Kristine A. Madsen

Underdiagnosis of pediatric obesity during outpatient preventive care visits.

OBJECTIVEnTo examine obesity diagnosis, obesity-related counseling, and laboratory testing rates among obese pediatric patients seen in US preventive outpatient visits and to determine patient, provider, and practice-level factors that are associated with obesity diagnosis.nnnMETHODSnBy using 2005-2007 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data, outpatient preventive visits made by obese (body mass index ≥95%) 2- to 18-year-old patients were examined forxa0frequencies of obesity diagnosis, diet, exercise, or weight reduction counseling, and glucose or cholesterol testing. Multivariable logistic regression was used to examine whether patient-level (gender, age, race/ethnicity, insurance type) and provider/practice-level (geographic region, provider specialty, and practice setting) factors were associated with physician obesity diagnosis.nnnRESULTSnPhysicians documented an obesity diagnosis in 18%xa0(95% confidence interval, 13-23) of visits made by 2- to 18-year-old patients with a body mass index ≥95%. Documentation of an obesity diagnosis was more likely for non-white patients (odds ratio 2.87; 95% confidence interval, 1.3-6.3). Physicians were more likely to provide obesity-related counseling (51% of visits) than to conduct laboratory testing (10% of visits) for obese pediatric patients.nnnCONCLUSIONnRates of documented obesity diagnosis, obesity-related counseling, and laboratory testing for comorbid conditions among obese pediatric patients seen in US outpatient preventive visits are suboptimal. Efforts should target enhanced obesity diagnosis as a first step toward improving pediatric obesity management.

Parent modeling: perceptions of parents' physical activity predict girls' activity throughout adolescence.

OBJECTIVESnTo determine whether parent modeling of physical activity (PA) has a differential impact on girls PA by race, whether the association declines with time, and to assess the contribution of parent modeling to girls activity relative to other potential predictors.nnnSTUDY DESIGNnLongitudinal examination of parent modelings impact on future log transformed metabolic equivalents (log METs) of leisure-time PA in 1213 African-American and 1166 Caucasian girls in the National Heart, Lung, and Blood Institute Growth and Health Study, from age 9 to 10 years through 18 to 19 years, using linear regression. Race interaction terms and time trends were examined.nnnRESULTSnGirls perceptions of parent modeling significantly predicted future log METs in each study year; associations remained stable with time and were similar by race. Girls perception of parent PA better predicted girl log METs than did parent self-report. On average, girls reporting that their parents exercised > or =3x/week were about 50% more active than girls with sedentary parents.nnnCONCLUSIONSnGirls perception of parent activity predicts PA for girls throughout adolescence, despite age-associated decreases in PA. We did not find differences in this association by race. Interventions designed to increase parental activity may improve parent health, positively influence daughters activity, and begin to address disparities in cardiovascular health.

Validation of a hip-worn accelerometer in measuring sleep time in children

This study compared measures of sleep from an accelerometer worn on the hip to measures obtained from an accelerometer worn on the wrist, the gold standard measure of sleep behavior in community research. The accelerometer worn on the hip provides a measure of total sleep time in 10- to 11-year-old children comparable to the wrist-worn unit. We provide an alternate method to ascertain bedtime and final wake time when diary data are missing. A hip-worn accelerometer may provide a cost-effective means of gathering physical activity and sleep data simultaneously in large samples of children with or without an accompanying sleep diary.

Would Students Prefer to Eat Healthier Foods at School

BACKGROUNDnThis study sought to elucidate students perceptions of school food environments and to assess correlations between perceptions and purchasing and consumption behaviors at school.nnnMETHODSnSeventh and ninth graders (n = 5365) at 19 schools in multiethnic, low-income California communities participating in the Healthy Eating Active Communities program completed questionnaires assessing their attitudes and behaviors regarding school food environments during spring 2006.nnnRESULTSnMost students (69%) reported that fresh fruit was important to be able to buy at school; more than chips (21%), candy (28%), or soda (31%). Reported importance of food offerings was correlated with the consumption of those items. Most students did not perceive foods/beverages offered at school to be healthy; fewer than a quarter reported eating fruits or vegetables (FV) at school. Students eating school lunch were more than twice as likely to consume FV, though if they also purchased from competitive venues, their consumption of candy, chips, and soda was similar to their peers who purchased only competitive foods.nnnCONCLUSIONnStudents report healthy foods to be important to be able to buy at school, but do not perceive their school food environment to be healthy and consume more unhealthy foods at school. Students served healthy items via school lunch are more likely to consume them; however, they also purchase and consume unhealthy items if available. Findings suggest that modifying school food environments to facilitate consumption of healthy foods and limit unhealthy foods will better match students preferences and could lead to improved dietary intake.

Use of SPARK to promote after-school physical activity.

BACKGROUNDnThe after-school period is potentially an important venue for increasing physical activity for youth. We sought to assess the effectiveness of the Sports, Play, and Recreation for Youth (SPARK) program to increase physical activity and improve cardiorespiratory fitness and weight status among elementary students after school.nnnMETHODSnThis quasi-experimental controlled study compared change in moderate to vigorous physical activity (MVPA), body mass index (BMI) z-score, and cardiorespiratory fitness (VO(2) ) over 5 months between students in after-school programs exposed to SPARK versus controls. Participants were fifth grade students at 3 intervention schools (N = 48) and 3 control schools (N = 52).nnnRESULTSnThere was no difference between groups in mean change in MVPA, BMI z-score, or cardiorespiratory fitness. After-school time dedicated to physical activity did not increase with the implementation of SPARK. Intervention students self-assessment of their activity levels relative to their peers significantly increased compared to control students (p = .011).nnnCONCLUSIONSnIn this 5-month study, the SPARK program did not increase MVPA in the after-school setting. Increasing the amount of time dedicated to physical activity may be as important as the curriculum used to effectively increase physical activity after school.

Physical activity and positive youth development: impact of a school-based program.

BACKGROUNDnProtective factors associated with positive youth development predict health and education outcomes. This study explored trends in these protective factors and in physical activity among low-income students, and determined the impact of a school-based youth development program on these trends.nnnMETHODSnThis study used a quasi-experimental time series design including data from 158 low-income schools from 2001 to 2007. Ninety-four schools had exposure to a school-based program promoting physical activity and youth development through structured play; 64 schools served as controls. Primary outcomes were 5th-grade student scores (n = 13,109) on a California statewide survey for physical activity (1-6 scale) and measures of protective factors including problem solving skills, meaningful participation in school, and caring adults (1-4 scales). Predictors were time (year) and schools number of years of exposure to the program.nnnRESULTSnOverall, significant annual declines were seen in protective factors, including students report of feeling safe (-0.03, 95% CI [-0.03, -0.01]), caring adults at school (-0.03 [-0.05, -0.02]), and problem solving skills (-0.03 [-0.04, -0.02]). Cumulative declines over 6 years were equivalent to a drop of 1 school-level SD. Each additional year of exposure to the program predicted greater meaningful participation (0.02 [0.001, 0.5]), problem-solving skills (0.03 [0.0001, 0.06]), and increased physical activity (0.06 [0.01, 0.10]); exposure throughout elementary school (6 years) increased scores by 1 school-level SD.nnnCONCLUSIONSnLow-income students reported a significant decline in protective factors since 2001. School partnerships with youth development programs promoting physical activity may ameliorate declines in emotional well-being and increase physical activity.

After-school program to reduce obesity in minority children: a pilot study

This study explored a community-based after-school program’s effect on obesity in minority children. Study participants included 178 third through fifth graders (47% Latino, 25% Asian, and 18% African-American) enrolled in America SCORES Bay Area. Outcomes were attendance, change in fitness (20-meter shuttle test), and body mass index (BMI) z-score over eight months. At baseline, 52 percent of children were overweight or obese. Children attended SCORES > 4 days/week and fitness significantly improved (p < 0.01). BMI z-score decreased by 0.04 (p = 0.10) overall, and by 0.05 (p = 0.08) among obese children, but increased among African-American children. These results suggest that SCORES increases fitness and may improve BMI in some minority children. Effect modification by race may relate to differential growth patterns or engagement in SCORES. These findings suggest community-based programs could effectively address obesity. A randomized trial of the SCORES program is warranted to rigorously examine this type of after-school program’s impact on child health.

The role of parental preferences in the management of fever without source among 3- to 36-month-old children: A decision analysis

OBJECTIVES. Recent analyses assessing the impact of the conjugate pneumococcal vaccine on the care of febrile children do not reflect the role parental preferences play in physicians decisions. The objective of this study was to identify the management strategy that would best suit parents, on the basis of their values for possible outcomes of fever of ≥39°C without source among well-appearing, 3- to 36-month-old children. METHODS. A decision analysis was performed to compare the benefits and outcomes of 3 management options (treat: blood culture and antibiotics for all children; test: blood culture and complete blood count for all children, with antibiotics for selected children; observe: no immediate intervention). A hypothetical cohort of 100000 children with fever of ≥39°C with no obvious source of infection was modeled for each strategy. Using this model, we identified the treatment option that would best suit each parents preferences, on the basis of parental utilities (from a prior study) for various interventions and outcomes at vaccine efficacies of 0% (ie, no vaccine) and 95%. In addition, we performed survival analyses to assess the morbidity and mortality rates associated with each treatment strategy at various vaccine efficacies. RESULTS. At a vaccine efficacy of 0%, the majority of parents preferences suggested the treat option, the strategy with the lowest mortality rate. At a vaccine efficacy of 95%, mortality rates were similar for all 3 management options (∼1 in 100000), but parental preferences were still aligned with different options; 50% suggested observe, 42% suggested test, and 8% suggested treat. CONCLUSIONS. Like physicians, parents have different approaches to risk. With the conjugate pneumococcal vaccine, risks of complications from fever without source are low regardless of treatment strategy. Rather than having a “one size fits all” approach, it is reasonable to incorporate parental preferences into the treatment decision.

A Clinic-Based Lifestyle Intervention for Pediatric Obesity: Efficacy and Behavioral and Biochemical Predictors of Response

AIMnTo examine efficacy and predictors of response to a lifestyle intervention for obese youth.nnnMETHODSnRetrospective chart review of 214 children and adolescents aged 8-19 years. Linear regression identified baseline predictors of response (delta BMI z-score) at first and ultimate follow-up visits.nnnRESULTSnMean delta BMI z-score from baseline was -0.04 (p < 0.001) at first follow-up and -0.09 (p < 0.001) at ultimate follow-up (median time 10 mo) among 156 children and adolescents. Higher baseline BMI z-score predicted poor response at first and ultimate follow-up, explaining 10% of variance in response. Fasting insulin explained 6% of response variance at first follow-up. delta BMI z-score at the first visit along with baseline BMI z-score explained up to 50% of variance in response at ultimate visit.nnnCONCLUSIONnClinic-based interventions improve weight status. Baseline variables predict only a small proportion of response; response at the first visit is a more meaningful tool to guide clinical decisions.

School‐Based BMI and Body Composition Screening and Parent Notification in California: Methods and Messages

BACKGROUNDnSchool-based body mass index (BMI) or body composition screening is increasing, but little is known about the process of parent notification. Since 2001, California has required annual screening of body composition via the FITNESSGRAM, with optional notification. This study sought to identify the prevalence of parental notification when screening is required but notification is optional, and the methods and messages used.nnnMETHODSnResearchers conducted phone interviews with 851 school districts (89%) in California and reviewed notification materials from 54 districts.nnnRESULTSnAs of 2008, 53% of California districts notified parents of screening results. Many districts (24%) did not know the reason for their notification policy. Most districts notified parents via a letter mailed home (70%) or sent home with the child (18%). Whereas 79% of sample letters provided students BMI, only 12% provided an explanation of BMI, and only half provided tips on what parents should do if concerned about their childs results.nnnCONCLUSIONSnIn California, where body composition screening is required but parent notification is not, approximately half of school districts elect to notify parents of results, most commonly via letter. Most letters do not explain BMI or percent body fat scores, nor do they suggest what parents should do for a child identified as at-risk. Further research to identify interpretable and actionable notification messages for parents will be critical if school-based BMI and body composition screening and notification is to reduce childhood obesity.