Virtual Nutrition Counseling in Pediatric Primary Care: An Integrated Approach to the Prevention and Management of Pediatric Obesity.

Given the rising prevalence of pediatric obesity, new approaches to the delivery of targeted nutrition counseling to not only prevent but also treat pediatric obesity are needed. The integration of a dietitian virtually was a successful quality improvement measure in this academic pediatric primary care clinic. The virtual dietitian provided age-appropriate nutrition counseling at well-child visits from 9 months to 6 years of age. Dietary counseling was also provided for children with overweight and obesity regardless of age. Vegetable, fruit, snack, and dairy intake was assessed in children who received counseling versus those who had traditional well childcare. Improved dairy habits were noted in the counseling cohort. A decrease in body mass index was not demonstrated in the patients with obesity or overweight; however, patient and provider satisfaction was quite high with this novel quality improvement measure. Virtual nutrition counseling can be easily integrated to facilitate a comprehensive pediatric medical home.

A pilot open-label feasibility trial examining an adjunctive mindfulness intervention for adolescents with obesity.

BACKGROUND: Obesity in adolescence is predictive of obesity in adulthood and risk for chronic disease. Traditional behavioral approaches to addressing obesity in adolescence rarely yield meaningful changes in body mass index (BMI), suggesting that adjunctive treatments are necessary. Herein, we describe a study examining whether it is feasible to integrate a brief mindfulness intervention with the usual recommended care for adolescent obesity in a pediatric weight management clinic. METHODS: We conducted a single arm open-label trial with 11 adolescent patients with obesity. Participants received the recommended standard of medical management of obesity (usual care) plus a six-week mindfulness intervention. To assess our primary aim of feasibility, we examined recruitment, retention, and satisfaction rates. Participants also completed measures of mindfulness, emotion regulation, disordered eating, quality of life, and executive functioning, and had their BMI and blood pressure measured. RESULTS: We recruited 11 adolescents to participate in the intervention, with 8 (73%) completing the entire program. Attendance rates (85%) and satisfaction rates (100%) were promising for a larger trial. While preliminary analyses of changes in health outcomes should be examined with caution, effect sizes ranged from small to large with some promising trends in eating behaviors. DISCUSSION: It might be feasible to augment existing behavioral interventions for adolescents with obesity with brief mindfulness; however, some adaptations are needed to enhance recruitment and retention. The lessons learned in this feasibility study can inform an adequately powered efficacy trial. TRIAL REGISTRATION: This research is registered on ClinicalTrials.gov (NCT03874377).

Pilot Testing of a Patient Decision Aid for Adolescents with Severe Obesity in US Pediatric Weight Management Programs within the COMPASS Network.

Shared decision-making (SDM) is a best practice for delivering high-quality, patient-centered care when there are multiple options from which to choose. A patient decision aid (PDA) to promote SDM for the treatment of adolescent severe obesity was piloted among 12-17-year-olds (n = 31) from six pediatric weight management programs within the Childhood Obesity Multi Program Analysis and Study System (COMPASS). Medical providers used a brochure that described indications, risks, and benefits of intensive lifestyle management alone versus bariatric surgery plus lifestyle. Immediately after, patients/families completed a survey. Patient/family perceptions of provider effort to promote understanding of health issues, to listen to what mattered most to them, and to include what mattered most to them in choosing next steps averaged 8.6, 8.8, and 8.7, respectively (0 = no effort, 9 = every effort). Nearly all (96%) reported knowing the risks/benefits of each treatment option and feeling clear about which risks/benefits mattered most to them. Most (93%) reported having enough support/advice to make a choice, and 89% felt sure about what the best choice was. Providers largely found the PDA to be feasible and acceptable. This pilot will guide a more rigorous study to determine the PDA's effectiveness to support decision-making for adolescent severe obesity treatment.

A Narrative Review of Medical and Genetic Risk Factors among Children Age 5 and Younger with Severe Obesity.

Severe obesity defined as an age- and gender-specific body mass index ≥120% of the 95th percentile in children younger than 5 years is well recognized as a significant challenge for prevention and treatment. This article provides an overview of the prevalence, classification of obesity severity, patterns of weight gain trajectory, medical and genetic risk factors, and comorbid disorders among young children with an emphasis on severe obesity. Studies suggest rapid weight gain trajectory in infancy, maternal smoking, maternal gestational diabetes, and genetic conditions are associated with an increased risk for severe obesity in early childhood. Among populations of young children with severe obesity seeking care, co-morbid conditions such as dyslipidemia and fatty liver disease are present and families report behavioral concerns and developmental delays. Children with severe obesity by age 5 represent a vulnerable population of children at high medical risk and need to be identified early and appropriately managed.

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.

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.

Whole-exome sequencing identifies novel LEPR mutations in individuals with severe early onset obesity.

OBJECTIVE: Obesity is a major public health problem that increases the risk for a broad spectrum of co-morbid conditions. Despite evidence for a strong genetic contribution to susceptibility to obesity, previous efforts to discover the relevant genes using positional cloning have failed to account for most of the apparent genetic risk variance. DESIGN AND METHODS: Deploying a strategy combining analysis of exome sequencing data in extremely obese members of four consanguineous families with segregation analysis, we screened for causal genetic variants. Filter-based analysis and homozygosity mapping were used to identify and prioritize putative functional variants. RESULTS: Two novel frameshift mutations in the leptin receptor in two of the families were identified. CONCLUSIONS: These results provide proof-of-principle that whole-exome sequencing of families segregating for extreme obesity can identify causal pathogenic mutations. The methods described here can be extended to additional families segregating for extreme obesity and should enable the identification of mutations in novel genes that predispose to obesity.

Adapting interpersonal psychotherapy for the prevention of excessive weight gain in rural African American girls.

OBJECTIVE: To obtain focus group data regarding the perspectives of rural African American (AA) girls, parents/guardians, and community leaders on obesity, loss of control (LOC) eating, relationships, and interpersonal psychotherapy for the prevention of excessive weight gain (IPT-WG). METHODS: 7 focus groups (N = 50 participants) were moderated and the transcripts analyzed by Westat researchers using widely accepted methods of qualitative and thematic analysis. A session was held with experts in health disparities to elucidate themes. RESULTS: Participants understood LOC eating; however, they had culturally specific perceptions including usage of alternative terms. Relationships were highly valued, specifically those between mothers and daughters. IPT-WG program components generally resonated with participants, although modifications were recommended to respect parental roles. Experts interpreted focus group themes and discussed potential barriers and solutions to recruitment and participation. CONCLUSION: Findings suggest that adapting IPT-WG may be acceptable to rural AA families. This research is the first step in developing a sustainable excessive weight gain and binge eating disorder prevention program for rural AA adolescents.

Parent report of binge eating in Hispanic, African American and Caucasian youth.

Binge eating is prevalent among weight loss treatment-seeking youth. However, there are limited data on the relationship between binge eating and weight in racial or ethnically diverse youth. We therefore examined 409 obese (BMI≥95th percentile for age and sex) treatment-seeking Hispanic (29.1%), Caucasian (31.7%), and African American (39.2%), boys and girls (6-18 years). Weight, height, waist circumference, and body fat were measured to assess body composition. Depressive symptoms were measured with the Children's Depression Inventory and disordered eating cognitions were measured with the Children's Eating Attitudes Test. Accounting for age, sex, body fat mass, and height, the odds of parents reporting that their child engaged in binge eating were significantly higher among Caucasian compared to African American youth, with Hispanic youth falling non-significantly between these two groups. Youth with binge eating had greater body adiposity (p=.02), waist circumference (p=.02), depressive symptoms (p=.01), and disordered eating attitudes (p=.04), with no difference between racial or ethnic group. We conclude that, regardless of race or ethnicity, binge eating is prevalent among weight loss treatment-seeking youth and is associated with adiposity and psychological distress. Further research is required to elucidate the extent to which binge eating among racially and ethnically diverse youth differentially impacts weight loss outcome.

Effects of a low glycemic load or a low-fat dietary intervention on body weight in obese Hispanic American children and adolescents: a randomized controlled trial.

BACKGROUND: In Hispanic children and adolescents, the prevalence of obesity and insulin resistance is considerably greater than in non-Hispanic white children. A low-glycemic load diet (LGD) has been proposed as an effective dietary intervention for pediatric obesity, but to our knowledge, no published study has examined the effects of an LGD in obese Hispanic children. OBJECTIVE: We compared the effects of an LGD and a low-fat diet (LFD) on body composition and components of metabolic syndrome in obese Hispanic youth. DESIGN: Obese Hispanic children (7-15 y of age) were randomly assigned to consume an LGD or an LFD in a 2-y intervention program. Body composition and laboratory assessments were obtained at baseline and 3, 12, and 24 mo after intervention. RESULTS: In 113 children who were randomly assigned, 79% of both groups completed 3 mo of treatment; 58% of LGD and 55% of LFD subjects attended 24-mo follow-up. Compared with the LFD, the LGD decreased the glycemic load per kilocalories of reported food intakes in participants at 3 mo (P = 0.02). Both groups had a decreased BMI z score (P < 0.003), which was expressed as a standard z score relative to CDC age- and sex-specific norms, and improved waist circumference and systolic blood pressure (P < 0.05) at 3, 12, and 24 mo after intervention. However, there were no significant differences between groups for changes in BMI, insulin resistance, or components of metabolic syndrome (all P > 0.5). CONCLUSIONS: We showed no evidence that an LGD and an LFD differ in efficacy for the reduction of BMI or aspects of metabolic syndrome in obese Hispanic youth. Both diets decreased the BMI z score when prescribed in the context of a culturally adapted, comprehensive weight-reduction program.

Independent benefits of meeting the 2008 physical activity guidelines to insulin resistance in obese latino children.

We examined the independent association between moderate-to-vigorous physical activity (MVPA) and insulin resistance (IR) among obese Latino children (N = 113; 7-15 years) who were enrolled in a community-based obesity intervention. Baseline information on physical activity was gathered by self-report. Clinical assessments of body composition, resting energy expenditure (REE), as well as glucose and insulin responses to an oral glucose tolerance test (OGTT) were performed after an overnight fast. Insulin resistance was defined as a 2 h insulin concentration >57 µU·mL(-1). We observed that those obese children who met the 2008 Guidelines for MVPA (≥60 min/day) experienced a significantly lower odds of IR compared with those not meeting the Guidelines (OR = 0.29; 95% CI: (0.10-0.92)) and these findings were independent of age, sex, pubertal stage, acculturation, fasting insulin, and 2 h glucose concentrations. Efforts to promote 60 min or more of daily MVPA among children from ethnic minority and high-risk communities should assume primary public health importance.

Energy prediction equations are inadequate for obese Hispanic youth.

Assessing energy requirements is a fundamental activity in clinical dietetics practice. A study was designed to determine whether published linear regression equations were accurate for predicting resting energy expenditure (REE) in fasted Hispanic children with obesity (aged 7 to 15 years). REE was measured using indirect calorimetry; body composition was estimated with whole-body air displacement plethysmography. REE was predicted using four equations: Institute of Medicine for healthy-weight children (IOM-HW), IOM for overweight and obese children (IOM-OS), Harris-Benedict, and Schofield. Accuracy of the prediction was calculated as the absolute value of the difference between the measured and predicted REE divided by the measured REE, expressed as a percentage. Predicted values within 85% to 115% of measured were defined as accurate. Participants (n=58; 53% boys) were mean age 11.8±2.1 years, had 43.5%±5.1% body fat, and had a body mass index of 31.5±5.8 (98.6±1.1 body mass index percentile). Measured REE was 2,339±680 kcal/day; predicted REE was 1,815±401 kcal/day (IOM-HW), 1,794±311 kcal/day (IOM-OS), 1,151±300 kcal/day (Harris-Benedict), and, 1,771±316 kcal/day (Schofield). Measured REE adjusted for body weight averaged 32.0±8.4 kcal/kg/day (95% confidence interval 29.8 to 34.2). Published equations predicted REE within 15% accuracy for only 36% to 40% of 58 participants, except for Harris-Benedict, which did not achieve accuracy for any participant. The most frequently accurate values were obtained using IOM-HW, which predicted REE within 15% accuracy for 55% (17/31) of boys. Published equations did not accurately predict REE for youth in the study sample. Further studies are warranted to formulate accurate energy prediction equations for this population.

Correlates of self-worth and body size dissatisfaction among obese Latino youth.

The current study examined self-worth and body size dissatisfaction, and their association with maternal acculturation among obese Latino youth enrolled in a community-based obesity intervention program. Upon entry to the program, a sample of 113 participants reported global self-worth comparable to general population norms, but lower athletic competence and perception of physical appearance. Interestingly, body size dissatisfaction was more prevalent among younger respondents. Youth body size dissatisfaction was associated with less acculturated mothers and higher maternal dissatisfaction with their child's body size. By contrast, although global self-worth was significantly related to body dissatisfaction, it was not influenced by mothers' acculturation or dissatisfaction with their own or their child's body size. Obesity intervention programs targeted to Latino youth need to address self-worth concerns among the youth as well as addressing maternal dissatisfaction with their children's body size.

Effects of high and low glycemic load meals on energy intake, satiety and hunger in obese Hispanic-American youth.

UNLABELLED: Some short-term pediatric studies have suggested beneficial effects of low glycemic load (LGL) meals on feelings of hunger and on energy intake. However, the effects of LGL diets have not been systematically studied in obese Hispanic children, who stand to benefit from successful interventions. OBJECTIVE: To examine the effects of LGL and high-GL (HGL) meals on appetitive responses and ad libitum energy intake of obese Hispanic youth. METHODS: A total of 88 obese Hispanic youth aged 7-15 years were enrolled in a community-based obesity intervention program and randomly assigned to consume meals designed as either LGL (n = 45) or HGL (n = 43). After 12 weeks, participants were admitted for a 24-hour metabolic study. Following the morning test meal, subjects serially reported hunger, fullness, and satiety using a visual analog scale. Blood insulin and glucose were measured. After 5 hours, participants were fed another test meal and given a snack platter from which to eat ad libitum. All test food was weighed and the energy, macronutrients, and glycemic load (GL) of consumed foods were calculated. RESULTS: The HGL group had significantly higher insulin (p = 0.0005) and glucose (p = 0.0001) responses to the breakfast meal compared with the LGL group. There were no significant between-group differences in energy consumed from the snack platter (1303 vs. 1368 kcal, p = 0.5), or in the subjective feelings of hunger (p = 0.3), fullness (p = 0.5) or satiety (p = 0.3) between the two groups. CONCLUSIONS: Our study provides no evidence that, for obese Hispanic youth, changing the GL of the diet affects short-term hunger, fullness, satiety, or energy intake. ClinicalTrials.gov Identifier: NCT01068197.

Student perceptions of effectiveness of the eight step preceptor (ESP) model in the ambulatory setting.

BACKGROUND: Balancing consistently effective clinical teaching with quality patient care is a crucial challenge for ambulatory preceptors. Educators have developed frameworks of specific teaching behaviors to facilitate consistent, efficient precepting, but few have evaluated their effectiveness. We modified an existing precepting model by incorporating additional adult learning principles to create the Eight Step Preceptor (ESP) model. We then determined if students perceived faculty to be more effective teachers when they incorporated more ESP components into their precepting sessions. PURPOSES: The objective was to describe the association between faculty using the ESP behaviors during their precepting and medical students' satisfaction with their learning. METHODS: A trained observer timed the duration of precepting sessions in a children's hospital ambulatory clinic between August and November 2001. Students rated faculty "teaching effectiveness," and both students and observer rated whether faculty effectively incorporated ESP behaviors during each session. RESULTS: Sessions lasted on average 26 +/- 14 min. Faculty gave a teaching point and feedback in over 50% of the precepting sessions but did not consistently incorporate the other ESP behaviors. Faculty use of more ESP behaviors correlated significantly with greater teaching effectiveness (r = .62, p < .003) but not significantly with duration of precepting sessions. CONCLUSIONS: Students perceived faculty as more effective teachers when they incorporated more ESP behaviors while precepting. The ESP model was associated with more effective ambulatory precepting in our study.

Body dissatisfaction, self-esteem, and overweight among inner-city Hispanic children and adolescents.

We examined the associations among self-reported body image, self-esteem, and measured body mass index (BMI) in El-Salvadoran American youth. Higher BMI was associated with body size dissatisfaction, lower peer esteem, and attempts to lose weight. Body size dissatisfaction was also significantly related to self-esteem in these El-Salvadoran American youth.

Prevalence of overweight among inner city Hispanic-American children and adolescents.

OBJECTIVE: National surveys have pointed to a particularly high risk of pediatric overweight among U.S. Hispanics. However, the data have been primarily from the Mexican-American community. We studied the prevalence of overweight and clinical comorbidities in children and youth of predominantly El Salvadoran ancestry. RESEARCH METHODS AND PROCEDURES: A sample of 309 Hispanic youth, 6-18 years was surveyed from two inner city Washington, DC, clinics. BMI; triceps skinfold (TSF) and subscapular skinfold thickness (SSSF); bioelectrical impedance analysis (BIA); and blood pressure measures were obtained, along with information regarding physical activity, sedentary behavior, dietary history, family, and personal medical history. RESULTS: Thirty-eight percent were overweight (BMI > or = 95th percentile) and 22% at risk for overweight (BMI 85-94th percentile). Thirty-four percent had TSF > or = 90th percentile and 29% had SSSF > or = 90th percentile. Fifty-one percent of males and 70% of females had body fat > 30%. Compared to their nonoverweight counterparts, overweight youth had significantly higher systolic blood pressure (111.4 +/- 1.3 vs. 104.5 +/- 0.9 mm Hg, p < 0.0001). Among children younger than 11 years, overweight was associated with onset of adrenarche (23% vs. 10%, p = 0.01). Participation in one or more sports teams was negatively correlated with overweight) p = 0.04). DISCUSSION: The prevalence of overweight and at risk for overweight in this sample was twice the national average for U.S. children and 1.7 times greater than that of Mexican-American children in national surveys. Overweight was associated with advanced pubertal development, high body fat, elevated blood pressure, and decreased sports participation.