Overcoming Challenges to Care in the Juvenile Justice System: A Case Study and Commentary.

Youth in the criminal justice system commonly suffer from multiple medical and psychological health problems. Because they likely live in lower socioeconomic environments, the medical care they receive through the justice system might be their only recent medical care and can result in the discovery of health problems or chronic illnesses that must be managed while in the system and beyond. We describe the case of an adolescent diagnosed with a serious chronic disease during his time in an urban detention center to illustrate how health workers and justice staff must use a team approach in caring for this vulnerable population of children. Barriers to appropriate care, including social and systems-level challenges, are discussed. The lessons learned in this case can be applied more broadly to other vulnerable youth populations, including those in foster care and impoverished communities where the primary care pediatrician (or other assigned pediatric specialist) is both the leader of the medical team and an advocate for quality care.

Fibroblast growth factor-21, body composition, and insulin resistance in pre-pubertal and early pubertal males and females.

OBJECTIVE: Accumulating evidence derived primarily from animal models suggests that fibroblast growth factor-21 (FGF-21) may affect the musculoskeletal system via effects on the capacity of tissues to respond to insulin. A proportion of musculoskeletal properties and underpinnings of promoting/preventing insulin resistance are established early in the pubertal transition. Thus, the objective of this study was to test the hypothesis that insulin resistance and/or obesity will promote greater FGF-21 concentration which will be inversely associated with musculoskeletal parameters [lean mass and bone mineral content (BMC)] in pre-/early pubertal children. Given the sexual dimorphic nature of musculoskeletal development of fat mass accrual, differences by obesity status and sex were also investigated. DESIGN: Cross-sectional. PATIENTS: Children ages 7-12 years (n = 69, 38% male, 48% non-Hispanic black, 45% obese). MEASUREMENTS: Fasting FGF-21, glucose and insulin measures were obtained. An estimate of insulin resistance was derived using the homoeostatic model assessment of insulin resistance (HOMA-IR). Body composition (BMC, lean mass and fat mass) was assessed by DXA. Multivariate regression analysis was used to evaluate the influence of FGF-21 on BMC, lean mass and HOMA-IR as dependent variables. Obesity status was established based on BMI z-score. RESULTS: FGF-21 concentrations did not differ by obesity status or by sex. There was an inverse association between FGF-21 and BMC among nonobese individuals (P = 0·01) and an inverse association between FGF-21 and lean mass among females (P = 0·02), which were both independent of fat mass. FGF-21 was inversely associated with HOMA-IR in males, but not females (P = 0·04). CONCLUSIONS: The existence of relationships of FGF-21 with musculoskeletal parameters and insulin resistance raises the possibility of crosstalk between these systems. These findings suggest that circulating FGF-21 may differ in its association with bone, lean mass and insulin resistance depending on sex and weight status.

Seasonal variability in body mass index change among children enrolled in the Pediatric Obesity Weight Evaluation Registry: A step in the right direction.

BACKGROUND: Research has shown children disproportionately gain excess weight over the summer months (vs. school months), with stronger effects for children with obesity. However, the question has not been investigated among children receiving care in paediatric weight management (PWM) programs. OBJECTIVE: To test for seasonal variability in weight change among youth with obesity in PWM care enrolled in the Pediatric Obesity Weight Evaluation Registry (POWER). METHOD: Longitudinal evaluation of a prospective cohort from 2014 to 2019 among youth in 31 PWM programs. Change in percentage of the 95th percentile for BMI (%BMIp95) was compared by quarter. RESULTS: Participants (N = 6816) were primarily ages 6-11 (48%), female (54%), 40% non-Hispanic White, 26% Hispanic and 17% Black, and 73% had severe obesity. Children were enrolled on average 424.9 ± 401.5 days. Participants reduced their %BMIp95 every season, but compared with Quarter 3 (July-September), reductions were significantly greater in Q1 (Jan-March, b = -0.27, 95%CI -0.46, -0.09), Q2 (April-June, b = -0.21, CI -0.40, -0.03), and Q4 (October-December, b = -0.44, CI -0.63, -0.26). CONCLUSION AND RELEVANCE: Across 31 clinics nationwide, children reduced their %BMIp95 every season, but reductions were significantly smaller during the summer quarter. While PWM successfully mitigated excess weight gain during every period, summer remains a high-priority time.

Reduced carbohydrate diet to improve metabolic outcomes and decrease adiposity in obese peripubertal African American girls.

OBJECTIVE: Obesity prevalence among African American (AA) girls is higher than that in other groups. Because typical energy-restriction obesity treatment strategies have had limited success, alterations in macronutrient composition may effectively improve metabolic outcomes in this population and affect future body composition trajectories. The objective was to evaluate the efficacy of a moderately restricted carbohydrate (CHO) versus a standard CHO diet on weight/fat loss and metabolic parameters in overweight/obese AA girls ages 9 to 14 years. METHODS: A total of 26 AA girls (ranging from 92nd body mass index percentile and above) were assigned to either a reduced- (SPEC: 42% energy from CHO, n = 12) or a standard- (STAN: 55% of energy from CHO, n = 14) CHO diet (protein held constant) for 16 weeks. All of the meals were provided and clinically tailored to meet the estimated energy requirements (resting energy expenditure × 1.2 in eucaloric phase and resting energy expenditure × 1.2 - 1000 kcal in energy deficit phase). The first 5 weeks encompassed a eucaloric phase evaluating metabolic changes in the absence of weight change. The subsequent 11 weeks were hypocaloric (1000 kcal/day deficit) to promote weight/fat loss. Meal tests were performed during the eucaloric phase for metabolic analyses. Dual-energy x-ray absorptiometry was used to evaluate body composition. RESULTS: Both groups experienced reductions in weight/adiposity, but the difference did not reach significance. The solid meal test indicated improved glucose/insulin homeostasis on the SPEC diet up to 3 hours postingestion. In addition, significantly lower triglycerides (P < 0.001) were observed on the SPEC diet. CONCLUSIONS: Dietary CHO reduction favorably influences metabolic parameters but did not result in greater weight/fat loss relative to a standard diet in obese AA girls. Future research is needed to determine long-term effectiveness of a reduced CHO diet on glucose and insulin homeostasis and how it may apply to weight maintenance/fat loss during development alone and/or in combination with additional weight loss/metabolic improvement strategies.

The role of European genetic admixture in the etiology of the insulin resistance syndrome in children: are the effects mediated by fat accumulation?

OBJECTIVES: To evaluate the contribution of European genetic admixture (EUADM) to insulin resistance syndrome (IRS) in a multiethnic sample of children age 7-12 years, and to explore whether body fat affects this relationship. STUDY DESIGN: Anthropometric measurements and blood pressure were assessed in 243 children. After an overnight fast, an intravenous glucose tolerance test was conducted, and measures of fasting insulin/glucose, lipids, insulin sensitivity (SI), and acute insulin response to glucose (AIRg) were obtained. The proportion of EUADM was determined by maximum likelihood estimation using 140 ancestry informative markers. Subjects were stratified into tertiles according to the proportion of EUADM for analyses. Subjects were categorized as lean or obese using body fat percentage cutpoints (25% in boys, 30% in girls). RESULTS: Among lean subjects (72%), the tertile representing the greatest proportion of EUADM was associated with higher SI (P<.001) and serum glucose (P<.05) and lower insulin (P<.05), AIRg (P<.001), high-density lipoprotein cholesterol (P=.05), and blood pressure (P<.05). However, among obese subjects, EUADM was associated only with SI (P<.05). CONCLUSIONS: Our results suggest that population differences in IRS likely have a genetic component, but that the influence of genetic background may be masked by obesity.

Advocacy and Collaborative Health Care for Justice-Involved Youth.

Children and adolescents who become involved with the justice system often do so with complex medical, mental health, developmental, social, and legal needs. Most have been exposed to childhood trauma or adversity, which both contribute to their involvement with the justice system and negatively impact their health and well-being. Whether youth are held in confinement or in their home communities, pediatricians play a critical role in promoting the health and well-being of justice-involved youth. Having a working knowledge of the juvenile justice system and common issues facing justice-involved youth may help pediatricians enhance their clinical care and advocacy efforts. This policy statement is a revision of the 2011 policy "Health Care for Youth in the Juvenile Justice System." It provides an overview of the juvenile justice system, describes racial bias and overrepresentation of youth of color in the justice system, reviews the health and mental health status of justice-involved youth, and identifies advocacy opportunities for juvenile justice reform.