Thao-Ly T. Phan

Evaluation of intelligence in an adolescent bariatric population.

BACKGROUND The use of bariatric surgery as treatment for morbid obesity in adolescents has nearly tripled in recent years. Intelligence is an important component to a patients assent of surgery and maintenance of a healthy lifestyle. The objective of this study was to describe the intelligence testing performance of a cohort of adolescents seeking laparoscopic adjustable gastric banding (LAGB). Twenty-nine patients (93% female, 62% white) with a mean age of 16 years and mean body mass index (BMI) of 49 kg/m(2) were enrolled in an adolescent bariatric program in the United States. METHODS We conducted a cross-sectional analysis, evaluating patient intelligence at a single preoperative time point using the Weschler Intelligence Scale for Children-IV or Weschler Adult Intelligence Scale-IV. Intelligence quotient (IQ) scores were analyzed descriptively and in relationship to patient anthropometric measurements and characteristics. RESULTS Mean IQ was average for age (95, SD 16), although 21% of patients had an IQ<80 and no patients had an IQ>120. There was no significant association between IQ and BMI, weight, or waist circumference. Mean IQ was lower in patients who had failed a grade compared with those who had not failed a grade (P<.01) and in patients whose parents had not graduated college compared with those whose parents had (P< .05). CONCLUSION In our cohort of adolescents seeking LAGB, mean IQ was average for age, suggesting capability to understand the procedure and healthy lifestyle concepts. Patients who exhibit deficits in intellect prior to surgery may benefit from educational resources and clinician support tailored to their reasoning abilities.

Psychological contributors to noncompletion of an adolescent preoperative bariatric surgery program

BACKGROUND Noncompletion of preoperative bariatric programs is a significant problem among adolescents. Adult studies suggest that psychological factors contribute to noncompletion of preoperative bariatric programs. OBJECTIVE The aim of this study was to determine the association between adolescent psychological functioning and completion of the preoperative phase of a bariatric program. SETTING The study was conducted at a tertiary care childrens hospital affiliated with a university medical center. METHODS Seventy-four adolescents and their parents completed an assessment measure of psychological functioning with the Behavior Assessment System for Children, Second Edition. We compared these scores between adolescents who completed the preoperative phase of the bariatric program and proceeded to surgery (completers) to those who did not (noncompleters) using multivariate analysis of covariance and logistic regression analyses, adjusting for demographic characteristics and baseline body mass index. RESULTS The mean age was 16.0 (1.1) years, most were female (79.8%), and the group was diverse (48.6%, Caucasian; 33.8%, black; 17.6%, other, including Hispanic, Asian, and biracial). Average body mass index was 50.5 (7.6) kg/m2. Forty-two percent of participants were noncompleters. Noncompleters were reported by parents to have more clinically significant externalizing and internalizing behaviors and fewer adaptive behaviors. Noncompleters self-reported more clinically significant internalizing symptoms, emotional problems, and poor personal adjustment. CONCLUSION Adolescents who did not complete the preoperative phase of a bariatric surgery program had more clinically significant psychological symptoms across multiple domains compared with those who successfully proceeded to bariatric surgery. Early identification and treatment of psychological symptoms may be important in helping adolescents successfully proceed to surgery.

Impact of Psychosocial Risk on Outcomes among Families Seeking Treatment for Obesity

Objectives To test the hypothesis that children with elevated psychosocial risk would have increased attrition and worse weight outcomes in weight management treatment. Study design This was a prospective cohort study of 100 new patients, aged 4‐12 years, in a weight management clinic. Parents completed the Psychosocial Assessment Tool. Logistic regression analyses were conducted to calculate the odds of attrition from the clinic and a nonmeaningful change in body mass index (BMI) z‐score (ie, <0.1 unit decrease in BMI z‐score) over a 6‐month period based on psychosocial risk category, adjusting for child demographics and baseline weight category. Results The majority of patients were male (59%), black (36%) or white (43%), and had severe obesity (55%), and 59% of families were categorized as having moderate or high psychosocial risk. Over the 6‐month period, 53% of families were lost to follow‐up, and 67% did not have a clinically meaningful decrease in BMI z‐score. Compared with children of families with low psychosocial risk, children of families with moderate or high psychosocial risk were 3.1 times (95% CI, 1.3‐7.2 times) more likely to be lost to follow‐up and 2.9 times (95% CI, 1.1‐7.9 times) more likely to have a non–clinically meaningful change in BMI z‐score. Conclusions Children presenting with increased psychosocial risk have higher attrition and poorer weight outcomes, supporting the need for psychosocial screening as a standard component of pediatric weight management treatment.

Disparities in parent confidence managing child weight-related behaviors.

OBJECTIVE To describe ethnic disparities in parental confidence managing child weight-related behaviors. METHODS This was a cross-sectional survey of 59 parents of children with obesity between 4 and 7 years of age presenting to a tertiary care pediatric weight management clinic. Parents completed a validated measure assessing their confidence managing their childs weight-related behaviors (parent confidence score). Students t-tests and linear regression analyses were used to determine parent and child characteristics associated with parent confidence score. RESULTS Families were ethnically diverse with half being of Hispanic ethnicity. Mean parent confidence score was 159 (SD 66) with 71% of parents with parent confidence scores below the clinical cut-off for the measure. Parent confidence score was lower among Hispanic (mean 133, SD 67) compared to non-Hispanic parents (mean 184, SD 55, p < 0.01). Parent confidence score was most strongly associated with parental ethnicity (β = -0.39, p = 0.002, adjusted R(2) = 0.14). CONCLUSION Parental confidence managing weight-related behaviors was low among parents of young obese children, especially those of Hispanic ethnicity. PRACTICE IMPLICATIONS This study highlights the need to assess parental confidence in managing weight-related behaviors as part of pediatric obesity care and to provide counseling to improve parental management of weight-related behaviors in a culturally-appropriate manner.

A Delayed-Control Trial Examining the Impact of Body Mass Index Recognition on Obesity-Related Counseling

Background. Rates of body mass index (BMI) calculation and plotting remain low. We examined whether providing a BMI wheel and brief education to pediatric residents and attendings would increase rates of “BMI recognition” and obesity-related counseling. Methods. A delayed-control design was used to evaluate a 20-minute intervention. A total of 1640 records of well-child visits were reviewed to determine the proportion of records in which BMI was calculated and plotted and counseling provided. Results. In clinic A, there was a significant increase in the proportion of records in which BMI was recognized from pre- to postintervention (P < .01). No changes in clinic B occurred until after the delayed intervention. Obesity-related counseling was more likely to occur if BMI was recognized. Conclusion. Brief education and BMI wheel increased rates of BMI recognition. BMI recognition was associated with increased obesity management. Additional efforts should be incorporated to further increase BMI recognition and assist providers in treating these children.

Characteristics of Children 2 to 5 Years of Age With Severe Obesity

In this analysis of nationally representative data, we characterize sociodemographic, dietary intake, and screen time habits of preschool-aged children with SO compared with their peers. BACKGROUND AND OBJECTIVES: As a distinct group, 2- to 5-year-olds with severe obesity (SO) have not been extensively described. As a part of the Expert Exchange Workgroup on Childhood Obesity, nationally-representative data were examined to better characterize children with SO. METHODS: Children ages 2 to 5 (N = 7028) from NHANES (1999–2014) were classified as having normal weight, overweight, obesity, or SO (BMI ≥120% of 95th percentile). Sociodemographics, birth characteristics, screen time, total energy, and Healthy Eating Index 2010 scores were evaluated. Multinomial logistic and linear regressions were conducted, with normal weight as the referent. RESULTS: The prevalence of SO was 2.1%. Children with SO had higher (unadjusted) odds of being a racial and/or ethnic minority (African American: odds ratio [OR]: 1.7; Hispanic: OR: 2.3). They were from households with lower educational attainment (OR: 2.4), that were single-parent headed (OR: 2.0), and that were in poverty (OR: 2.1). Having never been breastfed was associated with increased odds of obesity (OR: 1.5) and higher odds of SO (OR: 1.9). Odds of >4 hours of screen time were 1.5 and 2.0 for children with obesity and SO. Energy intake and Healthy Eating Index 2010 scores were not significantly different in children with SO. CONCLUSIONS: Children ages 2 to 5 with SO appear to be more likely to be of a racial and/or ethnic minority and have greater disparities in social determinants of health than their peers and are more than twice as likely to engage in double the recommended screen time limit.

Integrating childhood obesity resources into the patient-centered medical home: Provider perspectives in the United States

Pediatric primary care providers play a critical role in managing obesity yet often lack the resources and support systems to provide effective care to children with obesity. The objective of this study was to identify system-level barriers to managing obesity and resources desired to better managing obesity from the perspective of pediatric primary care providers. A 64-item survey was electronically administered to 159 primary care providers from 26 practices within a large pediatric primary care network. Bivariate analyses were performed to compare survey responses based on provider and practice characteristics. Also factor analysis was conducted to determine key constructs that effect pediatric interventions for obesity. Survey response rate was 69% (n = 109), with the majority of respondents being female (77%), physicians (67%), and without prior training in obesity management (74%). Time constraints during well visits (86%) and lack of ancillary staff (82%) were the most frequently reported barriers to obesity management. Information on community resources (99%), an on-site dietitian (96%), and patient educational materials (94%) were most frequently identified as potentially helpful for management of obesity in the primary care setting. Providers who desired more ancillary staff were significantly more likely to practice in clinics with a higher percentage of obese, Medicaid, and Hispanic patients. Integrating ancillary lifestyle expert support into primary care practices and connecting primary care practices to community organizations may be a successful strategy for assisting primary care providers with managing childhood obesity, especially among vulnerable populations.

Electronic Gaming Characteristics Associated with Class 3 Severe Obesity in Youth Who Attend the Pediatric Weight Management Programs of the COMPASS Network

BACKGROUND The prevalence of severe obesity and electronic game use among youth has increased over time. METHODS We administered a survey assessing gaming and psycho-demographic characteristics to youth aged 11-17 attending five weight management programs. We conducted chi-square and logistic regression analyses to describe the association between class 3 severe obesity and gaming characteristics. RESULTS Four hundred twelve youth (51% female, 26% Black, 25% Hispanic, 43% White, and 44% with class 3 severe obesity) completed the survey. There was a stepwise relationship between time spent gaming and class 3 severe obesity, with 28% of those playing 2 to <4 hours a day, 48% of those playing 4 to <6 hours a day, and 56% of those playing ≥6 hours a day having class 3 severe obesity (p = 0.002). Compared to youth without class 3 severe obesity, youth with class 3 severe obesity were more likely to have a TV in the bedroom (76% vs. 63%, p = 0.004) and play games on a console (39% vs. 27%, p = 0.03) and were less likely to report parental limit setting on type of games played (7% vs. 16%, p = 0.006). Youth who played games ≥4 hours a day were 1.94 times (95% confidence interval 1.27-3.00) more likely to have class 3 severe obesity than those who played <4 hours a day, after adjustment for demographic, behavioral, and academic variables. CONCLUSIONS Our study demonstrates a clear association between gaming characteristics, especially time spent gaming, and severe obesity in youth. Further research testing family-based interventions that target gaming behaviors in youth are needed.