Ihuoma Eneli

Maternal levels of dichlorodiphenyl-dichloroethylene (DDE) may increase weight and body mass index in adult female offspring

Objectives: To investigate the effect of prenatal exposure to polychlorinated biphenyls (PCBs) and dichlorodiphenyl-dichloroethylene (DDE) on weight, height and body mass index (BMI) in adult female offspring of the Michigan fisheater cohort examined between 1973 and 1991. Methods: 259 mothers from the Michigan fisheater cohort were studied. Prenatal exposure to PCBs and DDE was estimated by extrapolating maternal measurements to the time that the women gave birth. 213 daughters aged 20–50 years in 2000 were identified and 83% of them participated in at least one of two repeated investigations in 2001/02 (n = 151) and 2006/07 (n = 129). To assess the effect of prenatal PCB and DDE exposure on anthropometric measurements, generalised estimating equations nested for repeated measurements (2001/02 and 2006/07) and for sharing the same mother were used. We controlled for maternal height and BMI and for daughters’ age, birth weight, having been breastfed and number of pregnancies. Results: Maternal height and BMI were significant predictors of the daughters’ height, weight and BMI. Low birth weight (<2500 g) was significantly associated with reduced adult offspring weight and BMI. The weight and BMI of adult offspring were statistically significantly associated with the extrapolated prenatal DDE levels of their mothers. Controlling for confounders and compared to maternal DDE levels of <1.503 μg/l, offspring BMI was increased by 1.65 when prenatal DDE levels were 1.503–2.9 μg/l and by 2.88 if levels were >2.9 μg/l. Prenatal PCB levels showed no effect. Conclusion: Prenatal exposure to the oestrogenic endocrine-disrupting chemical DDE may contribute to the obesity epidemic in women.

Patient Engagement and Attrition in Pediatric Obesity Clinics and Programs: Results and Recommendations

Pediatric tertiary care institutions are well positioned to provide multidisciplinary, intensive interventions for pediatric obesity known as stage 3 treatment. One contributor to the difficulty in administering this treatment is the high rate of patient attrition. Little is known about the practices used by pediatric weight-management clinics and group-based programs to minimize attrition. Hospital members and nonmembers of FOCUS on a Fitter Future were surveyed on the methods used to engage and retain obese children in their clinics and programs. Shortly thereafter, a benchmarking activity that centered on rates of patient nonattendance at initial and follow-up clinic visits was initiated among FOCUS-group-participating hospitals. Clinic- and group-based program results were contrasted. Staff from group-based programs reported that the majority of patients did not complete even 50% of program follow-up visits. Multiple patient/family- and clinic/program-level barriers to retention were identified. Attention to successful techniques should be paid during planning for new programs and improvement of established ones.

Patterns of psychotropic medication use in very young children with attention-deficit hyperactivity disorder

ABSTRACT. Psychotropic medications are increasingly used for very young children. Patterns of use in a well-described group of children 3 years and younger with a diagnostic label of attention-deficit hyperactivity disorder (ADHD) reveal both reasons to use such medications and concerns about how these medications are used. Of 223 children with ADHD, more than half (n = 127) received psychotropic medications in an idiosyncratic manner, both in the specific medication and in use over time. Almost half of the children who were medicated did not have opportunities for monitoring as often as every 3 months, despite the fact that more than half received psychotropic medications for 6 months or longer. Children with comorbid mental health conditions and chronic health conditions were at greater risk for receiving psychotropic medications. These patterns of use demonstrate a compelling need for guidance in psychopharmacological treatment of very young children.

The trust model: a different feeding paradigm for managing childhood obesity.

or carbohydrate counting, eliminating certain foods, or overreliance on low-fat or low-calorie food options. No type of food is restricted; the trust model posits that dietary restriction creates feelings of deprivation, which lead children to crave and overindulge in the restricted food when an opportunity arises. Pressuring children to eat also is strictly discouraged because it can disconnect children from their hunger, satiety, and appetite cues. Specifically, caregivers are responsible for selecting foods to present at meals and snacks, the timing for meals and snacks, choosing the place to eat, sitting and eating with children, and keeping the atmosphere pleasant. Children are responsible for what to eat and how much (or even whether) to eat from the food provided. Food selection is emphasized only within the scope of creating meals and snacks of increasing variety and balance within the context of the family’s abilities and preferences. Caregivers are taught to plan and serve a balanced meal with protein, carbohydrates, fruits and/or vegetables, dairy/calcium, and fat. The trust model is implemented within an environmental context of recognizing children’s physical and emotional stages of development, children’s natural growth patterns, food choices and availability, the medical and psychosocial characteristics of the caregiver and the child, and shared responsibility for physical activity (Figure 1). Satter (5) stresses that caregivers not misinterpret children’s natural growth pattern as a manifestation of a feeding problem per se, as children will be of different sizes and shapes due to their genetic constitution. Four behaviors interfere with caregivers’ ability to guide (nurture and preserve) the development of children’s trust in their internal hunger, appetite, and satiety cues: misinterpretation of normal weight, restriction of food intake, pressures to eat when children refuse food, and using food as a calming agent (5). Satter contends that some caregivers overcontrol children’s intake because of underlying conscious or subconscious anxieties about weight, body image, appearance, nutritional quality of the diet, specific food group or nutrient consumption, or inconsistent food supply. Others undersupport children’s feeding by not providing regular feeding opportunities or appropriate modeling for eating, which leads to a chaotic food environment. Satter believes overcontrol and undersupport are the core of nonorganic child weight and growth problems and must be addressed in order to treat or prevent these problems (5). The difference between the trust model and traditional dietary methods is not external vs. internal control, but rather caregivers taking leadership by structuring feeding opportunities and giving their children autonomy within that structure (Table 1). In the trust model, the caregiver takes responsibility for the feeding environment, yet honors children’s self-regulatory processes, thus building trust. It postulates that children who are not permitted to control their food intake learn self-doubt, ambivalence, and dependency with regard to eating and regulating their food intake. Children who are trusted to regulate how much to eat develop positive self-esteem, learn responsibility and selfcare skills, appreciate their bodies, and do not become preoccupied with food (6). A common assumption is that small portion sizes, fat restriction, and calorie awareness are necessary in controlling weight gain for overweight children and will lead to weight loss if these behaviors are pursued rigorously. However, dietary restriction has been shown to backfire, as it is associated with preoccupation with food, eating in the absence of hunger, poorer self-esteem, and further weight gain (1–4). The efficacy of current dietary treatments, particularly for long-term weight maintenance, is doubtful. Most of these interventions rely on dietary restriction as their primary strategy. Hence, there is a compelling need to investigate pediatric obesity intervention paradigms without a core focus on dietary restriction. One such paradigm is the trust model proposed by Satter, a dietitian and social worker with experience in child– caregiver feeding dynamics (5). This paper will review the model constructs and examine its applicability as a dietary intervention for preventing and managing childhood obesity. The trust model emphasizes the division of feeding responsibility between caregivers and children and trust in the child’s ability to self-regulate food intake by recognizing hunger, appetite, and satiety cues within the context of regular eating patterns (i.e., pleasant and structured meals and snacks) (Figure 1). The model deemphasizes portion sizes, the food pyramid, calorie the trust Model: A Different Feeding Paradigm for Managing Childhood obesity

An Integrated Framework For The Prevention And Treatment Of Obesity And Its Related Chronic Diseases

Improved patient experience, population health, and reduced cost of care for patients with obesity and other chronic diseases will not be achieved by clinical interventions alone. We offer here a new iteration of the Chronic Care Model that integrates clinical and community systems to address chronic diseases. Obesity contributes substantially to cardiovascular disease, type 2 diabetes mellitus, and cancer. Dietary and physical activity interventions will prevent, mitigate, and treat obesity and its related diseases. Challenges with the implementation of this model include provider training, the need to provide incentives for health systems to move beyond clinical care to link with community systems, and addressing the multiple elements necessary for integration within clinical care and with social systems. The Affordable Care Act, with its emphasis on prevention and new systems for care delivery, provides support for innovative strategies such as those proposed here.

Parent Perspectives on Attrition From Tertiary Care Pediatric Weight Management Programs

Objective. To describe parent/caregiver reasons for attrition from tertiary care weight management clinics/programs. Study design. A telephone survey was administered to 147 parents from weight management clinics/programs in the National Association of Children’s Hospitals and Related Institutions’ (now Children’s Hospital Association’s) FOCUS on a Fitter Future II collaborative. Results. Scheduling, barriers to recommendation implementation, and transportation issues were endorsed by more than half of parents as having a moderate to high influence on their decision not to return. Family motivation and mismatched expectations between families and clinic/program staff were mentioned as influential by more than one-third. Only mismatched expectations correlated with patient demographics and referral patterns. Conclusions. Although limited by small sample size, the study found that parents who left geographically diverse weight management clinics/programs reported similar reasons for attrition. Future efforts should include offering alternative visit times, more treatment options, and financial and transportation assistance and exploring family expectations.

Parental Preferences on Addressing Weight-Related Issues in Children

Little is known about parental preferences on how providers should approach or manage weight-related concerns. A cross-sectional survey was conducted of 292 parents in a pediatric primary care faculty group practice. Of the 292 respondents, 90% were women, 45% had a child on Medicaid, and 53% had a body mass index of 25 or more. Only 12.1% of parents reported they had an overweight child. The term “gaining too much weight” was preferred 2:1 to “overweight” (51.1% versus 25.9%, P < .001). Most respondents (62.3%) thought the physicians office was the best place to manage an overweight child. Parents who reported they had an overweight child were more likely to prefer individual than group sessions compared with those without an overweight child (odds ratio, 2.1; 95% confidence interval, 1.2-3.7). Further research is needed to investigate the reasons underlying these preferences and how they positively or negatively impact program satisfaction, attrition rates, and behavior change outcomes.

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 Childrens 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.

An Evaluation of Mother-Centered Anticipatory Guidance to Reduce Obesogenic Infant Feeding Behaviors

OBJECTIVE: To evaluate the effect of 2 anticipatory guidance styles (maternal focused [MOMS] and infant focused [Ounce of Prevention]) directed at mothers of infants aged newborn to 6 months on their infant feeding behaviors at 1 year compared with routine advice as outlined in Bright Futures (BF). METHODS: This is a cluster randomized trial. A total of 292 mother/infant dyads were enrolled at their first well-child visit to 3 urban pediatric clinics in Columbus, Ohio. Intervention-specific brief advice and 1-page handouts were given at each well visit. In addition to infant weights and lengths, surveys about eating habits and infant feeding practices were completed at baseline and 12 months. RESULTS: Baseline data revealed a group with high rates of maternal overweight (62%) and obesogenic habits. At 12 months, the maternal-focused group gave their infants less juice (8.97 oz vs 14.37 oz, P < .05), and more daily servings of fruit (1.40 vs 0.94, P < .05) and vegetables (1.41 vs 1.03, P < .05) compared with BF mothers. Ounce of Prevention mothers also gave less juice (9.3 oz, P < .05) and more fruit servings (1.26 P < .05) than BF. CONCLUSIONS: Brief specific interventions added to well-child care may affect obesogenic infant feeding behaviors of mothers and deserves further study as an inexpensive approach to preventing childhood obesity.

Severe childhood obesity: an under-recognised and growing health problem

Childhood obesity is a serious and urgent public health problem. In the last 10 years, there has been a concerted effort in the USA and globally to develop and implement educational, medical and public health interventions designed to attenuate its growth. The success of these efforts was probably responsible for the plateau in the prevalence rate of childhood obesity noted in the last two years. While the attenuation of the overall prevalence of childhood obesity is promising, data from the same cohort reveal a concerning upward trend in the number of children with severe obesity. The consequences of severe childhood obesity can be devastating. When compared to their moderately obese peers, children with severe obesity are at greater risk for adult obesity, early atherosclerosis, hypertension, type 2 diabetes, metabolic syndrome, fatty liver disease and premature death. The determinants for severe obesity include the same lifestyle, environmental, familial and societal risk factors reported for overweight or obesity. While all these risk factors must be screened for, genetic influences are distinct considerations that may have greater bearing especially with early-onset obesity. Treatments for severe childhood obesity include lifestyle intervention, specialised low-calorie diets and bariatric surgery. Outcomes of these treatments vary, with bariatric surgery clearly the most successful of the three for both short-term and long-term weight loss. Severe obesity in children and adolescents remains a challenging health condition. The enormous medical, emotional and financial burden these children and their families endure signals an urgent need to further investigate and standardise treatment modalities and improve outcomes.