Carolyn Bradner Jasik

Adolescent Obesity and Puberty: The “Perfect Storm”

Obesity is the most serious long‐term health risk currently facing Americas adolescents. Weight gain during adolescence carries a higher risk for adult obesity and the metabolic syndrome. This review highlights early adolescence as a particularly high‐risk time for weight gain due to the synergy of naturally occurring metabolic changes along with increasing behavioral risk factors. One of the first potential health effects of abnormal weight gain during this period is earlier puberty, usually manifested as thelarche. The obesity epidemic is clearly implicated in the national trend toward earlier thelarche, although the data are not as strong in relation to menarche. Leptin activation of the hypothalamic‐pituitary axis, combined with insulin resistance, and increased adiposity may result in the higher estrogen levels that are linked to breast development. Young adolescents also experience a sharp decline in their level of physical activity, worsening nutritional habits, and other important psychosocial and developmental risk factors that may contribute to obesity and estrogen‐dependent disease in later life, including polycystic ovary syndrome and breast cancer. Unfortunately, the very psychosocial factors that contribute to abnormal weight gain during early adolescence make prevention and treatment in this population particularly challenging. Therefore, intervening prior to pubertal onset becomes even more important given the risk factors present once puberty begins.

Gender differences in prediabetes and insulin resistance among 1356 obese children in Northern California.

AIMS While it has been shown that there are gender differences in prediabetes and insulin resistance among adults, less is known about whether these differences exist in children. Obese children have elevated risk for developing metabolic dysfunction, and this analysis was conducted to compare obese boys and girls. METHODS Biomarkers of prediabetes (IFG and HbA1c) and insulin resistance (HOMA-IR), were examined for 1356 obese children (2-19 years) who presented to a pediatric weight management clinic between 2008 and 2012. Gender differences were analyzed with multivariate logistic regression. RESULTS Boys were more likely than girls to have IFG (adjusted OR: 1.68; CI: 1.06-2.65), but less likely to have elevated HOMA-IR (adjusted OR 0.71; CI: 0.52 -0.97). The female predominance of insulin resistance was present at younger ages than the male predominance of IFG. There were no gender differences with respect to HbA1c. Elevated HbA1c identified 20.7% of the sample as prediabetic whereas IFG identified 7.8%. CONCLUSIONS Similar to findings in adults, obese children appear to exhibit more impaired fasting glucose among boys and a higher predominance of insulin resistance among girls. However, HbA1c identified a larger proportion of these high-risk, obese youth as prediabetic than IFG.

The Association of BMI Status With Adolescent Preventive Screening

OBJECTIVE: To examine the relationship between BMI status (normal, overweight, and obese) and preventive screening among adolescents at their last checkup. METHODS: We used population-based data from the 2003–2007 California Health Interview Surveys, telephone interviews of adolescents aged 12 to 17 years with a checkup in the past 12 months (n = 9220). Respondents were asked whether they received screening for nutrition, physical activity, and emotional distress. BMI was calculated from self-reported height and weight: (1) normal weight or underweight (<85th percentile); (2) overweight (85th–94th percentile); and (3) obese (>95th percentile). Multivariate logistic regression models tested how screening by topic differed according to BMI status, adjusting for age, gender, income, race/ethnicity, and survey year. RESULTS: Screening percentages in the pooled sample (all 3 years) were higher for obese, but not overweight, adolescents for physical activity (odds ratio: 1.4; P < .01) and nutrition (odds ratio: 1.6; screening did not differ P < .01). Stratified analysis by year revealed higher screening for obese (versus normal-weight) adolescents for nutrition and physical activity in 2003 and for all 3 topics in 2005. However, by 2007, screening did not differ according to BMI status. Overall screening between 2003 and 2007 declined for nutrition (75%–59%; P < .01), physical activity (74%–60%; P < .01), and emotional distress (31%–24%; P < .01). CONCLUSIONS: Obese adolescents receive more preventive screening versus their normal-weight peers. Overweight adolescents do not report more screening, but standards of care dictate increased attention for this group. These results are discouraging amid a rise in pediatric obesity and new guidelines that recommend screening by BMI status.

Body Image and Health : Eating Disorders and Obesity

Eating behavior in adolescents can be as high risk as other behaviors that arise during this period and can have serious health consequences. This article presents a framework for screening and treatment of abnormal adolescent eating behavior by the primary care provider. A review of the types of disordered eating is presented along with suggested ways to screen. Indications for subspecialty eating disorder referrals and key aspects of screening and intervention in adolescent obesity and eating disorders are also reviewed. Specific attention is paid to the aspects of care that can be provided in primary care and multidisciplinary care.

Unlocking the Potential of the Patient Portal for Adolescent Health

Electronic health records (EHRs) are now central to the provision of preventive services in the United States. Between 2003 and 2013, the adoption of EHRs by physician practices skyrocketed from 17.3 to 78.4 percent [1]. For children’s hospitals, EHR adoption increased from 21 to 59 percent between 2008 and 2011 [2]. The federal Meaningful Use (MU) program fueled much of the EHR adoption through incentives provided to institutions that meet core requirements. To date, the Centers for Medicare and Medicaid Services has paid

Public Savings from the Prevention of Unintended Pregnancy: A Cost Analysis of Family Planning Services in California

31 billion to providers and hospitals through the MU program [3]. A core component of MU requirements is the successful implementation of a patient portal: specifically, access and use by patients or proxies as measured by sending messages, downloading care summaries, and answering surveys. The purpose of these provisions is to provide open access for patients or parents to their health records. For adolescents, however, this objective is at odds both with long-standing federal and state laws that protect adolescent confidentiality and with best practices for adolescent preventive services [4,5]. Conflicts arise because most EHRs are not designed to provide granular control over parental access to records and the release of information related to adolescent health care [6,7]. Still, despite widespread concerns over the way in which vendor-based EHRs accommodate confidential care, little has changed as EHR adoption increases [8,9]. Institutions are left with a dilemma: make do with existing tools or invest in labor-intensive modifications of existing technology. To avoid the unintended release of health-related information, most institutions disable key patient portal functions for adolescent parents. This strategy excludes adolescents and their parents from the benefits of the patient portal, although adolescents are uniquely suited to leveraging technology for their health care. A few institutions have emerged as leaders in this space by taking on the onerous task of providing access to both parents and teens. This approach not only satisfies MU requirements, but it also unlocks a new avenue to reach parents and teens. The study by Thompson et al. [10] in this issue of Journal of Adolescent Health is among the first to report the large-scale implementation of a patient portal that provides access to both parents and teens while still preserving confidentiality.