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Golden NH, Kapphahn CJ, Cheng J, Kreiter A, Downey AE, Accurso EC, Machen VI, Adams SH, Buckelew SM, Moscicki AB, Le Grange D, Garber AK. Course and outcome in individuals with atypical anorexia nervosa: Findings from the Study of Refeeding to Optimize iNpatient Gains (StRONG). Int J Eat Disord 2024; 57:799-808. [PMID: 37507351 PMCID: PMC10822019 DOI: 10.1002/eat.24029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023]
Abstract
OBJECTIVE We previously reported that participants with atypical anorexia nervosa (atypical AN) had higher historical and admission weights, greater eating disorder psychopathology, but similar rates of amenorrhea and weight suppression at baseline as compared to anorexia nervosa (AN); here, we compare 1-year outcomes. METHOD Weight, % median body mass index (%mBMI), Eating Disorder Examination Questionnaire (EDE-Q) scores, resumption of menses, and rehospitalizations were examined at 3, 6, and 12 months post-discharge. Analyses (N = 111) compared changes in %mBMI, weight suppression, and EDE-Q scores over time between atypical AN and AN. RESULTS Among the participants (48 atypical AN, 63 AN), both groups gained weight but those with atypical AN had lower gains than those with AN in %mBMI (p = .02) and greater weight suppression (p = .002) over time. EDE-Q scores improved over time, independent of weight suppression, with no significant difference between atypical AN and AN. Groups did not differ by rates of resumption of menses (80% atypical AN, 76.9% AN) or rehospitalization (29.2% atypical AN, 37.9% AN). Greater weight suppression predicted longer time to restore menses and more days of rehospitalization. DISCUSSION Individuals with atypical AN regained a smaller proportion of body mass and were more weight suppressed over time. Change in eating disorder cognitions, resumption of menses, and rehospitalization rates at 1-year follow-up did not differ between groups. There was no significant difference in weight suppression between groups for those who were psychologically improved at 12 months. Findings highlight limitations in our understanding of weight recovery in atypical AN. New metrics for recovery are urgently needed. PUBLIC SIGNIFICANCE Little is known about outcome in atypical anorexia nervosa (atypical AN). We examined recovery metrics in young people with atypical AN and anorexia nervosa (AN) 1 year after medical hospitalization. Individuals with atypical AN showed slower weight gain and remained further from their pre-illness weight. There were no differences in the rates of psychological recovery, resumption of menses, or rehospitalization. New metrics are needed to assess recovery in atypical AN.
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Affiliation(s)
- Neville H Golden
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University, Stanford, California, USA
| | - Cynthia J Kapphahn
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University, Stanford, California, USA
| | - Jing Cheng
- Department of Preventive & Restorative Dental Sciences, University of California, San Francisco, California, USA
| | - Anna Kreiter
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University, Stanford, California, USA
| | - Amanda E Downey
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Erin C Accurso
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Vanessa I Machen
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Sally H Adams
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Sara M Buckelew
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Anna-Barbara Moscicki
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, Los Angeles, California, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
- Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois, USA
| | - Andrea K Garber
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
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Garber AK, Cheng J, Accurso EC, Buckelew SM, Downey AE, Le Grange D, Gorrell S, Kapphahn CJ, Kreiter A, Moscicki AB, Golden NH. Short-term outcomes of the study of refeeding to optimize inpatient gains for patients with atypical anorexia nervosa. Int J Eat Disord 2024; 57:859-868. [PMID: 38179719 DOI: 10.1002/eat.24115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE The StRONG trial demonstrated the safety and efficacy of higher calorie refeeding (HCR) in hospitalized adolescents and young adults with malnutrition secondary to restrictive eating disorders. Here we compare refeeding outcomes in patients with atypical anorexia nervosa (atypical AN) versus anorexia nervosa (AN) and examine the impact of caloric dose. METHOD Patients were enrolled upon admission and randomized to meal-based HCR, beginning 2000 kcal/day and advancing 200 kcal/day, or lower calorie refeeding (LCR), beginning 1400 kcal/day and advancing 200 kcal every other day. Atypical AN was defined as %median BMI (mBMI) > 85. Independent t-tests compared groups; multivariable linear and logistic regressions examined caloric dose (kcal/kg body weight). RESULTS Among n = 111, mean ± SD age was 16.5 ± 2.5 yrs; 43% had atypical AN. Compared to AN, atypical AN had slower heart rate restoration (8.7 ± 4.0 days vs. 6.5 ± 3.9 days, p = .008, Cohen's d = -.56), less weight gain (3.1 ± 5.9%mBMI vs. 5.4 ± 2.9%mBMI, p < .001, Cohen's d = .51) and greater hypomagnesemia (29% vs. 11%, p = .03, OR = 3.29). These suboptimal outcomes were predicted by insufficient caloric dose (32.4 ± 6.9 kcal/kg in atypical AN vs. 43.4 ± 9.8 kcal/kg in AN, p < .001, Cohen's d = 1.27). For every 10 kcal/kg increase, heart rate was restored 1.7 days (1.0, 2.5) faster (p < .001), weight gain was 1.6%mBMI (.8, 2.4) greater (p < .001), and hypomagnesemia odds were 70% (12, 128) lower (p = .02). DISCUSSION Although HCR is more efficacious than LCR for refeeding in AN, it contributes to underfeeding in atypical AN by providing an insufficient caloric dose relative to the greater body weight in this diagnostic group. PUBLIC SIGNIFICANCE The StRONG trial previously demonstrated the efficacy and safety of higher calorie refeeding in patients with malnutrition due to restrictive eating disorders. Here we show that higher calorie refeeding contributes to underfeeding in patients with atypical anorexia nervosa, including poor weight gain and longer time to restore medical stability. These findings indicate these patients need more calories to support nutritional rehabilitation in hospital.
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Affiliation(s)
- Andrea K Garber
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Jing Cheng
- Department of Preventive and Restorative Dental Sciences, University of California, San Francisco, California, USA
| | - Erin C Accurso
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Sara M Buckelew
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Amanda E Downey
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
- Department of Psychiatry and Behavioral Neuroscience, The University of Chicago (Emeritus), Chicago, Illinois, USA
| | - Sasha Gorrell
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Cynthia J Kapphahn
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, Los Angeles, California, USA
| | - Anna Kreiter
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, Los Angeles, California, USA
| | - Anna-Barbara Moscicki
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, Los Angeles, California, USA
| | - Neville H Golden
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University, Stanford, California, USA
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Nagata JM, Vargas R, Sanders AE, Stuart E, Downey AE, Chaphekar AV, Nguyen A, Ganson KT, Buckelew SM, Garber AK. Clinical characteristics of hospitalized male adolescents and young adults with atypical anorexia nervosa. Int J Eat Disord 2024; 57:1008-1019. [PMID: 38205657 PMCID: PMC11018472 DOI: 10.1002/eat.24132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/22/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVE To describe the clinical characteristics of male adolescents and young adults hospitalized for medical complications of atypical anorexia nervosa (atypical AN) and to compare their clinical characteristics with females with atypical AN and males with anorexia nervosa (AN). METHOD A retrospective review of electronic medical records for patients with atypical AN and AN aged 9-25 admitted to the UCSF Eating Disorders Program from May 2012 to August 2020 was conducted. RESULTS Among 21 males with atypical AN (mean age 15.1 ± 2.7, mean %mBMI 102.0 ± 11.8), medical complications evidenced by admission laboratory values included anemia (52.9%), vitamin D insufficiency/deficiency (52.6%), and zinc deficiency (31.6%). Compared with females with atypical AN (n = 69), males with atypical AN had longer length of stay (11.4 vs 8.4 days, p = .004), higher prescribed kcal at discharge (4114 vs 3045 kcal, p < .001), lower heart rate nadir (40.0 vs 45.8, p = .038), higher aspartate transaminase (AST, 37.9 vs 26.2 U/L, p = .032), higher alanine transaminase (ALT, 30.6 vs 18.3 U/L, p = .005), and higher rates of anemia (52.9% vs 19.4%, p = .005), with no differences in vitamin D, zinc, and vital signs. Compared with males with AN (n = 40), males with atypical AN had no significant differences in vital signs or laboratory assessments during the hospitalization. DISCUSSION Atypical AN in males leads to significant medical comorbidity, and males with atypical AN require longer hospital stays compared to females with atypical AN. Rates of abnormal vital signs and abnormal serum laboratory values during hospital admissions do not differ in males with atypical AN compared to AN. PUBLIC SIGNIFICANCE Adolescent and young adult males with atypical anorexia nervosa experience significant medical complications. Males with atypical anorexia nervosa had longer hospitalizations and higher prescribed nutrition at discharge than females. Medical complications of atypical anorexia nervosa in male adolescents and young adults were generally equal to those of male adolescents and young adults with anorexia nervosa. Clinicians should be aware of unique medical complications of males with atypical anorexia nervosa.
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Affiliation(s)
- Jason M. Nagata
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Ruben Vargas
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Austin E. Sanders
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Elena Stuart
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Amanda E. Downey
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Anita V. Chaphekar
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Anthony Nguyen
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Kyle T. Ganson
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Sara M. Buckelew
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Andrea K. Garber
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
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Downey AE, Odette M, Sanders AE, Kuykendall M, Saunders E, Nagata JM, Forsberg S, Buckelew SM, Garber AK. What medical providers need to elevate outpatient care for adolescents and young adults with binge-eating disorder: A novel protocol. Int J Eat Disord 2024; 57:294-302. [PMID: 38130097 DOI: 10.1002/eat.24110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/22/2023] [Accepted: 11/23/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE Binge-eating disorder (BED) in adolescents and young adults is underrecognized and understudied and no standardized guidelines exist for medical providers caring for this population. To highlight the lack of extant evidence, we examine the demographic characteristics of youth with BED in an academic eating disorders (EDs) program and primary care clinic and describe the needs of their medical care providers. METHOD A retrospective chart review was conducted for patients who met criteria for BED from July 2021 to June 2022. We surveyed their medical providers to understand their needs in caring for this population. A multidisciplinary team with expertise in the care of youth with EDs amalgamated current evidence in caring for youth with BED into a protocolized care schema designed for implementation in the outpatient medical setting. RESULTS Eighteen youth with BED were reviewed, 14 identified as female, 3 as male, and 1 as "Other." Average age was 15.4 (2.7) years old, and mean body mass index was 35.90 (8.25). 33.3% (6) patients identified as White/Caucasian, followed by 22.2% (4) Hispanic/Latinx. Eleven of 18 were privately insured. The most common medical recommendations were for regular meals and snacks and for individual psychotherapy. Medical providers desired more education about identification and management of youth with BED. CONCLUSIONS To address the lack of medical care guidelines for youth with BED, recommendations in this Forum include: increased education for medical providers, standardized medical monitoring, an emphasis on psychotherapy, and a weight-inclusive orientation. PUBLIC SIGNIFICANCE Adolescents and young adults with BED are underrecognized and undertreated. Little is known about the characteristics of these patients and the medical care these patients receive within academic EDs program. For the first time, preliminary recommendations for medical care are provided.
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Affiliation(s)
- Amanda E Downey
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Michelle Odette
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Austin E Sanders
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Mikayla Kuykendall
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Elizabeth Saunders
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Jason M Nagata
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Sarah Forsberg
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Sara M Buckelew
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Andrea K Garber
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
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Nagata JM, Chaphekar AV, Vargas R, Nguyen A, Downey AE, Patel KP, Ganson KT, Stuart E, Vendlinski S, Buckelew SM, Garber AK. Sex differences in cholesterol and triglyceride levels among hospitalized adolescents and young adults with eating disorders. Int J Eat Disord 2024; 57:184-194. [PMID: 37864342 PMCID: PMC10842641 DOI: 10.1002/eat.24072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 09/25/2023] [Accepted: 09/25/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVE To determine sex differences in cholesterol and triglyceride levels among adolescents and young adults hospitalized for medical complications of eating disorders. METHODS A retrospective electronic medical record review of patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical stabilization, between 2012 and 2020, was conducted. Non-fasting total cholesterol and triglycerides were collected; however, LDL and HDL levels were not available. RESULTS Among 83 males and 441 females, mean ± SD age was 15.5 ± 2.8 years, 64.1% had anorexia nervosa, and admission percent median body mass index was 87.3 ± 13.9. The proportion of males and females with high total cholesterol (13.3% vs. 18.1%, Cramer's V = 0.05, p = .28) and high triglyceride levels (9.6% vs. 8.1%, Cramer's V = 0.02, p = .63) did not differ. Mean total cholesterol levels were higher in females compared to males (F 169.6 ± 41.1 mg/dL vs. M 154.5 ± 45.1 mg/dL, Cohen's d = 0.36, p = .003), although a majority were within the normal range. In adjusted linear regression models, male (compared to female) sex (B = -14.40, 95% CI -24.54, -4.27) and higher percent median body mass index (B = -0.33, 95% CI -0.60, -0.06) were associated with lower total cholesterol levels in adjusted models (R2 = 0.04). DISCUSSION Building on prior work showing equally severe complications of eating disorders in males compared to females, we did not find sex differences in those presenting with high total cholesterol or triglycerides. Future research is needed to understand the pathophysiology and role of dyslipidemia in acute malnutrition, and the impact of nutritional rehabilitation and weight restoration. PUBLIC SIGNIFICANCE We found that the proportion of male and female adolescents and young adults hospitalized for medical complications of an eating disorder with high total cholesterol did not significantly differ. Although average total cholesterol levels were higher in female compared to male patients with eating disorders, a majority of these levels remained within the normal range. Patients with more severe malnutrition had a higher risk of elevated total cholesterol levels. Clinicians should consider monitoring cholesterol levels in young people hospitalized for restrictive eating disorders.
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Affiliation(s)
- Jason M. Nagata
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Anita V. Chaphekar
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Ruben Vargas
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Anthony Nguyen
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Amanda E. Downey
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Khushi P. Patel
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Kyle T. Ganson
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Elena Stuart
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Siena Vendlinski
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Sara M. Buckelew
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
| | - Andrea K. Garber
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503 San Francisco, CA 94143, USA
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Gorrell S, Vendlinski SS, Thompson AS, Downey AE, Kramer R, Hail L, Clifton S, Forsberg S, Reilly EE, Saunders E, Buckelew SM, Le Grange D. Modification of an inpatient medical management protocol for pediatric Avoidant/Restrictive Food Intake Disorder: improving the standard of care. J Eat Disord 2023; 11:165. [PMID: 37737186 PMCID: PMC10514937 DOI: 10.1186/s40337-023-00895-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/16/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND No guidelines currently exist that represent a standardization of care for Avoidant/Restrictive Food Intake Disorder (ARFID) on an inpatient service. Unique features of this diagnosis (e.g., sensory sensitivity contributing to involuntary emesis) suggest that established protocols that were developed for anorexia nervosa might be less effective for adolescents with ARFID. To inform improved inpatient medical stabilization and care for these patients, we first provide an overview of clinical characteristics for patients with ARFID who presented to a pediatric hospital for inpatient eating disorder care. We use these descriptives to outline the rationale for, and executions of, modifications to an inpatient protocol designed to flexibly meet the needs of this clinical population. METHODS Chart review with descriptive statistics were conducted for patients who had received an ARFID diagnosis from March 2019 to March 2023 (N = 32, aged 9-23). We then present a case series (n = 3) of adolescents who either transitioned to a novel adjusted protocol from an original standard of care on the inpatient service, or who received only the standard protocol. RESULTS The sample was aged M(SD) = 15.6 (3.3) years, 53% male, and a majority (69%) presented with the ARFID presentation specific to fear of negative consequences. On average, patients had deviated from their growth curve for just over two years and presented with mean 76% of their estimated body weight. Of those requiring nasogastric tube insertion during admission (n = 8, 25%), average duration of tube placement was 15 days. From within this sample, case series data suggest that the adjusted protocol will continue to have a positive impact on care trajectory among adolescents admitted for ARFID including improved weight gain, reduction of emesis, and improved food intake. CONCLUSIONS Findings demonstrate the likely need to tailor established medical inpatient protocols for those with ARFID given different symptom presentation and maintenance factors compared to patients with anorexia nervosa. Further research is warranted to explore the longer-term impact of protocol changes and to inform standardization of care for this high priority clinical population across care sites.
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Affiliation(s)
- Sasha Gorrell
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, 675 18th St., San Francisco, CA, 94143, USA.
| | - Siena S Vendlinski
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Arianna S Thompson
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Amanda E Downey
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, 675 18th St., San Francisco, CA, 94143, USA
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Rachel Kramer
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, 675 18th St., San Francisco, CA, 94143, USA
| | - Lisa Hail
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, 675 18th St., San Francisco, CA, 94143, USA
| | - Sharon Clifton
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Sarah Forsberg
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, 675 18th St., San Francisco, CA, 94143, USA
| | - Erin E Reilly
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, 675 18th St., San Francisco, CA, 94143, USA
| | - Elizabeth Saunders
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Sara M Buckelew
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, 675 18th St., San Francisco, CA, 94143, USA
- Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, IL, USA
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7
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Barney A, Mendez-Contreras S, Hills NK, Buckelew SM, Raymond-Flesch M. Telemedicine in an adolescent and young adult medicine clinic: a mixed methods study. BMC Health Serv Res 2023; 23:680. [PMID: 37349720 DOI: 10.1186/s12913-023-09634-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 06/02/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Adolescents and young adults are a diverse patient population with unique healthcare needs including sensitive and confidential services. Many clinics serving this population began offering telemedicine during the Covid-19 pandemic. Little is known regarding patient and parent experiences accessing these services via telemedicine. METHODS To assess for trends and disparities in telemedicine utilization in the first year of the pandemic, we used the electronic health record to obtain patient demographic data from an adolescent and young adult medicine clinic in a large urban academic institution. Characteristics of patients who had accessed telemedicine were compared to those who were only seen in person. Mean age was compared using t-test, while other demographic variables were compared using chi-squared test or Fisher's exact test. We performed qualitative semi-structured interviews with patients and parents of patients in order to characterize their experiences and preferences related to accessing adolescent medicine services via telemedicine compared to in-person care. RESULTS Patients that identified as female, white race, Hispanic/Latinx ethnicity were more likely to have utilized telemedicine. Telemedicine use was also more prevalent among patients who were privately insured and who live farther from the clinic. Although interview participants acknowledged the convenience of telemedicine and its ability to improve access to care for people with geographic or transportation barriers, many expressed preferences for in-person visits. This was based on desire for face-to-face interactions with their providers, and perception of decreased patient and parent engagement in telemedicine visits compared to in-person visits. Participants also expressed concern that telemedicine does not afford as much confidentiality for patients. CONCLUSIONS More work is needed to address patient and parent preferences for telemedicine as an adjunct modality to in-person adolescent and young adult medicine services. Optimizing quality and access to telemedicine for this patient population can improve overall healthcare for this patient population.
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Affiliation(s)
- Angela Barney
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, United States.
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California San Diego, San Diego, United States.
| | | | - Nancy K Hills
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco School of Medicine, San Francisco, United States
| | - Sara M Buckelew
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, United States
| | - Marissa Raymond-Flesch
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, United States
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, United States
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Chaphekar AV, Downey A, Garber AK, Kuykendall M, Bojorquez-Ramirez P, Ganson KT, Buckelew SM, Nagata JM. Eating disorders in sexual minority adolescents and young adults: examining clinical characteristics and psychiatric co-morbidities in an inpatient medical setting. J Eat Disord 2023; 11:32. [PMID: 36855189 PMCID: PMC9972849 DOI: 10.1186/s40337-023-00756-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 02/17/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Sexual minority adolescents and young adults are at higher risk of eating disorders compared to heterosexual peers. However, little is known about the clinical and psychiatric presentation of this population requiring inpatient medical stabilization. Given the increased risk for eating disorder behaviors in sexual minority individuals amidst increased rates of medical hospitalizations secondary to eating disorders, it is important to understand presenting characteristics of this population. The objectives of this study were to (1) describe the clinical characteristics of sexual minority adolescents and young adults with eating disorders admitted for medical instability and (2) compare psychiatric co-morbidities and suicidality of sexual minority adolescents and young adults to heterosexual peers. METHODS A retrospective chart review was conducted of 601 patients admitted to a large inpatient eating disorders medical stabilization unit between 2012 and 2020. Data collected included demographics, medical data including vital signs, and psychiatric characteristics. Chi square or t-tests were used to examine potential differences in clinical characteristics and psychiatric co-morbidities between groups. Modified Poisson regression was used to assess associations between sexual orientation and psychiatric co-morbidities. RESULTS Over one fifth (21.1%, n = 103) of our inpatient sample identified as a sexual minority individual. The average age of participants was 15.6 years (2.7). Sexual minority adolescents and young adults had higher percent median body mass index compared to heterosexual peers and yet equally severe vital sign instability on admission. Sexual minority adolescents and young adults were almost 1.5 times more likely to have a psychiatric comorbidity with higher rates of depression, anxiety, and post-traumatic stress disorder. Sexual minority adolescents and young adults were approximately two times more likely to have a history of self-injurious behaviors and/or suicidality. CONCLUSIONS Sexual minority adolescents and young adults with eating disorders have equally severe vital sign instability despite higher percent median body mass index on admission for medical stabilization. Sexual minority adolescents and young adults hospitalized for medical complications of eating disorders are far more likely to have an additional mental health disorder and a history of self-harm and/or suicidality, which may portend a less favorable long-term prognosis.
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Affiliation(s)
- Anita V Chaphekar
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503, San Francisco, CA, 94143, USA.
| | - Amanda Downey
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503, San Francisco, CA, 94143, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, 550 16th Street, Box 0503, San Francisco, CA, 94143, USA
| | - Andrea K Garber
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503, San Francisco, CA, 94143, USA
| | - Mikayla Kuykendall
- Nutrition and Food Services, San Francisco Medical Center, University of California, 1855 Fourth St, San Francisco, CA, 94143, USA
| | | | - Kyle T Ganson
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor St W, Toronto, ON, Canada
| | - Sara M Buckelew
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503, San Francisco, CA, 94143, USA
| | - Jason M Nagata
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0503, San Francisco, CA, 94143, USA
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Moreno R, Buckelew SM, Accurso EC, Raymond-Flesch M. Disparities in access to eating disorders treatment for publicly-insured youth and youth of color: a retrospective cohort study. J Eat Disord 2023; 11:10. [PMID: 36694235 PMCID: PMC9875472 DOI: 10.1186/s40337-022-00730-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 12/28/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Eating disorders are associated with substantial morbidity and mortality that can be minimized by timely access to evidence-based treatment. However, disparate access to eating disorders treatment may contribute to significant health disparities amongst marginalized groups. This study examined the association between insurance type (public vs. private) and receipt of recommended mental health treatment in a sample of racially/ethnically diverse youth who presented to an adolescent medicine clinic with malnutrition secondary to disordered eating. METHODS A retrospective chart review was conducted for youth ages 11-25 years (N = 1060) who presented to an urban adolescent medicine specialty program between June 1, 2012 and December 31, 2019 for malnutrition secondary to disordered eating. Bivariate and logistic regression analyses examined the association between insurance type (public vs. private) and other demographic/clinical factors on receipt of recommended treatment within six months of the initial evaluation. RESULTS Patients with public insurance were one third as likely to receive recommended treatment as patients with private insurance (AOR = 3.23; 95% CI = 1.99, 4.52), after adjusting for demographic and clinical factors. Latinx (AOR = 0.49; 95% CI = 0.31, 0.77) and Asian (AOR = 0.55; 95% CI = 0.32, 0.94) patients were half as likely to receive recommended treatment as White patients. CONCLUSIONS Access to evidence-based mental health treatment is a necessary first step towards health equity for individuals with eating disorders. Additional work is needed to dismantle systemic inequities that contribute to disparities in care for youth of color and those with public insurance.
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Affiliation(s)
- Ruby Moreno
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Sara M Buckelew
- Division of Adolescent & Young Adult Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Erin C Accurso
- Department of Psychiatry and Behavioral Sciences, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Marissa Raymond-Flesch
- Division of Adolescent & Young Adult Medicine, University of California, San Francisco, San Francisco, CA, USA. .,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA.
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10
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Nagata JM, Bojorquez-Ramirez P, Nguyen A, Ganson KT, McDonald CM, Machen VI, Downey A, Buckelew SM, Garber AK. Sex differences and associations between zinc deficiency and anemia among hospitalized adolescents and young adults with eating disorders. Eat Weight Disord 2022; 27:2911-2917. [PMID: 35624393 PMCID: PMC9556365 DOI: 10.1007/s40519-022-01396-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/18/2022] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To determine sex differences in and associations between zinc deficiency and anemia among adolescents and young adults hospitalized for medical complications of eating disorders. METHODS We retrospectively reviewed electronic medical records of 601 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical instability, between May 2012 and August 2020. Descriptive statistics, crude, and adjusted logistic regression models were used to assess the association between zinc deficiency (< 55 mcg/dL) and anemia (< 13.6 g/dL in males [M] and < 11.8 g/dL in females [F]). RESULTS A total of 87 males and 450 females met eligibility criteria (age 15.98 ± 2.81, 59.4% anorexia nervosa; admission body mass index 17.49 ± 2.82). In unadjusted comparisons, plasma zinc in males and females were not statistically different (M 64.88 ± 14.89 mcg/dL vs F 63.81 ± 13.96 mcg/dL, p = 0.517); moreover, there were no differences in the percentage of males and females with zinc deficiency (M 24.14% vs F 24.89%). However, a greater percentage of males than females were anemic (M 50.00% vs F 17.61%, p < 0.001), with similar findings in the subgroup with anorexia nervosa. In logistic regression models stratified by sex and eating disorder diagnosis, zinc deficiency was significantly associated with anemia in males (AOR 3.43, 95% CI 1.16, 10.13), but not females (AOR 1.47, 95% CI 0.86, 2.54). CONCLUSIONS For the first time, we demonstrate that zinc deficiency is equally severe in males compared to females hospitalized with medical complications from eating disorders, with nearly a quarter of inpatients experiencing zinc deficiency. Anemia is more common in males than females hospitalized with eating disorders. LEVEL OF EVIDENCE Level V: descriptive cross-sectional study.
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Affiliation(s)
- Jason M Nagata
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA.
| | | | - Anthony Nguyen
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
| | - Kyle T Ganson
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Christine M McDonald
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
| | - Vanessa I Machen
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
| | - Amanda Downey
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
| | - Sara M Buckelew
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
| | - Andrea K Garber
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
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Downey AE, Cheng J, Adams SH, Buckelew SM, Kapphahn CJ, Machen VI, Rosen EL, Moscicki AB, Golden NH, Garber AK. Renal Function in Patients Hospitalized With Anorexia Nervosa Undergoing Refeeding: Findings From the Study of Refeeding to Optimize Inpatient Gains. J Adolesc Health 2022; 71:432-437. [PMID: 35705423 PMCID: PMC10863996 DOI: 10.1016/j.jadohealth.2022.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/19/2022] [Accepted: 04/23/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Among complications of malnutrition secondary to anorexia nervosa (AN) or atypical anorexia nervosa (AAN), renal impairment remains poorly elucidated. Evaluating renal function in hospitalized pediatric patients with AN and AAN undergoing refeeding will yield important information to guide clinicians in screening and managing renal dysfunction in this population. METHODS This is a secondary analysis of data from the Study of Refeeding to Optimize Inpatient Gains trial, a multicenter randomized clinical trial comparing higher calorie refeeding versus lower calorie refeeding in 120 adolescents and young adults hospitalized with medical instability secondary to AN or AAN. Baseline disease characteristics were obtained. Vital sign measurements, weight, electrolytes, and fluid status were evaluated daily to ascertain medical stability. Renal function on admission and throughout hospitalization was quantified using daily creatinine measurement and calculation of the estimated glomerular filtration rate (eGFR) using the modified Schwartz equation. Regression analysis and mixed linear models were utilized to evaluate factors associated with eGFR. RESULTS Of the 111 participants who completed treatment protocol, 33% had a baseline eGFR less than 90, suggesting renal impairment. Patients who experienced more rapid weight loss and more severe bradycardia were more likely to have low admission eGFR. While eGFR improved during refeeding, eGFR change by day based on refeeding treatment assignment did not reach statistical significance (95% confidence interval, -1.61, 0.15]; p = .095). DISCUSSION Renal impairment is evident on admission in a significant number of adolescents and young adults hospitalized with AN and AAN. We demonstrate that short-term medical refeeding yields improvement in renal function.
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Affiliation(s)
- Amanda E Downey
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California; Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California.
| | - Jing Cheng
- Department of Preventive and Restorative Dental Sciences, University of California, San Francisco, California
| | - Sally H Adams
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California
| | - Sara M Buckelew
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California
| | - Cynthia J Kapphahn
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Vanessa I Machen
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California
| | - Elaine L Rosen
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles, California
| | - Anna-Barbara Moscicki
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles, California
| | - Neville H Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Andrea K Garber
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California
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12
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Nagata JM, Grandis A, Bojorquez-Ramirez P, Nguyen A, Downey AE, Ganson KT, Patel KP, Machen VI, Buckelew SM, Garber AK. Assessment of vitamin D among male adolescents and young adults hospitalized with eating disorders. J Eat Disord 2022; 10:104. [PMID: 35851069 PMCID: PMC9295348 DOI: 10.1186/s40337-022-00627-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/29/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Medical complications of eating disorders in males are understudied compared to females, as is the case of vitamin D deficiency. The aim of this study was to assess vitamin D levels among male and female adolescents and young adults hospitalized for medical complications of eating disorders. METHODS We retrospectively reviewed electronic medical records of patients aged 9-25 years (N = 565) admitted to the University of California, San Francisco Eating Disorders Program for medical instability, between May 2012 and August 2020. Serum vitamin D (25-hydroxy) level was assessed at admission as was history of prior calcium, vitamin D, or multivitamin supplementation. Linear regression was used to assess factors associated with vitamin D levels. RESULTS A total of 93 males and 472 females met eligibility criteria (age 15.5 ± 2.8, 58.8% anorexia nervosa; admission body mass index 17.6 ± 2.91). Among male participants, 44.1% had 25-hydroxyvitamin D levels < 30 ng/mL, 18.3% had 25-hydroxyvitamin D levels < 20 ng/mL, and 8.6% had 25-hydroxyvitamin D levels < 12 ng/mL. There were no significant differences in 25-hydroxyvitamin D levels in males compared to females, except that a lower proportion (1.9%) of female participants had 25-hydroxyvitamin D levels < 12 ng/mL (p = 0.001). Only 3.2% of males reported calcium or vitamin D-specific supplementation prior to hospital admission, while 8.6% reported taking multivitamins. White race, prior calcium/vitamin D supplementation, and higher calcium levels were associated with higher vitamin D levels on admission. CONCLUSIONS Nearly half of patients admitted to the hospital for malnutrition secondary to eating disorders presented with low 25-hydroxyvitamin D levels; males were more likely than females to have severe vitamin D deficiency. These findings support vitamin D assessment as part of the routine medical/nutritional evaluation for hospitalized eating disorder patients, with particular attention on male populations.
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Affiliation(s)
- Jason M Nagata
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA.
| | - Anna Grandis
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA
| | | | - Anthony Nguyen
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA
| | - Amanda E Downey
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Kyle T Ganson
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Khushi P Patel
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA
| | - Vanessa I Machen
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA
| | - Sara M Buckelew
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA
| | - Andrea K Garber
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA
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13
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Nagata JM, Bojorquez-Ramirez P, Nguyen A, Ganson KT, Machen VI, Cattle CJ, Buckelew SM, Garber AK. Sex differences in refeeding among hospitalized adolescents and young adults with eating disorders. Int J Eat Disord 2022; 55:247-253. [PMID: 34957571 PMCID: PMC8837601 DOI: 10.1002/eat.23660] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/12/2021] [Accepted: 12/13/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine sex differences in refeeding (i.e., short-term nutritional rehabilitation) outcomes among hospitalized adolescents and young adults with eating disorders. METHODS We retrospectively reviewed electronic medical records of 601 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical and nutritional management between May 2012 and August 2020. Descriptive statistics, crude, and adjusted linear regression models were used to assess the association between sex and nutritional outcomes and predictors of length of stay. RESULTS A total of 588 adolescents and young adults met eligibility criteria (16% male, mean [SD] age 15.96 [2.75], 71.6% anorexia nervosa, admission percent median body mass index [%mBMI] 87.1 ± 14.1). In unadjusted comparisons, there were no significant sex differences in prescribed kilocalories (kcal) per day at admission (2013 vs. 1980, p = .188); however, males had higher estimated energy requirements (EER, kcal) (3,694 vs. 2,925, p < .001). In linear regression models adjusting for potential confounders, male sex was associated with higher prescribed kcals at discharge (B = 835 kcal, p < .001), greater weight change (B = 0.47 kg, p = .021), and longer length of stay (B = 1.94 days, p = .001) than females. Older age, lower admission weight, lower prescribed kcal at admission, higher EER, and lower heart rate at admission were factors associated with longer length of stay in a linear regression model. DISCUSSION These findings support the development of individualized approaches for males with eating disorders to improve quality of care and health care efficiency among an underserved population.
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Affiliation(s)
- Jason M. Nagata
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA
| | | | - Anthony Nguyen
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA
| | - Kyle T. Ganson
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor St W, Toronto, ON, Canada
| | - Vanessa I. Machen
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA
| | - Chloe J. Cattle
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA
| | - Sara M. Buckelew
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA
| | - Andrea K. Garber
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA
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14
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Ford CA, Bourgeois F, Buckelew SM, Emans SJ, English A, Evans YN, Irwin CE, Richardson LP, Sherer S, Short S, Sieving RE, Simpson T, Tanaka D, White K. Twenty-First Century Cures Act Final Rule and Adolescent Health Care: Leadership Education in Adolescent Health (LEAH) Program Experiences. J Adolesc Health 2021; 69:873-877. [PMID: 34666958 DOI: 10.1016/j.jadohealth.2021.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Carol A Ford
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine/Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Fabienne Bourgeois
- Department of Pediatrics, Harvard Medical School/Boston Children's Hospital, Boston, Massachusetts
| | - Sara M Buckelew
- Department of Pediatrics, University of California at San Francisco/Benioff Children's Hospitals, San Francisco, California
| | - S Jean Emans
- Department of Pediatrics, Harvard Medical School/Boston Children's Hospital, Boston, Massachusetts
| | - Abigail English
- Center for Adolescent Health & the Law, Chapel Hill, North Carolina
| | - Yolanda N Evans
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Charles E Irwin
- Department of Pediatrics, University of California at San Francisco/Benioff Children's Hospitals, San Francisco, California
| | - Laura P Richardson
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Sara Sherer
- Department of Pediatrics, University of Southern California/Children's Hospital of Los Angeles, Los Angeles, California
| | - Sonja Short
- Department of Medical Informatics, University of Minnesota/Fairview Health System, Eagan, Minnesota
| | - Renee E Sieving
- School of Nursing and Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Tina Simpson
- Department of Pediatrics, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Diane Tanaka
- Department of Pediatrics, University of Southern California/Children's Hospital of Los Angeles, Los Angeles, California
| | - Krishna White
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine/Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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15
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Affiliation(s)
- Erin C. Accurso
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco
| | - Sara M. Buckelew
- Department of Pediatrics, University of California, San Francisco
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16
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Golden NH, Cheng J, Kapphahn CJ, Buckelew SM, Machen VI, Kreiter A, Accurso EC, Adams SH, Le Grange D, Moscicki AB, Sy AF, Wilson L, Garber AK. Higher-Calorie Refeeding in Anorexia Nervosa: 1-Year Outcomes From a Randomized Controlled Trial. Pediatrics 2021; 147:peds.2020-037135. [PMID: 33753542 PMCID: PMC8015147 DOI: 10.1542/peds.2020-037135] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES We recently reported the short-term results of this trial revealing that higher-calorie refeeding (HCR) restored medical stability earlier, with no increase in safety events and significant savings associated with shorter length of stay, in comparison with lower-calorie refeeding (LCR) in hospitalized adolescents with anorexia nervosa. Here, we report the 1-year outcomes, including rates of clinical remission and rehospitalizations. METHODS In this multicenter, randomized controlled trial, eligible patients admitted for medical instability to 2 tertiary care eating disorder programs were randomly assigned to HCR (2000 kcals per day, increasing by 200 kcals per day) or LCR (1400 kcals per day, increasing by 200 kcals every other day) within 24 hours of admission and followed-up at 10 days and 1, 3, 6, and 12 months post discharge. Clinical remission at 12 months post discharge was defined as weight restoration (≥95% median BMI) plus psychological recovery. With generalized linear mixed effect models, we examined differences in clinical remission over time. RESULTS Of 120 enrollees, 111 were included in modified intent-to-treat analyses, 60 received HCR, and 51 received LCR. Clinical remission rates changed over time in both groups, with no evidence of significant group differences (P = .42). Medical rehospitalization rates within 1-year post discharge (32.8% [19 of 58] vs 35.4% [17 of 48], P = .84), number of rehospitalizations (2.4 [SD: 2.2] vs 2.0 [SD: 1.6]; P = .52), and total number of days rehospitalized (6.0 [SD: 14.8] vs 5.1 [SD: 10.3] days; P = .81) did not differ by HCR versus LCR. CONCLUSIONS The finding that clinical remission and medical rehospitalization did not differ over 1-year, in conjunction with the end-of-treatment outcomes, support the superior efficacy of HCR as compared with LCR.
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Affiliation(s)
- Neville H. Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jing Cheng
- Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California, San Francisco, San Francisco, California
| | - Cynthia J. Kapphahn
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Sara M. Buckelew
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Vanessa I. Machen
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Anna Kreiter
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | | | - Sally H. Adams
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Daniel Le Grange
- Psychiatry and Behavioral Sciences,,Department of Psychiatry and Behavioral Neuroscience, School of Medicine, The University of Chicago, Chicago, Illinois; and
| | - Anna-Barbara Moscicki
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles, Los Angeles, California
| | - Allyson F. Sy
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Leslie Wilson
- Medicine, and Clinical Pharmacy, University of California, San Francisco, San Francisco, California
| | - Andrea K. Garber
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
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17
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Nagata JM, Thurston IB, Karazsia BT, Woolridge D, Buckelew SM, Murray SB, Calzo JP. Self-reported eating disorders and sleep disturbances in young adults: a prospective cohort study. Eat Weight Disord 2021; 26:695-702. [PMID: 32222955 PMCID: PMC7529665 DOI: 10.1007/s40519-020-00888-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 03/05/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To evaluate the prospective association between eating disorders, disordered eating behaviors, and sleep disturbances in young adults. METHODS We used prospective cohort data of young adults aged 18-26 from the National Longitudinal Study of Adolescent to Adult Health (N = 12,082). Self-reported exposures of interest (at 18-26 years) included (1) an eating disorder diagnosis proxy; disordered eating behaviors such as (2) restrictive eating behaviors including fasting/skipping meals, (3) compensatory behaviors including vomiting, laxatives/diuretics, or weight loss pills; and (4) loss of control/overeating. Self-reported sleep disturbances at 7-year follow-up included trouble falling or staying asleep. RESULTS In negative binomial regression models, all four exposures predicted both sleep disturbance outcomes at 7-year follow-up, when adjusting for demographic covariates and baseline sleep disturbances. When additionally adjusting for baseline depressive symptoms, the associations between eating disorder diagnosis proxies and trouble falling (incidence rate ratio [IRR] 1.24; 95% CI 1.05-1.46) and staying (IRR 1.16; 95% CI 1.01-1.35) asleep remained statistically significant; however, the associations between eating behaviors and sleep disturbances were attenuated. CONCLUSIONS Eating disorders in young adulthood predict sleep disturbances at 7-year follow-up. Young adults with eating disorders or who engage in disordered eating behaviors may be assessed for sleep disturbances. LEVEL III Evidence obtained from well-designed cohort or case-control analytic studies.
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Affiliation(s)
- Jason M Nagata
- Department of Pediatrics, University of California San Francisco, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA.
| | - Idia B Thurston
- Department of Psychological and Brain Sciences, Texas A&M University, College Station, TX, USA
| | - Bryan T Karazsia
- Department of Psychology, The College of Wooster, Wooster, OH, USA
| | - Daniel Woolridge
- Department of Pediatrics, University of California San Francisco, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
| | - Sara M Buckelew
- Department of Pediatrics, University of California San Francisco, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
| | - Stuart B Murray
- Department of Psychiatry & Behavioral Sciences, University of Southern California, Los Angeles, CA, USA
| | - Jerel P Calzo
- Division of Health Promotion and Behavioral Science, School of Public Health, San Diego State University, San Diego, CA, USA
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Garber AK, Cheng J, Accurso EC, Adams SH, Buckelew SM, Kapphahn CJ, Kreiter A, Le Grange D, Machen VI, Moscicki AB, Sy A, Wilson L, Golden NH. Short-term Outcomes of the Study of Refeeding to Optimize Inpatient Gains for Patients With Anorexia Nervosa: A Multicenter Randomized Clinical Trial. JAMA Pediatr 2021; 175:19-27. [PMID: 33074282 PMCID: PMC7573797 DOI: 10.1001/jamapediatrics.2020.3359] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE The standard of care for refeeding inpatients with anorexia nervosa, starting with low calories and advancing cautiously, is associated with slow weight gain and protracted hospital stay. Limited data suggest that higher-calorie refeeding improves these outcomes with no increased risk of refeeding syndrome. OBJECTIVE To compare the short-term efficacy, safety, and cost of lower-calorie vs higher-calorie refeeding for malnourished adolescents and young adults with anorexia nervosa. DESIGN, SETTING, AND PARTICIPANTS In this multicenter randomized clinical trial with prospective follow-up conducted at 2 inpatient eating disorder programs at large tertiary care hospitals, 120 adolescents and young adults aged 12 to 24 years hospitalized with anorexia nervosa or atypical anorexia nervosa and 60% or more of median body mass index were enrolled from February 8, 2016, to March 7, 2019. The primary analysis was a modified intent-to-treat approach. INTERVENTIONS Higher-calorie refeeding, beginning at 2000 kcal/d and increasing by 200 kcal/d vs lower-calorie refeeding, beginning at 1400 k/cal and increasing by 200 kcal every other day. MAIN OUTCOMES AND MEASURES Main outcomes were end-of-treatment outcomes; the primary end point of this trial will be clinical remission over 12 months. Short-term efficacy was defined a priori as time to restore medical stability in the hospital, measured by the following 6 indices: 24-hour heart rate of 45 beats/min or more, systolic blood pressure of 90 mm Hg or more, temperature of 35.6 °C or more, orthostatic increase in heart rate of 35 beats/min or less, orthostatic decrease in systolic blood pressure of 20 mm Hg or less, and 75% or more of median body mass index for age and sex. The prespecified safety outcome was incidence of electrolyte abnormalities; cost efficacy was defined as savings associated with length of stay. RESULTS Because 9 participants withdrew prior to treatment, the modified intention-to-treat analyses included 111 participants (93%; 101 females [91%]; mean [SD] age, 16.4 [2.5] years). Higher-calorie refeeding restored medical stability significantly earlier than lower-calorie refeeding (hazard ratio, 1.67 [95% CI, 1.10-2.53]; P = .01). Electrolyte abnormalities and other adverse events did not differ by group. Hospital stay was 4.0 days shorter (95% CI, -6.1 to -1.9 days) among the group receiving higher-calorie refeeding, which was associated with a savings of $19 056 (95% CI, -$28 819 to -$9293) in hospital charges per participant. CONCLUSIONS AND RELEVANCE In the first randomized clinical trial in the US to compare refeeding approaches in patients with anorexia nervosa and atypical anorexia nervosa, higher-calorie refeeding demonstrated short-term efficacy with no increase in safety events during hospitalization. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02488109.
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Affiliation(s)
- Andrea K. Garber
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Jing Cheng
- Department of Preventive and Restorative Dental Sciences, University of California, San Francisco
| | - Erin C. Accurso
- Department of Psychiatry and Behavioral Medicine, University of California, San Francisco
| | - Sally H. Adams
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Sara M. Buckelew
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Cynthia J. Kapphahn
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Anna Kreiter
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Daniel Le Grange
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco,Department of Psychiatry and Behavioral Medicine, University of California, San Francisco,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois (emeritus)
| | - Vanessa I. Machen
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Anna-Barbara Moscicki
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles
| | - Allyson Sy
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Leslie Wilson
- Department of Clinical Pharmacy, University of California, San Francisco
| | - Neville H. Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
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Vance SR, Buckelew SM, Dentoni-Lasofsky B, Ozer E, Deutsch MB, Meyers M. A Pediatric Transgender Medicine Curriculum for Multidisciplinary Trainees. MedEdPORTAL 2020; 16:10896. [PMID: 32352033 PMCID: PMC7187914 DOI: 10.15766/mep_2374-8265.10896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 11/22/2019] [Indexed: 06/11/2023]
Abstract
INTRODUCTION While pediatricians should receive training in the care of transgender youth, a paucity of formal educational curricula have been developed to train learners to care for this vulnerable population. METHODS We developed a curriculum including six online modules and an in-person afternoon session observing clinic visits in a pediatric gender clinic. Learners-fourth-year medical students, interns, and nurse practitioner trainees-received protected time during an adolescent medicine rotation to complete the online modules (total duration: 77 minutes). For 20 learners, we assessed the impact of the entire curriculum-online modules and in-person observation-on self-perceived knowledge of considerations for transgender youth. For 31 learners, we assessed the effect of the online modules alone on knowledge and self-efficacy. Descriptive analyses illustrated changes in educational domains by learner group. RESULTS On evaluations of the entire curriculum (modules and observation), median self-perceived knowledge scores (1 = not at all knowledgeable/aware, 5 = extremely knowledgeable/aware) increased within learner groups: pediatric interns (from 2.3 to 4.0), nurse practitioner trainees (from 2.9 to 4.7), fourth-year medical students (from 3.3 to 4.9), and psychiatry interns (from 2.8 to 4.4). Assessment of learners completing only the online modules demonstrated increases in median knowledge and self-efficacy scores within learner groups. All learner groups highly valued the curriculum. DISCUSSION Our curriculum for multidisciplinary learners in the care of transgender youth was successful and well received. Increasing learner knowledge and self-efficacy is an important step towards skill development in patient care for the transgender youth population.
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Affiliation(s)
- Stanley R. Vance
- Assistant Clinical Professor, Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, School of Medicine
| | - Sara M. Buckelew
- Professor, Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, School of Medicine
| | - Brian Dentoni-Lasofsky
- Psychiatric Nurse Practitioner, Department of Psychiatry, University of California, San Francisco, School of Medicine
| | - Elizabeth Ozer
- Professor, Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, School of Medicine
- Director, Faculty Equity Advisor Program, Office of Diversity and Outreach, University of California, San Francisco
| | - Madeline B. Deutsch
- Associate Professor, Department of Family Community Medicine, University of California, San Francisco, School of Medicine
| | - Matthew Meyers
- Fellow, Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, School of Medicine
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Garber AK, Cheng J, Accurso EC, Adams SH, Buckelew SM, Kapphahn CJ, Kreiter A, Le Grange D, Machen VI, Moscicki AB, Saffran K, Sy AF, Wilson L, Golden NH. Weight Loss and Illness Severity in Adolescents With Atypical Anorexia Nervosa. Pediatrics 2019; 144:peds.2019-2339. [PMID: 31694978 PMCID: PMC6889949 DOI: 10.1542/peds.2019-2339] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Lower weight has historically been equated with more severe illness in anorexia nervosa (AN). Reliance on admission weight to guide clinical concern is challenged by the rise in patients with atypical anorexia nervosa (AAN) requiring hospitalization at normal weight. METHODS We examined weight history and illness severity in 12- to 24-year-olds with AN (n = 66) and AAN (n = 50) in a randomized clinical trial, the Study of Refeeding to Optimize Inpatient Gains (www.clinicaltrials.gov; NCT02488109). Amount of weight loss was the difference between the highest historical percentage median BMI and admission; rate was the amount divided by duration (months). Unpaired t tests compared AAN and AN; multiple variable regressions examined associations between weight history variables and markers of illness severity at admission. Stepwise regression examined the explanatory value of weight and menstrual history on selected markers. RESULTS Participants were 16.5 ± 2.6 years old, and 91% were of female sex. Groups did not differ by weight history or admission heart rate (HR). Eating Disorder Examination Questionnaire global scores were higher in AAN (mean 3.80 [SD 1.66] vs mean 3.00 [SD 1.66]; P = .02). Independent of admission weight, lower HR (β = -0.492 [confidence interval (CI) -0.883 to -0.100]; P = .01) was associated with faster loss; lower serum phosphorus was associated with a greater amount (β = -0.005 [CI -0.010 to 0.000]; P = .04) and longer duration (β = -0.011 [CI -0.017 to 0.005]; P = .001). Weight and menstrual history explained 28% of the variance in HR and 36% of the variance in serum phosphorus. CONCLUSIONS Weight history was independently associated with markers of malnutrition in inpatients with restrictive eating disorders across a range of body weights and should be considered when assessing illness severity on hospital admission.
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Affiliation(s)
- Andrea K. Garber
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Jing Cheng
- Preventive and Restorative Dental Sciences
| | | | - Sally H. Adams
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Sara M. Buckelew
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Cynthia J. Kapphahn
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Anna Kreiter
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Daniel Le Grange
- Psychiatry, and,Professor Emeritus, Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois; and
| | - Vanessa I. Machen
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Anna-Barbara Moscicki
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles, Los Angeles, California
| | - Kristina Saffran
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Allyson F. Sy
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Leslie Wilson
- Clinical Pharmacy, University of California, San Francisco, San Francisco, California
| | - Neville H. Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
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Nagata JM, Garber AK, Buckelew SM. Weight restoration in atypical anorexia nervosa: A clinical conundrum. Int J Eat Disord 2018; 51:1290-1293. [PMID: 30488483 PMCID: PMC6295247 DOI: 10.1002/eat.22953] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/10/2018] [Accepted: 08/21/2018] [Indexed: 12/31/2022]
Abstract
The determination of the treatment goal weight for adolescents with a restrictive eating disorder (ED) and a prior history of obesity, such as in atypical anorexia nervosa (AAN), represents an ongoing challenge for clinicians. This determination is particularly complex given competing interests of physical recovery from significant weight loss, mental recovery from ED psychopathology, and the medical comorbidities associated with obesity. We report the case of a 15-year old female with a history of obesity and irregular periods who presented with significant weight loss and absence of menses for 3 months. She was hospitalized for severe malnutrition and bradycardia, initiated family based treatment, and regained periods. However, her vital sign instability and eating disorder cognitions did not resolve until she reached a weight at which point her periods again ceased due to polycystic ovary syndrome. This case highlights the need for regular monitoring during weight recovery and the clinical challenge of determining the treatment goal weight in adolescents with EDs and prior obesity.
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Affiliation(s)
- Jason M. Nagata
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Andrea K. Garber
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Sara M. Buckelew
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California
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Affiliation(s)
- Stanley R Vance
- Pediatrics Department; Division of Adolescent and Young Adult Medicine; University of California San Francisco; California USA
| | - Brian Lasofsky
- Psychiatry Department; University of California San Francisco; California USA
| | - Elizabeth Ozer
- Pediatrics Department; Division of Adolescent and Young Adult Medicine; Office of Diversity and Outreach; University of California San Francisco; California USA
| | - Sara M Buckelew
- Pediatrics Department; Division of Adolescent and Young Adult Medicine; University of California San Francisco; California USA
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Nagata JM, Buckelew SM. Mitochondrial Neurogastrointestinal Encephalomyopathy in the Differential Diagnosis of Eating Disorders. J Adolesc Health 2017; 61:661. [PMID: 28935389 DOI: 10.1016/j.jadohealth.2017.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 06/28/2017] [Indexed: 01/06/2023]
Affiliation(s)
- Jason M Nagata
- Division of Adolescent and Young Adult Medicine, University of California San Francisco, San Francisco, California
| | - Sara M Buckelew
- Division of Adolescent and Young Adult Medicine, University of California San Francisco, San Francisco, California
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24
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Vance SR, Deutsch MB, Rosenthal SM, Buckelew SM. Enhancing Pediatric Trainees' and Students' Knowledge in Providing Care to Transgender Youth. J Adolesc Health 2017; 60:425-430. [PMID: 28065519 DOI: 10.1016/j.jadohealth.2016.11.020] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/20/2016] [Accepted: 11/13/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE To enhance pediatric trainees' and students' knowledge of the psychosocial and medical issues facing transgender youth through a comprehensive curriculum. METHODS During the 2015-2016 academic year, we administered a transgender youth curriculum to fourth-year medical students, pediatric interns, psychiatry interns, and nurse practitioner students on their 1-month adolescent and young adult medicine rotation. The curriculum included six interactive, online modules and an observational experience in a multidisciplinary pediatric gender clinic. The online modules had a primary care focus with topics of general transgender terminology, taking a gender history, taking a psychosocial history, performing a sensitive physical examination, and formulating an assessment, psychosocial plan, and medical plan. At the completion of the curriculum, learners completed an evaluation that assessed change in perceived awareness and knowledge of transgender-related issues and learner satisfaction with the curriculum. RESULTS Twenty learners participated in the curriculum with 100% completing the curriculum evaluations, 100% reporting completing all six online modules, and 90% attending the gender clinic. Learners demonstrated a statistically significant improvement in all pre-post knowledge/awareness measures. On a Likert scale where 5 indicated very satisfied, learners' mean rating of the quality of the curriculum was 4.5 ± .7; quality of the modules was 4.4 ± .7; and satisfaction with the observational experience was 4.5 ± .8. CONCLUSIONS A comprehensive curriculum comprised interactive online modules and an observational experience in a pediatric gender clinic was effective at improving pediatric learners' perceived knowledge of the medical and psychosocial issues facing transgender youth. Learners also highly valued the curriculum.
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Affiliation(s)
- Stanley R Vance
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California.
| | - Madeline B Deutsch
- Department of Family Community Medicine, University of California, San Francisco, San Francisco, California
| | - Stephen M Rosenthal
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Sara M Buckelew
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California
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Whittle AE, Buckelew SM, Satterfield JM, Lum PJ, O'Sullivan P. Addressing Adolescent Substance Use: Teaching Screening, Brief Intervention, and Referral to Treatment (SBIRT) and Motivational Interviewing (MI) to Residents. Subst Abus 2015; 36:325-31. [DOI: 10.1080/08897077.2014.965292] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Amy E. Whittle
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Sara M. Buckelew
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Jason M. Satterfield
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Paula J. Lum
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Patricia O'Sullivan
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
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Forman SF, McKenzie N, Hehn R, Monge MC, Kapphahn CJ, Mammel KA, Callahan ST, Sigel EJ, Bravender T, Romano M, Rome ES, Robinson KA, Fisher M, Malizio JB, Rosen DS, Hergenroeder AC, Buckelew SM, Jay MS, Lindenbaum J, Rickert VI, Garber A, Golden NH, Woods ER. Predictors of outcome at 1 year in adolescents with DSM-5 restrictive eating disorders: report of the national eating disorders quality improvement collaborative. J Adolesc Health 2014; 55:750-6. [PMID: 25200345 DOI: 10.1016/j.jadohealth.2014.06.014] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 06/27/2014] [Accepted: 06/28/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The National Eating Disorders Quality Improvement Collaborative evaluated data of patients with restrictive eating disorders to analyze demographics of diagnostic categories and predictors of weight restoration at 1 year. METHODS Fourteen Adolescent Medicine eating disorder programs participated in a retrospective review of 700 adolescents aged 9-21 years with three visits, with DSM-5 categories of restrictive eating disorders including anorexia nervosa (AN), atypical AN, and avoidant/restrictive food intake disorder (ARFID). Data including demographics, weight and height at intake and follow-up, treatment before intake, and treatment during the year of follow-up were analyzed. RESULTS At intake, 53.6% met criteria for AN, 33.9% for atypical AN, and 12.4% for ARFID. Adolescents with ARFID were more likely to be male, younger, and had a longer duration of illness before presentation. All sites had a positive change in mean percentage median body mass index (%MBMI) for their population at 1-year follow-up. Controlling for age, gender, duration of illness, diagnosis, and prior higher level of care, only %MBMI at intake was a significant predictor of weight recovery. In the model, there was a 12.7% change in %MBMI (interquartile range, 6.5-19.3). Type of treatment was not predictive, and there were no significant differences between programs in terms of weight restoration. CONCLUSIONS The National Eating Disorders Quality Improvement Collaborative provides a description of the patient population presenting to a national cross-section of 14 Adolescent Medicine eating disorder programs and categorized by DSM-5. Treatment modalities need to be further evaluated to assess for more global aspects of recovery.
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Affiliation(s)
- Sara F Forman
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts.
| | - Nicole McKenzie
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Rebecca Hehn
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, Massachusetts
| | - Maria C Monge
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Cynthia J Kapphahn
- Division of Adolescent Medicine, Stanford University School of Medicine, Stanford, California
| | - Kathleen A Mammel
- Division of Adolescent Pediatrics, Beaumont Children's Hospital, Royal Oak, Michigan
| | - S Todd Callahan
- Division of Adolescent Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eric J Sigel
- Children's Hospital of Colorado, Section of Adolescent Medicine, University of Colorado, Aurora, Colorado
| | - Terrill Bravender
- Department of Pediatrics, The Ohio State University, Columbus, Ohio; Nationwide Children's Hospital, Columbus, Ohio
| | - Mary Romano
- Division of Adolescent Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ellen S Rome
- Section of Adolescent Medicine, Department of General Pediatrics, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Kelly A Robinson
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Martin Fisher
- Division of Adolescent Medicine, Steven and Alexandra Cohen Children's Medical Center, North Shore-Long Island Jewish Health System, New Hyde Park, New York; Department of Pediatrics, Hofstra North Shore-Long Island Jewish School of Medicine, Hempstead, New York
| | - Joan B Malizio
- Division of Adolescent Medicine, Steven and Alexandra Cohen Children's Medical Center, North Shore-Long Island Jewish Health System, New Hyde Park, New York
| | - David S Rosen
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Albert C Hergenroeder
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Sara M Buckelew
- Department of Pediatrics, University of California, San Francisco, California
| | - M Susan Jay
- Division of Adolescent Medicine, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | | | | | - Andrea Garber
- Division of Adolescent Medicine, University of California San Francisco, San Francisco, California
| | - Neville H Golden
- Division of Adolescent Medicine, Stanford University School of Medicine, Stanford, California
| | - Elizabeth R Woods
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
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Satterfield JM, Bereknyei S, Hilton JF, Bogetz AL, Blankenburg R, Buckelew SM, Chen HC, Monash B, Ramos JS, Rennke S, Braddock CH. The prevalence of social and behavioral topics and related educational opportunities during attending rounds. Acad Med 2014; 89:1548-57. [PMID: 25250747 PMCID: PMC4213280 DOI: 10.1097/acm.0000000000000483] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
PURPOSE To quantify the prevalence of social and behavioral sciences (SBS) topics during patient care and to rate team response to these topics once introduced. METHOD This cross-sectional study used five independent raters to observe 80 inpatient ward teams on internal medicine and pediatric services during attending rounds at two academic hospitals over a five-month period. Patient-level primary outcomes-prevalence of SBS topic discussions and rate of positive responses to discussions-were captured using an observational tool and summarized at the team level using hierarchical models. Teams were scored on patient- and learner-centered behaviors. RESULTS Observations were made of 80 attendings, 83 residents, 75 interns, 78 medical students, and 113 allied health providers. Teams saw a median of 8.0 patients per round (collectively, 622 patients), and 97.1% had at least one SBS topic arise (mean = 5.3 topics per patient). Common topics were pain (62%), nutrition (53%), social support (52%), and resources (39%). After adjusting for team characteristics, the number of discussion topics raised varied significantly among the four services and was associated with greater patient-centeredness. When topics were raised, 38% of teams' responses were positive. Services varied with respect to learner- and patient-centeredness, with most services above average for learner-centered, and below average for patient-centered behaviors. CONCLUSIONS Of 30 SBS topics tracked, some were addressed commonly and others rarely. Multivariable analyses suggest that medium-sized teams can address SBS concerns by increasing time per patient and consistently adopting patient-centered behaviors.
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Affiliation(s)
- Jason M Satterfield
- Dr. Satterfield is professor of clinical medicine, Division of General Internal Medicine, University of California, San Francisco, San Francisco, California. Dr. Bereknyei is a research scholar, Stanford Center for Medical Education Research and Innovation, Stanford University, Stanford, California. Dr. Hilton is professor, Division of Biostatistics, University of California, San Francisco, San Francisco, California. Ms. Bogetz is project coordinator, Division of General Internal Medicine, University of California, San Francisco, San Francisco, California. Dr. Blankenburg is clinical assistant professor, General Pediatrics, Stanford University, Stanford, California. Dr. Buckelew is associate clinical professor, Department of Pediatrics, University of California, San Francisco, San Francisco, California. Dr. Chen is professor, Department of Pediatrics, University of California, San Francisco, San Francisco, California. Dr. Monash is assistant professor, Division of Hospital Medicine, University of California, San Francisco, San Francisco, California. Ms. Ramos is program coordinator, Stanford Center for Medical Education Research and Innovation, Stanford University, Stanford, California. Dr. Rennke is assistant professor, Division of Hospital Medicine, University of California, San Francisco, San Francisco, California. Dr. Braddock is vice dean for medical education, University of California, Los Angeles, Los Angeles, California
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Forman SF, Grodin LF, Graham DA, Sylvester CJ, Rosen DS, Kapphahn CJ, Callahan ST, Sigel EJ, Bravender T, Peebles R, Romano M, Rome ES, Fisher M, Malizio JB, Mammel KA, Hergenroeder AC, Buckelew SM, Golden NH, Woods ER. An eleven site national quality improvement evaluation of adolescent medicine-based eating disorder programs: predictors of weight outcomes at one year and risk adjustment analyses. J Adolesc Health 2011; 49:594-600. [PMID: 22098769 DOI: 10.1016/j.jadohealth.2011.04.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 04/27/2011] [Accepted: 04/28/2011] [Indexed: 11/16/2022]
Abstract
PURPOSE This quality improvement project collected and analyzed short-term weight gain data for patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED programs nationally. METHODS Data on presentation and treatment of low-weight ED patients aged 9-21 years presenting in 2006 were retrospectively collected from 11 independent ED programs at intake and at 1-year follow-up. Low-weight was defined as < 90% median body weight (MBW) which is specific to age. Treatment components at each program were analyzed. Risk adjustment was performed for weight gain at 1 year for each site, accounting for clinical variables identified as significant in bivariate analyses. RESULTS The sites contained 6-51 patients per site (total N = 267); the mean age was 14.1-17.1 years; duration of illness before intake was 5.7-18.6 months; % MBW at intake was 77.5-83.0; and % MBW at follow-up was 88.8-93.8. In general, 40%-63% of low weight ED subjects reached ≥90% MBW at 1-year follow-up. At intake, patients with higher % MBW (p = .0002) and shorter duration of illness (p = .01) were more likely to be ≥90% MBW at follow-up. Risk-adjusted odds ratios controlled for % MBW and duration of illness were .8 (.5, 1.4)-1.3 (.3, 3.8), with no significant differences among sites. CONCLUSION A total of 11 ED programs successfully compared quality improvement data. Shorter duration of illness before intake and higher % MBW predicted improved weight outcomes at 1 year. After adjusting for risk factors, program outcomes did not differ significantly. All adolescent medicine-based ED programs were effective in assisting patients to gain weight.
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Affiliation(s)
- Sara F Forman
- Division of Adolescent/Young Adult Medicine, Children's Hospital Boston, Boston, Massachusetts 02115, USA.
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Buckelew SM, Adams SH, Irwin CE, Gee S, Ozer EM. Increasing clinician self-efficacy for screening and counseling adolescents for risky health behaviors: results of an intervention. J Adolesc Health 2008; 43:198-200. [PMID: 18639796 DOI: 10.1016/j.jadohealth.2008.01.018] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Revised: 12/20/2007] [Accepted: 01/09/2008] [Indexed: 11/28/2022]
Abstract
This study evaluates a training and tools intervention to increase provider self-efficacy to screen and counsel adolescents for risky behavior. Two clinics within a health maintenance organization served as intervention sites, and two as comparison sites. Self-efficacy to deliver adolescent services increased significantly in the intervention group relative to the comparison group.
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Affiliation(s)
- Sara M Buckelew
- Division of Adolescent Medicine, Department of Pediatrics, Research and Policy Center for Childhood and Adolescence, University of California, San Francisco, California 94118, USA.
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Buckelew SM, Yu J, English A, Brindis CD. Innovations in preventive mental health care services for adolescents. J Adolesc Health 2008; 42:519-25. [PMID: 18407048 DOI: 10.1016/j.jadohealth.2007.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2007] [Revised: 08/27/2007] [Accepted: 10/22/2007] [Indexed: 11/29/2022]
Abstract
PURPOSE This descriptive study examined programs designed to provide mental health-related preventive services to at-risk adolescents. METHODS Qualitative interviews were conducted with state and local program directors and key personnel in public health and mental health departments and academic researchers who have initiated preventive services. RESULTS States and local communities offer varied mental health-related preventive services for high-risk adolescents in diverse settings. Services include public education, screening, early intervention for adolescents, and educational programs for primary care providers. Funding mechanisms include state general funds, foundation grants, and Medicaid and the State Children's Health Insurance Program dollars. Evaluation is essential to maintain services and to persuade funders and other stakeholders to sustain these efforts. CONCLUSIONS State and local prevention-related mental health programs have been implemented with limited funding, but significant local advocacy and community support. More extensive evaluation and cost effectiveness studies may encourage policymakers to expand services. Further data are necessary to determine how prevention-related mental health programs can best serve vulnerable youth.
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Affiliation(s)
- Sara M Buckelew
- Division of Adolescent Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA.
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Buckelew SM, Pierrie H, Chabra A. What Fathers Need: A Countywide Assessment of the Needs of Fathers of Young Children. Matern Child Health J 2005; 10:285-91. [PMID: 16231109 DOI: 10.1007/s10995-005-0014-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2005] [Accepted: 08/22/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Realizing the paucity of data available concerning fatherhood, the Fatherhood Collaborative of San Mateo County, a public-private community partnership with leadership from the local Maternal, Child and Adolescent Health (MCAH) program, conducted a countywide needs assessment to ask fathers of young children about their personal and service-related needs in order to assist local stakeholders in expanding and improving services for families. METHODS Both quantitative and qualitative data were collected. A total of 204 fathers of children aged 0 to 5 years completed a 35-question survey. In addition, 80 fathers and community representatives participated in nine focus groups. RESULTS A complex set of needed services for fathers in the county emerged from the assessment, including: father-child activities; parks and recreational activities; better schools; parenting classes; support groups; high quality, affordable childcare; and general legal assistance. Only one-half felt the county was doing a good or excellent job in supporting fathers. CONCLUSIONS This assessment is one county's effort to collect data about fathers, from fathers, in order to shape MCAH programming to better serve families. This assessment may serve as a model for other MCAH programs interested in improving services for fathers and families.
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Affiliation(s)
- Sara M Buckelew
- Maternal, Child and Adolescent Health Programs, San Mateo County Health Department, San Mateo, California 94403, USA
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