Daniel Hardoff

Indirect calorimetry in the nutritional management of eating disorders

The caloric prescription, a key component of the nutritional therapy of anorexia nervosa (AN) and bulimia nervosa (BN), may be empirically prescribed, or based on predicted resting energy expenditure (REE), yet adaptive changes in the metabolic rate may render both methods unreliable. Indirect calorimetry measurement of fasting REE was obtained in 32 patients with AN (n = 21) or BN (n = 11). Predicted REE was calculated according to the Harris-Benedict equation, and empiric caloric prescriptions were made by experienced physicians. In the AN group, mean measured REE was significantly lower than predicted REE (p = .00). The empiric caloric prescription was, as intended, significantly higher than the measured REE, but the two methods correlated significantly (r = .53, p < .05). The predicted REE overestimated caloric needs but was also highly correlated with measured REE (r = .69, p < .001). By regression analysis, measured REE could be calculated from predicted REE as follows: measured REE (Kcal/day) = (1.84 x Harris-Benedict predicted REE) - 1,435. In the BN group, mean measured REE was not significantly different from the empiric caloric prescription (p = .09) but was significantly lower than the Harris-Benedict predicted REE (p = .022). Neither correlated with measured REE in BN. Therefore, in BN indirect calorimetry is the only reliable method for determining caloric needs. In AN indirect calorimetry remains the preferred method, but when not available, we recommend the above equation to determine resting energy requirements.

Medical complications in male adolescents with anorexia nervosa

PURPOSE Medical information on male anorectics is scant. We present data on 10 males with anorexia nervosa, who were treated at our Eating Disorders Center during a twelve-year period. METHODS Retrospective chart review. RESULTS All patients were malnourished weighing 80% or less of their ideal body weight with a mean B.M.I. of 13.5 +/- 2.0. Height below the 50th percentile was evident in 80% of the patients, and was below the 10th percentile in 30% of the patients. Structural brain changes on brain computerized tomography scans were noted in seven out of nine patients and more than 50% had mild anemia relative to the Tanner stage. Other findings included a mean presenting heart rate of 68.3 +/- 17: four out of ten patients had presenting heart rates of 80 or greater and of these, three had serious medical problems and were severely malnourished. Two patients had cardiac complications and one had a life-threatening electrolyte disturbance. CONCLUSION Despite the small number of patients, the proportion of male adolescent anorectics with medical abnormalities seems high, and may be due to difficulties in establishing the diagnosis and delay in seeking medical attention. Patients who had heart rates of 80 or greater were perhaps sicker and further along in their development of congestive heart failure, thus explaining their initial relative tachycardia. We suggest a higher index of suspicion for congestive heart failure and closer medical monitoring when a malnourished adolescent with anorexia nervosa presents with relatively elevated heart rates.

Attitudes and practices of Israeli physicians toward adolescent health care: A national survey

PURPOSE To assess practices and attitudes of Israeli physicians with regard to adolescent health. METHODS Questionnaires were sent to a sample of 1050 Israeli physicians specializing in pediatrics (P) family practice (FP), and internal medicine (IM). They were requested to report their experience, perceived skills, and desire for further training regarding 16 adolescent health items grouped under four topics: medical, sexuality, risk behavior, and psychosocial problems. A scoring system was applied to assess their report. Attitudes toward confidentiality in the same topics were also surveyed. RESULTS Questionnaires were received from 306 (29%) physicians, of whom 42% were P, 35% were FP, and 29% were IM. The majority (96%) of respondents included adolescents in their practice, and adolescents comprised 33%, 17%, and 11% of the registered patient population of the P, FP, and IM, respectively. The mean scores for practice, perceived skills, and desire for further training were generally low. Analysis of variance revealed significant differences among the three physicians groups in all surveyed topics, resulting from the low scores of the IM group. A diversity regarding confidentiality was noted, in that younger FP were most willing to keep health issues confidential. CONCLUSIONS Physicians in Israel have limited experience and perceive themselves to be underskilled in dealing with adolescent health issues. Training programs in adolescent health need to be developed to meet the needs of physicians in Israel.

Self-assessment of pubertal maturation in socially disadvantaged learning-disabled adolescents

Reasonable concordance has been demonstrated between physicians assessment of pubertal maturation and self-assessment by healthy adolescents studying in the mainstream educational system. The purpose of this study was to determine whether pubertal maturation self-assessment may be used as a reliable screening instrument in learning-disabled adolescents. Self-assessment of sexual maturation, was investigated in 80 7th- and 8th-grade Israeli students studying in a residential school for socially disadvantaged learning-disabled adolescents of normal intelligence (LD group), and in 63 Israeli students of the same age group attending a mainstream urban school (C group). All 143 students were examined by one investigator for their annual physicals, and clinical assessment of Tanner stage was then performed. Following the examination students were asked to identify their present pubic hair maturation stage according to Tanner plates. Of the LD group, 58% assessed their pubertal stage in agreement with the investigators assessment as did 70% of the C group. Underestimation of pubertal stage was more common in students more advanced in their pubertal development, and overestimation was more common among students who were less advanced in their maturation. Within approximation of one Tanner stage difference between the examiner and student assessments, concordance rate reached 95% in both groups. Self-assessment of pubertal development in school settings may be used as a reliable screening instrument in learning-disabled adolescents with normal intelligence, when an approximation of one developmental stage is accepted.

Altered lipid profiles in passive smoking urban adolescents as indicated by urinary cotinine.

Atherosclerotic vascular changes begin in early childhood and accelerate dining adolescence. Risk factors for the development of cardiovascular disease include hyperlipidemia and smoking. Cigarette smoking is associated with elevation of plasma lipids, including an elevated ratio of total cholesterol to high density cholesterol /1,2/. Exposure to cigarette smoke has been investigated, using various indicators including measurement of alveolar carbon monoxide, salivary thiocyanate, and salivary, urine and serum cotinine 131. Cotinine is a metabolite of nicotine which has a relatively long half life of 17 hours. Urinary cotinine measurements have been suggested to detect passive exposure to cigarette smoke /3,5/. The emphasis has been put on exposure of infants and young children 16,11, with special reference to respiratory illnesses /8/. Recently, passive smoking has been shown to be associated with altered lipid profiles in a suburban adolescent population, where cotinine was measured in serum samples, indicating an increased risk for atherosclerosis 191. Forty two percent of urban adolescents have been shown to have multiple risk factors for cardiovascular disease /10/. We describe here an association between altered lipid profiles and passive exposure to cigarette smoke in urban high school students, using urinary cotinine as an indicator for passive smoking.

Adolescent health care education and training: insights from Israel.

Abstract There is a growing need for health care professionals to extend their knowledge in adolescent health care. Formal training curricula in adolescent medicine have been established in the United States, Canada, and Australia, yet many other countries have developed shorter training programs to enable interested physicians to further pursue knowledge and practical experience in delivering improved quality health care for adolescents. The Israeli experience in building an infrastructure that allows students and physicians to learn about adolescent medicine and to train in the field is described. It includes a series of lectures and seminars for medical students during medical school and at the clinical rotations in pediatric wards; the development of hospital-based and community-based multidisciplinary adolescent health services where residents can practice adolescent health care; a 3-year diploma course in adolescent medicine for specialists in pediatrics and family medicine; mini courses in adolescent medicine for pediatricians and family practitioners working in community settings; and a simulated patient-based program regarding communication with adolescents, aimed for all professional levels – medical students, residents, and specialists. This infrastructure has been developed to create a leading group of physicians, who are able to operate adolescent clinics and to teach adolescent medicine. Recently, a formal fellowship program in adolescent medicine has been approved by the Scientific Council of the Israel Medical Association. The Israeli experience described here could be applied in countries, where formal training programs in adolescent health care are not yet established.

Adolescent medicine with a 100 year perspective.

Adolescent medicine was born out of scientific advances from a wide variety of disciplines, changes in societal mores and the explosion of technology that occurred during the 20th century. The past 100 years of clinical practice and research have provided a wealth of information that has improved our understanding of the biologic and physical development of adolescents as well as the epidemiology of high-risk adolescent behaviors. The present challenge for all providers of health care to adolescents is to continue to examine the effect of these high-risk behaviors and develop mechanisms to address and limit the impact of these behaviors, just as the scientists and practitioners of the 20th century made great strides in treatment and cure of medical illnesses. With a broad base of scientific knowledge, formalization into an academic field and strong government and organizational support adolescent medicine are energized by these factors and can only envision continued growth in this important field of medicine.

Tribute to a giant: Emanuel Chigier, MD, 1928–2017

1 Adolescent medicine coordinator, Israel Medical Simulation Center, Sheba medical Center, Tel Hashomer, Ramat Gan, Israel, E-mail: drhardoff@gmail.com 2 National Institute of Child Health and Human Development, Jerusalem, Israel 3 Health Services, Division for Intellectual and Developmental Disabilities, Ministry of Social Affairs and Social Services, Jerusalem, Israel 4 Department of Pediatrics, Mt Scopus Campus, Hadassah Hebrew University Medical Center, Jerusalem, Israel 5 Kentucky Children’s Hospital, University of Kentucky, Lexington, KY, USA 6 Center for Healthy Development, School of Public Health, Georgia State University, Atlanta, GA, USA