Stephen J. Pont

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.

Social Influences on Self-Reported Physical Activity in Overweight Latino Children

Psychosocial variables influence physical activity for different age groups, sex, and ethnic groups. However, little is known about their influence on physical activity in preadolescent Latino children. The authors examined how a) confidence in ones ability to be physically active (self-efficacy); b) ideas about the consequences of being physically active (beliefs), and c) the influences of family and friends on physical activity (social influences) effect physical activity levels in overweight (body mass index ≥85%) Latino preadolescent children. One hundred and fourteen preadolescents participated in a larger intervention designed to improve healthy lifestyles for Latino families. The authors report baseline data collected at a community-based primary care clinic. Multivariate regression analyses showed that only social influences significantly predicted (P < .01) the metabolic equivalent adjusted self-reported baseline physical activity. Prevention and intervention strategies that augment social influences on physical activity are likely to result in more physical activity and improved health in these children.

Incorporating primary and secondary prevention approaches to address childhood obesity prevention and treatment in a low-income, ethnically diverse population: study design and demographic data from the Texas Childhood Obesity Research Demonstration (TX CORD) study.

BACKGROUND There is consensus that development and evaluation of a systems-oriented approach for child obesity prevention and treatment that includes both primary and secondary prevention efforts is needed. This article describes the study design and baseline data from the Texas Childhood Obesity Research Demonstration (TX CORD) project, which addresses child obesity among low-income, ethnically diverse overweight and obese children, ages 2-12 years; a two-tiered systems-oriented approach is hypothesized to reduce BMI z-scores, compared to primary prevention alone. METHODS Our study aims are to: (1) implement and evaluate a primary obesity prevention program; (2) implement and evaluate efficacy of a 12-month family-centered secondary obesity prevention program embedded within primary prevention; and (3) quantify the incremental cost-effectiveness of the secondary prevention program. Baseline demographic and behavioral data for the primary prevention community areas are presented. RESULTS Baseline data from preschool centers, elementary schools, and clinics indicate that most demographic variables are similar between intervention and comparison communities. Most families are low income (≤

Stool Cultures and Antimicrobial Prescriptions Related to Infectious Diarrhea

25,000) and Hispanic/Latino (73.3-83.8%). The majority of parents were born outside of the United States. Child obesity rates exceed national values, ranging from 19.0% in preschool to 35.2% in fifth-grade children. Most parents report that their children consume sugary beverages, have a television in the bedroom, and do not consume adequate amounts of fruits and vegetables. CONCLUSIONS Interventions to address childhood obesity are warranted in low-income, ethnically diverse communities. Integrating primary and secondary approaches is anticipated to provide sufficient exposure that will lead to significant decreases in childhood obesity.

National rates of diarrhea-associated ambulatory visits in children.

Stool cultures can be important in guiding antimicrobial therapy for diarrhea. From among 11.64 million person-years of Tennessee Medicaid enrollment data collected from 1995 through 2004, 315,828 diarrheal episodes were identified. Stool cultures were performed for only 15,820 episodes (5.0%). Antimicrobials were prescribed for 32,949 episodes (10.4%), 89.4% of which were not accompanied by a stool culture. White race and urban residence were associated with higher rates of stool culture. Frequent use of antimicrobials for diarrhea without stool culture may indicate inappropriate antimicrobial use and has critical implications for public health.

Trends in healthcare usage attributable to diarrhea, 1995-2004.

OBJECTIVE To estimate national rates of ambulatory healthcare visits due to diarrhea- and rotavirus-associated illness before the introduction of rotavirus vaccine. STUDY DESIGN Annual rates for diarrhea-associated visits in children age < 5 years were calculated for 1995-2004 using National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, and US Census Bureau data. Rates by age, race, and time period were compared using Poisson regression. RESULTS Annual rates of outpatient and emergency department (ED) visits for 1995-2004 were 955 (95% confidence interval [CI] = 803 to 1107) and 314 (95% CI = 278 to 350)/10,000 person-years, respectively. Annual outpatient (P = .470) and ED (P = .734) visit rates remained stable from 1995 to 2004. Outpatient visits were less frequent in African Americans than Caucasians (716/10,000 person-years vs 1012/10,000 person-years; P < .05; incidence rate ratio [IRR] = 0.71; 95% CI = 0.51 to 0.99), whereas ED visits were more frequent in African Americans than Caucasians (520/10,000 person-years vs 286/10,000 person-years; P < .05; IRR = 1.83; 95% CI = 1.58 to 2.11). Approximately 29% of outpatient diarrhea-associated outpatient visits (273/10,000 person-years; 95% CI = 145 to 401) and 25% of diarrhea-associated ED visits (78/10,000 person-years; 95% CI = 64 to 83) were due to rotavirus. CONCLUSIONS Diarrhea- and rotavirus-associated illness is associated with significant healthcare utilization. Future studies are needed to investigate factors causing differences in healthcare use by race and to explore the impact of the rotavirus vaccine.

Mapping Data Shape Community Responses To Childhood Obesity

OBJECTIVE To determine current diarrhea-associated healthcare usage rates and associated sociodemographic factors. These data can be used to determine the impact of the rotavirus vaccine. STUDY DESIGN Using discharge diagnosis codes, we determined diarrhea-associated visit rates for children aged 0 to 18 years enrolled in Tennessee Medicaid, 1995-2004. Poisson regression compared data across time and within strata. The winter residual excess method estimated the rotavirus burden. RESULTS Analyzing approximately 500 000 person-years annually, outpatient and hospitalization rates remained stable from 1995 to 2004; emergency department (ED) rates approximately doubled, incidence rate ratio (IRR): 1.92 (1.81-2.04). White children used healthcare at greater rates than black children: outpatient IRR 1.90: (1.85-1.95), ED IRR: 1.69 (1.64-1.74), and inpatient IRR: 1.82 (1.73-1.92); and rural children greater than urban: outpatient IRR 1.66 (1.62-1.70), ED IRR 1.14 (1.11-1.17), inpatient IRR 1.88 (1.80-1.97). Children aged 0 to 35 months experienced 1627 outpatient and 792 ED visits, and 148 hospitalizations per 10 000 child-years; rotavirus may have affected up to 40% of these hospitalizations. CONCLUSIONS Diarrhea-associated ED visit rates nearly doubled from 1995 to 2004. Future studies could explore factors resulting in increased healthcare usage by white children and those living in rural areas and document the rotavirus vaccines impact after its release.

Efficacy of a community‐ versus primary care–centered program for childhood obesity: TX CORD RCT

Geographic information system (GIS) mapping can help communities visualize the health of their neighborhoods and identify opportunities for improvement. In Austin, Texas, Childrens Optimal Health, a nonprofit association, used GIS to map the prevalence of obesity among middle school children and to identify contributory factors. The maps indicated that obesity is a problem in all Austin middle schools. Two neighborhoods outside downtown Austin have particularly high concentrations of overweight and obese students. Maps also showed that the neighborhoods have different proportions of fast-food outlets, grocery stores selling fresh produce, green recreation space, and students failing cardiovascular testing. The mapping exercise spurred community groups to propose obesity interventions tailored to each neighborhood.

Strategies to recruit a diverse low-income population to child weight management programs from primary care practices

This randomized controlled trial was conducted to determine comparative efficacy of a 12‐month community‐centered weight management program (MEND2‐5 for ages 2‐5 or MEND/CATCH6‐12 for ages 6‐12) against a primary care‐centered program (Next Steps) in low‐income children.

Predictors of Severe Obesity in Low-Income, Predominantly Hispanic/Latino Children: The Texas Childhood Obesity Research Demonstration Study

Purpose and Objectives Primary care practices can be used to engage children and families in weight management programs. The Texas Childhood Obesity Research Demonstration (TX CORD) study targeted patients at 12 primary care practices in diverse and low-income areas of Houston, Texas, and Austin, Texas for recruitment to a trial of weight management programs. This article describes recruitment strategies developed to benefit both families and health care practices and the modification of electronic health records (EHRs) to reflect recruitment outcomes. Intervention Approach To facilitate family participation, materials and programs were provided in English and Spanish, and programs were conducted in convenient locations. To support health care practices, EHRs and print materials were provided to facilitate obesity recognition, screening, and study referral. We provided brief training for providers and their office staffs that covered screening patients for obesity, empathetic communication, obesity billing coding, and use of counseling materials. Evaluation Methods We collected EHR data from 2012 through 2014, including demographics, weight, and height, for all patients aged 2 to 12 years who were seen in the 12 provider practices during the study’s recruitment phase. The data of patients with a body mass index (BMI) at or above the 85th percentile were compared with the same data for patients who were referred to the study and patients who enrolled in the study. We also examined reasons that patients referred to the study declined to participate. Results Overall, 26% of 7,845 patients with a BMI at or above the 85th percentile were referred to the study, and 27% of referred patients enrolled. Enrollment among patients with a BMI at or above the 85th percentile was associated with being Hispanic and with more severe obesity than with patients of other races/ethnicities or less severe obesity, respectively. Among families of children aged 2 to 5 years who were referred, 20% enrolled, compared with 30% of families of older children (>5 y to 12 y). Referral rates varied widely among the 12 primary care practices, and referral rates were not associated with EHR modifications. Implications for Public Health Engagement and recruitment strategies for enrolling families in primary care practice in weight management programs should be strengthened. Further study of factors associated with referral and enrollment, better systems for EHR tools, and data on provider and office adherence to study protocols should be examined. EHRs can track referral and enrollment to capture outcomes of recruitment efforts.