Wendy Slusser

Provider encouragement of breast-feeding: evidence from a national survey.

Objective To examine the influence of provider encouragement on breast-feeding among women of different social and ethnic backgrounds in the United States. Methods A nationally representative sample of 2017 parents with children younger than 3 years was surveyed by telephone. The responses of the 1229 women interviewed were included in the analysis. Respondents were asked to recall whether their physicians or nurses had encouraged or discouraged them from breast-feeding. The effects of provider encouragement on breast-feeding initiation and duration were evaluated by multivariate logistic regression. The sample was then stratified to allow subset analyses by race and ethnicity, education, income class, age group, and marital status. Results More than one-third (34.4%) of respondents did not initiate breast-feeding. Three-fourths (73.2%) of women reported having been encouraged by their physicians or nurses to breast-feed; 74.6% of women who were encouraged initiated breast-feeding, compared with only 43.2% of those who were not encouraged (P < 0.001). Women who were encouraged to breast-feed were more than four times (relative risk 4.39; 95% confidence interval 2.96, 6.49) as likely to initiate breast-feeding as women who did not receive encouragement. The influence of provider encouragement was significant across all strata of the sample. In populations traditionally less likely to breast-feed, provider encouragement significantly increased breast-feeding initiation, by more than threefold among low-income, young, and less-educated women; by nearly fivefold among black women; and by nearly 11-fold among single women. Conclusion Provider encouragement significantly increases breast-feeding initiation among American women of all social and ethnic backgrounds.

Trends and Outcomes of Adolescent Bariatric Surgery in California, 2005–2007

OBJECTIVE: The goal of this study was to evaluate trends, and outcomes of adolescents who undergo bariatric surgery. PATIENTS AND METHODS: Patients younger than 21 years who underwent elective bariatric surgery between 2005 and 2007 were identified from the California Office of Statewide Health Planning and Development database. Multivariate logistic regression was used to identify factors associated with the type of surgery. RESULTS: Overall, 590 adolescents (aged 13–20 years) underwent bariatric surgery in 86 hospitals. White adolescents represented 28% of those who were overweight but accounted for 65% of the procedures. Rates of laparoscopic adjustable gastric banding (LAGB) increased 6.9-fold from 0.3 to 1.5 per 100 000 population (P < .01), whereas laparoscopic Roux-en-Y gastric bypass (LRYGB) rates decreased from 3.8 to 2.7 per 100 000 population (P < .01). Self-payers were more likely to undergo LAGB (relative risk [RR]: 3.51 [95% confidence interval: 2.11–5.32]) and less likely to undergo LRYGB (RR: 0.45 [95% confidence interval: 0.33–0.58]) compared with privately insured adolescents. The rate of major in-hospital complication was 1%, and no deaths were reported. Of the patients who received LAGB, 4.7% had band revision/removal. In contrast, 2.9% of those who received LRYGB required reoperations. CONCLUSIONS: White adolescent girls disproportionately underwent bariatric surgery. Although LAGB has not been approved by the US Food and Drug Administration for use in children, its use has increased dramatically. There was a complication rate and no deaths. Long-term studies are needed to fully assess the efficacy, safety, and health care costs of these procedures in adolescents.

Pediatric Overweight Prevention through a Parent Training Program for 2–4 Year Old Latino Children

BACKGROUND Latino preschool children in the United States are at high risk for obesity. The objective of this study was to measure over a one-year period whether a parent training based on social learning theory combined with evidence-based interventions to promote optimal nutrition and physical activity will reduce the upward trend of BMI z-scores in groups of 2–4 year old Latino children living in low-income households. METHODS Seven weekly classes with 2 booster classes were delivered to low-income Latino parents with 2–4 year old children. A randomized controlled pilot study evaluated the effectiveness of the intervention that contrasts 61 children whose parents were randomized to receive Parent Training (PT) with 60 Wait-list (WL) subjects. Forty subjects did not attend the one-year follow up assessment, resulting in 81 subjects who have measurements for both baseline and one-year follow up assessments. To adjust for differential dropout rates and missing observations, imputation of missing data was done using a carefully constructed model that included relevant independent variables. RESULTS There were no significant subject differences between groups at baseline for family characteristics and BMI categories for child and parent. Children in the intervention group decreased their BMI z-scores significantly on average by .20 (SE= .08) compared to children in the control group who increased z scores on average by .04 (SE=.09) at one year (P<.05). CONCLUSIONS Parent training is effective to reduce the risk of overweight in preschool Latino children living in low-income households. The findings need to be examined in a larger sample of children.

Predictors of Breastfeeding Duration for Employees of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

During the past decade there has been increasing breastfeeding support within the Women, Infants, and Children (WIC) program. For this study, it was hypothesized that employees at WIC would initiate and continue to breastfeed significantly longer than the National averages. Female employees, mostly paraprofessionals, from six Los Angeles County WIC agencies participated in the study to determine breastfeeding rates and predictors of breastfeeding success. As expected, 99% of WIC employees initiated breastfeeding and 68.6% continued to breastfeed to one year, significantly exceeding National averages. Four variables accounted for 30% of the variance in duration of breastfeeding: intent to exclusively breastfeed, delayed introduction of infant formula, attendance at breastfeeding support groups and availability of work-site breastpumps. Given that nearly 70% of the study participants reached the American Academy of Pediatrics goal of breastfeeding to 12 months or more, it is clear that full-time employment and breastfeeding can be compatible given appropriate work-site support.

Multidisciplinary Pediatric Obesity Clinic via Telemedicine Within the Los Angeles Metropolitan Area: Lessons Learned

Telemedicine has been shown to be effective for rural populations, but little is reported on pediatric obesity care via telemedicine in urban settings. This study aims to assess feasibility and acceptability of multidisciplinary pediatric obesity care via telemedicine within the same metropolitan area in terms of information technology, coordination, patient care, and clinical outcomes. All project notes and communications were reviewed to extract key lessons from implementation. Patient and Provider Satisfaction Questionnaires were conducted to assess overall satisfaction; baseline and follow-up information were collected from chart reviews to evaluate clinical outcomes. Based on the questionnaires, 93% of responding patients (n = 28) and 88.3% of referring providers (n = 17) felt satisfied with the appointment. Chart review indicated a trend for decreased or stabilized body mass index and blood pressure (n = 32). Implementation of telemedicine for tertiary multidisciplinary pediatric obesity care in urban settings is both feasible and acceptable to patients and health care providers.

Detailed Description of the Nutrition Component of a Pediatric Overweight Prevention Program: Reply to Anchondo

I appreciate Dr. Anchondo’s thoughtful comparisons between the Traffic Light Diet, the American Academy of Pediatrics (AAP) Expert Recommendations, Bright Futures, and Ellyn Satter’s ‘‘.philosophy of internal regulation related to eating.’’ The nutrition intervention used in the study was not described in detail in the article ‘‘Pediatric overweight prevention through a parent training program for 2–4 year old Latino children,’’ 6 and this may account for Dr. Anchondo’s comments. To clarify, there were no caloric restrictions implemented nor was there an intent for children to lose weight in this study. The focus of the study intervention was to create a home environment that promoted healthy parenting routines and provided access and availability to healthy food and beverage options to support healthy growth among the preschool children. Evidence demonstrates that increasing the availability and accessibility of healthy foods and beverages, such as healthy and low-calorie drinks and fruits and vegetables, increases their consumption. We used a modification of the Traffic Light Diet for our families to provide clear guidelines for them on what foods and drinks would be healthier to have in the home environment. We also incorporated into the intervention the list of evidence-based steps and strategies outlined in the AAP childhood obesity prevention Expert Committee recommendations and the Bright Futures guidelines. The original study was catalyzed by an observation in our primary care clinic that serves predominantly Latino families; we observed accelerated weight gain compared to height gains with subsequent rising BMI percentiles among our preschool low-income Latino population, similar to national trends. In our study, families were taught to create an environment where the child finds the healthy choice the easy choice and to allow the child to self-regulate their food and beverage consumption within this context. Our study demonstrates the effectiveness of this approach in reducing the accelerated weight gain in the Latino preschool population studied in ‘‘Pediatric overweight prevention through a parent training program for 2–4 year old Latino children.’’

Retrospective Review of Comorbid Conditions in a Multidisciplinary Pediatric Weight Management Clinic

A retrospective medical chart review was conducted of patients enrolled in the Fit for Healthy Weight Clinic (Fit Clinic). At initial evaluation, comorbidities were identified by the patient and pediatrician. The number of comorbidities increased with age among patients. In reviewing the differences among the number of identified comorbidities among grade school age and adolescent patients, increases of 30% were observed in gastrointestinal-associated, 23% in psychiatric, 18% in endocrine, 16% in cardiovascular, and 14% in respiratory comorbidities. Fit Clinic patients already manifest many known obesity-related comorbidities as evidenced in identified conditions and abnormal laboratory values. The elevated blood pressures, blood glucose, and cholesterol levels raise concern for the future development of coronary artery disease and type 2 diabetes mellitus. With an average of five obesity-related comorbidities, Fit Clinic patients already have more comorbidities than what is evidenced in large US population-based studies, demonstrating that solely addressing body mass index is not sufficient.

Barriers and Comorbidities from a Pediatric Multidisciplinary Tertiary Care Obesity Program

Background: The UCLA Fit for Healthy Weight Clinic (Fit Clinic) is a multidisciplinary tertiary care weight management program tailored to meet the needs of overweight and obese pediatric patients who have not met their goals in the primary care setting. The objective of this retrospective cohort study was to evaluate the barriers to healthy lifestyles and common comorbidities among patients seeking care at the Fit Clinic. Methods: A retrospective chart review was conducted of all the patients who attended the Fit Clinic between April 2008 and October 2011 (n=115). Weights, heights, blood pressures, laboratory values, dates of birth, gender, dates of visit, and self-identified comorbidities and barriers to physical activity and healthful eating were collected. Results: Patients identified an average of 5.8 comorbid systems at their first clinic visit. The most commonly identified barriers to healthy eating were lack of selfdiscipline (63%), that dieting “is hard work” (55%), and dislike of healthy foods (30%). There was a significant improvement (p<0.05) in BP after an average of three clinic visits across all patients with elevated BP. A majority of patients demonstrated either a decrease or stabilization in BMI. Conclusion: This study adds evidence to support the recommendation to provide a multidisciplinary team approach to the care of morbidly obese pediatric patients not meeting their goals in a primary care setting by addressing barriers to health.

The Differential Effect of Hospital-Based Provider Encouragement to Breastfeed among White, Hispanic and African American Mothers: Evidence from the Commonwealth Survey of Parents with Young Children

The Differential Effect of Hospital-Based Provider Encouragement to Breastfeed among White, Hispanic and African American Mothers: Evidence from the Commonwealth Survey of Parents with Young Children