Adolfo J. Ariza

Risk factors for overweight in five- to six-year-old Hispanic-American children: a pilot study.

The objective of this study was to determine the prevalence of and possible risk factors for overweight in a sample of 5- to 6-year-old Hispanic (predominantly Mexican American) children in Chicago, Illinois, to see if overweight is more common in more highly acculturated immigrant families. There were 250 kindergarten students (92% of those eligible) attending two public elementary schools serving primarily Mexican American neighborhoods measured for height and weight. Consenting mothers were interviewed (n=80) and measured (n=38). The interview tool covered demography, acculturation, infant and toddler feeding practices, current cating patterns and food preparation habits, physical activity, and psychosocial family characteristics. Overweight was conservatively defined as weight-for-height at or above the National Center for Health Statistics 95th percentile. The data were used to describe the prevalence of overweight. Overweight and nonoverweight children were compared on all survey variables using appropriate statistical tests, with significance set at .05. There were 23% of the total sample of children (n=250) and 26% of the subsample of children (those whose mothers were interviewed) who were overweight. Analysis limited to children in the subsample explored risk factors. The median score on the Acculturation Scale was 4.0 (range 2.4–10.4) on a scale of 2.4 (entirely not acculturated) to 12 (fully acculturated). There was no significant association between overweight and Acculturation Scale score. Overweight children were more likely than those not overweight to watch television for more than 3 hours during weekend days (48% vs. 22%, P=.03). Overweight children were also more likely to consume sweetened beverages (powdered drinks, soda pop, atole) daily (67% vs. 39%, P=.03). There was a trend indicating that free access to food at home increased the risk of overweight (P=0.06). No other family- or child-level variables were related to overweight. Only 40% of mothers with an overweight child correctly assessed these children as overweight. Approximately one quarter of the children in the study were overweight. Our hypothesis that their obesity was linked to acculturation was not confirmed. Longer hours of child television viewing on weekends and higher levels of sweetened beverage consumption were important behaviors associated with the occurrence of overweight. These data should be considered when designing future studies in this population.

Heritability and Environmental Factors Affecting Vitamin D Status in Rural Chinese Adolescent Twins

CONTEXT Factors associated with the high prevalence of vitamin D deficiency in China are not well described, especially among Chinese adolescents. OBJECTIVES The aim of the study was to examine important environmental or sociodemographic factors influencing 25-hydroxyvitamin D [25(OH)D] levels and estimate its heritability. DESIGN A sample of 226 male and female adolescent twins aged 13-20 yr from a large prospective twin cohort of rural Chinese children and adolescents that has been followed for 6 yr were evaluated. MAIN OUTCOME MEASURE(S) Blood level of 25(OH)D was measured using tandem mass spectrometry methodology. RESULTS The overall mean (SD) 25(OH)D level was 18.0 (9.4) ng/ml, with wide variation by gender and season. In males (47.4% of subjects), the mean (SD) 25(OH)D level was 12.1 (4.2) ng/ml in non-summer and 27.4 (8.8) ng/ml in summer; in females, it was 10.1 (4.1) ng/ml in non-summer and 19.5 (6.3) ng/ml in summer. A multivariate model that included gender, age, season, physical activity, and student status demonstrated that male gender, summer season, and high physical activity significantly increased 25(OH)D levels. Summer season and male gender also significantly decreased the risk of being in the lowest 25(OH)D tertile. Overall, 68.9% of the variability in 25(OH)D level was attributable to additive genetic influence. Stratification by gender found that in males, 85.9% of the variability in 25(OH)D level was attributable to such influence, but in females, it was only 17%. CONCLUSION In this sample of rural Chinese adolescents, 25(OH)D level was influenced by gender, season, and physical activity level. There was a strong genetic influence on 25(OH)D level in males only.

Describing primary care encounters: the Primary Care Network Survey and the National Ambulatory Medical Care Survey.

PURPOSE The purpose of this study was to describe clinical encounters in primary care research networks and compare them with those of the National Ambulatory Medical Care Survey (NAMCS). METHODS Twenty US primary care research networks collected data on clinicians and patient encounters using the Primary Care Network Survey (PRINS) Clinician Interview (PRINS-1) and Patient Record (PRINS-2), which were newly developed based on NAMCS tools. Clinicians completed a PRINS-1 about themselves and a PRINS-2 for each of 30 patient visits. Data included patient characteristics; reason for the visit, diagnoses, and services ordered or performed. We compared PRINS data with data obtained from primary care physicians during 5 cycles of NAMCS (1997–2001). Data were weighted; PRINS reflects participating networks and NAMCS provides national estimates. RESULTS By discipline, 89% of PRINS clinicians were physicians, 4% were physicians in residency training, 5% were advanced practice nurses/nurse-practitioners, and 2% were physician’s assistants. The majority (53%) specialized in pediatrics (34% specialized in family medicine, 9% in internal medicine, and 4% in other specialties). All NAMCS clinicians were physicians, with 20% specializing in pediatrics. When NAMCS and PRINS visits were compared, larger proportions of PRINS visits involved preventive care and were made by children, members of minority racial groups, and individuals who did not have private health insurance. A diagnostic or other assessment service was performed for 99% of PRINS visits and 76% of NAMCS visits (95% confidence interval, 74.9%–78.0%). A preventive or counseling/education service was provided at 64% of PRINS visits and 37% of NAMCS visits (95% confidence interval, 35.1%–38.0%). CONCLUSIONS PRINS presents a view of diverse primary care visits and differs from NAMCS in its methods and findings. Further examinations of PRINS data are needed to assess their usefulness for describing encounters that occur in primary care research networks.

Influences on parents’ decisions for home and automobile smoking bans in households with smokers

OBJECTIVE To understand clinician influence on use of home and automobile smoking bans in homes of children living with a smoker. METHODS Parents were surveyed on tobacco use, smoking bans, demographics and opinions about tobacco, including harm from environmental tobacco smoke (ETS). Responses from 463 diverse households with smokers were analyzed. RESULTS 42% of respondents smoked; 50% had a home smoking ban and 58% an automobile smoking ban. Nonsmokers living with a smoker, those who strongly agreed in ETS harm, and those having a child < or = 5 years more often had a home smoking ban. Those recalling their childs doctor ever asking the respondent about their smoking status and African American respondents less frequently had a home ban. Automobile smoking bans were more often held by those with strong agreement in ETS harm and less often found in families having a child receiving Medicaid/uninsured. CONCLUSIONS Having a strong perception of harm from ETS exposure was associated with having smoking bans. Aspects of health encounters not measured by this study may be negatively influencing adoption of home smoking bans or lead to recall bias. PRACTICE IMPLICATIONS Clinicians should examine the strength, focus, and response to their messages to parents about tobacco.

The epidemiology of overweight in children: relevance for clinical care.

Childhood obesity is a well-recognized problem in the United States1-3 and in some other countries (eg, in Latin America).4 It can cause other medical problems in childhood and adolescence,5 6 tends to persist,7 8 and long-standing obesity brings health risks in adults.9 Thus, current childhood obesity promises to contribute lower adult quality of life and higher medical costs in the future. To guide both prevention and treatment, a thorough understanding of its patterns, causes, and treatment options is needed. The article by Mei et al10 in this issue of Pediatrics electronic pages adds to our understanding of patterns of ponderosity in low-income children, based on a study of children receiving WIC services between 1983 and 1995. The investigators focus on overweight, defined as weight for height ≥85th percentile (the term “obesity” is not used). During the time studied, the percentage of overweight children increased from 18.6% to 21.6% for children 0 to 5 years. The trend was most marked for boys, Hispanic children, the oldest preschoolers (age 4 to 5), and those in cities.10 These findings are consistent with recent publications on children 2 to 11 years old2 3; the finding that percentage of overweight children among those 0 to 1 year of age has been increasing is new. This report makes it clear that despite growing evidence that early childhood overweight has increased dramatically in recent years,1-3 10 the rise continues. This suggests that awareness of the problem and its correlates may not be guiding clinicians toward effective intervention. Mei et al conclude their report with a call for new research to address many unanswered questions. We agree that further research is needed (as discussed further below), but those who work with children and families need … Address correspondence to: Katherine Kaufer Christoffel, MD, MPH, Childrens Memorial Hospital, #46, 2300 Childrens Plaza, Chicago, IL 60614.

Guidelines Help Clinicians: Identify Risk Factors for Overweight in Children

The pediatric office has an important role in national efforts to reverse rising trends in the prevalence of childhood overweight. Overweight may be established at a young age and is difficult to reverse. Lifestyle choices associated with overweight are common and their development may begin in very young children. Therefore, there is a necessity to apply a preventive strategy that addresses all children to promote healthy lifestyle choices from birth onward and to develop an intervention strategy that works by changing family habits so that healthy lifestyle habits are reinforced. It is crucial to develop, evaluate, and apply new systems and practical approaches to aid in this effort in the pediatric practice setting.

Vitamin D levels, insulin resistance, and cardiovascular risks in very young obese children

Abstract Objective: To examine the relationships of 25-hydroxyvitamin D (25-OHD) levels with the measures of insulin resistance and cardiovascular risk, and identify the clinical factors associated with low 25-OHD in young obese children. Design and methods: Data from 83 children ages 2–6 years seen for obesity care (clinic latitude 42°N) were analyzed. Insulin resistance [homeostasis model assessment of insulin resistance (HOMA-IR)] and cardiovascular risks were examined in relationship to 25-OHD levels using correlation statistics. χ2 and logistic regression models were applied to identify the factors associated with vitamin D deficiency (25-OHD levels <20 ng/mL) and insufficiency (<30 ng/mL). Results: Children’s mean age was mean 4.9 years and they were predominantly Hispanic. Mean body mass index (BMI) Z-score was 3.2 and mean HOMA-IR was 2.8. Mean 25-OHD was 30.9 ng/mL (6% <20 ng/mL and 46% 20–29 ng/mL). There were no significant correlations between 25-OHD and BMI (Spearman’s ρ=–0.096, p=0.389), BMI Z-score (Spearman’s ρ=0.104, p=0.350), HOMA-IR (Spearman’s ρ=–0.144, p=0.269), total cholesterol (Spearman’s ρ=–0.028, p=0.833), or triglycerides (Spearman’s ρ=–0.026, p=0.846). Vitamin D deficiency was significantly associated with older age, lower milk intake, and testing in winter months. 25-OHD level <30 ng/mL was associated with older age, African-American and Hispanic race/ethnicity, and testing in winter months. All factors retained significance in a multivariate logistic regression model, with African-American (odds ratio=14.4) and Hispanic (odds ratio=7.2) race/ethnicity being the strongest predictors of 25-OHD levels <30 ng/mL. Conclusions: In these children, 25-OHD was not associated with insulin resistance or cardiovascular risks. Considering age, race/ethnicity, diet, and season may help identify young obese children needing vitamin D management.

Childhood overweight: management approaches in young children.

Management of overweight in young children may be our best opportunity for confronting the nationwide epidemic of childhood obesity. Doing so will require all health care providers to improve their identification, assessment, and guidance on this issue. As a group, we must make it a priority to obtain height and weight measurements on every child and to interpret them correctly. We must be comprehensive in our medical investigation in order to uncover identifiable causes and recognize comorbidities. Most of all, we must motivate families, as a whole, to confront this issue with us by increasing physical activity, decreasing sedentary behaviors, and improving eating practices. As health professionals in a society that is not yet poised to fight this epidemic, we must lead the way.

Promoting Growth Interpretation and Lifestyle Counseling in Primary Care

OBJECTIVE To pilot a practice-directed intervention to promote growth interpretation and lifestyle counseling during child health supervision visits. STUDY DESIGN The intervention at 4 diverse primary care practices included education, facilitation by a practice-change leadership team, tools, and guidance from the study team. Preintervention and postintervention evaluations used were clinician interviews, in-office surveys of parents, 1-month post-visit telephone survey, visit observations, and medical record reviews. Outcomes evaluated growth interpretation documentation, clinician recognition of overweight, topic discussed at health supervision visit, and parental visit content recall and health behavior changes. RESULTS The intervention was well accepted, and tools provided were deemed helpful. Documentation of growth interpretation was higher after intervention (pre versus post: 32% vs 87%; P< .001). Parent reports of topics discussed were similar between evaluation periods (pre versus post: growth 96% vs 99%; diet 90% vs 93%; physical activity 81% vs 85%). Observed topics at health supervision visits were similarly high and were unchanged between periods. Parental recall of topics at 1 month was also high and similar between periods. Parental report of adoption of a healthier behavior for themselves or their child at 1 month did not significantly change. CONCLUSIONS The Systematic Nutritional Assessment in Pediatric Practice intervention provides a promising model to increase interpretation and documentation of growth.

Do Hospitalized Pediatric Patients Have Weight and Blood Pressure Concerns Identified

OBJECTIVES To assess the frequency and recognition of abnormal nutritional status and elevated admitting blood pressure (BP) in hospitalized children. STUDY DESIGN From children aged 3 to 18 years who were hospitalized during 4 months of 2005 (n = 1143), a stratified sample of paper-based medical records were reviewed for demographics, anthropometric and BP measurements and interpretations, care related to nutrition and BP, and discharge diagnoses. Records of 317 of 337 (94%) selected patients were reviewed, and data from 277 of these patients (records with weight and height documented) were analyzed. US references were applied to assign body mass index and BP percentiles. Data were weighted to account for sampling. RESULTS A total of 51% of subjects were Medicaid/self-pay, with a median age of 9.1 years; and 20% of subjects were obese (14% overweight, 58% healthy weight, 8% underweight). Body mass index was plotted/calculated for 35% of subjects. Six percent of subjects had BP >99th percentile + 5 mm Hg (18% BP 95th to < or =99th percentile + 5 mm Hg). A nutrition referral was documented for 61% of subjects who were underweight and 39% of subjects who were obese. BP concerns were documented for 26% of subjects with BP >99th percentile + 5 mm Hg. CONCLUSIONS Many pediatric inpatients had abnormal nutritional status or elevated BP. Systems to improve interpretation of these measures, which are commonly obtained in pediatric hospital settings, are needed.