < 0.001), diabetes (8.4 vs 13.6%, P = 0.03), tobacco use (9.3 vs 18.3%, P < 0.001), obesity (13.0 vs 25.4%, P < 0.001), and overweight/obesity rates (45.0 vs 61.5%, P < 0.001). During 2004-2014, obesity rates increased among those with mental illness (25.4 to 36.7%, P < 0.001) and without mental illness (13.0 to 24.5%, P < 0.001). The overall mental illness prevalence among refugees was 16%, ranging from 6.9% among Asians to 43.9% among Cubans. Women were more likely to have mental illness (odds ratio = 2.45; 95% confidence interval [CI] = 1.68-3.58) than men. Refugees who lived longer in the USA were more likely to carry psychiatric diagnoses (OR = 1.12; 95% CI = 1.04-1.21). CONCLUSION: Mental illness rates varied considerably across various refugee groups. Rates of obesity and NCDs among refugees with mental illness were higher than among those without mental disorders. Gender, region of origin, and length of stay in the USA were associated with mental illness. Accurate and culturally sensitive screenings and assessments of mental illness are needed to reduce these health disparities.

Mismatch in Children's Weight Assessment, Ideal Body Image, and Rapidly Increased Obesity Prevalence in China: A 10-Year, Nationwide, Longitudinal Study.

OBJECTIVE: This study examined secular trends in children's weight-status assessment, measured weight status, and ideal body image and their associations with subsequent changes in BMI, and it explored the differences between sociodemographic groups in China. METHODS: Longitudinal data from the China Health and Nutrition Survey of 4,605 children aged 6 to 17 collected between 2000 and 2011 were used and fitted to mixed models. RESULTS: From 2000 to 2011, overweight/obesity prevalence increased from 6.5% to 16.8%, but the percentage of children with self-perceived weight status as "fat" remained around 2.0%; 49.0% of children underestimated their weight status at baseline. Self-perceived body image of most participants was tracked during follow-up. Children who perceived themselves as being fat at baseline had a higher BMI increase over time during follow-up than those with an average body image (ß [SE] = 0.99 [0.14] kg/m2 per year, P < 0.001). Boys, young children, recent cohorts, and rural children had higher BMI increases than their counterparts. Over time, the thin-body silhouette became more desirable (8.4 percentage points higher, P < 0.001). CONCLUSIONS: Chinese children experience a large incongruence between their weight-status assessment, ideal body image, and actual weight status. Health promotion programs should examine their role in assisting children in developing a healthy body image and gaining greater self-motivation toward promoting a healthy lifestyle.

An Evaluation of the Effectiveness of the National Aeronautics and Space Administration Mission-X Child Health Promotion Program in the United States.

PURPOSE: To examine the effects of the National Aeronautics and Space Administration Mission-X: Train Like an Astronaut program (MX) on children's health-related knowledge and behaviors of a sample of US participants. DESIGN: A nonexperimental pilot intervention study in 5 cities with a pre-post comparison of children's health-related knowledge and behaviors in the United States in 2014 and 2015. SAMPLE: Children (n = 409) with a mean age (standard deviation) of 10.1 (1.7) years. MEASURES: Children answered pre- and postintervention questionnaires. We measured the differences in children's health knowledge on nutrition and physical fitness and behaviors on diet and physical activity as scores. INTERVENTION: A 6-week web- and school-based intervention for a healthier lifestyle by introducing physical fitness and science activities based on actual astronaut training under a teacher's supervision. ANALYSIS: Nonparametric analysis and logistic regression models. RESULTS: Participants significantly improved both of their health behaviors on physical activity ( P < .001) and diet ( P = .06) and their health knowledge regarding nutrition ( P < .001) and physical fitness ( P < .001) after the intervention. The improvement in children's behaviors ( P < .001), knowledge ( P < .001), and the total score ( P < .001) after intervention did not significantly vary by sex or age, after adjusting for year of participation and state of residency. DISCUSSION: The MX seems effective in improving health behaviors and health knowledge of participating children, which may serve as a model for sustainable global child health promotion program. Further research is needed to test its long-term effects on child health.

Double burden of diseases worldwide: coexistence of undernutrition and overnutrition-related non-communicable chronic diseases.

OBJECTIVE: This systematic examination and meta-analysis examined the scope and variation of the worldwide double burden of diseases and identified related socio-demographic factors. DESIGN: We searched PubMed for studies published in English from January 1, 2000, through September 28, 2016, that reported on double disease burden. Twenty-nine studies from 18 high-income, middle-income and low-income countries met inclusion criteria and provided 71 obesity-undernutrition ratios, which were included in meta-regression analysis. RESULTS: All high-income countries had a much higher prevalence of obesity than undernutrition (i.e. all the obesity/undernutrition ratios >1); 55% of the ratios in lower middle-income and low-income countries were <1, but only 28% in upper middle-income countries. Meta-analysis showed a pooled obesity-undernutrition ratio of 4.3 (95% CI = 3.1-5.5), which varied by country income level, subjects' age and over time. The average ratio was higher in high-income rather than that in lower middle-income and low-income countries (ß [SE] = 10.8 [2.6]), in adults versus children (7.1 [2.2]) and in data collected since 2000 versus before 2000 (5.2 [1.5]; all P values < 0.05). CONCLUSIONS: There are considerable differences in the obesity versus undernutrition ratios and in their prevalence by country income level, age groups and over time, which may be a consequence of the cumulative exposure to an obesogenic environment.

A Systematic Examination of Food Intake and Adaptation to the Food Environment by Refugees Settled in the United States.

The United States is the largest refugee resettlement country in the world. Refugees may face health-related challenges after resettlement in the United States, including higher rates of chronic diseases due to problems such as language barriers and difficulty adapting to new food environments. However, reported refugee diet challenges varied, and no systematic examination has been reported. This study examined refugee food intake pre- and postresettlement in the United States and differences in intake across various refugee groups. We systematically reviewed relevant studies that reported on refugee food intake and adaptation to the US food environment. We searched PubMed for literature published between January 1985 and April 2015, including cross-sectional and prospective studies. Eighteen studies met inclusion criteria. Limited research has been conducted, and most studies were based on small convenience samples. In general, refugees increased meat and egg consumption after resettling in the United States. Changes in refugee intake of vegetables, fruits, and dairy products varied by socioeconomic status, food insecurity, past food deprivation experience, length of stay in the United States, region of origin, and age. South Asians were more likely to maintain traditional diets, and increased age was associated with more conservative and traditional diets. Despite the abundance of food in the United States, postresettlement refugees reported difficulty in finding familiar or healthy foods. More research with larger samples and follow-up data are needed to study how refugees adapt to the US food environment and what factors may influence their food- and health-related outcomes. The work could inform future interventions to promote healthy eating and living among refugees and help to reduce health disparities.