Development and Implementation of a Multidisciplinary Clinic Focused on the Care of Adolescents with Youth-Onset Type 2 Diabetes.

Introduction: Diabetes self-management education and lifestyle interventions are the cornerstones of type 2 diabetes (T2D) care; however, the higher risk of comorbidities among youth with T2D requires a comprehensive care model. Traditionally, sub-specialty care relies on a referral model placing the burden on patients/families. In response, we developed a pediatric T2D multidisciplinary clinic (MDC)-A single physical location where patients can access various sub-specialists. The goals of the MDC are to aid with lifestyle modifications and provide referral/access to sub-specialists within the MDC, as determined through screening labs and assessment tools. Methods: We conducted a retrospective chart review of youth seen in the T2D MDC clinic at Cincinnati Children's Hospital from 1/2020 to 12/2021. We evaluated the frequency that youth met with each specialist and completion rates of annual screening labs. Results: The cohort consisted of 227 youth with T2D (mean age 17.6 years, mean BMI 40.9kg/m2, 64% female, 50% Black or African American, 65% public insurance). All patients met with a diabetes provider and 81.2% met with a registered dietitian/certified diabetes education specialist. Exercise physiology met with 51.5% of patients, gastroenterology met with 34.8% of patients, social work met with 44.1% of patients, clinical psychology met with 27.3% of patients, and bariatric surgery met with 9.7% of patients. Percent completion of annual labs were: 98.2% for HbA1c, 84.6% for urine microalbumin, 83.7% for lipids, 90% for liver function, 59.5% for retinopathy, and 45.4% for the Patient Health Questionnaire-9. Conclusion: The majority of patients received diabetes and nutrition education and annual screening labs. Exercise counseling and sub-specialty care remain below 60% in part due to services not being available at every MDC. Our goals are to increase access to subspecialty care within the MDC's and consider additional care delivery methods to provide comprehensive care to youth with T2D.

Trajectories of Psychopathology and Dysregulation 2-4 Years following Adolescent Bariatric Surgery.

OBJECTIVE: This study examined psychopathology and weight over 4 years following bariatric surgery in adolescents with obesity, as compared to a nonsurgical group. The role of psychological dysregulation in relation to psychopathology in the 2-4 year "maintenance phase" following surgery was also examined. METHODS: Adolescent participants (122 surgical and 70 nonsurgical) completed height/weight and psychopathology assessments annually for 4 years, with dysregulation assessed at Year 2. Analyses examined the association of "High" and "Low" psychopathology with weight over time using logistic regression. Mediation analyses in the surgical group examined indirect effects of dysregulation on percent weight loss through Year 4 psychopathology. RESULTS: There were lower odds of "High" internalizing symptoms in the surgical group versus the nonsurgical group from baseline (presurgery) to Year 4 (OR = .39; p < .001; 42.3% "High" internalizing in surgical; 66.7% in nonsurgical) and during the 2-4 year maintenance phase (OR = .35, p < .05; 35.1% "High" internalizing in surgical; 60.8% in nonsurgical). There was a significant mediation effect in the surgical group: higher dysregulation was associated with greater Year 4 internalizing symptoms (ß = .41, p < .001) which in turn was associated with less Year 4 percent weight loss (ß = -.27, p < .05). CONCLUSIONS: While the surgical group was less likely to experience internalizing symptoms, internalizing psychopathology was related to less percent weight loss in this group. Internalizing symptoms mediated the relationship between dysregulation and percent weight loss in the surgical group. Postoperative mental health follow-up is needed for adolescents into young adulthood.

Weight change predicts college adjustment and depressive symptoms among first-year college students.

ObjectiveWeight change is common during the first year of college and may be related to different outcomes for men and women. This study examined the moderating effects of gender on the association between weight change and college adjustment and depressive symptoms. Participants: One-hundred and eighty-one 18-19-year-old college freshmen (56.9% female; 84.5% Caucasian). Methods: Students completed a one-time survey about demographics, weight, college adjustment, and depressive symptoms during their second semester of college. Results: Increased weight change was associated with fewer depressive symptoms for both men and women (p < .04). For men, increased weight change was associated with better overall college adjustment, more positivity about college, less negativity about college, and less homesickness (all p < .02). Conclusions: Universities could target men and women differently in regard to weight, college adjustment, and mental health to promote a positive college experience and optimal mental health.

Nutrition interventions for youth with dyslipidemia: a National Lipid Association clinical perspective.

A heart-healthy lifestyle, beginning at an early age and sustained throughout life, may reduce risk for cardiovascular disease in youth. Among youth with moderate to severe dyslipidemia and/or those with familial hypercholesterolemia, lipid-lowering medications are often needed for primary prevention of cardiovascular disease. However, lifestyle interventions are a foundation for youth with dyslipidemia, as well as those without dyslipidemia. There are limited data supporting the use of dietary supplements in youth with dyslipidemia at this time. A family-centered approach and the support of a multi-disciplinary healthcare team, which includes a registered dietitian nutritionist to provide nutrition counseling, provides the best opportunity for primary prevention and improved outcomes. While there are numerous guidelines that address the general nutritional needs of youth, few address the unique needs of those with dyslipidemia. The goal of this National Lipid Association Clinical Perspective is to provide guidance for healthcare professionals caring for youth with disorders of lipid and lipoprotein metabolism, including nutritional guidance that complements the use of lipid lowering medications.

Health-Related Social Needs Facing Youth with NonAlcoholic Fatty Liver Disease.

Background: The objective of this study was to identify the prevalence of health-related social needs among youth with nonalcoholic fatty liver disease (NAFLD). Methods: Retrospective review of prospectively administered health-related social needs questionnaires from Steatohepatitis Clinics. Results: Patients with NAFLD (n=271) were predominantly male (72%), and non-Hispanic (68%). The most common unmet need was food insecurity (13%, n=36). Families who endorsed food insecurity at the first visit were 27-fold more likely to have unmet health-related social needs persist at subsequent visits than those who were food-secure at their first visit (95% CI: 6.7-111). Conclusion: Screening for social, economic, and environmental needs may identify previously unrecognized family challenges and may enhance intervention delivery, inform resource allocation, and improve outcomes.

Insight Into the Adolescent Patient Experience With Nonalcoholic Fatty Liver Disease.

OBJECTIVES: Nonalcoholic fatty liver disease (NAFLD) is the leading chronic liver disease in youth, yet little is known about the adolescent patient's experience with NAFLD, which is key for treatment engagement. We examined adolescents' experiences with NAFLD diagnosis, thoughts on how NAFLD affects their daily life, understanding and perceptions of diagnosis and treatment, and impressions of how to improve care. METHODS: Utilizing a mixed-method design, adolescents with NAFLD (N = 16; Mean age = 15.8 years; Mean BMI = 37 kg/m 2 ) participated in focus groups. To supplement qualitative data, adolescents and their caregiver completed measures assessing illness perceptions, adolescent quality of life, and eating/activity behaviors. RESULTS: Focus group themes suggested reactions to diagnosis varied from unconcerned to anxious. NAFLD diagnosis occurred within the context of other psychological/medical concerns and was not perceived to affect most adolescents' daily lives. Although adolescents understood general contributors to NAFLD, comprehension of their diagnosis varied. Adolescents were more likely to make lifestyle changes when families were supportive, and they preferred tailored recommendations for health behavior change from the healthcare team. Notably, 62.5% of adolescents were more concerned about their weight than NAFLD. Almost half (43.8%) identified as food insecure. CONCLUSIONS: Adolescents with NAFLD may benefit from personalized treatment. Care could be enhanced by ensuring comprehension of diagnosis, problem-solving personal, and family barriers and increasing family support. Harnessing adolescents' desire for weight loss may be a more salient driver for change in disease status. Interventions should also address systemic barriers such as food insecurity to ensure equitable care.

Unhealthy Eating, Psychopathology, and Nonalcoholic Fatty Liver Disease in Youth Presenting for Bariatric Surgery.

OBJECTIVES: Little is known about the behavioral and psychosocial correlates of pediatric nonalcoholic fatty liver disease (NAFLD). Given diet contributes to the development and persistence of NAFLD, we examined (1) the prevalence of unhealthy eating behaviors (UEB), (2) whether these varied by NAFLD or nonalcoholic steatohepatitis (NASH) presence, and explored (3) the association of psychopathology with NAFLD. METHODS: Before metabolic and bariatric surgery (MBS), adolescents (N = 159; Mage = 16.4; MBMI = 53.7 kg/m2, 73% girls, 62.3% white) self-reported presence/absence of 10 UEB (Questionnaire on Eating and Weight Patterns-Revised, Night Eating Questionnaire, Look AHEAD). NAFLD and NASH presence was assessed by intraoperative liver biopsy. Height/weight, blood pressure, and blood specimens were obtained. A medical comorbidity index was created (prediabetes/diabetes, dyslipidemia, elevated blood pressure). Psychopathology was assessed in a subgroup completing the Youth Self-Report (N = 98). RESULTS: Binge eating disorder symptomatology was associated with higher odds of NAFLD whereas frequent eating out was associated with lower odds of NAFLD. Among those with NAFLD frequent eating out was associated with higher odds of NASH while nocturnal eating was associated with lower odds of NASH. Separate models identified internalizing psychopathology as associated with higher odds of NAFLD after controlling for demographics, number of UEB, and medical comorbidities. CONCLUSIONS: Results suggest potential phenotypical differences between adolescents presenting for MBS with/without NAFLD, with implications for behavioral/psychosocial targets for screening and intervention. Replication should occur in a sample with greater gender and ethnic diversity to improve generalizability. Understanding differences in the context of surgical weight loss and comorbidity resolution is indicated.

Suicidal thoughts and behaviors in adolescents who underwent bariatric surgery.

BACKGROUND: Extant literature warns of elevated suicide risks in adults postbariatric surgery, making understanding risks for adolescent patients imperative. OBJECTIVES: To examine prevalence and predictors/correlates of suicidal thoughts and behaviors (STBs) in adolescents with severe obesity who did/did not undergo bariatric surgery from presurgery/baseline to 4 years postsurgery. SETTING: Five academic medical centers. METHODS: Using a prospective observational design, surgical adolescents (n = 153; 79% female, 65% white, mean [M]age = 17 yr, Mbody mass index[BMI] = 52 kg/m2) and nonsurgical comparators (n = 70; 80% female, 54% white, Mage = 16 yr, MBMI = 47 kg/m2) completed psychometrically sound assessments at presurgery/baseline and postsurgery years 2 and 4 (year 4: n = 117 surgical [MBMI = 38 kg/m2], n = 56 nonsurgical [MBMI = 48 kg/m2]). RESULTS: For the surgical group, rates of STBs were low (year 2 [1.3%-4.6%]; year 4 [2.6%-7.9%], similar to national base rates. Groups did not differ on a year 4 postsurgical STBs (post-STBs) composite (post-STBs: ideation/plan/attempt; n = 18 surgical [16%], n = 10 nonsurgical [18%]; odds ratio = .95, P = .90). For the surgical group, predictors/correlates identified within the broader suicide literature (e.g., psychopathology [P < .01], victimization [P < .05], dysregulation [P < .001], drug use [P < .05], and knowing an attemptor/completer [P < .001]) were significantly associated with post-STBs. Surgery-specific factors (e.g., percent weight loss, weight satisfaction) were nonsignificant. Of those reporting a lifetime attempt history at year 4, only a minority (4/13 surgical, 3/9 nonsurgical) reported a first attempt during the study period. Of 3 decedents (2 surgical, 1 nonsurgical), none were confirmed suicides. CONCLUSIONS: The present study indicates that undergoing bariatric surgery in adolescence does not heighten (or lower) risk of STB engagement across the initial 4 years after surgery. Suicide risks present before surgery persisted, and also newly emerged in a subgroup with poorer psychosocial health.

Change, predictors and correlates of weight- and health-related quality of life in adolescents 2-years following bariatric surgery.

BACKGROUND/OBJECTIVES: Weight-related quality of life (WRQOL) and generic health-related quality of life (HRQOL) have been identified as important patient-reported outcomes for obesity treatment and outcome research. This study evaluated patterns of WRQOL and HRQOL outcomes for adolescents at 24-months post-bariatric surgery relative to a nonsurgical comparator sample of youth with severe obesity, and examined potential weight-based (e.g., BMI, weight dissatisfaction) and psychosocial predictors and correlates of these outcomes. SUBJECTS/METHODS: Multi-site data from 139 adolescents undergoing bariatric surgery (Mage = 16.9; 79.9% female, 66.2% White; MBody Mass Index [BMI] = 51.5 kg/m2) and 83 comparators (Mage = 16.1; 81.9 % female, 54.2% White; MBMI = 46.9 kg/m2) were collected at pre-surgery/baseline, 6-, 12-, and 24-months post-surgery/baseline with high participation rates across time points (>85%). Self-reports with standardized measures of WRQOL/HRQOL as well as predictors/covariates (e.g., weight dissatisfaction, social support, peer victimization, family dysfunction, loss of control eating, self-worth, and internalizing symptoms) were obtained. Growth curve models using structural equation modeling examined WRQOL/HRQOL over time and linear regressions examined predictors and correlates of WRQOL/HRQOL outcomes. RESULTS: Significant improvement in WRQOL and Physical HRQOL, particularly in the first postoperative year with a leveling off subsequently, was found for the surgical group relative to comparators, but with no significant Mental HRQOL change. At 24 months, the surgical group had significantly greater WRQOL/HRQOL across most subscales. Within the surgical group at 24 months, weight-based variables were significantly associated with WRQOL and Physical HRQOL, but not Mental HRQOL. Mental HRQOL was associated with greater internalizing symptoms and loss of control eating. CONCLUSIONS: For adolescents undergoing bariatric surgery, most clinically meaningful changes in WRQOL and Physical HRQOL occurred early postoperatively, with weight-based variables as the primary drivers of 24-month levels. In contrast, expectations for Mental HRQOL improvement following surgery should be tempered, with 24-month levels significantly associated with psychosocial rather than weight-based correlates.

Community Socioeconomic Deprivation and Nonalcoholic Fatty Liver Disease Severity.

BACKGROUND AND OBJECTIVES: Nonalcoholic fatty liver disease (NAFLD) is linked to obesity. Obesity is associated with lower socioeconomic status (SES). An independent link between pediatric NAFLD and SES has not been elucidated. The objective of this study was to evaluate the distribution of socioeconomic deprivation, measured using an area-level proxy, in pediatric patients with known NAFLD and to determine whether deprivation is associated with liver disease severity. METHODS: Retrospective study of patients <21 years with NAFLD, followed from 2009 to 2018. The patients' addresses were mapped to census tracts, which were then linked to the community deprivation index (CDI; range 0--1, higher values indicating higher deprivation, calculated from six SES-related variables available publicly in US Census databases). RESULTS: Two cohorts were evaluated; 1 with MRI (magnetic resonance imaging) and/or MRE (magnetic resonance elastography) findings indicative of NAFLD (n = 334), and another with biopsy-confirmed NAFLD (n = 245). In the MRI and histology cohorts, the majority were boys (66%), non-Hispanic (77%-78%), severely obese (79%-80%), and publicly insured (55%-56%, respectively). The median CDI for both groups was 0.36 (range 0.15-0.85). In both cohorts, patients living above the median CDI were more likely to be younger at initial presentation, time of MRI, and time of liver biopsy. MRI-measured fat fraction and liver stiffness, as well as histologic characteristics were not different between the high- and low-deprivation groups. CONCLUSIONS: Children with NAFLD were found across the spectrum of deprivation. Although children from more deprived neighborhoods present at a younger age, they exhibit the same degree of NAFLD severity as their peers from less deprived areas.

Halo or horn? A qualitative study of mothers' experiences with feeding children during the first year following bariatric surgery.

BACKGROUND: Obesity is a chronic condition that has an intergenerational effect. The aims of the study were to better understand the impact of maternal bariatric surgery on obesogenic risks to child offspring in the home via documenting mothers' thoughts, behaviors, and experiences around child feeding, family meals, and the home food environment during her first year postsurgery. METHOD: Utilizing a mixed-method cross-sectional design, 20 mothers (Mage = 39.6 ±â€¯5.7 years, 75% White, MBMI = 33.6 ±â€¯4.3 kg/m2, Mtime = 7.7 ±â€¯3.1 months post-surgery) of children ages 6-12 years completed validated self-report measures and participated in a focus group. Mother and child heights/weights were measured. RESULTS: The majority of children (N = 20; Mage = 9.2 ±â€¯2.3 years, 65% White, 60% female) were overweight (N = 12; BMI≥85th percentile) and were not meeting the American Academy of Pediatrics healthy eating and activity recommendations to treat/reduce obesity risk. As child zBMI increased, mothers expressed significantly more weight concern (r = 0.59, p = 0.01) and lower obesity-specific quality of life (r = -0.56, p = 0.01), yet assumed less responsibility for child eating choices (r = -0.47, p = 0.04). Qualitative data demonstrated disconnects between mothers' changes to achieve her own healthier weight and applying this knowledge to feeding her child/family. CONCLUSIONS: While bariatric surgery and requisite lifestyle change are effective tools for weight loss at the individual level, there is a great need for innovative family-based solutions. Pediatric obesity is preventable or risk-diminished if addressed early. Maternal bariatric surgery may be a unique (yet missed) opportunity to intervene.

Psychotropic Medications Are Associated With Increased Liver Disease Severity in Pediatric Nonalcoholic Fatty Liver Disease.

OBJECTIVES: The aim of the study was to determine whether pediatric patients with nonalcoholic fatty liver disease (NAFLD) exposed to psychotropic medications have more severe liver disease compared to their counterparts who are not on these medications. We hypothesize that use of psychotropic agents is associated with liver disease severity. METHODS: Children and adolescents with biopsy-confirmed NAFLD were included in this study. Histology data, detailed clinical information, and results of serum biochemistries performed within 3 months of the liver biopsy were collected retrospectively. Univariate and multivariate modeling was used to determine differences between the groups and to control for confounders. RESULTS: A total of 228 patients were included, 17 (8%) of whom where on psychotropic medications at the time of the liver biopsy. Patients on psychotropic medications were more likely to also be on metformin (53% vs 18%, P < 0.01) and antihypertensive medications (29% vs 8%, P < 0.01) compared to children with NAFLD who were not on psychotropic agents. There were no differences in regards to biochemical evidence of liver injury, insulin resistance, and dyslipidemia between the groups. On histology, however, the use of psychotropic medications was associated with increased steatosis severity (score 2.4 vs 1.9, P = 0.04) and increased likelihood of having an NAFLD Activity Score ≥5 (seen in 59% vs 35% or patients; P = 0.05, respectively). CONCLUSIONS: In this large cohort of children with biopsy-confirmed NAFLD, the use of psychotropic medications was associated with increased liver disease severity. Exposure to psychotropic agents should be considered when risk stratifying children with NAFLD.

Cognition enhancement by modafinil: a meta-analysis.

INTRODUCTION: Currently, there are a number of pharmaceuticals available that have potential to enhance cognitive functioning, some of which may ultimately be considered for such use in military operations. Some drugs with potential for cognition enhancement have already been studied for use in military operations specific to their primary effect in sleep regulation (i.e., dextroamphetamine, modafinil, caffeine). There is considerable information available on many of these drugs. However, considerations for military appropriateness must be based on proficient research (e.g., randomly controlled trial design). METHODS: A meta-analysis was conducted to summarize the current state of knowledge of these potentially cognition-enhancing drugs. The analysis only included studies which met inclusion criteria relevant to military research. RESULTS: The results of the literature review reveal a gap in research of the enhancement properties of the drugs of interest. The results yielded three studies (all of which studied modafinil) that met the criteria. The meta-analysis of these three studies revealed a relatively weak pooled effect of modafinil on some aspects of cognitive performance in normal, rested adults. DISCUSSION: While the results of this study support the efficacy of modafinil, the main finding is the large literature gap evaluating the short- and long-term effects of these drugs in healthy adults.