Trends of Antihypertensive Prescription Among US Adults From 2010 to 2019 and Changes Following Treatment Guidelines: Analysis of Multicenter Electronic Health Records

BACKGROUND

Guidelines for the use of antihypertensives changed in 2014 and 2017. To understand the effect of these guidelines, we examined trends in antihypertensive prescriptions in the United States from 2010 to 2019 using a repeated cross-sectional design.

METHODS AND RESULTS

Using electronic health records from 15 health care institutions for adults (20-85 years old) who had ≥1 antihypertensive prescription, we assessed whether (1) prescriptions of beta blockers decreased after the 2014 Eighth Joint National Committee (JNC 8) report discouraged use for first-line treatment, (2) prescriptions for calcium channel blockers and thiazide diuretics increased among Black patients after the JNC 8 report encouraged use as first-line therapy, and (3) prescriptions for dual therapy and fixed-dose combination among patients with blood pressure ≥140/90 mm Hg increased after recommendations in the 2017 Hypertension Clinical Practice Guidelines. The study included 1 074 314 patients with 2 133 158 prescription episodes. After publication of the JNC 8 report, prescriptions for beta blockers decreased (3% lower in 2018-2019 compared to 2010-2014), and calcium channel blockers increased among Black patients (20% higher in 2015-2017 and 41% higher in 2018-2019, compared to 2010-2014), in accordance with guideline recommendations. However, contrary to guidelines, dual therapy and fixed-dose combination decreased after publication of the 2017 Hypertension Clinical Practice Guidelines (9% and 11% decrease in 2018-2019 for dual therapy and fixed-dose combination, respectively, compared to 2015-2017), and thiazide diuretics decreased among Black patients after the JNC 8 report (6% lower in 2018-2019 compared to 2010-2014).

CONCLUSIONS

Adherence to guidelines on prescribing antihypertensive medication was inconsistent, presenting an opportunity for interventions to achieve better blood pressure control in the US population.

Wellness Achieved Through Changing Habits: A Randomized Controlled Trial of an Acceptance-Based Intervention for Adolescent Girls With Overweight or Obesity

Background: Obesity prevalence among adolescent girls continues to rise. Acceptance-based therapy (ABT) is effective for weight loss in adults and feasible and acceptable for weight loss among adolescents. This pilot randomized controlled trial (RCT) assessed effectiveness of an adolescent-tailored ABT intervention on decreasing weight-related outcomes and improving psychological outcomes compared with enhanced care. Methods: In this 6-month, two-arm pilot RCT, participants were randomized to the ABT intervention or to enhanced care. The ABT intervention condition attended 15 virtual, 90-minute group sessions. The enhanced care comparison received 15 healthy lifestyle handouts and virtually met twice with a registered dietitian. The primary outcome assessed was change in BMI expressed as a percentage of the 95th percentile (%BMIp95). Results: Participants included 40 girls (ages 14-19) assigned to ABT (n = 20) or enhanced care (n = 20). A decrease in %BMIp95 was observed within the ABT intervention [d = -0.19, 95% confidence interval, CI: (-0.36 to -0.02)], however, not within the enhanced care comparison [d = -0.01, 95% CI: (-0.09 to 0.07)]. The ABT group showed slight changes in psychological flexibility [d = -0.34, 95% CI: (-0.62 to -0.06)] over enhanced care [d = -0.11, 95% CI: (-0.58 to 0.37)]. There was no significant intervention effect noted between groups. Conclusion: In this pilot RCT, the ABT intervention was as effective as enhanced care for weight loss. However, previous ABT studies occurred in person, and this study was conducted virtually due to COVID-19. Thus, future research investigating the potential effectiveness of ABT in-person among adolescents and optimization of virtual interventions is needed.

Effects of sleep disturbance on trauma-focused psychotherapy outcomes in posttraumatic stress disorder: A systematic review

This study aimed to synthesize existing research on the effects of sleep disturbances on trauma-focused psychotherapy outcomes in adults with posttraumatic stress disorder (PTSD). A systematic review using PubMed, PsycINFO, Embase, Web of Science, and PTSDpubs was performed up to April 2021. Two independent reviewers screened articles for inclusion, performed data extraction, and assessed risk of bias and certainty of the evidence. Narrative synthesis was conducted based on the type of sleep disorder symptom assessed. Sixteen primary studies were included in this review, the majority of which had a high overall risk of bias. Results suggested that sleep disorder symptoms were associated with higher overall PTSD severity across treatment; however, they did not interfere with treatment effectiveness, with the exception of sleep-disordered breathing. Improvements in insomnia, sleep duration, and sleep quality during treatment were associated with greater treatment gains. Certainty of the evidence ranged from low to very low. These results suggest that it may not be necessary to address sleep disorder symptoms prior to initiating trauma-focused psychotherapy. Instead, concurrent treatment of sleep- and trauma-related symptoms may be most beneficial. Continued research is needed to clarify the mechanistic relationship between sleep and treatment outcomes and to guide clinical decision-making.

A Systematic Review of Sleep Disturbances in Pediatric Inflammatory Bowel Disease

OBJECTIVE

The current systematic review (PROSPERO ID: CRD42020220142) aims to characterize sleep health in pediatric inflammatory bowel disease (IBD) and evaluate disease-related and psychosocial prognostic factors associated with sleep disturbances in pediatric IBD.

METHODS

A search of PubMed, PsycINFO, CINAHL, Web of Science, and Cochrane databases was performed. Included studies were written in English, presented original peer-reviewed research, included participants with a mean age of 8-18 years, and reported on at least one quantitative sleep outcome for children with IBD or factors impacting sleep for these children. Studies that did not report on a sleep outcome or factors influencing sleep, or only examined fatigue were excluded. Study quality was evaluated using validated quality assessment tools. The data from the included studies were extracted and synthesized across sleep health domains.

RESULTS

Database searches yielded 122 records (total participants = 3,905). After full-text and reference/citation searches, 28 articles were included in the review. Methods used to evaluate sleep widely varied across studies and a majority of the studies were cross-sectional. Results suggest that children with IBD may not experience more frequent sleep disturbance than healthy children. Greater sleep disturbance in pediatric IBD was found to be associated with poorer psychosocial functioning and greater active disease/severe symptoms.

CONCLUSIONS

The findings from this review highlight the complex associations between sleep disturbances, inflammation, disease severity, and psychosocial functioning in children with IBD. Additional research with greater methodological rigor (e.g., use of validated sleep measures, longitudinal design, reporting of effect sizes) is warranted to further elucidate these relationships.

SUMMARY

The current systematic review examines the existing evidence and methods of measurement of sleep disturbances in pediatric inflammatory bowel disease. We describe and evaluate factors associated with sleep disturbance in this population. The quality of evidence, strengths and weaknesses of the literature, and future directions are described.

Parents of minor children lose less weight during a behavioral weight loss intervention: Findings from the Rural LEAP trial

Objective

The transition to parenthood is associated with worsening health behaviors, yet the impact of parental status on successful weight loss has rarely been examined. The purpose of this study was to examine the effect of parental status of minor children on weight loss and behavioral adherence in a rural community-based weight loss intervention.

Methods

Five hundred and twenty-eight adults (age 21-75 years, body mass index [BMI] 30-45 kg/m2) were enrolled in a group-based weight loss intervention consisting of 16 weekly sessions delivered in face-to-face group sessions at Cooperative Extension Service (CES) offices. Participants who were parents with at least one minor child (≤18 years old) in the home were compared to participants with no minor children in the home. Measures included percent weight loss, session attendance, adherence to self-monitoring, and achieving calorie and physical activity goals.

Results

Compared to participants without minor children, parents with minor children lost significantly less weight (7.5% vs. 6.2%, respectively; p = 0.01), and were less likely to lose ≥5% of baseline weight (59.2% vs. 70.2%, respectively; p = 0.02). In addition, parents with minor children attended significantly fewer sessions, had lower adherence to self-monitoring, and met calorie and step goals less often (all ps < 0.001). The association between parental status and percent weight loss was not significantly moderated by gender of the parent.

Conclusions

Parents of minor children had greater difficulty adhering to intervention goals and lost less weight than participants without minor children. Future research should investigate whether tailoring intervention to meet the unique needs of parents can enhance outcomes, especially given the large segment of the population represented by this group.

Cleaning of anthropometric data from PCORnet electronic health records using automated algorithms

Objective

To demonstrate the utility of growthcleanr, an anthropometric data cleaning method designed for electronic health records (EHR).

Materials and Methods

We used all available pediatric and adult height and weight data from an ongoing observational study that includes EHR data from 15 healthcare systems and applied growthcleanr to identify outliers and errors and compared its performance in pediatric data with 2 other pediatric data cleaning methods: (1) conditional percentile (cp) and (2) PaEdiatric ANthropometric measurement Outlier Flagging pipeline (peanof).

Results

687 226 children (<20 years) and 3 267 293 adults contributed 71 246 369 weight and 51 525 487 height measurements. growthcleanr flagged 18% of pediatric and 12% of adult measurements for exclusion, mostly as carried-forward measures for pediatric data and duplicates for adult and pediatric data. After removing the flagged measurements, 0.5% and 0.6% of the pediatric heights and weights and 0.3% and 1.4% of the adult heights and weights, respectively, were biologically implausible according to the CDC and other established cut points. Compared with other pediatric cleaning methods, growthcleanr flagged the most measurements for exclusion; however, it did not flag some more extreme measurements. The prevalence of severe pediatric obesity was 9.0%, 9.2%, and 8.0% after cleaning by growthcleanr, cp, and peanof, respectively.

Conclusion

growthcleanr is useful for cleaning pediatric and adult height and weight data. It is the only method with the ability to clean adult data and identify carried-forward and duplicates, which are prevalent in EHR. Findings of this study can be used to improve the growthcleanr algorithm.

Changes in obesity and BMI among children and adolescents with selected chronic conditions during the COVID-19 pandemic

OBJECTIVE

The aim of this study was to examine COVID-19 pandemic-related changes in obesity and BMI among patients aged 5 to <20 years with selected chronic conditions.

METHODS

A longitudinal study in 293,341 patients aged 5 to <20 years who were prescribed one of five medication classes (for depression, psychosis, hypertension, diabetes, or epilepsy) and who had BMI measures from January 2019 to March 2021 was conducted. Generalized estimating equations and linear mixed-effects models were used, accounting for within-child repeated measures and stratified by age, race, ethnicity, gender, and class of medication prescribed, to compare obesity and BMI z score during the pandemic (June through December 2020) versus pre-pandemic (June through December 2019).

RESULTS

Obesity prevalence increased from 23.8% before the pandemic to 25.5% during the pandemic; mean (SD) BMI z score increased from 0.62 (1.26) to 0.65 (1.29). Obesity prevalence during the pandemic increased at a faster rate compared with pre-pandemic among children aged 5 to <13 years (0.27% per month; 95% CI: 0.11%-0.44%) and 13 to <18 years (0.24% per month; 95% CI: 0.09%-0.40%), with the largest increases among children aged 5 to <13 years who were male (0.42% per month), Black (0.35% per month), or Hispanic (0.59% per month) or who were prescribed antihypertensives (0.28% per month).

CONCLUSIONS

The COVID-19 pandemic has exacerbated the obesity epidemic and widened disparities among children with selected chronic conditions. These findings highlight the importance of continuing efforts to specifically help high-risk populations who are experiencing weight gain from the pandemic.

Comparison of Rates of Type 2 Diabetes in Adults and Children Treated With Anticonvulsant Mood Stabilizers

IMPORTANCE

Anticonvulsant mood stabilizer treatment is associated with an increased risk of weight gain, but little is known about the risk of developing type 2 diabetes (T2D).

OBJECTIVE

To evaluate the comparative safety of anticonvulsant mood stabilizers on risk of T2D in adults and children by emulating a target trial.

DESIGN, SETTING, AND PARTICIPANTS

This observational cohort study used data from IBM MarketScan (2010-2019), with a 5-year follow-up period. The nationwide sample of US commercially insured patients included children (aged 10-19 years) and adults (aged 20-65 years) who initiated anticonvulsant mood stabilizer treatment. Data were analyzed from August 2020 to May 2021.

EXPOSURES

Initiation and continuation of carbamazepine, lamotrigine, oxcarbazepine, or valproate.

MAIN OUTCOMES AND MEASURES

Onset of T2D during follow-up. Weighted pooled logistic regression was used to estimate the association of initiation and continuation of carbamazepine, lamotrigine, oxcarbazepine, or valproate with the risk of developing T2D. Inverse probability weights were used to control for confounding and loss to follow-up by measured baseline and time-varying covariates.

RESULTS

The analysis included 274 206 adults (159 428 women [58%]; mean [SD] age, 39.9 [13.2] years) and 74 005 children (38 672 girls [52%]; mean [SD] age, 15.6 [2.6] years) who initiated an anticonvulsant mood stabilizer. In adults, initiation of valproate was associated with an increased risk of developing T2D compared with initiation of lamotrigine (5-year risk difference [RD], 1.17%; 95% CI, 0.66% to 1.76%). The number needed to harm was 87 patients initiating valproate for 1 patient to develop T2D within 5 years compared with initiation of lamotrigine. Point estimates were similar when evaluating the association of treatment continuation (5-year RD, 1.99%; 95% CI, -0.64% to 5.31%). The estimated association was smaller and more variable comparing carbamazepine and oxcarbazepine to lamotrigine. In children, RDs were much smaller and more variable (5-year RD for initiation of oxcarbazepine vs lamotrigine, 0.29%; 95% CI, -0.12% to 0.69%; 5-year RD for initiation of valproate vs lamotrigine, 0.18%; 95% CI, -0.09% to 0.49%).

CONCLUSIONS AND RELEVANCE

In this cohort study, valproate was associated with the highest risk of developing T2D in adults. The comparative safety was generally similar in children, but estimates were small and variable. In the absence of randomized trials, emulating target trials within health care databases can generate the age-specific drug safety data needed to inform treatment decision-making.

Latent profiles of the feeding practices of caregivers of rural children with overweight and obesity and associations with child eating behaviors

Previous research has shown that food parenting practices, which vary within the context of sociocultural factors, are associated with child weight, eating behaviors, and body dissatisfaction. While parents typically engage in multiple food parenting practices, few studies have examined what subgroups or combinations of food parenting practices are associated with child health outcomes and sociocultural factors. The current study examined profiles of food parenting practices among school-age children with overweight/obesity (OW/OB) from rural communities and examined how they may be associated with sociocultural factors, child-eating habits, and health outcomes. The study included 270 children with OW/OB aged 8-12 (M_age = 10.36 years) and their caregivers. Caregivers completed a measure assessing perceptions of their feeding practices and sociocultural questionnaires. Children completed measures assessing disordered eating habits, weight control behaviors, and body dissatisfaction. Weight status was measured for caregivers and children with height and weight measurements. Latent variable mixture modeling (LVMM) was conducted. Three profiles emerged: (a) Lower Parental Involvement, (b) Higher Parental Involvement, and (c) Mixed Parental Involvement. Lower family income and non-White child race were related to membership in the "Higher Parental Involvement" profile. After controlling for income and child race, children in the "Mixed Parental Involvement" profile reported significantly higher body dissatisfaction than children in the "Lower Parental Involvement" profile. There are subgroups of caregivers of rural children with OW/OB that demonstrate various patterns of parent feeding practices, and these subgroups differ by income, race, and child body dissatisfaction. Future research should consider how caregiver-specific feeding practices may impact child eating behaviors and their body image development, as well as the impact cultural factors may have on parent feeding practices.

Meta-analysis of lifestyle modification interventions addressing overweight and obesity in preschool-age children

OBJECTIVE

Increased rates of pediatric obesity extend into early childhood. There have been increasing calls for intervention programs specifically designed to address obesity in preschool-age youth. A review of the literature is critical to guide intervention and future research. The objective of this study was to conduct a meta-analysis of randomized, controlled trials examining the efficacy of lifestyle modification interventions to address overweight and obesity in preschool-age children.

METHOD

Six electronic databases were searched for articles through December 8, 2020. After screening articles for inclusion criteria, 14 articles with 12 randomized, controlled trials (41 effect sizes, 2,525 participants) were included in this meta-analysis. Weighted-standardized mean differences for body mass index-related variables were calculated using random-effects models to estimate effect sizes. Risk of bias assessment was conducted.

RESULTS

There was a statistically significant impact of the interventions on child weight outcomes. Cohen's d was .32 (95% CI [.09, .55]). The quality of evidence was assigned a "low" GRADE rating.

CONCLUSIONS

Lifestyle modification interventions for overweight and obesity in preschool-age children produce small but significant changes in child weight status. However, few new trials have been published in the last 5 years and the quality of evidence in this area is low, limiting confidence in the estimates and the power to examine potential moderator effects. Additional quality, randomized, control trials that report study information consistent with consort guidelines, use intent-to-treatment procedures, assess and report health behaviors and treatment adherence to explore mechanisms of change, and examine sustained effects of interventions are needed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Pediatric Obesity Treatment via Telehealth: Current Evidence and Future Directions

PURPOSE OF REVIEW

Telehealth delivery of pediatric weight management interventions may address time, travel, and cost barriers to in-person interventions, thus improving accessibility. This narrative review highlights findings from the past 5 years of pediatric lifestyle interventions for weight management that utilize telehealth for treatment delivery. We describe impressions and future directions.

RECENT FINDINGS

We identified and included 20 studies that described unique interventions from the past 5 years. The majority of reviewed studies indicated statistically significant reductions in BMI z-scores, high retention and attendance, and high satisfaction. However, mean decreases in BMI z-scores were marginal (approximately 0.10) in all but two studies. Studies did not often report effect sizes. Pediatric telehealth weight management interventions demonstrate good feasibility and acceptability. Improvement in reporting results and more rigorous research, including use of randomized designs, recruitment of larger samples, and incorporation of extended follow-up is needed to determine clinical impact and magnitude of effects.

Pediatric weight bias in prehealth profession undergraduates: an idiographic approach

Bias toward individuals with overweight/obesity (OV/OB) exists among health professionals and trainees with the potential to affect the quality of healthcare interactions. Given most research is adult-focused, this study aimed to examine the influence of weight status on clinical judgments in a pediatric context. Sixteen virtual human scenes representing hypothetical medical encounters of pediatric patients and their mothers were presented to prehealth profession undergraduates (n = 92). Characteristics, or cues, of patient and mother weight status (healthy weight vs. obese) and dyad race (Caucasian vs. African American) were manipulated across scenes. Participants provided ratings for assessment questions, including perceived treatment adherence and responsibility for health, for each scene. Data were examined via idiographic (i.e., individual-level) analysis, which involved generation of separate multiple regressions per participant per assessment question to capture the influence of the cues on participants' ratings. Results represent secondary outcomes from another study published elsewhere. Current analyses revealed that 12%-22% of participants relied on cues of weight status when making assessments about patient and mother adherence and responsibility for health. The majority of these participants equated higher weight status with poorer anticipated treatment adherence and greater health responsibility. Results suggest that the weight status of pediatric patients and their mothers' plays a considerable role in prehealth profession undergraduates' clinical judgments, with the future potential to affect disparities in pediatric care. This study highlights the importance of considering child and maternal factors and utilizing a novel approach that may serve as a model for further investigation of this issue.

Association of Early Antibiotic Exposure With Childhood Body Mass Index Trajectory Milestones

IMPORTANCE

Past studies have showed associations between antibiotic exposure and child weight outcomes. Few, however, have documented alterations to body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) trajectory milestone patterns during childhood after early-life antibiotic exposure.

OBJECTIVE

To examine the association of antibiotic use during the first 48 months of life with BMI trajectory milestones during childhood in a large cohort of children.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used electronic health record data from 26 institutions participating in the National Patient-Centered Clinical Research Network from January 1, 2009, to December 31, 2016. Participant inclusion required at least 1 valid set of same-day height and weight measurements at each of the following age periods: 0 to 5, 6 to 11, 12 to 23, 24 to 59, and 60 to 131 months (183 444 children). Data were analyzed from June 1, 2019, to June 30, 2020.

EXPOSURES

Antibiotic use at 0 to 5, 6 to 11, 12 to 23, 24 to 35, and 36 to 47 months of age.

MAIN OUTCOMES AND MEASURES

Age and magnitude of BMI peak and BMI rebound.

RESULTS

Of 183 444 children in the study (mean age, 3.3 years [range, 0-10.9 years]; 95 228 [51.9%] were boys; 80 043 [43.6%] were White individuals), 78.1% received any antibiotic, 51.0% had at least 1 episode of broad-spectrum antibiotic exposure, and 65.0% had at least 1 episode of narrow-spectrum antibiotic exposure at any time before 48 months of age. Exposure to any antibiotics at 0 to 5 months of age (vs no exposure) was associated with later age (β coefficient, 0.05 months [95% CI, 0.02-0.08 months]) and higher BMI (β coefficient, 0.09 [95% CI, 0.07-0.11]) at peak. Exposure to any antibiotics at 0 to 47 months of age (vs no exposure) was associated with an earlier age (-0.60 months [95% CI, -0.81 to -0.39 months]) and higher BMI at rebound (β coefficient, 0.02 [95% CI, 0.01-0.03]). These associations were strongest for children with at least 4 episodes of antibiotic exposure. Effect estimates for associations with age at BMI rebound were larger for those exposed to antibiotics at 24 to 35 months of age (β coefficient, -0.63 [95% CI, -0.83 to -0.43] months) or 36 to 47 (β coefficient, -0.52 [95% CI, -0.72 to -0.31] months) than for those exposed at 0 to 5 months of age (β coefficient, 0.26 [95% CI, 0.01-0.51] months) or 6 to 11 (β coefficient, 0.00 [95% CI, -0.20 to 0.20] months).

CONCLUSIONS AND RELEVANCE

In this cohort study, antibiotic exposure was associated with statistically significant, but small, differences in BMI trajectory milestones in infancy and early childhood. The small risk of an altered BMI trajectory milestone pattern associated with early-life antibiotic exposure is unlikely to be a key factor during prescription decisions for children.

Feasibility/acceptability of an acceptance-based therapy intervention for diverse adolescent girls with overweight/obesity

BACKGROUND

Behavioral obesity interventions using an acceptance-based therapy (ABT) approach have demonstrated efficacy for adults, yet feasibility and acceptability of tailoring an ABT intervention for adolescents remains unknown.

OBJECTIVE

This study assessed the feasibility and acceptability of an ABT healthy lifestyle intervention among diverse adolescent cisgender girls with overweight/obesity (OW/OB).

METHODS

Adolescent cisgender girls aged 14-19 with a BMI of ≥85th percentile-for-sex-and-age were recruited for participation in a single-arm feasibility study. The primary outcomes were recruitment and retention while the secondary outcome was change in BMI Z-score over the 6-month intervention. Exploratory outcomes included obesity-related factors, health-related behaviors, and psychological factors.

RESULTS

Recruitment goals were achieved; 13 adolescents (>60% racial/ethnic minorities) participated in the intervention, and 11 completed the intervention (85% retention). In completers (n = 11), a mean decrease in BMI Z-score of -0.15 (SD = 0.34, Cohen's d = -0.44) was observed. Improvements were also noted for change in percentage of 95th percentile (d = -0.35), percent body fat (d = -0.35), quality of life (d = 0.71), psychological flexibility (d = -0.86), and depression (d = -0.86).

CONCLUSIONS

These preliminary findings suggest an ABT healthy lifestyle intervention tailored for adolescent cisgender girls with OW/OB may be an acceptable treatment that could lead to improvements in BMI Z-score, obesity-related measures, and psychological outcomes.

Attention deficit hyperactivity disorder medications and BMI trajectories: The role of medication type, sex and age

OBJECTIVES

Attention deficit hyperactivity disorder (ADHD) and the medications used to treat it are associated with obesity. Stimulants lead to weight loss, while antipsychotics and antidepressants lead to weight gain. Little is known, however, how alpha-2-agonists impact weight, or the independent effect on BMI of these four classes of medications, which are often prescribed concurrently. We aimed to estimate the proximal change in BMI associated with start of medication and to assess whether medication-specific departures in BMI varied by age and sex.

STUDY DESIGN

We analysed longitudinal electronic health records from children (4-19 years) with an ADHD diagnosis seen at one healthcare system (2011-2018). Their BMI z-scores were fit as a cubic function of age via a mixed model, separately by sex and adjusting for race/ethnicity. From this model, we estimated annual changes in BMI-z after medication, allowing changes to vary by age and sex.

RESULTS

Among the 22 714 children with ADHD (mean initial age = 10.0), 4335 (19.1%) were never prescribed ADHD medication. The others (80.9%) experienced departures in BMI-z after start of all four medication classes, which varied across age and sex (interaction P-values < .01). All medications had larger impacts at younger ages. As expected, decreased BMI-z was observed with stimulants, while antidepressants and antipsychotics led to BMI-z increases; alpha-agonists also were associated with BMI-z increases.

CONCLUSIONS

This longitudinal study revealed that ADHD medications are independently associated with proximal changes in BMI-z after initiation, significantly varying by sex and age. Future research should study further the interactions of these medications on long-term impacts on obesity.

Eating behaviors and dietary quality in childhood acute lymphoblastic leukemia survivors

BACKGROUND

Childhood acute lymphoblastic leukemia (ALL) survivors' increased risk for adverse health outcomes could be mitigated through consuming a balanced diet. Nonetheless, >70% of adult survivors do not meet survivorship dietary recommendations. ALL treatment may amplify risk for restricted dietary preferences (picky eating) and poor self-regulation of food intake that could contribute to suboptimal diets in survivorship. This study aims to: (a) characterize differences in picky eating and self-regulation of food intake between survivors and peer controls; and (b) examine the associations between these eating behaviors and dietary quality in ALL survivors relative to peer controls.

METHODS

Participants were children (5-13 years) with (n = 32) and without (n = 32) a history of ALL and their caregivers. Children's dietary quality (Healthy Eating Index-2015) was calculated from 24-h dietary recalls. Caregivers completed the Child Eating Behavior Questionnaire-Food Fussiness subscale and the Child Self-Regulation in Eating Questionnaire.

RESULTS

Independent samples t-tests revealed survivors exhibited greater picky eating than peer controls but comparable self-regulation of food intake. Bootstrapped grouped multivariate regression results showed that for ALL survivors, greater picky eating was associated with worse dietary quality (controlling for age and self-regulation of food intake). For peer controls, worse self-regulation of food intake was associated with poorer dietary quality (controlling for picky eating and age).

CONCLUSIONS

Results provide preliminary support that different eating behaviors contribute to poor dietary quality in children with and without an ALL history. These findings suggest that interventions to improve ALL survivors' dietary quality may benefit targeting picky eating.

Behavioral Weight Loss Intervention Preferences of Adolescents with Overweight/Obesity

Background: Behavioral lifestyle interventions are the foundation of adolescent obesity treatment. Tailoring an intervention using adolescent stakeholder engagement during the development process could improve intervention effectiveness. Methods: Adolescents with overweight/obesity ages 14-19 (n = 41) participated in 11 sex-specific focus groups (girls = 6, boys = 5) and were asked their preferences regarding who should lead the intervention and be involved, what the messaging of the program should be, how to make the program engaging and maintain participation, and how to best measure nutrition intake and activity. Transcripts were coded and analyzed for emergent themes. Results: Mean age was 16.0 ± 1.8 years and participants were racially/ethnically diverse. Adolescents preferred interventions that avoid a focus on "weight loss," and instead emphasize "healthy lifestyle," which represents a more comprehensive goal of targeting physical and mental well-being. Most participants indicated preferences for a relatable instructor with prior weight loss experience. Both sexes preferred optional parental involvement, as some parents were described as helpful, while others were perceived as a hindrance to success. Boys and girls identified incentives, engaging activities, and electronic communication as core components for engagement and retention, with girls emphasizing socialization and building relationships. Sex differences in preferences were observed. Girls had more concerns about intervention participation and preferred interventions to be sex stratified. Conclusions: Behavioral interventions to treat adolescent obesity should focus messaging/content on healthy lifestyles, rather than weight loss, and be sex stratified. Development and implementation of future behavioral interventions for adolescent obesity should consider tailoring to adolescent preferences when possible to improve feasibility, acceptability, and effectiveness.

The Relationship Between Executive Functioning, Type 1 Diabetes Self-Management Behaviors, and Glycemic Control in Adolescents and Young Adults

PURPOSE OF REVIEW

Understanding barriers to self-management behaviors and glycemic stability may inform specific needs for behavior change in adolescents and young adults with type 1 diabetes (T1D). The current review aims to systematically synthesize the literature on the relationships between executive functioning, self-management, and A1C in adolescents and young adults with T1D. Fifteen studies were retained in the current review. Study quality assessment for the majority of the studies were "Fair" or "Good."

RECENT FINDINGS

This review highlights several advances in research design, including use of longitudinal designs, data from multiple informants, and use of objective measures. Adolescents and young adults reported that more executive functioning weaknesses were related to decreased self-management behaviors and higher A1C. The current review demonstrated that self-perceived executive functioning weaknesses negatively impact self-management behaviors and A1C. Future research is needed to determine the utility of objective measures in assessing the relationships between executive functioning, T1D self-management, and A1C.

Latent Profiles of Health Behaviors in Rural Children with Overweight and Obesity

OBJECTIVE

The objectives were to identify profiles of school-age children with overweight and obesity (OW/OB) from rural counties based on patterns of diet, activity, and sleep, to examine demographic predictors, and to examine whether profiles were differentially associated with psychosocial functioning.

METHODS

Participants included 163 children (Mage = 9.8) and parents. Children wore accelerometers to assess physical activity and sleep duration. Consumption of fruits and vegetables (F/V) and sugar-sweetened beverages (SSB) was assessed with a food frequency questionnaire. Self-report of emotional, social, and academic health-related quality of life (HRQOL), peer victimization, social skills, and social problem behaviors was collected, as well as parent-report of HRQOL. Latent variable mixture modeling (LVMM) was conducted.

RESULTS

Sleep did not significantly contribute to profile differentiation and was removed. Four profiles emerged: (a) Low F/V + Low SSB + Low activity, (b) Low F/V + Low SSB + Moderate activity, (c) High F/V + High SSB + Low activity, and (d) Moderate F/V + Moderate SSB + High activity. Older children were more likely to be in profile 1. After controlling for child age, parents of children in profile 1 reported significantly lower child social HRQOL than parents of children in profiles 2 and 4. Children in profile 4 reported experiencing significantly lower victimization than those in profile 3.

CONCLUSIONS

There are subgroups of rural children with OW/OB that engage in various combinations of healthy and unhealthy behaviors. LVMM has the potential to inform future interventions and identify needs of groups of children with OW/OB.

Youth safety perceptions of weight control behaviors: A moderated mediation study

BACKGROUND

Youth may engage in healthy weight control behaviors (HWCBs) and unhealthy weight control behaviors (UWCBs) to lose or maintain weight. Youth observation of WCBs by supporter groups (parents/siblings/peers) and youth beliefs about the safety of WCBs may impact which WCBs youth use. The primary aim of this study was to examine the mediating role of youth safety perceptions of WCBs on the relationships between supporter group engagement in WCBs and youth engagement in WCBs. Youth BMI-z-score was analyzed as a moderator.

METHODS

Participants were 219 youth (52.1% females), ages 10-17, attending an outpatient medical appointment. Participants completed questionnaires about their WCB use, whether they perceived WCBs as safe/unsafe, and whether they perceived parents, siblings and peers to use WCBs. A standardized formula including youth age, sex, height, and weight was used to calculate BMI-z-score.

RESULTS

A moderated mediation model examining parental and youth engagement in UWCBs revealed that for youth in the healthy to overweight/obese (OV/OB) range, greater safety perception of UWCBs mediated the relationship between higher parent engagement in UWCBs and higher youth engagement in UWCBs. Furthermore, youth safety perception of HWCBs mediated the relationship between perceived parent, sibling, and peer engagement in HWCBs and youth engagement in HWCBs.

CONCLUSION

This study identifies perceived parent, sibling, and peer WCBs and youth safety perceptions as mechanisms affecting youth WCB engagement, particularly for youth in the OV/OB range. Intervention effectiveness may increase if parent, sibling, and peer WCBs are targeted and education about safe/unsafe ways to control weight is provided.

The use of internet sources for nutritional information is linked to weight perception and disordered eating in young adolescents

The internet serves as an accessible and confidential resource for young adolescents seeking nutritional information. However, the quality of information retrieved online is mixed and could have serious implications for users. Young adolescents who perceive themselves as overweight may be disproportionately affected as they are at greater risk for disordered eating. The current study aimed to (1) assess whether the frequency of use of different internet sources to obtain nutritional information differs between healthy weight young adolescents and those with overweight/obesity based on both objective and perceived weight status and (2) evaluate the relationships between different internet sources utilized for nutritional information and disordered eating. Young adolescents (n = 167; 10-15 years) completed the Children's Eating Attitudes Test (ChEAT; total disordered eating), indicated their perceived weight status, and reported how often they obtained nutritional information from the following internet sources: professional websites, personal websites, social media, commercial weight loss websites, and forums. Objective height and weight measurements were obtained. Young adolescents that perceived themselves to be a little overweight or overweight reported greater use of personal websites (p = .012), commercial weight loss websites (p = .011), and social media (p = .019) for nutritional information than those that did not perceive themselves to be a little overweight or overweight. The frequency of use of internet sources for nutritional information did not differ based on objective weight status. Greater use of each of the internet sources for nutritional information was related to greater disordered eating (p's < 0.05). While longitudinal research is needed to further examine these relationships, healthcare providers and teachers should provide young adolescents with guidance for interpreting and using online nutritional information to encourage valid and reliable health recommendations.

Perceived barriers/facilitators to a healthy lifestyle among diverse adolescents with overweight/obesity: A qualitative study

Objective

Effectiveness of behavioural obesity treatments in adolescents is modest. Thus, incorporating participant feedback may lead to improvement of intervention acceptability. This qualitative study's objective was to assess perceived barriers/facilitators to weight loss and healthy lifestyles among diverse adolescents with overweight/obesity (OW/OB).

Methods

Adolescents ages 14-19 with BMI ≥ 85th percentile participated in focus groups and identified perceived barriers/facilitators to weight loss and healthy lifestyles.

Results

Ten sex-stratified focus groups (n = 41; n = 13 males, n = 28 females) were conducted in 2018 and 2019. Females reported experiencing weight struggles, whereas males often stated no struggles with weight, despite all participants meeting criterion for OW/OB. Barriers included eating behaviours, family members and internal motivation, with additional barriers of physical activity, friends, time and support cited in females. Facilitators included parental, familial and peer support of healthy eating and exercise, modelling behaviours, internal motivation and organized sports. Two additional findings regarding adolescents' perceived barriers/facilitators include substantial overlap and sex differences of perceived barriers/facilitators.

Conclusions

Adolescent males and females with OW/OB experience weight status differently, affecting their perceived barriers/facilitators to weight loss and healthy lifestyles. Tailoring weight management interventions to the unique needs of adolescent females versus adolescent males has the potential to improve intervention quality and effectiveness.

Use of Ecological Momentary Assessment to Measure Self-Monitoring of Blood Glucose Adherence in Youth With Type 1 Diabetes

OBJECTIVE

Daily self-monitoring of blood glucose (SMBG) is essential for type 1 diabetes management yet is challenging during adolescence. Ecological momentary assessment (EMA) is the repeated sampling of behaviors and experiences in real time in the natural environment. The purpose of this study was to evaluate 1) the validity of self-reported SMBG values via text message-delivered EMA surveys compared with objective SMBG values via glucose meters and 2) in-the-moment motivators and barriers to performing SMBG in a pediatric type 1 diabetes population.

METHODS

Youth (n = 62, aged 11-21 years) with type 1 diabetes received three text messages daily for 10 days containing surveys inquiring about SMBG engagement. Objective SMBG values were downloaded from glucose meters.

RESULTS

On average, participants reported performing SMBG 4 times/day. Of the self-reported SMBG values, 39.6% were accurate. Inaccurate values included additions (i.e., self-reported value with no objective value), omissions (i.e., objective value with no self-reported value), and alterations (difference between self-report and objective SMBG values ≥10 mg/dL). Of the matched pairs of self-reported and objective SMBG values, 41.3% were altered. Bland-Altman plots determined that the mean difference between self-reported and objective glucose data were -5.43 mg/dL. Participants reported being motivated to check their blood glucose because it was important for their health, and reported barriers included wanting to ignore the task, forgetting, and not having devices.

CONCLUSION

Youth's self-reported SMBG values may not align with objective readings. The results of this study can facilitate future research to determine individual factors related to SMBG and accuracy of self-reporting.

Featured Article: Behavior Interventions Addressing Obesity in Rural Settings: The E-FLIP for Kids Trial

OBJECTIVE

To assess the effectiveness of behavioral parent-only (PO) and family-based (FB) interventions on child weight, dietary intake, glycated hemoglobin, and quality of life in rural settings.

METHODS

This study was a three-armed, randomized controlled trial. Participants were children (age 8-12 years) with overweight or obesity and their parents. A FB (n = 88), a PO (n = 78) and a health education condition (HEC) (n = 83) each included 20 group contacts over 1 year. Assessment and treatment contacts occurred at Cooperative Extension Service offices. The main outcome was change in child body mass index z-score (BMIz) from baseline to year 2.

RESULTS

Parents in all conditions reported high treatment satisfaction (mean of 3.5 or higher on a 4-point scale). A linear mixed model analysis of change in child BMIz from baseline to year 1 and year 2 found that there were no significant group by time differences in child BMIz (year 2 change in BMIz for FB = -0.03 [-0.1, 0.04], PO = -0.01 [-0.08, 0.06], and HEC = -0.09 [-0.15, -0.02]). While mean attendance across conditions was satisfactory during months 1-4 (69%), it dropped during the maintenance phase (42%). High attendance for the PO intervention was related to greater changes in child BMIz (p < .02). Numerous barriers to participation were reported.

CONCLUSION

Many barriers exist that inhibit regular attendance at in-person contacts for many families. Innovative delivery strategies are needed that balance treatment intensity with feasibility and acceptability to families and providers to facilitate broad dissemination in underserved rural settings.ClinicalTrials.gov Identifier: NCT01820338.

Effect of Telehealth Extended Care for Maintenance of Weight Loss in Rural US Communities: A Randomized Clinical Trial

IMPORTANCE

Lifestyle interventions for obesity produce reductions in body weight that can decrease risk for diabetes and cardiovascular disease but are limited by suboptimal maintenance of lost weight and inadequate dissemination in low-resource communities.

OBJECTIVE

To evaluate the effectiveness of extended care programs for obesity management delivered remotely in rural communities through the US Cooperative Extension System.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted from October 21, 2013, to December 21, 2018, in Cooperative Extension Service offices of 14 counties in Florida. A total of 851 individuals were screened for participation; 220 individuals did not meet eligibility criteria, and 103 individuals declined to participate. Of 528 individuals who initiated a 4-month lifestyle intervention, 445 qualified for randomization. Data were analyzed from August 22 to October 21, 2019.

INTERVENTIONS

Participants were randomly assigned to extended care delivered via individual or group telephone counseling or an education control program delivered via email. All participants received 18 modules with posttreatment recommendations for maintaining lost weight. In the telephone-based interventions, health coaches provided participants with 18 individual or group sessions focused on problem solving for obstacles to the maintenance of weight loss.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in body weight from the conclusion of initial intervention (month 4) to final follow-up (month 22). An additional outcome was the proportion of participants achieving at least 10% body weight reduction at follow-up.

RESULTS

Among 445 participants (mean [SD] age, 55.4 [10.2] years; 368 [82.7%] women; 329 [73.9%] white), 149 participants (33.5%) were randomized to individual telephone counseling, 143 participants (32.1%) were randomized to group telephone counseling, and 153 participants (34.4%) were randomized to the email education control. Mean (SD) baseline weight was 99.9 (14.6) kg, and mean (SD) weight loss after the initial intervention was 8.3 (4.9) kg. Mean weight regains at follow-up were 2.3 (95% credible interval [CrI], 1.2-3.4) kg in the individual telephone counseling group, 2.8 (95% CrI, 1.4-4.2) kg for the group telephone counseling group, and 4.1 (95% CrI, 3.1-5.0) kg for the education control group, with a significantly smaller weight regain observed in the individual telephone counseling group vs control group (posterior probability >.99). A larger proportion of participants in the individual telephone counseling group achieved at least 10% weight reductions (31.5% [95% CrI, 24.1%-40.0%]) than in the control group (19.1% [95% CrI, 14.1%-24.9%]) (posterior probability >.99).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that providing extended care for obesity management in rural communities via individual telephone counseling decreased weight regain and increased the proportion of participants who sustained clinically meaningful weight losses.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02054624.

Pre-surgical stress and social support predict post-surgical percent excess weight loss in a population of bariatric surgery patients

Although bariatric surgery is an effective treatment of morbid obesity, many patients fail to lose significant weight or regain weight over time. This study examined pre-surgical psychosocial predictors (stress, social support for healthy eating, emotion regulation, and sleep quality/quantity) of three-month post-surgical percent excess weight loss (EWL) in a population of adult bariatric surgery patients. Overall, findings suggest higher levels of stress (B = -.248, p =.017) and less social support for healthy eating (B =.311, p =.013) predict lower three-month post-surgery percent EWL. Emotion regulation, and sleep measures did not predict post-surgery percent EWL. Therefore, level of stress and social support should be assessed prior to bariatric surgery and considered important pre-surgical intervention targets.

Cost-Effectiveness of Three Doses of a Behavioral Intervention to Prevent or Delay Type 2 Diabetes in Rural Areas

BACKGROUND

Rural Americans have higher prevalence of obesity and type 2 diabetes (T2D) than urban populations and more limited access to behavioral programs to promote healthy lifestyle habits. Descriptive evidence from the Rural Lifestyle Intervention Treatment Effectiveness trial delivered through local cooperative extension service offices in rural areas previously identified that behavioral modification with both nutrition education and coaching resulted in a lower program delivery cost per kilogram of weight loss maintained at 2-years compared with an education-only comparator intervention.

OBJECTIVE

This analysis extended earlier Rural Lifestyle Intervention Treatment Effectiveness trial research regarding weight loss outcomes to assess whether nutrition education with behavioral coaching delivered through cooperative extension service offices is cost-effective relative to nutrition education only in reducing T2D cases in rural areas.

DESIGN

A cost-utility analysis was conducted.

PARTICIPANTS/SETTING

Trial participants (n=317) from June 2008 through June 2014 were adults residing in rural Florida counties with a baseline body mass index between 30 and 45, but otherwise identified as healthy.

INTERVENTION

Trial participants were randomly assigned to low, moderate, or high doses of behavioral coaching with nutrition education (ie, 16, 32, or 48 sessions over 24 months) or a comparator intervention that included 16 sessions of nutrition education without coaching. Participant glycated hemoglobin level was measured at baseline and the end of the trial to assess T2D status.

MAIN OUTCOME MEASURES

T2D categories by treatment arm were used to estimate participants' expected annual health care expenditures and expected health-related utility measured as quality adjusted life years (ie, QALYs) over a 5-year time horizon. Discounted incremental costs and QALYs were used to calculate incremental cost-effectiveness ratios for each behavioral coaching intervention dose relative to the education-only comparator.

STATISTICAL ANALYSES PERFORMED

Using a third-party payer perspective, Markov transition matrices were used to model participant transitions between T2D states. Replications of the individual participant behavior were conducted using Monte Carlo simulation.

RESULTS

All three doses of the behavioral coaching intervention had lower expected total costs and higher estimated QALYs than the education-only comparator. The moderate dose behavioral coaching intervention was associated with higher estimated QALYs but was costlier than the low dose; the moderate dose was favored over the low dose with willingness to pay thresholds over $107,895/QALY. The low dose behavioral coaching intervention was otherwise favored.

CONCLUSIONS

Because most rural Americans live in counties with cooperative extension service offices, nutrition education with behavioral coaching programs similar to those delivered through this trial may be effective and efficient in preventing or delaying T2D-associated consequences of obesity for rural adults.

Subjective social status in adolescents with asthma: Psychosocial and physical health outcomes

OBJECTIVE

Asthma prevalence and morbidity are disproportionately higher among youth with lower socioeconomic status (SES). Examination of subjective social status (SSS) may improve understanding of associations between SES and health outcomes in pediatric asthma.

METHOD

Fifty adolescents with asthma (Mage = 13.2 years, SD = 1.23; 54% male; 55.1% African American) completed the MacArthur Scale of Subjective Social Status-Youth Version, Daily Life Stressors Scale, Children's Depression Inventory-Short Form, Adolescent Sleep-Wake Scale-short version, and Asthma Control Test during the baseline visit of a study of health behaviors. Body mass index z scores (BMIz) were calculated using height and weight obtained during the visits. Hierarchical linear regressions examined associations between SSS and psychosocial and physical health outcomes, controlling for caregiver-reported objective SES.

RESULTS

Caregiver-reported objective SES was not associated with adolescent SSS. SSS-society was associated with daily stress (b = -3.14), t(47) = -2.13, p = .033; asthma control (β = .34, p = .045); BMIz (β = .38, p = .013); and sleep quality (β = .49, p = .001). SSS-community was associated with daily stress (b = -3.76), t(46) = -3.07, p = .002, and sleep quality (β = .36, p = .010). SSS was not associated with depressive symptoms.

CONCLUSIONS

Adolescents' SSS may not always reflect caregiver's objective SES. Perceived social status may play a role in the experience of daily stress, asthma control, BMIz, and sleep quality among adolescents with asthma. SSS may offer a novel means of assessing health disparities in pediatric asthma. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Executive Function and Dysregulated Eating Behaviors in Pediatric Obesity

Objective

To examine the association between caregiver proxy report of executive function (EF) and dysregulated eating behavior in children with obesity.

Methods

Participants were 195 youth with obesity aged 8-17 years, and their legal guardians. Youth height, weight, demographics, depressive symptoms, eating behaviors, and EF were assessed cross-sectionally during a medical visit. Analyses of covariance, adjusted for child age, gender, race/ethnicity, standardized BMI, depressive symptoms, and family income were used to examine differences in youth EF across caregiver and youth self-report of eating behaviors.

Results

Youth EF differed significantly by caregiver report of eating behavior but not youth self-report. Post hoc analyses showed that youth with overeating or binge eating had poorer EF than youth without these eating behaviors.

Conclusions

Executive dysfunction, as reported by caregivers, in youth with obesity may be associated with dysregulated eating behaviors predictive of poor long-term psychosocial and weight outcomes. Further consideration of EF-specific targets for assessment and intervention in youth with obesity may be warranted.

Mother and Father Controlling Feeding Behaviors and Associations With Observed Mealtime Family Functioning

Objective

Mealtime family functioning is important in shaping health behaviors associated with overweight/obesity, particularly for preschool-aged children. Parental controlling feeding behaviors (i.e., restriction and pressure to eat), may impact mealtime family functioning and thus be targets of prevention and intervention efforts. The current study aimed to address literature gaps by examining both mother and father self-reports of controlling feeding behaviors, and the discrepancies between parents’ reports. Further, the study examined the associations among controlling feeding behaviors and objective mealtime family functioning in a community sample of preschool-aged children.

Methods

The sample included 27 children between 2 and 6 years of age and their immediate family members. Two mealtimes were videotaped for each family and coded for family functioning using the Mealtime Interaction Coding System, and self-reports of feeding practices were collected using the Child Feeding Questionnaire.

Results

Mother controlling feeding behaviors were not significantly related to any mealtime family functioning domain. Father controlling feeding behaviors were only significantly related to interpersonal involvement. However, discrepancies in the use of controlling feeding behaviors accounted for nearly one fourth of the variance in overall family functioning and affect management, with greater discrepancies being related to poorer family functioning.

Conclusions

Interventions may be designed to reduce parental discrepancies in the use of controlling feeding behaviors. Future research should consider longitudinal design, using larger, more representative samples, to better understand the impact of parental controlling feeding behaviors, particularly the impact of parental discrepancies in these areas, on mealtime family functioning and subsequent health outcomes.

Family functioning mediates the relationship between child behavior problems and parent feeding practices in youth with overweight or obesity

Parental feeding practices play a significant role in children's health behaviors. Given the high prevalence of childhood obesity, it is important to examine factors that may influence parental feeding practices. This study examined the role of family functioning on the relationship between child behavior problems and parent feeding practices. We hypothesized that higher problematic child behavior would correlate with lower parental engagement in healthy parent feeding practices, with greater family dysfunction mediating that relationship. Participants (n = 220) were rural-dwelling parents of school-aged children with overweight or obesity. Participants completed the McMaster Family Assessment Device, Child Behavior Checklist (CBCL), and Child Feeding Questionnaire at baseline. Mediation models were used with youth behavioral problems (CBCL) as the independent variable, parental feeding practices as the dependent variable, and family functioning as the mediator. Two significant mediation models revealed (a) family functioning mediated the relationship between child behavior problems and parental perception of responsibility taking for child eating, and (b) family functioning mediated the relationship between child behavior problems and parental monitoring of their child's eating. More child behavior problems were associated with unhealthier family functioning, which was associated with less parental monitoring of children's unhealthy food intake and reduced responsibility taking for feeding and meal planning of their children. These findings suggest the synergistic effect of child behavior problems with poorer family functioning may be a risk factor for unhealthy parent feeding practices in children with overweight or obesity. If these relationships are supported by longitudinal research, behavior interventions for children with obesity should consider poor family functioning and child behavior as potential barriers to parental monitoring and responsibility of children's feeding practices.

Parent perceptions of restrictive feeding on the relationship between youth BMI z-score and weight control behavior use in African American youth: A mediational study

BACKGROUND

Children with higher body weights engage in more healthy weight control behaviors (HWCBs) and unhealthy weight control behaviors (UWCBs) compared to healthy weight peers. Parent restrictive feeding (parental attempts to limit what and how much children eat in an effort to manage youth weight) has also been associated with youth weight. However, there is limited research on parental feeding practices among non-Caucasian samples, despite evidence that parental feeding may function differently across races. Therefore, the current study aimed to examine the mediating role of parent restrictive feeding on the relationship between youth body mass index (BMI) z-score and youth use of HWCBs and UWCBs among African American youth.

METHODS

Measures were completed by youth (ages 10-13 years) and their parents at a pediatric primary-care appointment. Youth completed a weight control behavior questionnaire asking youth to answer whether or not they have engaged in specific behaviors to lose weight. Parents completed a questionnaire on parent-feeding practices. Youth height and weight were obtained from their medical records.

RESULTS

Mediation models revealed parent restrictive feeding significantly mediated the relationship between youth BMI z-score and HWCB use, but not between youth BMI z-score and UWCB use.

CONCLUSION

Results from the current study suggest parent restrictive feeding in African American populations may encourage health promoting youth weight management behaviors. Additional research is warranted to investigate how cultural factors may impact the relationships between parent restrictive feeding practices and youth weight control behaviors as there may be important clinical implications when working with diverse populations.

Impact of Child and Maternal Weight on Healthcare Trainee Clinical Assessment Decision Making: A Virtual Human Study

BACKGROUND

Adult literature documents that healthcare providers rely on patient characteristics, such as age, race, and weight, when making clinical decisions. However, little research has examined these biases among pediatric populations. This study aimed to examine the impact of child and maternal weight and race on clinical decision-making of healthcare trainees in the context of a pediatric pain assessment using standardized virtual pediatric patients and mothers.

METHODS

Ninety-two healthcare trainees read a standardized clinical vignette describing a child with chronic pain, which was accompanied by eight virtual human (VH) scenes-each with a child and mother. Scenes varied by the dyad's race, child's weight status, and mother's weight status. For each scene, participants were asked to make six healthcare assessment ratings.

RESULTS

Participants rated children (M = 42.44 vs. 48.69; p < 0.001) and mothers (M = 51.06 vs. 65.31; p < 0.001) with obesity as being less likely to adhere to physician recommendations compared with healthy weight children and mothers. Child patients with obesity (M = 38.88 vs. 30.08; p < 0.001) and mothers with obesity (M = 49.71 vs. 43.71; p < 0.001) were also rated as bearing more responsibility for the child's health status compared with healthy weight peers.

CONCLUSIONS

This study provides evidence that child and mother weight can impact clinical decision-making, as well as for the utility of VH technology in studying decision-making among healthcare trainees and providers.

Objectively measured pediatric obesity prevalence using the OneFlorida Clinical Research Consortium

We characterized the prevalence of obesity among Florida children 2-19years old using electronic health records (EHRs). The obesity prevalence for 331,641 children was 16.9%. Obesity prevalence at 6-11years (19.5%) and 12-19years (18.9%) were approximately double the prevalence of obesity among children 2-5years (9.9%). The highest prevalence of severe obesity occurred in rural Florida (21.7%) and non-Hispanic children with multiple races had the highest obesity prevalence (21.1%) across all racial/ethnic groups. Our results highlight EHR as a low-cost alternative to estimate the prevalence of obesity and severe obesity in Florida children, both overall and within subpopulations.

Using Virtual Human Technology to Examine Weight Bias and the Role of Patient Weight on Student Assessment of Pediatric Pain

The purpose of the study was to investigate the influence of weight bias and demographic characteristics on the assessment of pediatric chronic pain. Weight status, race, and sex were manipulated in a series of virtual human (VH) digital images of children. Using a web-based platform, 96 undergraduate students with health care-related majors (e.g., Health Science, Nursing, Biology, and Pre-Medicine) read a clinical vignette and provided five ratings targeting the assessment of each VH child's pain. Students also answered a weight bias questionnaire. Group-based analyses were conducted to determine the influence of the VH child's weight and demographic cues, as well as greater weight bias on assessment ratings. Male and VH children with obesity were rated as more likely to avoid non-preferred activities due to pain compared to female and healthy weight children, respectively (both p < .001). The pain of VH children with obesity was rated as more likely to be influenced by psychological/behavioral issues compared to the pain of healthy weight VH children (p = .022). African American VH children were rated as experiencing significantly greater pain than Caucasian VH children (p = .037). As child weight increased, low weight bias participants felt more sympathy, while high weight bias participants felt less sympathy (p = .002). Also, low weight bias participants showed increased motivation to help, while high weight bias participants showed less motivation to help, as VH patient weight increased (p = .008). Child weight and evaluator weight bias may be influential in the assessment of pediatric pain. If supported by future research, results highlight the importance of training in evidence-based practice and education on weight bias for students majoring in health-care fields.

A Behavioral Family Intervention for Children with Overweight and Asthma

Objective

The Childhood Health and Asthma Management Program (CHAMP) is a behavioral family lifestyle intervention for youth with overweight or obesity (OV/OB) and asthma. This pilot randomized controlled trial examined the feasibility, acceptability, and preliminary efficacy of CHAMP.

Methods

A sample of 24 children (M_age = 8.67) with asthma and a BMI ≥ 85^th percentile and their caregivers participated in a pilot randomized controlled trial. Families were recruited from local pediatrician offices and pediatric pulmonary and allergy clinics and randomized to CHAMP or a health education attention control condition. Children's height, weight, lung function, asthma control, and asthma-related quality of life (QOL) were collected at baseline, post-intervention, and 6-months post-treatment. Analysis of covariance and standardized mean differences were used to assess changes in outcome variables among participants attending > 50% of sessions (n = 12).

Results

Families participating in CHAMP reported high satisfaction; however, there were a number of barriers to recruitment and regular session attendance. There were no statistically significant between group differences at post-intervention or long-term follow-up. From baseline to post-intervention, there were small to large effect sizes favoring CHAMP for BMI z-scores, asthma control, and measures of lung function. There were small to medium effect sizes favoring CHAMP at long-term follow-up for BMI z-scores, asthma control, and asthma-related QOL.

Conclusions

CHAMP had adequate acceptability in this trial. We did not find significant results favoring CHAMP in comparison to the control group, however, lessons learned provide important directions for modifications in anticipation of a larger trial.

Applying Interactive Mobile health to Asthma Care in Teens (AIM2ACT): Development and design of a randomized controlled trial

Early adolescents have difficulties performing asthma self-management behaviors, placing them at-risk for poor asthma control and reduced quality of life. This paper describes the development and plans for testing an interactive mobile health (mHealth) tool for early adolescents, ages 12-15years, and their caregivers to help improve asthma management. Applying Interactive Mobile health to Asthma Care in Teens (AIM2ACT) is informed by the Pediatric Self-management model, which posits that helpful caregiver support is facilitated by elucidating disease management behaviors and allocating treatment responsibility in the family system, and subsequently engaging in collaborative caregiver-adolescent asthma management. The AIM2ACT intervention was developed through iterative feedback from an advisory board composed of adolescent-caregiver dyads. A pilot randomized controlled trial of AIM2ACT will be conducted with 50 early adolescents with poorly controlled asthma and a caregiver. Adolescent-caregiver dyads will be randomized to receive the AIM2ACT smartphone application (AIM2ACT app) or a self-guided asthma control condition for a 4-month period. Feasibility and acceptability data will be collected throughout the trial. Efficacy outcomes, including family asthma management, lung function, adolescent asthma control, asthma-related quality of life, and self-efficacy for asthma management, will be collected at baseline, post-treatment, and 4-month follow-up. Results from the current study will inform the utility of mHealth to foster the development of asthma self-management skills among early adolescents.

Psychometric properties of the Kids' Child Feeding Questionnaire-Restriction

BACKGROUND

Research exploring parental restrictive feeding is mixed and shows that it both negatively and positively affects children's dietary intake. One hypothesis for these inconsistent findings is the use of parent-report vs. youth-report measures of parental restrictive feeding, but there are limited psychometrically-sound youth-report measures of this construct. Therefore, the current study aims to evaluate the psychometric properties of a measure of parent restrictive feeding practices, the Kids' Child Feeding Questionnaire-Restriction (KCFQ-R), from the youth perspective.

METHODS

The 7-item, youth-report KCFQ-R is composed of the restriction subscale from the Kids' Child Feeding Questionnaire. This measure was completed by 225 youth attending a primary care appointment.

RESULTS

Initial exploratory factor analysis and communalities yielded a single factor solution explaining 39.93% of the variability in the data. Internal consistency using the seven items was .73. The KCFQ-R demonstrated external validity through its significant relationship with parent concern about child overweight.

CONCLUSIONS

Results provide preliminary support that the KCFQ-R is a psychometrically sound and reliable measure of youth-reported parental restrictive feeding practices. Given the mixed research on the effects of parent-reported parental feeding restriction on various child outcomes, this youth-report measure may help clarify these relationships. Future research should examine youth-report measures of other parent feeding domains.

The Role of Child and Adolescent Adjustment Problems and Sleep Disturbance in Parent Psychological Distress

The goal of this study was to examine the moderating role of youth sleep disturbance on the relationship between youth internalizing and externalizing symptoms and parent psychological distress. Participants were 225 youth (ages 8-17) and parent dyads attending a primary care clinic appointment. Participants completed questionnaires that assessed parent psychological distress, youth internalizing symptoms, youth externalizing symptoms, and youth sleep disturbance. Moderation analyses were conducted to examine whether youth sleep disturbance moderated the relationship between youth internalizing and externalizing symptoms and parent psychological distress. The interaction between youth internalizing symptoms and youth sleep disturbance was significantly related to parent psychological distress, such that having increased sleep disturbance amplified the positive relationship between internalizing symptoms and parent psychological distress. The moderation model explained 52% of the variance in parent psychological distress. The interaction between youth externalizing symptoms and youth sleep disturbance was also significantly related to parent psychological distress, such that increased sleep disturbance amplified the positive relationship between externalizing symptoms and parent psychological distress. This model accounted for 53% of the variance in parent psychological distress. Greater youth sleep disturbance strengthens the positive relationship between youth internalizing/externalizing symptoms and parent psychological distress. Accordingly, reducing youth sleep disturbance may serve as an appropriate intervention target in families experiencing increased parent psychological distress.

Influence of asthma status on sleep variability in overweight/obese youth

OBJECTIVE

Pediatric asthma and overweight/obesity (OV/OB) frequently co-occur and youth with both conditions exhibit poor sleep/bedtime habits. This study assessed differences in week-to-weekend bedtime/wake time variability among OV/OB youth with/without comorbid asthma, and tested whether variability predicted weekday sleep.

METHODS

OV/OB youth (n = 142; 28% comorbid asthma; 7-12 years) wore an Accelerometer for 5 days (2 weekend days), providing estimates of week-to-weekend bedtime/wake-time variability, weekday Total Sleep Time (TST), weekday time in bed (TIB), and weekday wake after sleep onset (WASO).

RESULTS

There were no demographic differences between groups beyond lower family income for the OV/OB+asthma group. The OV/OB+asthma group exhibited later weekday (mean OV/OB+asthma = 10:39 pm, mean OV/OB only = 10:30pm) and weekend (mean OV/OB+asthma = 11:41 pm, mean OV/OB only = 11:17pm) bedtimes, earlier weekday waketimes (mean OV/OB+asthma = 6:40 am, mean OV/OB only = 6:51 am), and similar weekend waketimes (mean OV/OB+asthma = 7:54 pm, mean OV/OB only = 7:52 pm. Univariate MANOVA follow-ups indicated a main effect of asthma group for week-to-weekend bedtime and waketime variability, with the OV/OB+asthma group evidencing approximately 30 minutes greater bedtime (OV/OB+asthma mean = 90 minutes) and waketime (OV/OB+asthma mean = 108 minutes) variability. Within the OV/OB+asthma group, greater waketime variability predicted fewer minutes of weekday TIB and WASO. Within the OV/OB only group, wake time variability predicted fewer minutes of weekday TIB.

CONCLUSION

Findings suggest that asthma status confers risk for more week-to-weekend variability among currently OV/OB youth, and that greater variability shortens the weekday sleep period. Further research on reasons for greater week-to-weekend sleep variability in asthma is needed.

Youth internalizing symptoms, sleep-related problems, and disordered eating attitudes and behaviors: A moderated mediation analysis

PURPOSE

Internalizing symptoms increase the risk for disordered eating; however, the mechanism through which this relationship occurs remains unclear. Sleep-related problems may be a potential link as they are associated with both emotional functioning and disordered eating. The present study aims to evaluate the mediating roles of two sleep-related problems (sleep disturbance and daytime sleepiness) in the relationship between youth internalizing symptoms and disordered eating, and to explore if age moderates these relations.

METHODS

Participants were 225 youth (8-17years) attending a primary care appointment. Youth and legal guardians completed questionnaires about youth disordered eating attitudes and behaviors, internalizing symptoms, sleep disturbance, and daytime sleepiness. Mediation and moderated mediation analyses were utilized.

RESULTS

The mediation model revealed both youth sleep disturbance and daytime sleepiness independently mediated the association between internalizing symptoms and disordered eating attitudes and behaviors, and explained 18% of the variance in disordered eating. The moderated mediation model including youth age accounted for 21% of the variance in disordered eating; youth age significantly interacted with sleep disturbance, but not with daytime sleepiness, to predict disordered eating. Sleep disturbance only mediated the relationship between internalizing symptoms and disordered eating in youth 12years old and younger, while daytime sleepiness was a significant mediator regardless of age.

CONCLUSION

As sleep-related problems are frequently improved with the adoption of health behaviors conducive to good sleep, these results may suggest a relatively modifiable and cost-effective target to reduce youth risk for disordered eating.

The effects of media, self-esteem, and BMI on youth's unhealthy weight control behaviors

PURPOSE

Youth engage in a variety of methods to manage their weight, including unhealthy weight control behaviors (UWCBs). The purpose of this study was to examine factors associated with youth's engagement in UWCBs, including media influence, youth's BMI z-score and self-esteem.

METHODS

Participants were 179 youth, aged 10-17, attending a primary care clinic appointment. Youth completed questionnaires assessing frequency of UWCBs, global self-worth, and perception of media influence to lose weight. BMI z-score was calculated based on height and weight measurements obtained from medical charts. The SPSS macro, PROCESS, was used to conduct moderation analyses.

RESULTS

Over 40% of youth endorsed using at least one UWCB in the past year. Girls reported using more UWCBs and engaging in UWCBs more frequently than boys. For boys, media influence to lose weight was only related to UWCB frequency for those with a BMI z-score of 1.23 and above. For girls, media influence was only related to UWCB frequency for those with low to average levels of global self-worth.

CONCLUSIONS

Girls' and boys' use of UWCBs is impacted by different factors. Prevention efforts should consider targeting factors, such as weight status and self-esteem, which are uniquely associated with gender.

Temporal Associations Between Sleep and Physical Activity Among Overweight/Obese Youth

OBJECTIVE

Examine average interindividual and temporal intraindividual associations between time of sleep onset (sleep onset), total sleep time (TST), and minutes in moderate-to-very-vigorous physical activity per hour (MVPA/h) among overweight/obese youth.

METHODS

Overweight/obese youth (n = 134; 7-12 years) wore an accelerometer for 16+ hr/day, 5-7 days, which provided daily objective estimates of MVPA/h, TST, and sleep onset.

RESULTS

Multilevel models revealed an intraindividual effect of TST, such that nights with longer TST preceded less MVPA/h during the midnight-to-midnight monitoring period; a significant random effect qualified this relationship. Average interindividual TST did not predict mean MVPA/h, whereas sleep onset significantly predicted mean MVPA/h.

CONCLUSIONS

Later time of sleep onset (as opposed to TST) was the strongest predictor of group-level decreased physical activity. At the individual level, longer TST than usual predicted less MVPA/h than usual. Results suggest the need for more person-centered research and a greater focus on sleep timing among youth.

The Moderating Role of Body Dissatisfaction in the Relationship between ADHD Symptoms and Disordered Eating in Pediatric Overweight and Obesity

BACKGROUND

Identifying factors linked to disordered eating in overweight and obesity (OV/OB) may provide a better understanding of youth at risk for disordered eating. This project examined whether ADHD symptoms and body dissatisfaction were associated with disordered eating.

METHODS

ADHD symptoms, disordered eating, and body dissatisfaction were assessed in 220 youth ages 7-12 who were OV/OB.

RESULTS

Multiple linear regressions showed that body dissatisfaction and ADHD symptoms were associated with disordered eating.

DISCUSSION

Children with ADHD symptoms and OV/OB may be at greater risk for disordered eating when highly dissatisfied with their bodies. Healthcare providers should assess body image and disordered eating in youth with comorbid OV/OB and ADHD.