Sleep duration predicts cardiometabolic risk in obese adolescents.

OBJECTIVE: To examine the independent contributions of objectively measured sleep duration and fragmentation on cardiometabolic risk accumulation in free-living obese adolescents. STUDY DESIGN: Characteristics of metabolic syndrome (waist circumference, mean arterial pressure, fasting high-density lipoprotein cholesterol, triglycerides, glucose) were measured in obese adolescents and standardized residuals (z-scores) were summed (inverse high-density lipoprotein cholesterol) to create a continuous cardiometabolic risk score (cMetScore), adjusted for age, sex, and race. Sleep and physical activity were objectively measured in habitual, free-living conditions for 7 days (SenseWear Pro3, BodyMedia, Pittsburgh, Pennsylvania; n = 37; 54% female, ages 11-17 years). Associations between sleep duration and cMetScore were assessed via multiple linear regression. RESULTS: Body mass index, total sleep time, and sleep session length were each correlated with cMetScore (P < .05 all). Total sleep time was inversely and independently associated with cMetScore (r = -0.535, P = .001) and was the best independent predictor of metabolic risk. CONCLUSIONS: Sleep duration inversely predicts cardiometabolic risk in obese adolescents, even when we controlled for various measures of physical activity, anthropometry, and adiposity. Further research should investigate the biological mechanism of this relationship and the potential treatment effect of sleep intervention in decreasing cardiometabolic risk in this population.

A risk score for identifying overweight adolescents with dysglycemia in primary care settings.

OBJECTIVE: To develop a clinical risk scoring system for identifying adolescents with dysglycemia (prediabetes or diabetes) who need further confirmatory testing and to determine whether the addition of non-fasting tests would improve the prediction of dysglycemia. STUDY DESIGN: A sample of 176 overweight and obese adolescents (10-17 years) had a history/physical exam, a 2-h oral glucose tolerance test, and non-fasting tests [hemoglobin A1c, 1-h glucose challenge test (GCT), and random glucose test] performed. Given the low number of children with diabetes, we created several risk scoring systems combining the clinical characteristics with non-fasting tests for identifying adolescents with dysglycemia and compared the test performance. RESULTS: Sixty percent of participants were white and 32% were black; 39.2% had prediabetes and 1.1% had diabetes. A basic model including demographics, body mass index percentile, family history of diabetes, and acanthosis nigricans had reasonable test performance [area under the curve (AUC), 0.75; 95% confidence interval (95% CI), 0.68-0.82]. The addition of random glucose (AUC, 0.81; 95% CI, 0.75-0.87) or 1-h GCT (AUC, 0.82; 95% CI, 0.75-0.88) to the basic model significantly improved the predictive capacity, but the addition of hemoglobin A1c did not (AUC, 0.76; 95% CI, 0.68-0.83). The clinical score thresholds to consider for the basic plus random glucose model are total score cutoffs of 60 or 65 (sensitivity 86% and 65% and specificity 60% and 78%, respectively) and for the basic plus 1-h GCT model are total score cutoffs of 50 or 55 (sensitivity 87% and 73% and specificity 59% and 76%, respectively). CONCLUSIONS: Pending a validation in additional populations, a risk score combining the clinical characteristics with non-fasting test results may be a useful tool for identifying children with dysglycemia in the primary care setting.

The role of social media in online weight management: systematic review.

BACKGROUND: Social media applications are promising adjuncts to online weight management interventions through facilitating education, engagement, and peer support. However, the precise impact of social media on weight management is unclear. OBJECTIVE: The objective of this study was to systematically describe the use and impact of social media in online weight management interventions. METHODS: PubMed, PsycINFO, EMBASE, Web of Science, and Scopus were searched for English-language studies published through March 25, 2013. Additional studies were identified by searching bibliographies of electronically retrieved articles. Randomized controlled trials of online weight management interventions that included a social media component for individuals of all ages were selected. Studies were evaluated using 2 systematic scales to assess risk of bias and study quality. RESULTS: Of 517 citations identified, 20 studies met eligibility criteria. All study participants were adults. Because the included studies varied greatly in study design and reported outcomes, meta-analysis of interventions was not attempted. Although message boards and chat rooms were the most common social media component included, their effect on weight outcomes was not reported in most studies. Only one study measured the isolated effect of social media. It found greater engagement of participants, but no difference in weight-related outcomes. In all, 65% of studies were of high quality; 15% of studies were at low risk of bias. CONCLUSIONS: Despite the widespread use of social media, few studies have quantified the effect of social media in online weight management interventions; thus, its impact is still unknown. Although social media may play a role in retaining and engaging participants, studies that are designed to measure its effect are needed to understand whether and how social media may meaningfully improve weight management.

Association of High Normal Body Weight in Youths With Risk of Hypertension.

Importance: Ample evidence links obesity to hypertension in youths. However, the association of high normal body mass index (BMI) with obesity and the interaction with different weight trajectories are not well understood. Objective: To examine the hypertension risk associated with high normal BMI for age and different weight trajectories in youths. Design, Setting, and Participants: This retrospective cohort study assessed 801 019 youths aged 3 to 17 years in an integrated health care system in Southern California from January 1, 2008, to February 28, 2015, with a maximum follow-up of 5 years from January 1, 2008, to February 28, 2020. Data analysis was performed from 2018 to 2022. Exposures: Youths were compared by first available (baseline) sex-specific BMI for age and change in the distance to the median BMI for age during the 5-year follow-up. Main Outcomes and Measures: Cox proportional hazards regression models with age as a time scale to assess hypertension risk (based on 2017 Blood Pressure Guidelines by the American Academy of Pediatrics from 3 consecutive independent visits), adjusted for sex, race and ethnicity, socioeconomic status, baseline year, and birth year. Results: A total of 801 019 youths (mean [SD] age, 9.4 [4.6] years; 409 167 [51.1%] female]; 59 399 [7.4%] Asian and Pacific Islanders, 65 712 [8.2%] Black, and 427 492 [53.4%] Hispanic) were studied. Compared with youths with a baseline BMI for age in the 40th to 59th percentiles, the adjusted hazard ratio (aHR) for hypertension within a maximum of 5 years was 1.26 (95% CI, 1.20-1.33) for youths between the 60th and 84th percentiles if they maintained their BMI for age. With every 1-unit annual increase in the distance to the median BMI for age, the aHR increased by 1.04 (95% CI, 1.04-1.05). The aHR was 4.94 (95% CI, 4.72-5.18) in youths with a baseline BMI for age in the 97th percentile or higher who maintained their body weight. Weight gain increased the risk associated with baseline BMI for age in the 97th percentile or higher with an aHR of 1.04 (95% CI, 1.04-1.05) per 1-unit annual increase in the distance to the median BMI for age. The risk associated with weight change was higher in youths living with low to high normal weight and overweight than in youths living with severe obesity. Conclusions and Relevance: In this cohort study of youths, high normal body weight above the 60th percentile of BMI for age was associated with increased risk of hypertension. Weight gain was associated with further increases in hypertension risk. Further research is needed to evaluate the wide range of body weight considered normal in youths and the health risks associated with high normal weight.

Disparities in weight changes during the COVID-19 pandemic-related lockdown in youths.

OBJECTIVE: This study evaluates whether changes in weight among school-aged youth in California due to the COVID-19 lockdown vary by social constructs of race/ethnicity and associated social factors. METHODS: Including 160,472 youth aged 5 to 17 years enrolled at Kaiser Permanente Southern California, mixed effects models stratified by age group were fitted to estimate changes in distance from the median BMI-for-age from March 2020 to January 2021 (lockdown) compared with the same period before the pandemic. RESULTS: Excess pandemic weight gain was higher among Black and Hispanic youth aged 5 to 17 years than among White and Asian youth; this difference was most pronounced in those aged 5 to 11 years. In youth aged 5 to 11 years, the distance from the median BMI-for-age increased by 1.72 kg/m2 (95% CI: 1.61-1.84) in Hispanic and 1.70 kg/m2 (95% CI: 1.47-1.94) in Black youth during the lockdown compared with 1.16 kg/m2 (95% CI: 1.02-1.29) in non-Hispanic White youth. The excess weight gain was also higher in youth with fewer neighborhood parks and those with state-subsidized health insurance. CONCLUSIONS: The COVID-19 pandemic lockdown led to a gain of excess body weight, particularly for Black and Hispanic youth; this weight gain varied by social factors associated with race and ethnicity.

Use of the socio-ecological model to explore trusted sources of COVID-19 information in Black and Latinx communities in Michigan.

BACKGROUND: Identifying trusted sources of health information and exploring what makes these sources trustworthy is an important aspect of public health. This exploration requires embracing the cultural differences in minoritized communities, which are often treated as homogeneous. This qualitative study identifies and analyze the sources of trusted COVID-19 information among Black and Latinx communities in Michigan and assesses the rationale underlying this trust. METHODS: Interviews were conducted with 24 Black and 16 Latinx participants (n = 40) in four Michigan counties significantly impacted by COVID-19. The socio-ecological model was applied as an analytical framework for understanding the entities considered trusted sources of information. Within each level of the model, the dimensions of trustworthiness most salient for participants were identified. RESULTS: We found that sources of information came from all levels of the model, including interpersonal (COVID-19 survivors, church representatives, friends, relatives), organizational (employers, healthcare providers, traditional news reports), social media (hybrid source), community (members and groups), and public policy (county health department, federal and state government). Furthermore, participants determined whether they could trust information about COVID-19 by cross-referencing multiple resources. We identified competence, confidence, communication, and system trust as the dimensions of trustworthiness most often reported by participants. CONCLUSIONS: Our research suggests public health communications should engage in cross-referencing practices, providing information from sources at all levels of interaction, cultural competency, and awareness of historical/structural inequities. These efforts would be further strengthened by attending to needs for both factual information as well as care and personal connection.

Parental Perspectives Regarding the Impact of the COVID-19 Pandemic on Their Children.

Background: The COVID-19 pandemic has brought profound changes to the health of families worldwide. Yet, there is limited research regarding its impact on children. The pandemic may exacerbate factors associated with excess weight, which is particularly concerning due to the potential association between excess weight and severity of COVID-19 infection. This study investigates parental perspectives of changes in fruit/vegetable (FV) intake, processed food (PF) intake, outdoor playtime (OP), physical activity (PA) levels, and recreational screen time (RST) among children living in Michigan during the pandemic. Methods: The study team and community partners developed and distributed a survey using snowball sampling to reach families living largely in Central and Southeastern Michigan. Nonlinear mixed-effects proportional odds models were used to examine associations between child weight status along with demographic/household factors and changes in five weight-related behaviors. Results: Parents (n = 1313; representing 2469 children) reported a decrease in OP, FV, and PA levels, while there was an increase in RST and PF intake among their children. Household income was protective against a decrease in OP, PA, and FV but was associated with increased RST. Children's weight status was associated with decreased FV. Age was negatively associated with OP and PA, and positively associated with RST. Conclusions: These findings suggest an adverse influence of the pandemic on weight-related behaviors, particularly among adolescents in families with lower incomes and those with excess weight. Further work is needed to measure any impact on BMI trajectory and to identify interventions to reverse negative effects.

MICEAL Black and Latinx Perspectives on COVID-19 Vaccination: A Mixed-Methods Examination.

OBJECTIVES: To describe the differences and similarities in perceptions and attitudes regarding COVID-19 vaccination among Black and Latinx Michiganders. METHODS: Utilizing a convergent mixed-methods approach, forty interviews were conducted with 24 Black and 16 Latinx community members between December 2020 and June 2021 across four Michigan counties disproportionately affected by COVID-19. Survey data were collected from a representative sample of 1598 individuals living in Detroit between January and March 2021. RESULTS: Vaccine hesitancy was a more prevalent theme among Black interview participants than Latinx participants. Trust in experts and vaccine access were significantly more influential in the decision to vaccinate for Latinx residents compared to Black residents. Latinx individuals reported greater intention to receive a COVID-19 vaccine compared to Black respondents. Multinomial logit models revealed that 30% of Black participants expressed hesitancy about the COVID-19 vaccine compared to 10% of Latinx respondents. CONCLUSIONS AND IMPLICATIONS: This study provides a deeper understanding of key differences and similarities in vaccine acceptance/hesitancy across race/ethnicity. The findings can enhance health interventions and outcomes by informing the development of culturally responsive practices tailored to specific communities.

Bariatric surgery decision making challenges: the stability of teens' decisions and the treatment failure paradox.

PURPOSE: Criteria for adolescent bariatric surgery include failure of ≥6 months of organized weight loss attempts. We wished to explore whether adolescents, initially wanting surgery, change their mind during a 6-month weight loss program and how many meet the treatment failure criterion. METHODS: A retrospective chart review of adolescents enrolled in a weight loss program between 3/2007 and 2/2009. RESULTS: Twenty-one (13 % of total patients) initially wanted bariatric surgery. Most were Medicaid enrollees (70 %), female (85 %), and white (60 %). The mean age was 15 years and mean BMI was 51 (range 36-71). Five did not meet BMI, comorbidity, or psychological criteria for surgery. Eight lost weight and therefore did not meet the treatment failure criterion. Of these, seven no longer wanted surgery. Eight did not lose weight and therefore met the treatment failure criterion; five of these decided against surgery due to difficulty in making recommended lifestyle changes. CONCLUSION: Most patients initially wanting bariatric surgery changed their minds. The treatment failure criterion presented a paradox, because most patients who met the criterion exhibited difficulty in making the lifestyle changes. To aid provider/patient decisions about bariatric surgery, further work should explore the criteria for surgery and stability of adolescents' decisions regarding bariatric surgery.

Reimagining a summer research program during COVID: Strategies for enhancing research workforce diversity.

Well-designed, accessible short-term research training programs are needed to recruit and retain underrepresented persons into clinical and translational research training programs and diversify the workforce. The Michigan Institute for Clinical and Health Research developed a summer research program, training over 270 students in 15 years. In response to the 2020 COVID-19 pandemic, we pivoted swiftly from an in-person format to a fully remote format. We describe this process, focusing on factors of diversity, equity, and inclusion including enabling student participation in remote research activities. We collected data about students' learning experiences since the program's inception; therefore, we could evaluate the impact of remote vs. in-person formats. We examined data from five cohorts: three in-person (2017-2019; n = 57) and two remote (2020-2021; n = 45). While there was some concern about the value of participating in a remote format, overall students in both formats viewed the program favorably, with students in the remote cohorts rating some aspects of the program significantly more favorably. In addition, more students who identified as Black or African American participated in the remote format than in the in-person format. We describe lessons learned from this unprecedented challenge and future program directions.

Employing Smartphone Health Apps in Weight Management for Adolescents: Analysis on Experiences and Perspectives From Pediatric Providers.

The rising popularity of smartphone health applications (apps) offers great potential for facilitating pediatric weight management. Pediatric providers can determine health interventions for young patients with excess weight. We surveyed 51 pediatric providers at a Midwest academic medical institution and found that 78% thought currently available resources were not sufficient for pediatric weight management. In all, 76% of respondents reported use of at least one smartphone health app for their personal health. The quality of pediatric providers' experiences with their favorite app was strongly associated with their willingness to recommend the app to their patients (P < .001), but few of them have made such a recommendation in practice, mainly due to the lack of either personal knowledge about health apps or about evidence-based health apps for pediatric weight management. Moreover, respondents shared ideas about qualities for an effective health app, which shed new light on developing apps specifically for adolescents with excess weight.

Cost-effectiveness of a motivational interviewing obesity intervention versus usual care in pediatric primary care offices.

OBJECTIVE: This study aimed to assess the incremental cost-effectiveness ratio (ICER) of a 2-year motivational interviewing (MI) intervention versus usual primary care. METHODS: A national trial was implemented in the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics to evaluate MI versus usual care for children (2-8 years old; baseline BMI 85th-97th percentiles). Health care use, food costs, provider fees, and training costs were assessed, and sensitivity analyses were conducted. Primary outcome was the ICER, calculated as cost per unit change in BMI percentile for intervention versus usual care. RESULTS: At 2 years, 72% of enrolled parent/child dyads were retained; 312 children were included in the analysis. Mean BMI percentile point change was -4.9 and -1.8 for the intervention and control, respectively, yielding an incremental reduction of 3.1 BMI percentile points (95% CI: 1.2-5.0). The intervention cost $1051 per dyad ($658 for training DVD development). Incorporating health care and non-health care costs, the intervention ICER was $363 (range from sensitivity analyses: cost saving, $3159) per BMI percentile point decrease per participant over 2 years. CONCLUSIONS: Training pediatricians, nurse practitioners, and registered dietitians to deliver MI-based interventions for childhood obesity in primary care is clinically effective and acceptably cost-effective. Future work should explore this approach in broader dissemination.

Enhanced Myeloid Leukocytes in Obese Children and Adolescents at Risk for Metabolic Impairment.

Objective: We aimed to examine if myeloid leukocyte profiles are associated with metabolic impairment in children and adolescents with obesity, and if sex, age, or race influence this relationship. Methods: 282 children ages 8-17 were evaluated. Predictor measures were absolute neutrophil counts (ANC), absolute monocyte count, monocyte subtypes and C reactive protein (CRP). Outcome variables were waist circumference, fasting glucose and insulin, HOMA-IR, HbA1c (%) and lipid profiles. Pearson correlation coefficients were used to determine associations between predictor and outcome variables. Wilcoxon two-sample tests were used to evaluate differences by sex. Results: CRP (p < 0.0001), ANC (p < 0.0018), and classical monocytes (p = 0.05) were significantly higher in children with obesity. CRP, ANC and classical monocytes showed positive correlations with waist circumference, insulin, HOMA-IR and triglycerides. CRP was positively associated with ANC overall (p = 0.05). ANC demonstrated positive correlation with monocytes (p < 0.001). The associations between predictor and outcome variables were influenced by sex, race, and age. Conclusions: CRP and myeloid leukocyte populations, specifically classical monocytes and neutrophils associate with both body composition and metabolic parameters in children with obesity suggesting that these cells may play a critical role in metabolic impairment. Race, gender and age interactions between monocytes and metabolic parameters were significant.

Waist circumference percentile thresholds for identifying adolescents with insulin resistance in clinical practice.

We formally evaluated waist circumference (WC) percentile cutoffs for predicting insulin resistance (IR) and whether different cutoffs should be used for adolescents of different race/ethnicities. Analysis was performed for 1575 adolescents aged 12-18 yr from the National Health and Nutrition Examination Survey 1999-2002. Adolescents were classified as having IR if they had a homeostasis model assessment-insulin resistance level, a validated measure of IR, of >4.39, and WC percentile was classified according to previously published universal (all races combined) and race/ethnicity-specific WC percentile cutoffs. Receiver operating characteristic curves for predicting IR were constructed comparing the race/ethnicity-specific vs. universal WC percentile cutoffs, and area under the curve (AUC) was calculated. Comparing universal with race/ethnicity-specific WC percentiles, there were no significant differences in AUC for Black, Mexican-American, or White adolescents. Because race/ethnicity-specific thresholds did not discriminate better than universal WC thresholds, universal WC thresholds may be used effectively to identify adolescents with IR in primary care practices. A WC > or =75th or > or =90th percentile for all race/ethnicities combined would be appropriate to apply in clinical practice for identification of adolescents with IR, a risk factor for development of type 2 diabetes.

Physicians' perspectives on increasing the use of BMI charts for young children.

The objective of the study was to explore the barriers and facilitators to using body mass index (BMI) for preschoolers. A survey was administered to a random sample of 600 pediatricians and family physicians in Michigan addressing usual practice for BMI charting, barriers, perceived influence of BMI chart innovations on the likelihood of increasing use of BMI and participating in training regarding obesity management. The response rate was 52%. Few respondents report that they generally use BMI charts for preschoolers (24%). The most frequently endorsed barrier was time and complexity involved in explaining BMI (70%). Respondents endorsed innovations such as color-coded charts (60%), and the inclusion of management recommendations (61%) as strong influences on the likelihood of using BMI more often. Frequently endorsed training modalities were workshops (47%), online (45%), and DVD (43%). Efforts to increase physician use of BMI should address methods to simplify communication of BMI, such as with color-coded charts, and provision of management recommendations based on BMI findings.

Community Healthcare and Technology to Enhance Communication in Pediatric Obesity Care.

Childhood obesity continues to be a critical healthcare issue and a paradigm of a pervasive chronic disease affecting even our youngest children. When considered within the context of the socioecological model, the factors that influence weight status, including the social determinants of health, limit the impact of multidisciplinary care that occurs solely within the medical setting. Coordinated care that incorporates communication between the healthcare and community sectors is necessary to more effectively prevent and treat obesity. In this article, the Expert Exchange authors, with input from providers convened at an international pediatric meeting, provide recommendations to address this critical issue. These recommendations draw upon examples from the management of other chronic conditions that might be applied to the treatment of obesity, such as the use of care plans and health assessment forms to allow weight management specialists and community personnel (e.g., school counselors) to communicate about treatment recommendations and responses. To facilitate communication across the healthcare and community sectors, practical considerations regarding the development and/or evaluation of communication tools are presented. In addition, the use of technology to enhance healthcare-community communication is explored as a means to decrease the barriers to collaboration and to create a web of connection between the community and healthcare providers that promote wellness and a healthy weight status.

Maternal perspectives on growth and nutrition counseling provided at preschool well-child visits.

BACKGROUND: The inclusion of growth assessment and nutrition-related anticipatory guidance in all well-child visits is recommended. Although prior studies have assessed whether these topics are discussed, the content of the discussions has not been explored from the maternal perspective. OBJECTIVE: To explore what mothers of preschoolers recall and understand about growth assessment and nutrition anticipatory guidance provided at their child's most recent well-child visit. METHODS: Qualitative, semistructured telephone interviews were performed with 20 mothers of preschoolers recruited from a Head Start program. Interviews were recorded and transcribed. Themes were identified and refined in an iterative process. RESULTS: Three main findings emerged: 1) although mothers generally recalled the use of growth charts and often recalled their child's height and weight percentiles, they were generally unable to articulate the meaning of these percentiles; 2) most mothers stated that their nutrition-related decisions were not influenced by growth chart findings. However, when growth chart findings were interpreted as positive, mothers found them reassuring. Conversely, when growth chart findings were interpreted as negative, mothers discounted the growth chart in favor of other comparisons of growth; 3) a considerable proportion of mothers reported that nutrition was not discussed at the most recent well-child visit, which mothers commonly attributed to a lack of weight or feeding problems for their child. CONCLUSION: Among the low-income mothers studied, growth chart use and findings were memorable but frequently misunderstood, while nutrition-related anticipatory guidance was not consistently recalled. These findings suggest opportunities to improve physician-patient communication regarding these topics.

Lessons for Physicians from Flint's Water Crisis.

Physicians form a vital front in recognizing unusual clinical presentations that could herald a health threat. In the Flint water crisis, physicians can be credited with playing critical roles in both uncovering the crisis and providing leadership when government failed to respond effectively. Yet most physicians in Flint were not formally trained in advocacy or leadership and might have recognized the health implications of the crisis more quickly had they received formal environmental health training. Furthermore, connections to other professional disciplines-and to the community-are vital for effective responses to environmental health threats. We explore some lessons learned in Flint that might help expedite resolution of future environmental health crises, particularly those involving aging infrastructure and diminished or dysfunctional regulation or oversight.