Julie Metos

Improving the Prevention, Early Recognition, and Treatment of Pediatric Obesity by Primary Care Physicians

To determine if participation in a learning collaborative (LC) would improve care processes for prevention, early recognition, and treatment of childhood obesity by primary care physicians (PCP), the authors conducted pre-post evaluations of the use of obesity related care processes by 18 primary care practices following participation in a 9-month LC based on the Model for Improvement. Prior to the LC, chart audits revealed that 55% of patients had a BMI recorded; this rose to 97% of patients at its conclusion. Following the LC, 11 practices had implemented systematic prevention advice to parents of infants compared with 3 prior to the LC. All practices developed plans for evaluation and management of children with an elevated BMI. Participation in an LC increased the number of primary care practices that provided anticipatory guidance regarding obesity prevention and that identified and treated overweight or obese children.

A Multivariate Analysis of Federally Mandated School Wellness Policies on Adolescent Obesity

PURPOSE To evaluate the effects of school wellness policies mandated by the 2004 Child Nutrition and WIC Reauthorization Act on the prevalence of overweight and obesity among adolescents. METHODS Multivariate logistic regressions, adjusted for clustering within school districts, were used to estimate the effects of district-level wellness policies on the odds of overweight and obesity among adolescents. The analyses were performed on a population-based sample obtained from the Utah Population Database, a compilation of vital characteristic, administrative, and genealogical records on all residents in Utah. Models controlled for individual, maternal, and familial characteristics, as well as characteristics of school district of residence. Self-reported body mass index was taken from drivers license data. RESULTS Each additional component included in a districts wellness policy was associated with as much as: 3.2% lower odds in the prevalence of adolescent overweight (OR = .968; 95% CI = .941-.997), 2.5% lower odds of obesity (OR = .975; CI = .952-.997), and 3.4% lower odds of severe obesity (OR = .966; CI = .938-.995). Wellness policy components related to diet were significantly associated with lower body mass indexes across all three thresholds, whereas those related to physical activity had significant associations for lower odds of severe obesity only. CONCLUSION Results suggest that school wellness policies can significantly reduce the risk of adolescent obesity. Further research should address specific policy components that are most effective in various populations, as well as the level of commitment that is required at both the school- and district-levels for sustained effect.

The Associations of Plant Protein Intake With All-Cause Mortality in CKD.

BACKGROUND Plant protein intake is associated with lower production of uremic toxins and lower serum phosphorus levels. Therefore, at a given total protein intake, a higher proportion of dietary protein from plant sources might be associated with lower mortality in chronic kidney disease. STUDY DESIGN Observational study. SETTINGS & PARTICIPANTS 14,866 NHANES III participants 20 years or older without missing data for plant and animal protein intake and mortality. PREDICTORS Plant protein to total protein ratio and total plant protein intake. Patients were stratified by estimated glomerular filtration rate (eGFR)<60 or ≥60mL/min/1.73m(2). OUTCOMES All-cause mortality. MEASUREMENTS Plant and total protein intakes were estimated from 24-hour dietary recalls. Mortality was ascertained by probabilistic linkage with National Death Index records through December 31, 2000. RESULTS Mean values for plant protein intake and plant protein to total protein ratio were 24.6±13.2 (SD) g/d and 33.0% ± 14.0%, respectively. The prevalence of eGFRs<60mL/min/1.73m(2) was 4.9%. There were 2,163 deaths over an average follow-up of 8.4 years. Adjusted for demographics, smoking, alcohol use, comorbid conditions, body mass index, calorie and total protein intake, and physical inactivity, each 33% increase in plant protein to total protein ratio was not associated with mortality (HR, 0.88; 95% CI, 0.74-1.04) in the eGFR≥60mL/min/1.73m(2) subpopulation, but was associated with lower mortality risk (HR, 0.77; 95% CI, 0.61-0.96) in the eGFR<60mL/min/1.73m(2) subpopulation. In sensitivity analyses, results were similar in those with eGFR<60mL/min/1.73m(2) defined by serum cystatin C level. LIMITATIONS Whether results are related to plant protein itself or to other factors associated with more plant-based diets is difficult to establish. CONCLUSIONS A diet with a higher proportion of protein from plant sources is associated with lower mortality in those with eGFR<60mL/min/1.73m(2). Future studies are warranted to determine the causal role of plant protein intake in reducing mortality in those with eGFR<60mL/min/1.73m(2).

Breast-feeding, Leptin: Adiponectin Ratio, and Metabolic Dysfunction in Adolescents with Obesity

Objectives Increased adiposity increases leptin and decreases adiponectin concentrations, resulting in an increased leptin:adiponectin ratio (LAR). In adults, components of the metabolic syndrome and other cardiometabolic risk factors, what we classify here as “metabolic dysfunction,” are associated with both a high LAR and a history of being breast-fed. The relation among breast-feeding, LAR, and degree of metabolic dysfunction in obese youth is unknown. The purpose of our pilot study was to explore this relation and estimate the effect size of the relations to determine the sample size needed to power future prospective studies. Methods We obtained fasting levels of leptin, adiponectin, lipids, insulin, and glucose from obese youth (aged 8–17 years). Weight, height, waist circumference, blood pressure, and breast-feeding history also were assessed. Results Of 96 participants, 78 were breast-fed as infants, 54% of whom were breast-fed for >6 months. Wide variation was observed in LARs among children who were and were not breast-fed (>100% coefficient of variation). Overall, prevalence of metabolic dysfunction in the cohort was 94% and was not proven to be associated with higher LAR. Conclusions In this cohort of obese youth, we found a high prevalence of breast-feeding, metabolic dysfunction, and wide variation in the LARs. Based on the effect size estimated, future studies would need to enroll >1500 patients or identify, stratify, and selectively enroll obese patients without metabolic dysfunction to accurately determine whether breast-feeding in infancy influences LARs or metabolic dysfunction among obese youth.

Adolescent Girls' Reactions to Nutrition and Physical Activity Assessment Tools and Insight into Lifestyle Habits.

Objective: The objective of this study was to understand adolescent girls’ experiences using practical diet and physical activity measurement tools and to explore the food and physical activity settings that influence their lifestyle habits. Design: Mixed methods study using quantitative and qualitative methods. Setting: Large city in the western USA. Participants were recruited from a larger study of girls and families. Methods: A total of 10 girls aged 13–17 years completed a 3-day food diary, a Food Frequency Questionnaire and wore a Fitbit wrist bracelet to measure physical activity for 30 days. Following the data collection period, a structured focus group using a phenomenological approach was held to understand girls’ experiences with the collection tools and to understand the internal and external environments in which they make eating and physical activity decisions. Results: Participants completed an average of 8,459 steps/day. Girls had an average Healthy Eating Index score of 37 (out of 100), with diets being particularly high in added sugars and low in nutrients found in fruits and vegetables. Girls perceived the 3-day food diaries and the Fitbit as representing their lives accurately, and had negative perceptions of the Food Frequency Questionnaire. Finally, girls described influences on their lifestyle behaviours, including boredom, summer-break, part-time work, availability and cost. Conclusion: This study demonstrates the efficacy and willingness of girls to utilise food diaries and activity trackers. Results confirm poor dietary intake and physical activity in this population, and describe influences on lifestyle behaviours unique to adolescent girls.