Megan B. Ratcliff

a Pilot Randomized Controlled Trial of a Clinic and Home-Based Behavioral Intervention to Decrease Obesity in Preschoolers

We evaluated the efficacy of a 6‐month clinic and home‐based behavioral intervention (Learning about Activity and Understanding Nutrition for Child Health; LAUNCH) to reduce obesity in preschool children ≥95th BMI percentile compared to enhanced standard of care (Pediatrician Counseling; PC). LAUNCH was a family‐based behavioral intervention that taught parents to use child behavior management strategies to increase healthy eating and activity for their children and themselves. PC presented the same diet and activity recommendations, but was delivered in a one‐time PC session. Eighteen children aged 2–5 years (mean 4.71 ± 1.01) with an average BMI percentile of 98 (±1.60) and an overweight parent were randomized to LAUNCH or PC. Assessments were conducted at baseline, 6 months (end of LAUNCH treatment) and 12 months (6 months following LAUNCH treatment). LAUNCH showed a significantly greater decrease on the primary outcomes of child at month 6 (post‐treatment) BMI z (−0.59 ± 0.17), BMI percentile (−2.4 ± 1.0), and weight gain (−2.7 kg ± 1.2) than PC and this difference was maintained at follow‐up (month 12). LAUNCH parents also had a significantly greater weight loss (−5.5 kg ± 0.9) at month 6 and 12 (−8.0 kg ± 3.5) than PC parents. Based on the data from this small sample, an intensive intervention that includes child behavior management strategies to improve healthy eating and activity appears more promising in reducing preschool obesity than a low intensity intervention that is typical of treatment that could be delivered in primary care.

Risk-Taking Behaviors of Adolescents With Extreme Obesity: Normative or Not?

OBJECTIVE: Present first published data detailing high-risk behaviors of adolescent high school students (HSS) with extreme obesity (BMI ≥ 99th percentile for age and gender) compared with healthy weight peers (5th–84th percentile). METHODS: The 2007 Youth Risk Behavior Survey was used to compare HSS with extreme obesity (N = 410) and healthy weight peers (N = 8669) in their engagement in (1) tobacco use, (2) alcohol/other drug use, (3) high-risk sexual behaviors, and (4) suicidal behaviors. Logistic regression was used to calculate gender-stratified odds ratios (OR) and 95% confidence intervals (CI), controlling for age and race. RESULTS: HSS with extreme obesity were similar to healthy weight peers in the prevalence of most behaviors related to alcohol/drug use, high-risk sexual activities, and suicide, with the following exceptions: relative to healthy weight HSS, both male and female students with extreme obesity more frequently reported ever trying cigarettes (female students, adjusted OR: 2.0 [95% CI: 1.3–3.2]; male students, OR: 1.5 [CI: 1.2–2.0]). Compared with healthy weight female students, female students with extreme obesity had lower odds of ever having sex (OR: 0.5 [CI: 0.3–0.9]), but greater odds of drinking alcohol/using drugs before their last sexual encounter (OR: 4.6 [CI: 1.2–17.6]), currently smoking (OR: 2.3 [CI: 1.2–4.4]), and using smokeless tobacco (OR: 4.6 [CI: 1.2–17.2]). Compared with healthy weight male students, male students with extreme obesity had greater odds of smoking before age 13 (OR: 1.4 [CI: 1.0–2.0]). CONCLUSIONS: With few exceptions, HSS with extreme obesity engage in high-risk behaviors at rates comparable with healthy weight peers, sometimes in even more dangerous ways. Health care providers should assess risk-taking behaviors in this cohort.

Strategies for Recruitment and Retention of Families From Low-Income, Ethnic Minority Backgrounds in a Longitudinal Study of Caregiver Feeding and Child Weight

Children from low socioeconomic status (SES) and ethnic minority backgrounds are at heightened risk for overweight, yet are underrepresented in the pediatric obesity literature. This article describes strategies employed to minimize barriers to recruitment and retention of African American families receiving Women, Infants, and Children services in a longitudinal study examining caregiver feeding and child weight. Seventy-six families enrolled in the study over 3½ years, and 50% of the families completed the study. Despite effortful planning, unanticipated barriers likely contributed to lengthy recruitment and a modest retention rate. Future research should incorporate lessons learned to modify and develop effective strategies for increasing engagement of low-SES and ethnic minority families in research.

Adolescent suicidal behavior across the excess weight status spectrum.

Relative suicidal behavioral risks (ideation, attempts) for overweight, obese, and extremely obese adolescents (vs. healthy weight) and who did/did not accurately perceive themselves as overweight were examined in this study.

Adolescent bariatric surgery: caregiver and family functioning across the first postoperative year

BACKGROUND The present study examined the psychological distress, parenting stress, and family functioning in female caregivers of adolescents undergoing bariatric surgery compared to that of caregivers of adolescents with extreme obesity not undergoing surgery across the first postoperative year. METHODS The female caregivers of 16 adolescents undergoing Roux-en-Y gastric bypass (mean age 16.6 years, mean body mass index 66.2 kg/m(2); 94% recruitment) and those of 28 comparison adolescents who had sought behavioral weight management (mean age 16.2 years, mean body mass index 46.3 kg/m(2); 90% recruitment) were included in the study. The caregivers completed measures of psychological distress (Symptom Checklist-90-Revised), parenting stress (Stress Index for Parents of Adolescents), and family functioning (Family Assessment Device) at baseline (before surgery) and at 6 and 12 months after surgery. Caregiver and adolescent anthropometric data were also obtained. RESULTS At baseline, clinical cutoffs were exceeded by 29.5% of the caregivers for psychological distress, 31.8% for family dysfunction, and 13.2% for parenting stress. Linear mixed modeling indicated that bariatric adolescents had a significantly greater body mass index at baseline than the comparison adolescents (t = -7.79, P <.001), with a substantial reduction by 12 months relative to the near-flat trajectory of the comparison group (t = 20.32, P <.001). No significant group differences at baseline or group trajectory differences were identified for any caregiver or family variable. CONCLUSION Our initial findings suggest that caregivers of adolescents with extreme obesity present with limited dysfunction and that bariatric surgery has no effect on caregiver distress, parenting stress, or family functioning across the first postoperative year. Larger samples and longer term follow-up will allow examination of what role caregiver/family factors play in the adolescent postoperative outcomes.

Prospective changes in body image dissatisfaction among adolescent bariatric patients: the importance of body size estimation.

BACKGROUND Body image dissatisfaction (BID) is pervasive among patients presenting for bariatric surgery but improves significantly postoperatively. These findings have been determined primarily from studies of adults. The objective of the present study was to examine the changes in BID among adolescents with extreme obesity from baseline/preoperatively to 6 and 12 months after receiving bariatric surgery at a pediatric medical center using body size estimation. METHODS BID was prospectively assessed among 16 adolescent bariatric patients (mean age 16.3 ± 1.2 years, mean body mass index [BMI] 66.2 ± 12.0, 67% female) using a standard visual/perceptual measure (i.e., Stunkard Figure Rating Scale). Participants identified their current and ideal body size, with a discrepancy score (current minus ideal) indicating BID. The body size estimation ratings were compared with attitudinal (i.e., Impact of Weight on Quality Of Life-Kids: Body Esteem and Self-Perception Profile for Adolescents: Physical Appearance) body image scores, BMI, and total weight-related quality of life. RESULTS A significant reduction occurred in the current body size (from 7.9 to 6.4, P <.001) from baseline to 6 months but not from 6 to 12 months. The current body size was related to BMI and percentage of excess weight loss but not attitudinal body image at each follow-up point. A smaller discrepancy (current minus ideal) was associated with greater total weight-related quality of life (r = -.68), with a trend toward significance for body esteem (r = -.65) at 12 months. CONCLUSION Adolescents undergoing bariatric surgery experience a significantly decreased BID within the first 12 months after surgery, with the most substantial change occurring from baseline to 6 months. The postoperative weight-related quality of life is more closely associated with the body size discrepancy than with the current body size.

The Relationship Between Adolescent Renal Transplant Recipients’ Perceived Adversity, Coping, and Medical Adherence

The aim of the present study was to assess adolescent renal transplant recipients’ perceived adversity (PA) for various aspects of living with a transplant, including its association with coping and medication non-adherence, from a theoretical perspective. Thirty-three adolescent renal transplant recipients were interviewed using structured questionnaires and medical record reviews. Health care provider ratings of adversity were also collected. Participants reported moderate levels of PA, with those who received a transplant at an older age reporting more adversity on several domains and girls reporting more adversity for missing school. Ratings of adversity for specific aspects of living with a transplant differed depending on age and medical factors and were related to specific coping strategies and measures of non-adherence. Consistent with the Self-Regulation Model, perceived consequences (represented as PA) appears to be related to coping and illness outcomes. Assessing PA and teaching appropriate coping strategies may yield better medical outcomes among this at-risk population.

Feasibility of ecological momentary assessment to characterize adolescent postoperative diet and activity patterns after weight loss surgery

BACKGROUND Adherence to postoperative lifestyle recommendations may be associated with weight outcomes among weight loss surgery (WLS) patients, but it is difficult to objectively assess and has not been reported among adolescents. Methods of assessment that are ecologically valid and provide important contextual information related to adherence are needed. The objective of this pilot study was to demonstrate the feasibility of using a form of ecological momentary assessment (i.e., daily phone diaries; DPD) to assess postoperative diet and activity patterns among a sample of adolescent WLS patients to determine adherence to best-practice lifestyle recommendations. SETTING University Hospital. METHODS Eight adolescent WLS patients completed 3 consecutive DPDs at 12 and 18 months postsurgery. RESULTS Ninety-four percent of DPDs were completed with an average 20.9 ± 5.0 activities/day. Although adolescents engaged in recommended lifestyle behaviors (e.g.,≥ 30 min moderate physical activity/d; duration of meals/snacks ≥ 20 min) some of the time, few were adherent to postoperative physical activity and dietary recommendations the majority of the time. CONCLUSION The DPD provides a feasible and informative methodology for assessing adherence behaviors among adolescent WLS patients. It is a relatively low burden method that may be useful in identifying behavioral targets for postoperative intervention. Adherence to postoperative lifestyle recommendations may be a serious concern among this cohort. These preliminary data shed light on potential targets for postoperative intervention. Targeting nonadherence is essential in not only improving health outcomes but in deciphering the true potential effectiveness of WLS in this at-risk population.

Learning about Activity and Understanding Nutrition for Child Health (LAUNCH): Rationale, design, and implementation of a randomized clinical trial of a family-based pediatric weight management program for preschoolers

Obesity affects nearly 2 million preschool age children in the United States and is not abating. However, research on interventions for already obese preschoolers is limited. To address this significant gap in the literature, we developed an intervention targeting obesity reduction in 2 to 5year olds, Learning about Activity and Understanding Nutrition for Child Health (LAUNCH). This paper describes the rationale, design, participant enrollment, and implementation of a 3-arm randomized, parallel-group clinical trial comparing LAUNCH to a motivational-interviewing intervention (MI) and standard care (STC), respectively. Whereas LAUNCH was designed as a skills based intervention, MI focused on addressing the guardians motivation to make changes in diet and activity and providing tools to do so at the guardians level of readiness to implement changes. Child body mass index z-score was the primary outcome, assessed at pretreatment, posttreatment (Month 6), and 6 and 12month follow-ups (Months 12 and 18). Mechanisms of weight change (e.g., dietary intake, physical activity) and environmental factors associated with weight (e.g., foods available in the home, caregiver diet) were also assessed. This study is unique because it is one of the few randomized controlled trials to examine a developmentally informed, clinic and home skills based behavioral family intervention for preschoolers who are already obese. Being obese during the preschool years increases the likelihood of remaining obese as an adult and is associated with serious health conditions; if this intervention is successful, it has the potential to change the health trajectories for young children with obesity.

Psychosocial Screening Among Youth Seeking Weight Management Treatment

The objectives of this study were to identify rates of, and factors associated with, “at-risk” scores on a brief psychosocial screener among overweight/obese youth seeking weight management treatment, as well as concordance between youth and caregiver reports. A retrospective chart review of 1443 consecutive patients ages 4 to 18 years and their caregivers was conducted. Almost 1 in 4 youth with overweight/obesity presented with psychosocial symptoms in the at-risk range for significant mental health issues based on caregiver report on the Pediatric Symptom Checklist (PSC) and 1 in 6 based on youth self-report on the Youth Pediatric Symptom Checklist (Y-PSC). Concordance between caregiver and youth was fair (agreement 24% to 40%). Higher scores were associated with male sex and older age on the PSC and with indication of depressive disorder in the electronic medical record on the Y-PSC. Conducting a brief psychosocial screen in comprehensive weight management programs is feasible and clinically indicated.