Prevalence of Weight Stigma in Medical Settings Among Reproductive-Aged Women in the All of Us Study

OBJECTIVE

To analyze health care treatment experiences among a diverse cohort of reproductive-aged women from the All of Us study, focusing on variations due to body mass index (BMI).

METHODS

We conducted a cross-sectional study that used data from the All of Us Research Program. We analyzed weight bias among reproductive-aged women aged 18-44 years. Weight bias was assessed using a proxy 7-item survey that evaluated discrimination in health care experiences, including courtesy, respect, service quality, being treated as competent, displaying fear, being treated as inferior, and being listened to during health care visits.

RESULTS

Overall, 16,791 reproductive-aged women (mean [SD] age, 35.8 [6.3]) were included in the study. Of 11,592 patients with data available on BMI, 582 were Asian (5.0%), 1,984 (17.1%) were Hispanic or Latinx, 1,007 (8.7%) were non-Hispanic Black, and 7,370 (63.6%) were non-Hispanic White. Approximately 24.2% of participants (n=2,878) had obesity, and 11.1% of participants (n=1,292) had severe obesity. In general, participants in higher BMI categories had negative experiences in the health care setting. Women with severe obesity were 1.5 to 2 times more likely to report poor experiences with their health care clinicians compared with women with healthy weight.

CONCLUSION

Results show significant disparities in the health care experiences among reproductive-aged women. As participants' BMI category increased, so did their negative experiences in the health care setting. These findings underscore the urgent need for targeted interventions to address these inequities. Health care systems must prioritize strategies to ensure that all individuals, regardless of weight or BMI, receive equitable and respectful care.

Baseline characteristics of SARS-CoV-2 vaccine non-responders in a large population-based sample

INTRODUCTION

Studies indicate that individuals with chronic conditions and specific baseline characteristics may not mount a robust humoral antibody response to SARS-CoV-2 vaccines. In this paper, we used data from the Texas Coronavirus Antibody REsponse Survey (Texas CARES), a longitudinal state-wide seroprevalence program that has enrolled more than 90,000 participants, to evaluate the role of chronic diseases as the potential risk factors of non-response to SARS-CoV-2 vaccines in a large epidemiologic cohort.

METHODS

A participant needed to complete an online survey and a blood draw to test for SARS-CoV-2 circulating plasma antibodies at four-time points spaced at least three months apart. Chronic disease predictors of vaccine non-response are evaluated using logistic regression with non-response as the outcome and each chronic disease + age as the predictors.

RESULTS

As of April 24, 2023, 18,240 participants met the inclusion criteria; 0.58% (N = 105) of these are non-responders. Adjusting for age, our results show that participants with self-reported immunocompromised status, kidney disease, cancer, and "other" non-specified comorbidity were 15.43, 5.11, 2.59, and 3.13 times more likely to fail to mount a complete response to a vaccine, respectively. Furthermore, having two or more chronic diseases doubled the prevalence of non-response.

CONCLUSION

Consistent with smaller targeted studies, a large epidemiologic cohort bears the same conclusion and demonstrates immunocompromised, cancer, kidney disease, and the number of diseases are associated with vaccine non-response. This study suggests that those individuals, with chronic diseases with the potential to affect their immune system response, may need increased doses or repeated doses of COVID-19 vaccines to develop a protective antibody level.

Assessing the Role of Asthma on the Relationship between Neurodevelopmental Disabilities and Adverse Birth Outcomes

BACKGROUND

Investigating asthma as an effect modifier between adverse birth outcomes and neurodevelopmental disabilities (NDDs) across different races is crucial for tailored interventions and understanding variable susceptibility among diverse populations.

METHODS

Data were collected through the National Survey of Children's Health. This cross-sectional study included 131,774 children aged 0 to 17 years. Study exposures comprised adverse birth outcomes including preterm birth and low birth weight. Weighted prevalence estimates and odds ratios with 95% confidence intervals (CIs) among children with and without adverse birth outcomes were calculated for NDDs including attention-deficit/hyperactivity disorder, autism spectrum disorder, cerebral palsy, seizure, and several others including behavior problems. Adjusted odds ratios were stratified by asthma status and separate interactions were assessed for each outcome.

RESULTS

Of 131,774 participants, 10,227 were born low birth weight (9.12%; 95% CI: 8.77% to 9.49%), 14,058 were born preterm (11.35%; 95% CI: 10.94% to 11.76%), and 16,166 participants had asthma (11.97%; 95% CI: 11.58% to 12.37%). There were 68,100 males (51.11%), 63,674 females (48.89%), 102,061 non-Hispanic Whites (NHW) (66.92%), 8,672 non-Hispanic Blacks (NHB) (13.97%), and 21,041 participants (19.11%) categorized as other. NHB children with adverse birth outcomes had higher prevalence of several NDDs compared to NHW children.

CONCLUSIONS

Asthma was not shown to be an effect modifier of the association between adverse birth outcomes and NDDs. Nevertheless, these results suggest that NDDs are more prevalent within US children with adverse birth outcomes, with higher rates among NHB compared to NHW children. These findings support screening for NDDs in pediatric health care settings among patients with adverse birth outcomes, particularly among those from ethnic minority backgrounds.

Factors Associated with the Decision to Complete Bariatric Metabolic Surgery among a Racially and Ethnically Diverse Sample of Adults: A Classification and Regression Tree Analysis

BACKGROUND

Less than 50% of eligible candidates who are referred complete Bariatric Metabolic Surgery (BMS). The factors influencing the decision to complete BMS, particularly how these factors vary across different racial and ethnic groups, remain largely unexplored.

METHODS

This prospective cohort study included adult patients referred to a bariatric surgeon or obesity medicine program between July 2019-September 2022. Sociodemographic characteristics, body mass index (BMI), anxiety, depression, body appreciation, and patient-physician relationship information were collected via survey and electronic health records. The association between BMS completion and potential decision-driving factors was examined using Classification and Regression Tree (CART) analysis.

RESULTS

A total of 406 BMS -eligible patients participated in the study (mean [SD] age: 47.5 [11.6] years; 87.2% women; 18.0% Hispanic, 39% non-Hispanic Black [NHB], and 39% non-Hispanic White [NHW]; mean [SD] BMI: 45.9 [10.1] kg/m2). A total of 147 participants (36.2%) completed BMS. Overall, the most influential factor driving the decision to complete BMS was younger age (< 68.4 years), higher patient satisfaction, and BMI (≥ 38.0 kg/m2). Hispanic participants prioritized age (< 55.4 years), female sex, and body appreciation. For NHB participants, the highest ranked factors were age < 56.3 years, BMI ≥ 35.8 kg/m2, and higher patient satisfaction. For NHW patients, the most influential factors were age (39.1 to 68.6 years) and higher body appreciation.

CONCLUSION

These findings highlight racial and ethnic group differences in the factors motivating individuals to complete BMS. By acknowledging these differences, healthcare providers can support patients from different backgrounds more effectively in their decision-making process regarding BMS.

A Randomized Controlled Cluster Trial of an Obesity Prevention Program for Children with Special Health Care Needs: Methods and Implications

Children with disabilities have higher prevalence estimates of obesity than typically developing children. The Healthy Caregivers-Healthy Children Phase 3 (HC3) project implemented an obesity prevention program adapted for children with special health care needs (CSHCN) that includes dietary intake and physical activity (PA) components. The primary outcome was a change in dietary intake, PA, and the body mass index (BMI) percentile. Ten childcare centers (CCCs) serving low-resource families with ≥30 2- to 5-year-olds attending were randomized to either the intervention (n = 5) or control (n = 5). The HC3 CCCs received (1) snack, beverage, PA, and screen time policies via weekly technical assistance; (2) adapted lesson plans for CSHCN; and (3) parent curricula. The control CCCs received a behavioral health attention curriculum. HC3 was delivered over three school years, with data collected at five different timepoints. It was delivered weekly for six months in year one. To ensure capacity building, the HC3 tasks were scaled back, with quarterly intervention delivery in year 2 and annually in year 3. Adaptations were made to the curriculum to ensure appropriate access for CSHCN. Given that the program was being delivered during the COVID-19 pandemic, special modifications were made to follow CDC safety standards. The primary outcome measures included the Environment and Policy Assessment and Observation (EPAO) tool, standardized dietary intake and PA assessments, and the child BMI percentile. CCCs are an ideal setting for targeting CSHCN for obesity prevention efforts as they provide an opportunity to address modifiable risk factors.

Association between asthma, obesity, and metabolic syndrome in adolescents and young adults

BACKGROUND

The association of asthma and metabolic syndrome (MetS) among adolescents and young adults (AYAs) remains unclear, as well as the role of obesity in this relationship.

METHODS

AYAs aged 12-25 years who participated in the 2011-2020 National Health and Nutrition Examination Survey were included in this cross-sectional analysis. The moderating effect of obesity (age- and sex-adjusted body mass index ≥ 95th%ile for adolescents or ≥ 30 kg/m2 for adults) on asthma and MetS were evaluated in four groups: 1) both asthma and obesity; 2) asthma and no obesity; 3) obesity and no asthma; and 4) healthy controls with no obesity/asthma.

RESULTS

A total of 7,709 AYAs (53.9% aged 12-18 years, 51.1% males, and 54.4% non-Hispanic White) were included in this analysis. 3.6% (95% CI 2.8-4.3%) had obesity and asthma, 7.6% (95% CI 6.8-8.4%) had asthma and no obesity, 21.4% (95% CI 19.6-23.2%) had obesity and no asthma, and 67.4% (95% CI 65.4-69.4%) had neither obesity nor asthma. The estimated prevalence of MetS was greater among those with both obesity and asthma versus those with only asthma (4.5% [95% CI 1.7-7.3%] vs. 0.2% [95% CI 0-0.5%], p < 0.001). Compared to healthy controls, those with both obesity and asthma had ∼10 times higher odds of having MetS (aOR 10.5, 95% CI 3.9-28.1).

CONCLUSIONS

Our results show the association between MetS and asthma is stronger in AYAs with BMI-defined obesity. Efforts to prevent and treat obesity may reduce MetS occurrence in AYAs with asthma.

Parent childhood experiences, parenting strategies, and youth health-related outcomes in Hispanic families with unhealthy weight: An intergenerational study

We aimed to examine whether (a) parents' childhood family mealtime experiences (CFM) (e.g., mealtime communication-based stress) and parents' socio-demographic characteristics (e.g., education level) predict parents' health-related parenting strategies (e.g., discipline), (b) health-related parenting strategies for eating and physical activity predict youth's health-related outcomes (e.g., dietary intake), (c) parenting strategies mediate the relationship between CFM and youth outcomes. A path model was used to examine the above-mentioned relationships. Data were obtained from the baseline assessment of a randomized clinical trial evaluating the efficacy of a family-based intervention to promote quality diet and increase physical activity. Participants were 280 Hispanic youth (52.1 % female, Mage = 13.01 ± 0.83) with unhealthy weight (MBody Mass Index %tile = 94.55 ± 4.15) and their parents (88.2 % female, Mage = 41.87 ± 6.49). Results indicated that childhood mealtime communication-based stress and mealtime structure were positively associated with control. Appearance weight control was positively associated with monitoring, discipline, limit-setting, and reinforcement. Parental mealtime control had positive associations with discipline, control, and limit-setting. Emphasis on mother's weight was positively associated with reinforcement. We also found positive associations between parental monitoring and youth's physical QOL and between parental discipline and fruits and vegetables intake. No mediating effect was found. Findings demonstrated significant effects of parents' childhood experience on parenting strategies, which in turn was associated with the youths' health-related outcomes. These results suggest the intergenerational effects of parent's childhood experience on their youth's health-related outcomes.

Efficacy of a Primary Care eHealth Obesity Treatment Pilot Intervention Developed for Vulnerable Pediatric Patients

Background: Challenges to treat excess weight in primary care settings include time constraints during encounters and barriers to multiple visits for patient families, especially those from vulnerable backgrounds. Dynamo Kids! (DK), a bilingual (English/Spanish) e-health intervention, was created to address these system-level challenges. This pilot study assessed the effect of DK use on parent-reported healthy habits and child BMI. Methods: In this 3-month, quasi-experimental cohort design, DK was offered to parents with children aged 6-12 years with BMI ≥85th percentile in three public primary care sites in Dallas, Texas. DK included three educational modules, one tracking tool, recipes, and links to internet resources. Parents completed an online survey before and after 3 months. Pre-post changes in family nutrition and physical activity (FNPA) scores, clinic-measured child %BMIp95, and self-reported parent BMI were assessed using mixed-effects linear regression modeling. Results: A total of 73 families (mean child age = 9.3 years; 87% Hispanic, 12% non-Hispanic Black, and 77% Spanish-speaking families) completed the baseline survey (participants) and 46 (63%) used the DK site (users). Among users, pre-post changes (mean [standard deviation]) showed an increase in FNPA scores (3.0 [6.3], p = 0.01); decrease in child %BMIp95 (-1.03% [5.79], p = 0.22); and decrease in parent BMI (-0.69 [1.76], p = 0.04). Adjusted models showed -0.02% [95% confidence interval: -0.03 to -0.01] change in child %BMIp95 for each minute spent on the DK website. Conclusions: DK demonstrated a significant increase in parent FNPA scores and decrease in self-reported parent BMI. e-Health interventions may overcome barriers and require a lower dosage than in-person interventions.

Disparities in Patient Family Social Determinants of Health in a Large Urban Pediatric Health System

INTRODUCTION

This analysis sought to identify disparities in social determinants of health (SDOH) outcomes at a Texas pediatric hospital.

METHODS

This retrospective study used electronic health records of pediatric patients families surveyed August -December 2022. Outcomes for health literacy, social support, food, transportation, energy, digital, and housing insecurity, and tobacco exposure were analyzed across demographic categories.

RESULTS

Among 15,294 respondents to the survey (mean child age, 8.73 years; 43.68% Hispanic, 29.73% non-Hispanic White, 18.27% non-Hispanic Black, 6.79% other race/ethnicity; 53.95% male), 50.25% of respondents reported at least one SDOH, whereas 23.39% reported two or more SDOH. The most prevalent SDOH was lack of social support (3,456, 23.91%). Hispanic, non-Hispanic Black, and other race/ethnicity respondents, non-English speakers, and public insurance users had higher odds of reporting almost all SDOH in logistic regression models adjusted for age, race/ethnicity, language, gender, and insurance type.

DISCUSSION

Race/ethnicity, language, and insurance type disparities were identified for all SDOH.

Trends in the relationship between suicide behaviors and obesity among adolescents in the United States from 1999 to 2019

Previous studies indicate that obesity is a risk factor of suicide behaviors among adolescents. Whether this association has remained consistent during the ongoing obesity epidemic remains unknown. The time trends of the obesity-suicide association were examined using the 1999-2019 biannual Youth Risk Behavior Survey data (n = 161,606). Prevalence odds ratio of suicide behaviors among adolescents with obesity (vs. adolescents with no obesity) for each survey year and time trends using National Cancer Institute Joinpoint regression analysis was calculated. For each year post-baseline, there was a significant increase of prevalence odds ratio of 1.4 (1.2-1.6)-1.6 (1.3-2.0) for suicide ideation, 1.3 (1.1-1.7) -1.7 (1.4-2.0) for plan, and 1.3 (1.0-1.7) -1.9 (1.5-2.4) for an attempt, except for the 2013 survey for attempt (1.19 [0.9-1.6]). Significant positive trends were found from1999 to 2019 for ideation and plan, with biannual %-changes of + 0.92 and + 1.22%, respectively. Adolescents with obesity have consistently higher odds of engaging in suicide behaviors than their peers without obesity since the beginning of the United States obesity epidemic, and this association grew stronger as the obesity epidemic continued.

Adaptation of a standardized lifestyle intervention to maximize health outcomes in adolescent metabolic and bariatric surgery patients

BACKGROUND

Metabolic and bariatric surgery (MBS) is safe and efficacious in treating adolescents with severe obesity. Behavioral/lifestyle programs can support successful preparation for surgery and post-MBS weight loss, but no standardized lifestyle intervention exists for adolescents. Here we describe the process of developing and adapting the Diabetes Prevention Program Group Lifestyle Balance (DPP/GLB) curriculum to support adolescents pre- and post-MBS.

METHODS

We collected both qualitative and quantitative data from a diverse group of adolescents (N = 19, mean age 15.2 years, range 13-17, 76% female, 42% non-Hispanic Black, 41% Hispanic, 17% other). Additionally, we included data from 13 parents, all of whom were mothers. These participants were recruited from an adolescent MBS program at Children's Health System of Texas. In an online survey, we asked participants to rank their preferences and interests in DPP/GLB content topics. We complemented these results with in-depth interviews from a subset of 10 participants. This qualitative data triangulation informed the development of the TeenLYFT lifestyle intervention program, designed to support adolescents who were completing MBS and described here. This program was adapted from adolescent and parent DPP/GLB content preferences, incorporating the social cognitive model (SCM) and the socioecological model (SEM) constructs to better cater to the needs of adolescent MBS patients.

RESULTS

Adolescents' top 3 ranked areas of content were: (1) steps to adopt better eating habits and healthier foods; (2) healthy ways to cope with stress; and (3) steps to stay motivated and manage self-defeating thoughts. Nearly all adolescent participants preferred online delivery of content (versus in-person). Mothers chose similar topics with the addition of information on eating healthy outside the home. Key themes from the adolescent qualitative interviews included familial support, body image and self-confidence, and comorbidities as key motivating factors in moving forward with MBS.

CONCLUSIONS

The feedback provided by both adolescents and parents informed the development of TeenLYFT, an online support intervention for adolescent MBS candidates. The adapted program may reinforce healthy behaviors and by involving parents, help create a supportive environment, increasing the likelihood of sustained behavior change. Understanding adolescent/parent needs to support weight management may also help healthcare providers improve long-term health outcomes for this patient population.

Application of inverse weighting analysis to assess the association of youth perceptions with the age of initiation of tobacco products

Introduction

To examine if perceptions of harmfulness and addictiveness of hookah and cigarettes impact the age of initiation of hookah and cigarettes, respectively, among US youth. Youth (12-17 years old) users and never users of hookah and cigarettes during their first wave of PATH participation were analyzed by each tobacco product (TP) independently. The effect of perceptions of (i) harmfulness and (ii) addictiveness at the first wave of PATH participation on the age of initiation of ever use of hookah was estimated using interval-censoring Cox proportional hazards models.

Methods

Users and never users of hookah at their first wave of PATH participation were balanced by multiplying the sampling weight and the 100 balance repeated replicate weights with the inverse probability weight (IPW). The IPW was based on the probability of being a user in their first wave of PATH participation. A Fay's factor of 0.3 was included for variance estimation. Crude hazard ratios (HR) and 95% confidence intervals (CIs) are reported. A similar process was repeated for cigarettes.

Results

Compared to youth who perceived each TP as "a lot of harm", youth who reported perceived "some harm" had younger ages of initiation of these tobacco products, HR: 2.53 (95% CI: 2.87-4.34) for hookah and HR: 2.35 (95% CI: 2.10-2.62) for cigarettes. Similarly, youth who perceived each TP as "no/little harm" had an earlier age of initiation of these TPs compared to those who perceived them as "a lot of harm", with an HR: 2.23 (95% CI: 1.82, 2.71) for hookah and an HR: 1.85 (95% CI: 1.72, 1.98) for cigarettes. Compared to youth who reported each TP as "somewhat/very likely" as their perception of addictiveness, youth who reported "neither likely nor unlikely" and "very/somewhat unlikely" as their perception of addictiveness of hookah had an older age of initiation, with an HR: 0.75 (95% CI: 0.67-0.83) and an HR: 0.55 (95% CI: 0.47, 0.63) respectively.

Discussion

Perceptions of the harmfulness and addictiveness of these tobacco products (TPs) should be addressed in education campaigns for youth to prevent early ages of initiation of cigarettes and hookah.

Sex Disparities in Longitudinal Use and Intensification of Guideline-Directed Medical Therapy Among Patients With Newly Diagnosed Heart Failure With Reduced Ejection Fraction

BACKGROUND

Guideline-directed medical therapies (GDMTs) are the mainstay of treatment for heart failure with reduced ejection fraction (HFrEF), but they are underused. Whether sex differences exist in the initiation and intensification of GDMT for newly diagnosed HFrEF is not well established.

METHODS

Patients with incident HFrEF were identified from the 2016 to 2020 Optum deidentified Clinformatics Data Mart Database, which is derived from a database of administrative health claims for members of large commercial and Medicare Advantage health plans. The primary outcome was the use of optimal GDMT within 12 months of HFrEF diagnosis. Consistent with the guideline recommendations during the time period of the study, optimal GDMT was defined as ≥50% of the target dose of evidence-based beta-blocker plus ≥50% of the target dose of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, or any dose of angiotensin receptor neprilysin inhibitor plus any dose of mineralocorticoid receptor antagonist. The probability of achieving optimal GDMT on follow-up and predictors of optimal GDMT were evaluated with time-to-event analysis with adjusted Cox proportional hazard models.

RESULTS

The study cohort included 63 759 patients (mean age, 71.3 years; 15.2% non-Hispanic Black race; 56.6% male). Optimal GDMT use was achieved by 6.2% of patients at 12 months after diagnosis. Female (compared with male) patients with HFrEF had lower use across every GDMT class and lower use of optimal GDMT at each time point at follow-up. In an adjusted Cox model, female sex was associated with a 23% lower probability of achieving optimal GDMT after diagnosis (hazard ratio [HR], 0.77 [95% CI, 0.71-0.83]; P<0.001). The sex disparities in GDMT use after HFrEF diagnosis were most pronounced among patients with commercial insurance (females compared with males; HR, 0.66 [95% CI, 0.58-0.76]) compared with Medicare (HR, 0.85 [95% CI, 0.77-0.92]); Pinteraction sex×insurance status=0.005) and for younger patients (age <65 years: HR, 0.65 [95% CI, 0.58-0.74]) compared with older patients (age ≥65 years: HR, 87 [95% CI, 80-96]) Pinteraction sex×age=0.009).

CONCLUSIONS

Overall use of optimal GDMT after HFrEF diagnosis was low, with significantly lower use among female (compared with male) patients. These findings highlight the need for implementation efforts directed at improving GDMT initiation and titration.

Prevalence of the metabolic syndrome by household food insecurity status in the United States adolescent population, 2001-2020: a cross-sectional study

BACKGROUND

Household food insecurity (FI) is a modifiable social determinant of health linked to chronic health outcomes. Little is known, however, about the prevalence of metabolic syndrome (MetS) in pediatric population-based studies by household FI status.

OBJECTIVES

The objective of the study was to estimate the prevalence of the MetS by household FI status over the past 2 decades.

METHODS

This cross-sectional study used data from the 2001-2020 National Health and Nutrition Examination Survey (NHANES). Participants were nonpregnant adolescents ages 12- 18 y in United States. The prevalence of MetS [elevated waist circumference and >2 of the following risk factors: elevated blood pressure, and fasting glucose, triglyceride, and/or low high-density lipoprotein (HDL) cholesterol concentrations] by FI status was evaluated using chi-square and logistic regression analyses.

RESULTS

The estimated prevalence of MetS was 2.66% [95% confidence interval (CI): 2.28%, 3.09%] in the final analytical sample (unweighted N = 12,932). A total of 3.39% (95% CI: 2.53%, 4.53%) of adolescents from FI households had MetS compared to 2.48% (95% CI: 2.11%, 2.9%) among adolescents with no household FI. Hispanic adolescents had the highest prevalence of MetS (3.73%, 95% CI: 3.05, 4.56) compared with adolescents who identified as non-Hispanic White (2.78%, 95% CI: 2.25, 3.43), non-Hispanic Black (1.58%, 95% CI: 1.19, 2.10). Adolescents with household FI (23.20%) were more likely to have MetS [odds ratio (OR): 1.38; 95% CI: 1.02, 1.88; I=0.039) compared with adolescents with no household FI, but in fully adjusted models this was not significant (OR: 1.13; 95% CI: 0.75, 1.72).

CONCLUSIONS

Using the most current NHANES data, the estimated prevalence of MetS in adolescents in United States was slightly higher among those from FI households. However, after adjusting for potential confounders, the relationship between household FI and MetS was nonsignificant, highlighting the complexity of factors contributing to MetS in this population. Hispanic adolescents share a disproportionate burden of MetS compared with their non-Hispanic counterparts.

Integration of e-Health Strategies for Post-COVID-19 Pandemic Pediatric Weight Management Programs

Background: The COVID-19 pandemic catalyzed a renewed urgency to address the obesity pandemic and accelerated the use of technology to treat pediatric obesity. Yet, there are significant incongruities between the existing literature on technology for obesity management and the current health care system that may lead to suboptimal outcomes and increased costs. This study reviewed the types of e-health strategies currently in use, highlighted inconsistencies and overlap in terminology, and identified future research directions in e-health for childhood obesity, including gaps in implementation science. Methods: This narrative literature review synthesized seminal articles from the literature, as well as recent articles, using PubMed and Google Scholar that focused on the use of technology in treating pediatric obesity. This inclusive strategy was intended to elucidate the heterogeneity in how different disciplines are using digital health terminology in pediatric obesity research. Results: Both the prevalence of e-health interventions and its associated terminology are increasing in the peer-reviewed literature, especially since the beginning of the COVID-19 pandemic. Yet, their definitions and usage are unstandardized, leading to a lack of cohesion in the research and between disciplines. There is a gap in implementation science outcomes, including reimbursement, that may significantly impact external validity and uptake. Conclusion: A more systematic and precise approach to researching e-health that can assess specific technologies and combinations of technologies, their short-term and long-term effect sizes, and feasibility can produce the necessary data that may lead to reimbursement policies and, ultimately, improved pediatric weight management outcomes.

Knowledge, Attitudes, and Subjective Norms Associated with COVID-19 Vaccination among Pregnant Women in Kenya: An Online Cross-Sectional Pilot Study Using WhatsApp

COVID-19 vaccination during pregnancy has been recommended, but the perceptions related to uptake remain unexplored. This pilot study aimed to explore how perceptions influence COVID-19 vaccine uptake among a sample of 115 pregnant women in Kenya, recruited via WhatsApp. Data were collected using an adapted online questionnaire between May and October 2022. Logistic analyses assessed the relationship between COVID-19 vaccination uptake and the Theory of Reasoned Action (TRA) constructs: attitudes and subjective norms. COVID-19 vaccination coverage was 73%, with vaccine hesitancy estimated at 41.4% among the unvaccinated group. Most participants had completed college education and had good knowledge of COVID-19 vaccines. There was no significant effect of enrollment in WhatsApp pregnancy groups on attitudes toward COVID-19 vaccination. Pregnant women were concerned about vaccine effectiveness (31.1%), and almost one-half (47.3%) were discouraged from receiving COVID-19 vaccines. Positive attitudes towards vaccination were associated with COVID-19 vaccination (aOR 2.81; 95% CI 1.12-7.04; p = 0.027), but no significant relationship was found between COVID-19 vaccination and strong subjective norms (influences to get COVID-19 vaccines). Our findings suggest that strategies to improve vaccination should consider targeting attitudes and proximal social networks (friends/family) to facilitate vaccination decision-making. WhatsApp can be used for research distribution and enhance the dissemination of accurate information.

Family-based pediatric weight management interventions in US primary care settings targeting children ages 6-12 years old: A systematic review guided by the RE-AIM framework

Obesity is a pandemic that disproportionately affects children from vulnerable populations in the USA. Current treatment approaches in primary care settings in the USA have been reported to be insufficient at managing pediatric obesity, primarily due to implementation challenges for healthcare systems and barriers for families. While the literature has examined the efficacy of pediatric obesity interventions focused on internal validity, it lacks sufficient reporting and analysis of external validity necessary for successful translation to primary care settings. We conducted a systematic review of the primary-care-setting literature from January 2007 to March 2020 on family-based pediatric weight management interventions in both English and/or Spanish for children ages 6-12 years in the USA using the Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. A literature search, using PRISMA guidelines, was conducted in January 2022 using the following electronic databases: Medline Ovid, Embase, and Cochrane Library. 22 270 records were screened, and 376 articles were reviewed in full. 184 studies were included. The most commonly reported dimensions of the RE-AIM framework were Reach (65%), Efficacy/Effectiveness (64%), and Adoption (64%), while Implementation (47%) and Maintenance (42%) were less often reported. The prevalence of reporting RE-AIM construct indicators ranged greatly, from 1% to 100%. This systematic review underscores the need for more focus on external validity to guide the development, implementation, and dissemination of future pediatric obesity interventions based in primary care settings. It also suggests conducting additional research on sustainable financing for pediatric obesity interventions.

Anxiety as a predictor of the age of initiation of tobacco and cannabis use in adolescents and young adults

BACKGROUND

Previous research has shown important links between anxiety and the use of tobacco and cannabis. However, it remains unclear whether anxiety leads youth to start using tobacco and cannabis at an earlier age.

METHODS

Data were drawn from Texas Adolescent Tobacco and Marketing Surveillance System for the years 2019-2021(Waves 9-14). Participants were in 10th-grade, 12th-grade, and two years post-high school at baseline. The outcomes were the age of first use of cigarettes, e-cigarettes, and cannabis. Interval-censoring Cox proportional hazards models were fit to examine the differences in the estimated age of initiation of tobacco and cannabis use by anxiety.

RESULTS

Among the 10th-grade cohort, participants with anxiety had an increased risk of an earlier age of cigarette [AHR = 2.29(1.63-3.23)], e-cigarette [AHR = 1.53(1.17-2.00)], and cannabis [AHR = 1.59(1.23-2.05)] initiation. Among the 12th-grade cohort, participants with anxiety had an increased risk of an earlier age of cigarette [AHR = 1.52(1.21-1.90), e-cigarette [1.25(1.01-1.60)] and cannabis [AHR = 1.35(1.09-1.67] initiation. Among the post-high school cohort, the only significant association found was for cannabis initiation [AHR = 1.33(1.11-1.58). Between ages 18-to-19 years in the 10th-grade cohort, and between ages 20-21 years in the 12th-grade cohort, cumulative incidence of each of the three outcomes initiation doubled among anxious youth.

CONCLUSIONS

This study's findings show that anxiety symptoms can increase the risk of substance use initiation at an earlier age, especially among the youngest adolescent cohort (∼15-to-16-year-olds). These findings highlight the importance of early screening and treatment of anxiety symptoms as a preventive measure to delay or prevent the onset of substance use initiation.

Impact of employment status and work setting on body weight and health behaviors among people with obesity

BACKGROUND

The impact of employment and the work-from-home (WFH) setting on body weight among people with obesity is unknown.

OBJECTIVE

This study examined the relationship between employment status, WFH setting, and change in body weight among adults with obesity during the COVID-19 pandemic.

METHODS

Patients from an obesity medicine clinic completed an online survey in 2022 to assess health, work, and lifestyle behaviors. Multiple regression models examined the association between WFH status and change in body weight.

RESULTS

The analytical sample included 380 patients (81.9% female, mean age 52.5 years, mean body mass index 43.25, 50.0% non-Hispanic White, 25.7% non-Hispanic Black, 18.7% Hispanic, 5.7% other ethnicity). During the pandemic, 28.7% were employed in a WFH setting (73.4% of this subgroup were in a WFH setting only), 36.1% were employed but not in a WFH setting, 11.8% were unemployed, and 23.4% were retired. Mean body weight change for participants who partially WFH during the pandemic was +5.4 (±7.2) % compared to those completely WFH -0.3 (±9.8) % (P = 0.006). After adjusting for key demographics, participants who were partially WFH gained 7.8% more weight compared to those completely WFH (β= 7.28, SE = 1.91, p <  0.001). The most significant predictors for weight gain after adjusting for WFH frequency (partially vs. completely) included overeating (aOR 11.07, 95% CI 3.33-36.77), more consumption of fast food (aOR 7.59, 95% 2.41-23.91), and depression (aOR 6.07, 95% CI 1.97-18.68).

CONCLUSION

These results show that during the COVID-19 pandemic, the WFH hybrid (combination of office and WFH) setting is associated with greater weight gain compared to those who completely WFH in people with obesity. Risk factors include overeating, higher fast food consumption, and depression.

Assessing the Prevalence Rates of Internalizing Symptomatology Among Multiracial Adolescents in the United States: A Systematic Review

This systematic review aimed to investigate the prevalence of internalizing symptomatology among Multiracial adolescents in the United States and to report on the methods utilized to measure Multiracial race and internalizing symptoms. A comprehensive search was conducted in Ovid MEDLINE, Embase, APA PsycInfo, and Web of Science Core Collection. The search was confined to peer-reviewed studies reporting the prevalence of any internalizing symptom among Multiracial adolescents between 10 and 24 years in the United States. Study selection, data abstraction, and quality assessments were managed by four team members. Between 2000 and 2023, nine studies provided prevalence estimates and used various methods to measure Multiracial race and internalizing symptoms. Prevalence estimates displayed considerable variability depending on symptom examined and measurement method utilized. For all internalizing symptomatology, estimates ranged between 7.5 and 55.2%; for depressive symptomatology, estimates ranged between 12.8 and 51.0%. No information on the prevalence of anxiety symptoms alone were provided. This review represents a pioneering attempt to report the prevalence of internalizing symptomatology among Multiracial adolescents in the United States, revealing significant gaps in current knowledge and methodological inconsistencies in the field. There exists a need for more comprehensive epidemiological research with this growing population.

Validation of the Childhood Family Mealtime Questionnaire in Mexican Adolescents with Obesity and Their Caregivers

BACKGROUND

Childhood obesity is a significant public health concern in Mexico, with far-reaching implications for the nation's healthcare system and economy. In light of this challenge, our study sought to validate the Childhood Family Mealtime Questionnaire (CFMQ) in Mexican adolescents living with obesity and their primary caregivers.

METHODS

A sample of 56 adolescents ages 13 to 17 years and their primary caregivers from one pediatric obesity clinic participated in the study. We conducted a comprehensive assessment of the CFMQ's consistency, reliability, and construct validity among all participants. Internal consistency was determined using Cronbach's α, and the questionnaire's reliability was assessed through test-retest and intraclass correlation coefficients. Construct validity was assessed through an exploratory factor analysis.

RESULTS

Our findings confirmed strong internal consistency and reliability for both adolescents and caregivers. Construct validity was established through exploratory factor analysis, refining the questionnaire while preserving its original seven dimensions. This validation of the CFMQ highlights its applicability in evaluating family mealtime experiences in this context, providing valuable insights into the dynamics that influence adolescent nutrition and health.

CONCLUSION

The CFMQ proves to be a reliable tool for assessing family mealtime experiences in Mexican adolescents living with obesity and their caregivers who seek care at third-level public hospitals.

Depressive symptoms and the age of initiation of tobacco and marijuana use among adolescents and young adults

BACKGROUND

Studies have demonstrated important associations between depressive symptoms and tobacco and marijuana use. However, to date, it is unknown if depressive symptoms predispose youth to tobacco and marijuana use at earlier ages over time.

METHODS

Data from the Texas Adolescent Tobacco and Marketing Surveillance System (TATAMS) for the years 2019-2021 (Waves 9-14) were used. Eligible samples include individuals who had never used cigarette (n=1776), e-cigarette (n=1353), or marijuana (n=1505) at basline and had complete data on covariates. Interval-censoring survival analysis was used to examine the differences in the estimated age of first use of cigarettes, e-cigarettes, and marijuana by depressive symptoms.

RESULTS

10th-grade cohort participants with depressive symptoms had increased risk of earlier age of first use of cigarette [AHR=1.45; 95% CI=1.02-2.04)], e-cigarette [AHR=1.65(1.27-2.15)], and marijuana [AHR=1.56(1.20-2.01)]. 12th-grade cohort participants with depressive symptoms had increased risk of earlier age of first use of cigarette [AHR=1.41(1.11-1.82), e-cigarette [AHR=1.35(1.10-1.87)] and marijuana [AHR=1.25(1.01-1.55)]. However, among the two-year post-high school cohort, depressive symptoms predicted the age of first use of marijuana only [AHR=1.34(1.13-1.60)]. Between ages 18-to-20 years, the estimated cumulative incidence of initiation almost doubled for all three products among depressive participants in 10th and 12th-grade cohorts.

CONCLUSIONS

Among 10th-grade, 12th-grade, and 2-year post-HS students, those with depressive symptoms initiate tobacco and marijuana use at earlier ages than peers without depressive symptoms. Early screening and management of depressive symptoms among adolescents and young adults may be a promising target for preventing or delaying the age of first use of substance use.

Transoral gastric outlet reduction for post-prandial hypoglycemia after Roux-en-Y gastric bypass

BACKGROUND

Post-prandial hypoglycemia is an uncommon but disabling late complication of Roux-en-Y gastric bypass (RYGB). Most patients can be treated with dietary interventions and medications; however, some patients develop refractory hypoglycemia that may lead to multiple daily episodes and seizures. While RYGB reversal surgery is an effective treatment, complication rates are high, and patients inevitably experience weight regain. Transoral gastric outlet reduction (TORe) is a minimally invasive treatment that is effective for early and late dumping syndrome. However, prior studies have not distinguished the effectiveness of TORe specifically for patients with post-prandial hypoglycemia. This study aims to describe a single institution's experience of TORe for treating post-prandial hypoglycemia.

METHODS

This is a case series of patients with prior RYGB complicated by post-prandial hypoglycemia who underwent TORe from February 2020 to September 2021. Pre-procedural characteristics and post-procedural outcomes were obtained. Outcomes assessed included post-prandial hypoglycemia episodes, dumping syndrome symptoms, and weight change.

RESULTS

A total of 11 patients underwent TORe from 2020 to 2021 for post-prandial hypoglycemia. Three (27%) patients had a history of seizures due to hypoglycemia. All had been advised on dietary changes, and ten patients (91%) were on medications for dumping. All patients reported a reduction in post-prandial hypoglycemic events as well as the majority of dumping syndrome symptoms during an average follow-up time of 409 ± 125 days. Ten patients (91%) had experienced weight regain from their post-RYGB nadir weight. For these patients, the average total body weight loss 12 months post-TORe was 12.4 ± 12%. There were no complications requiring hospitalization. One patient experienced post-TORe nausea and vomiting requiring dilation of the gastrojejunal anastomosis with resolution in symptoms.

CONCLUSION

TORe is a safe and effective treatment for post-prandial hypoglycemia and weight regain after RYGB in patients with symptoms refractory to medications and dietary changes.

Long-term immune response to SARS-CoV-2 infection and vaccination in children and adolescents

BACKGROUND

This analysis examined the durability of antibodies present after SARS-CoV-2 infection and vaccination in children and adolescents.

METHODS

Data were collected over 4 time points between October 2020-November 2022 as part of a prospective population-based cohort aged 5-to-19 years (N = 810). Results of the (1) Roche Elecsys® Anti-SARS-CoV-2 Immunoassay for detection of antibodies to the SARS-CoV-2 nucleocapsid protein (Roche N-test); and (2) qualitative and semi-quantitative detection of antibodies to the SARS CoV-2 spike protein receptor binding domain (Roche S-test); and (3) self-reported antigen/PCR COVID-19 test results, vaccination and symptom status were analyzed.

RESULTS

N antibody levels reached a median of 84.10 U/ml (IQR: 20.2, 157.7) cutoff index (COI) ~ 6 months post-infection and increased slightly to a median of 85.25 (IQR: 28.0, 143.0) COI at 12 months post-infection. Peak S antibody levels were reached at a median of 2500 U/mL ~6 months post-vaccination and remained for ~12 months (mean 11.6 months, SD 1.20).

CONCLUSIONS

This analysis provides evidence of robust durability of nucleocapsid and spike antibodies in a large pediatric sample up to 12 months post-infection/vaccination. This information can inform pediatric SARS-CoV-2 vaccination schedules.

IMPACT

This study provided evidence of robust durability of both nucleocapsid and spike antibodies in a large pediatric sample up to 12 months after infection. Little is known about the long-term durability of natural and vaccine-induced SARS-CoV-2 antibodies in the pediatric population. Here, we determined the durability of anti-SARS-CoV-2 spike (S-test) and nucleocapsid protein (N-test) in children/adolescents after SARS-CoV-2 infection and/or vaccination lasts at least up to 12 months. This information can inform future SARS-CoV-2 vaccination schedules in this age group.

Infant Nutrition and Other Early Life Risk Factors for Childhood Obesity According to Disability Status

One in five preschool-aged children in the United States is obese, and children with disabilities are significantly impacted. This study aimed to determine the association between age at solid food initiation and obesity prevalence in preschool-aged children while considering disability status, ethnicity, gestational age, and birth weight. Analysis was conducted on a sample of 145 children aged 2 to 5 years who were enrolled in ten childcare centers. Parents completed a survey assessing disability status, race and ethnicity, birth weight, gestational age, and age of solid food initiation. Height and weight were collected concurrently. Multivariable logistic regression models generated the odds of developing obesity based on age at solid food initiation, disability status, ethnicity, gestational age, and birth weight. There was no significant difference in the odds of being obese based on age at solid food introduction. Children with disabilities (OR = 0.17, 95% CI 0.04-0.6, p = 0.01) and children born preterm (OR = 0.28, 95% CI 0.08-0.79, p = 0.03) had significantly lower odds of being obese. Hispanic children (OR = 4.93, 95% CI 1.91-15.32, p = 0.002) and children with higher birth weights (OR = 1.47, 95% CI 1.17-1.92, p = 0.002) were more likely to be obese. With pediatric obesity rates continuing to rise, these findings can inform future intervention efforts.

Associations Between Neighborhood Opportunity and Indicators of Physical Fitness for New York City Public School Youth

Background: Fewer than 1/4th of US children and adolescents meet physical activity (PA) guidelines, leading to health disparities that track into adulthood. Neighborhood opportunity may serve as a critical modifiable factor to improve fitness attainment and reduce these disparities. We drew data from the Child Opportunity Index to examine associations between neighborhood indicators of opportunity for PA and multiple fitness indicators among New York City public school youth. Methods: Multilevel generalized linear mixed models were used to estimate the overall and sex-stratified associations between neighborhood indicators (green space, healthy food, walkability, commute time) and indicators for physical fitness [curl-ups, push-ups, Progressive Aerobic Cardiovascular Endurance Run (PACER), sit-and-reach] using the New York City FITNESSGRAM data set. Results: The analytic sample [n = 299,839; median (interquartile range) age = 16 (12-17)] was 50.1% female, 37.5% Hispanic, 26.2% non-Hispanic Black, and most (69.5%) qualified for free/reduced price school meals. Neighborhood indicators were positively associated with higher values of indicators for physical fitness. The strongest associations were observed between walkability and both BMI and PACER, and commute time with BMI, push-ups, and PACER. For example, walkability had the greatest magnitude of effects for BMI and muscular strength and endurance (BMI: β: -0.75, 95% confidence interval, CI: -1.01 to -0.49; PACER: β: 1.98, 95% CI: 1.59 to 2.37), and particularly for girls compared with boys (BMI, girls: β: -0.91, 95% CI: -1.22 to -0.66); BMI, boys: β: -0.56, 95% CI: -0.86 to -0.25); PACER, girls: β: 2.11, 95% CI: 1.68 to 2.54; push-ups, boys: β: 1.71, 95% CI: 1.31 to 2.12). Conclusion: Neighborhood indicators were associated with multiple measures of youth fitness. Continued research on neighborhood opportunity and youth fitness may better inform place-based public health interventions to reduce disparities.

The Use of Electronic Health Record Data to Identify Variation in Referral, Consent, and Engagement in a Pediatric Intervention for Overweight and Obesity: A Cross-Sectional Study

Clinical weight management programs face low participation. The authors assessed whether using electronic health record (EHR) data can identify variation in referral, consent, and engagement in a pediatric overweight and obesity (OW/OB) intervention. Using Epic EHR data collected between August 2020 and April 2021, sociodemographic and clinical diagnostic data (ie, International Classification of Disease [ICD] codes from visit and problem list [PL]) were analyzed to determine their association with referral, consent, and engagement in an OW/OB intervention. Bivariate analyses and multivariable logistic regression modeling were performed, with Bayesian inclusion criterion score used for model selection. Compared with the 581 eligible patients, referred patients were more likely to be boys (60% vs. 54%, respectively; P = 0.04) and have a higher %BMIp95 (119% vs. 112%, respectively; P < 0.01); consented patients were more likely to have a higher %BMIp95 (120% vs. 112%, respectively; P < 0.01) and speak Spanish (71% vs. 59%, respectively; P = 0.02); and engaged patients were more likely to have a higher %BMIp95 (117% vs. 112%, respectively; P = 0.03) and speak Spanish (78% vs. 59%, respectively; P < 0.01). The regression model without either ICD codes or PL diagnoses was the best fit across all outcomes, which were associated with baseline %BMIp95 and health clinic location. Neither visit nor PL diagnoses helped to identify variation in referral, consent, and engagement in a pediatric OW/OB intervention, and their role in understanding participation in such interventions remains unclear. However, additional efforts are needed to refer and engage younger girls with less extreme cases of OW/OB, and to support non-Hispanic families to consent.

Association of Social Determinants of Health, Race and Ethnicity, and Age of Menarche among US Women Over 2 Decades

INTRODUCTION

Age of menarche (AOM), or the first menstrual cycle, is one indicator of female puberty. The timing of AOM can be influenced by social determinants of health (SDOH). This study examined associations between SDOH and AOM over the past 2 decades in the United States.

METHODS

US National Health and Nutrition Examination Survey data (1999 to early 2020) were analyzed. Multinomial logistic regression analyses examined associations between AOM (early [11.99 years and younger], typical [12-13 years], and late [13.01 years and older]) and race/ethnicity, insurance coverage, education, family income-to-poverty ratio, money management, and home status.

RESULTS

AOM remained consistent over the past 2 decades (mean 12.50 years, SE 0.02) for the aggregate sample. Females identifying as Hispanic (excluding Mexican Americans) were 63% more likely (adjusted odds ratio [aOR] 1.63, 95% confidence interval [CI] 1.13-2.36) to report early menarche. Those identifying as other/multiracial were 46% more likely to report late menarche (aOR 1.46, 95% CI 1.13-1.89) vs non-Hispanic Whites. Financial and home status instability was associated with early menarche (aOR 1.46, 95% CI 1.17-1.83; aOR 1.25, 95% CI 1.05-1.48). Less than 9th-grade education was associated with late menarche (aOR 1.47, 95% CI 1.14-1.89).

CONCLUSION

Although the average AOM has remained stable in the United States over the past 20 years, identifying as Hispanic (excluding Mexican Americans) and financial/home instability are associated with early AOM, and lower education levels are associated with late AOM. Identifying programming and policy options targeting SDOH may help improve current and future reproductive health.

Quality of Life Among Caregivers of Children with Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder: A Cross Sectional Study

Caregivers of children with attention deficit-hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) experience more stress than caregivers of typically developing children but there is limited research evaluating caregivers' quality of life (QoL). This study aimed to describe the association of caregiver QoL in children with ASD and/or ADHD. This study included patients with ADHD and/or ASD seen in one pediatric specialty clinic between September 2018-August 2020. Caregivers were classified as those caring for children with ASD-only, ADHD-only, or youth with both conditions (ADHD + ASD). An adapted version of the PedsQL Family Impact Module was used to measure caregiver QoL. The sample included caregivers of 931 children. The majority of these children were male (74.7%), non-Hispanic white (63.3%), and aged 6 to 12 years (57.8%). Across the groups, significant differences were observed in patient age (p < 0.0001), preferred language (p = 0.005), and insurance (p = 0.001). Caregivers of non-Hispanic Black children had 4-times the odds of reporting feeling isolated from others (OR 4.36, 95% CI 1.19-16.00 p = 0.03). Those caring for children with ADHD-only had significantly lower odds of reporting helplessness or hopelessness (OR 0.45, 95% CI 0.26-0.80, p = 0.004), and difficulty talking about their child's health with others (OR 0.30, 95% CI 0.17-0.54, p < 0.0001). Similarly, caregivers of children who had ADHD + ASD reported higher odds of difficulty making decisions together as a family (OR 14.18, 95% CI 1.15-17.91, p=0.04) and difficulty solving family problems together (OR 45.12, 95% CI 2.70-752.87), p = 0.008). Caring for children with ADHD and/or ASD may affect caregiver QoL.

Persistent symptoms and conditions among children and adolescents hospitalised with COVID-19 illness: a qualitative study

OBJECTIVES

There is limited in-depth research exploring persistent symptoms and conditions among children and adolescents who contracted COVID-19 illness that required hospitalisation. The main objective of this study was to conduct qualitative interviews among families who had a child hospitalised with COVID-19 illness to elucidate their child's physical, mental and social health outcomes months after initial acute infection.

DESIGN, SETTING AND PARTICIPANTS

A qualitative study that composed of in-depth interviews among families with a child hospitalised with COVID-19 illness in one large urban US paediatric healthcare system. Parents (N=25) were recruited from an ongoing quantitative study to estimate the prevalence of long COVID in children hospitalised with COVID-19 illness. During in-depth interviews, parents were invited to describe their child's post-COVID-19 symptoms and experiences. Interviews were audiotaped, transcribed and coded in NVivo.

RESULTS

Seven themes were identified concerning the child's prolonged COVID-19 experiences: (1) post-traumatic stress disorder, (2) social anxiety, (3) severe symptoms on reinfection, (4) worsened pre-existing conditions, (5) lack of insurance coverage for costly treatments, (6) access and utilisation of support systems and (7) overall resilience and recovery. Four parent-specific themes were identified: (1) fear of COVID-19 unknowns, (2) mixed messaging from health information sources, (3) schools being both a support system and a hindrance and (4) desire for and access to support systems.

CONCLUSIONS

A subset of children who were hospitalised with COVID-19 illness are experiencing a range of serious mental health impacts related to persistent COVID-19 symptoms. Clinical and public health support strategies should be developed to support these children and their families as they reintegrate in school, social and community activities.

Longitudinal Associations Between Neighborhood Child Opportunity and Physical Fitness for New York City Public School Youth

Neighborhood environments can support fitness-promoting behavior, yet little is known about their influence on youth physical fitness outcomes over time. We examined longitudinal associations between neighborhood opportunity and youth physical fitness among New York City (NYC) public school youth. The Child Opportunity Index (COI), a composite index of 29 indicators measuring neighborhood opportunity at the census-tract level, along with scores on 4 selected COI indicators were linked to NYC FITNESSGRAM youth data at baseline. Fitness outcomes (measured annually, 2011-2018) included body mass index, curl-ups, push-ups, and Progressive Aerobic Cardiovascular Endurance Run (PACER) laps. Unstratified and age-stratified, adjusted, 3-level generalized linear mixed models, nested by census tract and time, estimated the association between COI and fitness outcomes. The analytical sample (n = 204,939) lived in very low (41%) or low (30%) opportunity neighborhoods. Unstratified models indicated that overall COI is modestly associated with improved youth physical fitness outcomes. The strongest opportunity-fitness associations were observed for PACER. Stratified models show differences in associations across younger vs. older youth. We find that neighborhood factors are associated with youth fitness outcomes over time, with the strength of the associations dependent on age. Future implications include better informed place-based interventions tailored to specific life stages to promote youth health.

Telehealth utilization among multi-ethnic patients with obesity during the COVID-19 pandemic

INTRODUCTION

The science of telemedicine has shown great advances over the past decade. However, the field needs to better understand if a change in care delivery from in-person to telehealth as a result of the COVID-19 pandemic will yield durable patient engagement and health outcomes for patients with obesity. The objective of this study was to examine the association of mode of healthcare utilization (telehealth versus in-person) and sociodemographic factors among patients with obesity during the COVID-19 pandemic.

METHODS

A retrospective medical chart review identified patients with obesity from a university outpatient obesity medicine clinic and a community bariatric surgery practice. Patients completed an online survey (1 June 2020-24 September 2020) to assess changes in healthcare utilization modality during subsequent changes in infection rates in the geographic area. Logistic regression analysis examined the association of mode of healthcare utilization and key sociodemographic characteristics.

RESULTS

A total of 583 patients (87% female, mean age 51.2 years (standard deviation 13.0), mean body mass index 40.2 (standard deviation 6.7), 49.2% non-Hispanic white, 28.7% non-Hispanic black, 16.4% Hispanic, 7% other ethnicity, 33.1% completed bariatric surgery) were included. Adjusted logistic regression models showed older age was inversely associated with telehealth use (adjusted odds ratio = 0.58, 95% confidence interval 0.34-0.98) and non-Hispanic black were more likely to use telehealth compared to non-Hispanic white (adjusted odds ratio = 1.72, 95% confidence interval 1.05-2.81).

CONCLUSIONS

The COVID-19 pandemic is impacting access to healthcare among patients with obesity. Telehealth is an emerging modality that can maintain healthcare access during the pandemic, but utilization varies by age and ethnicity in this high-risk population.

Endoscopic Sleeve Gastroplasty: A Practice Pattern Survey

PURPOSE

Obesity is a complex, chronic disease that is strongly associated with complications which cost the US healthcare system billions of dollars per year. Endoscopic sleeve gastroplasty (ESG) has emerged as a safe and effective procedure for treatment of obesity, but without practice guidelines there are likely to be variations practice. We sought to describe current practice patterns amongst endoscopists who perform ESG to help define areas of focus for future research and guideline development.

METHODS

We conducted an anonymous cross-sectional survey to examine practice patterns related to ESG. The survey was organized in 5 sections: Endoscopic Practice, Training, and Resources; Pre-ESG Evaluation and Payment Model; Perioperative/Operative Period; Post-operative Period; and Endobariatric Practice Other Than ESG.

RESULTS

A variety of exclusion criteria were reported by physicians performing ESG. Most respondents (n = 21/32, 65.6%) would not perform ESG for BMI under 27, and 40.6% (n = 13/32) would not perform ESG on patients with BMI over 50. The majority of respondents (74.2%, n = 23/31) reported ESG was not covered in their region, and most reported patients covered residual costs (67.7%, n = 21/31).

CONCLUSIONS

We found significant variability with respect to practice setting, exclusion criteria, pre-procedural evaluation, and medication use. Without guidelines for the selection of patients or standards for pre- and post-ESG care, substantial barriers to coverage will remain, and ESG will remain limited to those who can meet out-of-pocket costs. Larger studies are needed to confirm our findings, and future research should be focused on establishing patient selection criteria and standards in practices to provide guidance for endobariatric programs.

Use of Metabolic and Bariatric Surgery Among US Youth

This cohort study compares trends in use of metabolic and bariatric surgery among US youth and adults before and after publication of a 2019 American Academy of Pediatrics policy statement on access to such surgery.

Adolescent Polysubstance Use and Co-Occurring Weapon Carrying, Bullying Victimization, and Depressive Symptomology: Patterns and Differences in the United States

Adolescent substance use commonly co-occurs with poor mental health, bullying victimization and risky behaviors that may lead to violence. The purpose was to describe the United States (US) national prevalence of polysubstance use and co-occurring characteristics and associated demographic characteristics among youth. Middle and high school students in the 2019 CDC YRBS survey reported their demographics and current ( ≥ 1 days in the last 30 days) substances used (alcohol, cigarette, e-cigarette, cannabis); polysubstance combinations were generated. Cross-sectional weighted logistic regression estimated odds of polysubstance use and frequent use ( ≥ 6 days in the last 30 days) by weapon carrying, depressive symptoms, bullying victimization, and demographics. Mean age of the sample was 16 years, 51% were boys, 51% were non-Hispanic White. While accounting for 21% of the sample, 22-40% of Multiracial youth reported polysubstance use and frequent use. Odds of frequent polysubstance use (all combinations) were highest for weapon carrying youth.

The Association Between Tobacco and Cannabis Use and the Age of Onset of Depression and Anxiety Symptoms: Among Adolescents and Young Adults

INTRODUCTION

No studies have prospectively explored the association between the use of tobacco or cannabis use and the age of onset of depressive or anxiety symptoms, and no studies have identified the peak ages and ranges of onset of these symptoms among tobacco and/or cannabis users.

AIMS AND METHODS

This is a secondary analysis of Texas Adolescent Tobacco and Marketing Surveillance System data, waves 9-14 (2019-20121). Participants were in 10th grade, 12th grade, and 2 years post-high school (HS) at baseline (wave 9). Interval-censoring multivariable Cox proportional hazards models were fit to assess differences in the estimated age of onset of depression and anxiety by tobacco and cannabis use while adjusting for covariates.

RESULTS

We found that lifetime or ever cigarette, e-cigarette, and cannabis use had an increased risk of an earlier age of onset of depressive and anxiety symptoms across the three cohorts, and the youngest cohort was the most differentially impacted by substance use. Between ages 18 to 19 years in the 10th-grade cohort, between ages 20 to 21 years in the 12th-grade cohort, and between ages 22 to 23 years in the post-HS cohort, the estimated hazard function (or cumulative incidence) for reporting depressive and anxiety symptoms almost doubled among lifetime cigarette, e-cigarette, and cannabis users.

CONCLUSIONS

Tobacco and cannabis users should be screened for mental health problems at an earlier age, especially those aged 18 years and younger, and provided with age- and culturally appropriate resources to prevent or delay the onset of anxiety and/or depression symptoms.

IMPLICATIONS

The study's findings indicate that tobacco and cannabis use is directly linked to the early onset of depressive and anxiety symptoms among youth. This highlights the significance of early screening and substance use interventions, particularly for youth aged 18 years and younger, as they are disproportionately affected by both substance use and mental health problems. School-based interventions that are age- and culturally appropriate hold promise as they enable youth to seek professional help early, and in a supportive environment. Intervening early in substance shows promise in reducing the likelihood of developing mental health problems at a young age.

Determinants of COVID-19 Vaccination Decision-Making Behaviors among Pregnant Women in Sub-Saharan Africa: A Scoping Review

Despite the availability of the coronavirus disease 2019 (COVID-19) vaccination, uptake among pregnant women in Sub-Saharan Africa has been low. This scoping review aimed to identify and characterize determinants influencing COVID-19 vaccination decision-making behaviors among pregnant women in Sub-Saharan Africa. We searched five online databases for articles on COVID-19 vaccination among pregnant women in Sub-Saharan Africa. We identified studies published in English between March 2020 and April 2023 that assessed vaccine-specific issues, psychosocial constructs, and contextual factors associated with COVID-19 vaccination decision-making behaviors. Of the fourteen studies identified, over half (57.1%) were cross-sectional; three used qualitative research methods; and three involved multi-country participants. Most studies assessed COVID-19 vaccination acceptability and willingness. Overall, 85.7% of the publications examined knowledge, attitudes, or both as critical factors associated with COVID-19 vaccination. The prevalence of COVID-19 vaccine uptake during pregnancy was low in Sub-Saharan Africa (14.4-28%). While most current studies assess COVID-19 vaccination knowledge, research on maternal vaccination in Sub-Saharan Africa would benefit from the inclusion of theory-informed and driven studies that measure additional psychosocial factors and contextual constructs. Future studies should also employ study designs that can determine causal pathways of vaccination determinants and vaccination uptake.

Depression and Anxiety as Predictors of Metabolic and Bariatric Surgery Completion Among Ethnically Diverse Patients

BACKGROUND

Mental health conditions including depression and anxiety are often prevalent among metabolic and bariatric surgery (MBS) patients, but it is not known if these conditions predict the decision to complete the procedure and if this varies by race and ethnicity. This study aimed to determine if depression and anxiety are associated with MBS completion among a race/ethnically diverse sample of patients.

METHODS

This prospective cohort study included participants who were referred to an obesity program or two MBS practices between August 2019 and October 2022. Participants completed the Mini International Neuropsychiatric Interview (MINI) instrument to determine history of anxiety and/or depression, as well as MBS completion status (Y/N). Multivariable logistic regression models determined the odds of MBS completion by depression and anxiety status adjusting for age, sex, body mass index, and race/ethnicity.

RESULTS

The sample consisted of 413 study participants (87 % women, 40% non-Hispanic White, 39% non-Hispanic Black, and 18% Hispanic). Participants with a history of anxiety were less likely to complete MBS (aOR = 0.52, 95% CI = 0.30-0.90, p = 0.020). Women had increased odds of a history of anxiety (aOR = 5.65, 95% CI = 1.64-19.49, p = 0.006) and of concurrent anxiety and depression (aOR = 3.07, 95% CI = 1.39-6.79, p = 0.005) compared to men.

CONCLUSIONS

Results showed that participants with anxiety were 48% less likely to complete MBS compared to those without anxiety. Additionally, women were more likely to report a history of anxiety with and without depression versus men. These findings can inform pre-MBS programs about risk factors for non-completion.

Academic and Attendance Outcomes after Participation in a School Breakfast Program

BACKGROUND

Little is known about how school breakfast programs are associated with school attendance and academic performance. This study evaluated Dallas Independent School District's (DISD) breakfast after the bell (BATB) program that provides breakfast for both habitually tardy and non-tardy students on (1) academic performance and (2) student attendance over 2 school years.

METHODS

A pre-post study design evaluated the impact of the BATB program in elementary/middle/high schools on student attendance and academic outcomes. Paired t-tests evaluated changes in outcomes between 2017 to 2018 and 2018 to 2019 school years.

RESULTS

The analytical sample consisted of 30,493 students (70.32% BATB participants, 50.47% male, 68.78% Hispanic). BATB participants were over 2.5 times more likely to attend school versus non-BATB participants (aOR = 2.55; 95% confidence interval [CI]: 2.23-2.92; p < .001). Compared to pre-participation (2017-2018), unadjusted models showed 2018 to 2019 BATB participants' mean reading scores increased from 1502.72 to 1545.76 during the 2018 to 2019 academic year (p < .001). There were no significant changes in reading and math scores over the 2-year implementation after adjustment.

CONCLUSIONS

Results here showed that a school breakfast program that is housed in a large public school system that serves predominantly low resource, ethnically diverse students is associated with increased student attendance.

Learning Modality and Quality of Life Among US School-Age Children During the Coronavirus Pandemic

BACKGROUND

Shifts from in-person learning to virtual and hybrid learning modes in response to the coronavirus pandemic potentially impacted children's physical, emotional, social, and academic development. This study examined the association between virtual, in-person, and hybrid learning modality with parent-reported quality of life among US students (kindergarten-12th) in early 2021.

METHODS

Parents reported current learning modality and physical, emotional, social, and school quality of life for children (aged 5-11, n = 1381) and adolescents (aged 12-17, n = 640). Multivariable logistic regression models assessed the odds of impaired quality of life by learning modality.

RESULTS

Among children, hybrid and virtual learners had greater odds of impaired quality of life (adjusted odds ratio [aOR] 1.79, 95% confidence interval [CI] 1.22, 2.64 and aOR 1.57, 95% CI 1.17, 2.12, respectively) relative to in-person learners. Among adolescents, virtual learners had greater odds impaired physical (aOR 2.06, 95% CI 1.26, 3.38) and school function (aOR 2.23, 95% CI 1.38, 3.61) relative to in-person learners.

CONCLUSIONS

Learning modality was associated with student well-being, and appropriate alternative learning modalities may differ for younger and older students in terms of educational quality and quality of life.

Long-Acting Reversible Contraception for Adolescents: A Review of Practices to Support Better Communication, Counseling, and Adherence

Long-acting reversible contraception (LARC) methods, including levonorgestrel and copper intrauterine devices (IUDs) and the subdermal contraceptive implant, are the most effective reversible forms of contraception and thus are an important aspect of adolescent pregnancy prevention. While LARC efficacy, safety, and appropriateness are supported by major medical organizations and usage rates are increasing, overall LARC uptake among United States (US) adolescents remains lower than uptake of short-acting contraceptive methods. A better understanding of the barriers affecting adolescent LARC uptake and reasons for discontinuation could help facilitate effective communication. For example, learning how to improve adolescent-centered communication, shared decision-making, and motivational counseling strategies may be the first step to improving utilization rates. This narrative review includes three sections. First, this review will describe the history, mechanisms of action, and epidemiology of adolescent LARC use in the US and globally. Next, this review will describe key factors influencing adolescent LARC uptake, reasons for discontinuation, and multilevel barriers specific to adolescent LARC use. Finally, this review will characterize communication techniques and LARC counseling strategies for adolescents in the context of a reproductive justice approach set in the health belief model framework. The distinction between moving away from a presumptive counseling approach towards an adolescent-centered, shared decision-making approach to encourage parent-adolescent sexual health communication to lay the foundation of empowering adolescent reproductive autonomy should be the underpinning of all effective reproductive communication strategies.

Effectiveness of semaglutide versus liraglutide for treating post-metabolic and bariatric surgery weight recurrence

OBJECTIVE

The aim of this study was to compare the effectiveness of semaglutide versus liraglutide for treating post-metabolic and bariatric surgery (MBS) weight recurrence.

METHODS

A retrospective analysis of 207 adults with post-MBS weight recurrence treated with semaglutide 1.0 mg weekly (n = 115) or liraglutide 3.0 mg daily (n = 92) at an academic center from January 1, 2015, through April 1, 2021, was conducted. The primary end point was percentage body weight change at 12 months of treatment with regimens containing semaglutide or liraglutide.

RESULTS

The mean sample age was 55.2 years; mean BMI was 40.4 kg/m2 ; 89.9% were female; and 50% completed sleeve gastrectomy, 29% completed Roux-en-Y gastric bypass, and 21% completed adjustable gastric banding. Least-squares mean weight change at 12 months was -12.92% versus -8.77% in the semaglutide and liraglutide groups, respectively (p < 0.001). The adjusted odds ratios were 2.34 (95% CI: 1.28-4.29) for ≥10% weight loss and 2.55 (95% CI: 1.22-5.36) for ≥15% weight loss over 12 months in the semaglutide group versus liraglutide group, respectively. Weight-loss efficacy of semaglutide (vs. liraglutide) did not differ by subgroups explored, including age, sex, and MBS procedure.

CONCLUSIONS

These results show that treatment regimens including semaglutide 1.0 mg weekly lead to superior weight loss compared with liraglutide 3.0 mg daily for treating post-MBS weight recurrence, regardless of procedure type or the magnitude of weight recurrence.

SARS-CoV-2 Serostatus and COVID-19 Illness Characteristics by Variant Time Period in Non-Hospitalized Children and Adolescents

OBJECTIVE

To describe COVID-19 illness characteristics, risk factors, and SARS-CoV-2 serostatus by variant time period in a large community-based pediatric sample.

DESIGN

Data were collected prospectively over four timepoints between October 2020 and November 2022 from a population-based cohort ages 5 to 19 years old.

SETTING

State of Texas, USA.

PARTICIPANTS

Participants ages 5 to 19 years were recruited from large pediatric healthcare systems, Federally Qualified Healthcare Centers, urban and rural clinical practices, health insurance providers, and a social media campaign.

EXPOSURE

SARS-CoV-2 infection.

MAIN OUTCOME(S) AND MEASURE(S)

SARS-CoV-2 antibody status was assessed by the Roche Elecsys^® Anti-SARS-CoV-2 Immunoassay for detection of antibodies to the SARS-CoV-2 nucleocapsid protein (Roche N-test). Self-reported antigen or PCR COVID-19 test results and symptom status were also collected.

RESULTS

Over half (57.2%) of the sample (N = 3911) was antibody positive. Symptomatic infection increased over time from 47.09% during the pre-Delta variant time period, to 76.95% during Delta, to 84.73% during Omicron, and to 94.79% during the Omicron BA.2. Those who were not vaccinated were more likely (OR 1.71, 95% CI 1.47, 2.00) to be infected versus those fully vaccinated.

CONCLUSIONS

Results show an increase in symptomatic COVID-19 infection among non-hospitalized children with each progressive variant over the past two years. Findings here support the public health guidance that eligible children should remain up to date with COVID-19 vaccinations.

The Role of Intervention Fidelity, Culture, and Individual-Level Factors on Health-Related Outcomes Among Hispanic Adolescents with Unhealthy Weight: Findings from a Longitudinal Intervention Trial

Previous studies have suggested the impact of intervention fidelity on the management and prevention of chronic diseases; however, little is known about the effect of the contributing determinants (at multiple levels of influence) that can impact health-related interventions intending to improve the health status of Hispanic adolescents with overweight or obesity. The current study aimed to assess whether fidelity (i.e., dosage and quality of the program delivery), acculturation (i.e., orientation to the American culture, retention of Hispanic cultural values), and individual-level socio-demographic characteristics (i.e., income, education) predict changes in family processes (e.g., parent control), which in turn may affect adolescent health-related outcomes including body mass index (BMI), physical activity, dietary intake, and adolescents' health-related quality of life. A pathway analysis model was utilized to explore the study variables among 140 Hispanic parent-adolescent dyads randomized to Familias Unidas Health and Wellness (FUHW) intervention. Results indicated that fidelity was significantly associated with changes in parent-adolescent communication, parent monitoring, limit-setting, and control. Parents' education was associated with changes in parent limit-setting, and parent Hispanicism was associated with changes in parent limit-setting and discipline. The examination between family processes and adolescent health outcomes revealed that parents' higher discipline and improved communication with their adolescents were significantly associated with improved adolescents' quality of life, and parent control was positively associated with physical activity and negatively associated with BMI in adolescents. Our findings demonstrated the significant contribution of intervention fidelity and participants' characteristics in parenting strategies leading to adolescents' health outcomes to prevent obesity-related chronic diseases. Future research is needed to investigate the effect of environmental and organizational factors on the delivery of the intervention materials.

Physical Fitness Among Adolescents Who are Hispanic With Overweight or Obesity

PURPOSE

To describe cardiorespiratory, strength, muscular endurance, and flexibility fitness outcomes in a sample of adolescents who are Hispanic aged 11 to 15 years with overweight or obesity, stratified by age and sex.

METHODS

The sample included 280 adolescents (mean age: 13.0 ± 0.83 years, mean body mass index percentile: 94.6). Anthropometric measures included height, weight, body mass index percentile, and waist and hip circumference. Fitness measures included handgrip strength, sit-ups in 60 seconds, sit-and-reach test, and 6-minute walk test. We report mean scores for each fitness outcome measure and correlation coefficients with anthropometric measures.

RESULTS

Mean handgrip was 23.7 ± 6.48 kg, sit-and-reach test was 25.3 ± 8.13 cm, average sit-ups in 60 seconds were 19.4 ± 9.28, and 6-minute walk distance was 1960 ± 271 ft. Males outperformed females in all tests except sit-and-reach test.

DISCUSSION

Compared with published fitness values of healthy weight adolescents, our sample of adolescents who are Hispanic with overweight/obesity living in southern Florida is unconditioned in terms of cardiorespiratory fitness, strength, muscular endurance, and flexibility.

Association of Obesity, Suicide Behaviors, and Psychosocial Wellness Among Adolescents in the United States

BACKGROUND

Adolescents with obesity are more likely to exhibit suicide behaviors, but this association may be confounded by psychosocial stigma related to obesity. We examined whether the obesity is independently associated with suicide behaviors among United States adolescents, after adjusting for the psychosocial factors.

METHODS

We analyzed data from 2019 Youth Risk Behavior Survey data (N = 13,871 United States adolescents) on recent (past year) suicide behavior (attempt, ideation, and plan); demographics (age, sex, and race/ethnicity); and psychosocial factors (feeling sad/hopeless, alcohol and illegal drug use, being bullied, and sexually abused). Participants were classified as having obesity (Y/N) per standardized percentiles. Logistic regression was employed to examine the association between obesity and suicide attempt, ideation, and plan, while adjusting for psychosocial covariates.

RESULTS

The prevalence of suicide attempt, ideation, and plan was 8.90%, 18.75%, and 15.71%, respectively. Obesity prevalence was 15.5%. The odds of suicide attempt, ideation, and plan were 1.65 (1.30-2.11), 1.31 (0.89-1.61), and 1.27 (1.02-1.57), respectively, among those with obesity versus without obesity.

DISCUSSION

Obesity is significantly associated with a suicide attempt, ideation, and plan among United States adolescents, even after adjusting for confounding psychosocial factors. Further research on the temporality and causality of this association is needed.

Association of corticosteroid use and attention deficit/hyperactivity disorder in asthmatic children varies by age

OBJECTIVE

We aim to examine the impact of corticosteroids use on ADHD among children with asthma by administration routes.

METHODS

A population-based, cross-sectional analysis included pediatric patients ages 5-20 years old from the 2016 and 2019 Kids Inpatient Database (unweighted N = 111,702). ICD-10-CM codes were used to identify corticosteroids use, asthma, and ADHD cases. Survey logistic regression models with purposeful variable selection algorithms were built to examine the association between corticosteroids use, and ADHD by asthma severity and age. An inverse probability weighting (IPW) approach was used to help further control residual confounding.

RESULTS

Among children aged 5-11 years old, the odds of ADHD were significantly higher in children with moderate to severe asthma who used inhaled corticosteroids than nonusers (moderate asthma: adjusted odds ratios [aOR] 1.46, 95% confidence interval [CI] 1.14-2.44; severe asthma: aOR 1.61, 95% CI 1.18-2.21). Although oral corticosteroid use was not independently associated with ADHD in young children, combined use of inhaled and oral corticosteroid had almost 5 times higher odds of use among ADHD in children with severe asthma vs. nonusers (aOR 4.85, 95% CI 2.07 - 11.35). No associations were found between any corticosteroid use and ADHD among asthmatic children aged 12-20 years.

CONCLUSIONS

In this retrospective analysis, we found inhaled corticosteroids were positively associated with ADHD in younger children with moderate to severe asthma, but not in older children.