Advancing Nutrition Education, Training, and Research for Medical Students, Residents, Fellows, Attending Physicians, and Other Clinicians: Building Competencies and Interdisciplinary Coordination.

Nutrition plays an important role in health promotion and disease prevention and treatment across the lifespan. Physicians and other healthcare professionals are expected to counsel patients about nutrition, but recent surveys report minimal to no improvements in medical nutrition education in US medical schools. A workshop sponsored by the National Heart, Lung, and Blood Institute addressed this gap in knowledge by convening experts in clinical and academic health professional schools. Representatives from the National Board of Medical Examiners, the Accreditation Council for Graduate Medical Education, the Liaison Committee on Medical Education, and the American Society for Nutrition provided relevant presentations. Reported is an overview of lessons learned from nutrition education efforts in medical schools and health professional schools including interprofessional domains and competency-based nutrition education. Proposed is a framework for coordinating activities of various entities using a public-private partnership platform. Recommendations for nutrition research and accreditation are provided.

Update on Nutrition, Metabolism, and Lifestyle Curricula for Medical Education, Research, and Practice: USA.

Although physicians are expected to counsel their patients about nutrition-related health conditions, surveys report minimal to no medical nutrition education improvements in the United States medical schools. From 1998 to 2005, the National Institutes of Health (NIH) introduced and funded the Nutrition Academic Award program among 21 medical schools to incorporate nutrition into their curricula. Since then, nutrition champions have developed several education models and continue to advocate for inclusion of nutrition content in the U.S. Medical Licensing Examination and for recognition of nutrition as a national subspecialty in medicine. As a result, the American Society for Nutrition (ASN) and NIH published recommendations for remodeling nutrition education, training, and research. As medical education has shifted to a competency-based system, an inter-professional and competency-based approach to curricular changes was recommended. As a result, ASN aims to launch a coordinating center using a public-private partnership platform to achieve those goals. This collaborative will further allow for inclusion of all healthcare professionals engaged in improving patients' nutrition-related outcomes. This article describes the educational context and steps needed to advance the field of medical nutrition, metabolism, and lifestyles in the United States.

Clinical Considerations Regarding the Use of Obesity Pharmacotherapy in Adolescents with Obesity.

A growing number of youth suffer from obesity and in particular severe obesity for which intensive lifestyle intervention does not adequately reduce excess adiposity. A treatment gap exists wherein effective treatment options for an adolescent with severe obesity include intensive lifestyle modification or metabolic and bariatric surgery while the application of obesity pharmacotherapy remains largely underutilized. These youth often present with numerous obesity-related comorbid diseases, including hypertension, dyslipidemia, prediabetes/type 2 diabetes, obstructive sleep apnea, nonalcoholic fatty liver disease, musculoskeletal problems, and psychosocial issues such as depression, anxiety, and social stigmatization. Current pediatric obesity treatment algorithms for pediatric primary care providers focus primarily on intensive lifestyle intervention with escalation of treatment intensity through four stages of intervention. Although a recent surge in the number of Food and Drug Administration-approved medications for obesity treatment has emerged in adults, pharmacotherapy options for youth remain limited. Recognizing treatment and knowledge gaps related to pharmacological agents and the urgent need for more effective treatment strategies in this population, discussed here are the efficacy, safety, and clinical application of obesity pharmacotherapy in youth with obesity based on current literature. Legal ramifications, informed consent regulations, and appropriate off-label use of these medications in pediatrics are included, focusing on prescribing practices and prescriber limits.

Shape-Up and Eat Right Families Pilot Program: Feasibility of a Weight Management Shared Medical Appointment Model in African-Americans With Obesity at an Urban Academic Medical Center.

OBJECTIVES: Disparities in obesity care exist among African-American children and adults. We sought to test the feasibility of a pilot program, a 1-year family-based intervention for African-American families with obesity [shape up and eat right (SUPER)], adopting the shared medical appointment model (SMA) at an urban safety net hospital. OUTCOMES: Primary outcomes: (1) family attendance rate and (2) program satisfaction. Secondary outcomes: change in body mass index (BMI), eating behaviors, and sedentary activity. METHODS: Adult parents (BMI ≥ 25 kg/m2) ≥18 years and their child(ren) (BMI ≥ 85th percentile) ages 6-12 years from adult or pediatric weight management clinics were recruited. One group visit per month (n = 12) consisting of a nutrition and exercise component was led by a nurse practitioner and registered dietitian. Height and weight were recorded during each visit. Participants were queried on program satisfaction, food logs and exercise journals, Food Stamp Program's Food Behavior, and the Expanded Food and Nutrition Education Program food checklists. RESULTS: Thirteen participants from lower socioeconomic zip codes consented [n = 5 mothers mean age 33 years, BMI of 47.4 kg/m2 (31.4-73.6 kg/m2); n = 8 children; mean age 9 years, BMI of 97.6th percentile (94-99th percentile); 60% enrolled in state Medicaid]. Average individual attendance was 23.4% (14-43%; n = 13); monthly session attendance rates declined from 100 to 40% by program completion; two families completed the program in entirety. Program was rated (n = 5 adults) very satisfactory (40%) and extremely satisfactory (60%). Pre-intervention, families rated their eating habits as fair and reported consuming sugar-sweetened beverages or sports drinks, more so than watching more than 1 h of television (p < 0.002) or video game/computer activity (p < 0.006) and consuming carbonated sodas (p < 0.004). Post-intervention, reducing salt intake was the only statistically significant variable (p < 0.029), while children watched fewer hours of television and spent less time playing video games (from average 2 to 3 h daily; p < 0.03). CONCLUSION: Attendance was lower than expected though children seemed to decrease screen time and the program was rated satisfactory. Reported socioeconomic barriers precluded families from attending most sessions. Future reiterations of the intervention could be enhanced with community engagement strategies to increase participant retention.

Nutritional status and feeding practices in gastrointestinal surgery patients at Bach Mai Hospital, Hanoi, Vietnam.

BACKGROUND AND OBJECTIVES: The nutritional status and hospital feeding practices of surgical patients in Vietnam are not well documented. Based on a cross-sectional study at Bach Mai Hospital (BMH), the prevalence of malnutrition was found to be 33% in the surgical ward using a body mass index (BMI<18.5 kg/m(2). We conducted an observational study over a three month period to evaluate the feeding practices in the gastrointestinal (GI) surgery ward at Bach Mai Hospital (BMH) in Hanoi, Vietnam. METHODS AND STUDY DESIGN: Investigators from the U.S. and the Vietnamese National Institute of Nutrition (NIN) enrolled 72 subjects admitted for elective GI surgery in an observational study at BMH. Baseline anthropometrics and changes over time, body mass index (BMI), Subjective Global Assessment (SGA) and daily kcal and protein intake from oral diet, tube feeding, and parenteral nutrition (PN) from admission until discharge were documented. RESULTS: A total of 50% of subjects scored a B or C on the SGA; 48% of subjects had a BMI<18.5, while mean mid upper arm circumference was in the lownormal range (24±4 cm). Nearly all patients (98%) were given PN postoperatively, with oral feeding starting on an average of postoperative day 4. Only one patient was tube fed. Mean daily total calorie intake was 15 kcal/kg/day and protein intake was 0.61 g/kg/day during hospitalization. Micronutrient supplementation was minimal in subjects receiving PN. CONCLUSIONS: Hospital malnutrition in surgical patients in Vietnam is a significant problem, peri-operative feeding appears suboptimal and use of early postoperative PN was routine.

Addressing Pediatric Obesity in Ambulatory Care: Where Are We and Where Are We Going?

Since the "2007 summary report of child and adolescent overweight and obesity treatment" published by Barlow, many obesity intervention studies have been conducted in pediatric ambulatory care. Although several meta-analyses have been published in the interim, many studies were excluded because of the focus and criteria of these meta-analyses. Therefore, the primary goal of this article was to identify randomized case-control trials conducted in the primary care setting and to report on treatment approaches, challenges, and successes. We have developed four themes for our discussion and provide a brief summary of our findings. Finally, we identified major gaps and potential solutions and describe several urgent key action items.

Paediatric obesity: can medications help.

PURPOSE OF REVIEW: The purpose of this study is to review current and emergent antiobesity drugs in paediatrics. RECENT FINDINGS: Understanding of the pathophysiology of obesity is improving, but access to antiobesity drugs continues to be challenging, especially in paediatrics. Few antiobesity drug trials have been conducted in paediatrics and postmarketing findings remain a source of concern. New approaches by the European Medicines Agency and the US Food and Drug Administration have provided guidance for the development of antiobesity drugs. However, few are in the pipeline and high-quality trials in paediatrics are lacking. SUMMARY: We are providing a summary of available antiobesity drug therapies, barriers to treatment and emerging pharmacotherapies.

Nutrition competencies in health professionals' education and training: a new paradigm.

Most health care professionals are not adequately trained to address diet and nutrition-related issues with their patients, thus missing important opportunities to ameliorate chronic diseases and improve outcomes in acute illness. In this symposium, the speakers reviewed the status of nutrition education for health care professionals in the United States, United Kingdom, and Australia. Nutrition education is not required for educating and training physicians in many countries. Nutrition education for the spectrum of health care professionals is uncoordinated, which runs contrary to the current theme of interprofessional education. The central role of competencies in guiding medical education was emphasized and the urgent need to establish competencies in nutrition-related patient care was presented. The importance of additional strategies to improve nutrition education of health care professionals was highlighted. Public health legislation such as the Patient Protection and Affordable Care Act recognizes the role of nutrition, however, to capitalize on this increasing momentum, health care professionals must be trained to deliver needed services. Thus, there is a pressing need to garner support from stakeholders to achieve this goal. Promoting a research agenda that provides outcome-based evidence on individual and public health levels is needed to improve and sustain effective interprofessional nutrition education.

The need to advance nutrition education in the training of health care professionals and recommended research to evaluate implementation and effectiveness.

Nutrition is a recognized determinant in 3 (ie, diseases of the heart, malignant neoplasms, cerebrovascular diseases) of the top 4 leading causes of death in the United States. However, many health care providers are not adequately trained to address lifestyle recommendations that include nutrition and physical activity behaviors in a manner that could mitigate disease development or progression. This contributes to a compelling need to markedly improve nutrition education for health care professionals and to establish curricular standards and requisite nutrition and physical activity competencies in the education, training, and continuing education for health care professionals. This article reports the present status of nutrition and physical activity education for health care professionals, evaluates the current pedagogic models, and underscores the urgent need to realign and synergize these models to reflect evidence-based and outcomes-focused education.

Residency and specialties training in nutrition: a call for action.

Despite evidence that nutrition interventions reduce morbidity and mortality, malnutrition, including obesity, remains highly prevalent in hospitals and plays a major role in nearly every major chronic disease that afflicts patients. Physicians recognize that they lack the education and training in medical nutrition needed to counsel their patients and to ensure continuity of nutrition care in collaboration with other health care professionals. Nutrition education and training in specialty and subspecialty areas are inadequate, physician nutrition specialists are not recognized by the American Board of Medical Specialties, and nutrition care coverage by third payers remains woefully limited. This article focuses on residency and fellowship education and training in the United States and provides recommendations for improving medical nutrition education and practice.

A cross-sectional study of osteocalcin and body fat measures among obese adolescents.

UNLABELLED: Osteocalcin (OCN), a marker of osteoblast activity, has been implicated in the regulation of energy metabolism by the skeleton and thus may affect body fat measures. OBJECTIVE: To examine the relationships of OCN to body fat measures and whether they vary according to markers of energy and vitamin D metabolism. DESIGN AND METHODS: Data were obtained from 58 obese adolescents aged 13-17.9 years (38 females, 8 black or African-American). Total fat mass (FM) [dual X-ray absorptiometry (DXA)] and visceral adipose tissue (VAT) [computerized axial tomography (CT)] were calculated. Blood tests included leptin, OCN, 25-hydroxyvitamin D [25(OH)D], parathyroid hormone (PTH), thyroid function tests, and triglycerides. Markers of glucose metabolism were obtained from fasting and OGTT samples. RESULTS AND CONCLUSIONS: Adolescents with 25(OH)D <20 ng mL(-1) were considered deficient (n = 17/58); none had high PTH (PTH ≥ 65 pg mL(-1) ). OCN was associated with lower VAT (-84.27 ± 33.89 mm(2) ) and BMI (-0.10 ± 0.05 kg m(-2) ), not FM (P = 0.597) in a core model including age, sex, race, geographic latitude, summer, height z-score, and tanner stage. Adding 25(OH)D deficiency and PTH attenuated the inverse association of OCN to VAT. There was a significant interaction of OCN and 25(OH)D deficiency on FM (0.37 ± 0.18 kg, P = 0.041) and BMI (0.28 ± 0.10 kg m(-2) , P = 0.007) in this adjusted model, which was further explained by leptin. Adding A1C to the core model modified the relationship of OCN to VAT (-93.08 ± 35.05 mm(2) , P = 0.011), which was further explained by HOMA-IR. In summary, these findings provide initial evidence for a relationship between OCN and body fat measures that is dependent on energy metabolism and vitamin D status among obese adolescents.

Relation of body fat indexes to vitamin D status and deficiency among obese adolescents.

BACKGROUND: Data on the relation between vitamin D status and body fat indexes in adolescence are lacking. OBJECTIVE: The objective was to identify factors associated with vitamin D status and deficiency in obese adolescents to further evaluate the relation of body fat indexes to vitamin D status and deficiency. DESIGN: Data from 58 obese adolescents were obtained. Visceral adipose tissue (VAT) was measured by computed tomography. Dual-energy X-ray absorptiometry was used to measure total bone mineral content, bone mineral density, body fat mass (FM), and lean mass. Relative measures of body fat were calculated. Blood tests included measurements of 25-hydroxyvitamin D [25(OH)D], parathyroid hormone (PTH), osteocalcin, type I collagen C-telopeptide, hormones, and metabolic factors. Vitamin D deficiency was defined as 25(OH)D < 20 ng/mL. PTH elevation was defined as PTH > 65 ng/mL. RESULTS: The mean (+/-SD) age of the adolescents was 14.9 +/- 1.4 y; 38 (66%) were female, and 8 (14%) were black. The mean (+/-SD) body mass index (in kg/m(2)) was 36 +/- 5, FM was 40.0 +/- 5.5%, and VAT was 12.4 +/- 4.3%. Seventeen of the adolescents were vitamin D deficient, but none had elevated PTH concentrations. Bone mineral content and bone mineral density were within 2 SDs of national standards. In a multivariate analysis, 25(OH)D decreased by 0.46 +/- 0.22 ng/mL per 1% increment in FM (beta +/- SE, P = 0.05), whereas PTH decreased by 0.78 +/- 0.29 pg/mL per 1% increment in VAT (P = 0.01). CONCLUSIONS: To the best of our knowledge, our results show for the first time that obese adolescents with 25(OH)D deficiency, but without elevated PTH concentrations, have a bone mass within the range of national standards (+/-2 SD). The findings provide initial evidence that the distribution of fat may be associated with vitamin D status, but this relation may be dependent on metabolic factors. This study was registered at www.clinicaltrials.gov as NCT00209482, NCT00120146.

Expert panel on weight loss surgery: executive report update.

Rapid shifts in the demographics and techniques of weight loss surgery (WLS) have led to new issues, new data, new concerns, and new challenges. In 2004, this journal published comprehensive evidence-based guidelines on WLS. In this issue, we've updated those guidelines to assure patient safety in this fast-changing field. WLS involves a uniquely vulnerable population in need of specialized resources and ongoing multidisciplinary care. Timely best-practice updates are required to identify new risks, develop strategies to address them, and optimize treatment. Findings in these reports are based on a comprehensive review of the most current literature on WLS; they directly link patient safety to methods for setting evidence-based guidelines developed from peer-reviewed scientific publications. Among other outcomes, these reports show that WLS reduces chronic disease risk factors, improves health, and confers a survival benefit on those who undergo it. The literature also shows that laparoscopy has displaced open surgery as the predominant approach; that government agencies and insurers only reimburse procedures performed at accredited WLS centers; that best practice care requires close collaboration between members of a multidisciplinary team; and that new and existing facilities require wide-ranging changes to accommodate growing numbers of severely obese patients. More than 100 specialists from across the state of Massachusetts and across the many disciplines involved in WLS came together to develop these new standards. We expect them to have far-reaching effects of the development of health care policy and the practice of WLS.

Best practice updates for pediatric/adolescent weight loss surgery.

The objective of this study is to update evidence-based best practice guidelines for pediatric/adolescent weight loss surgery (WLS). We performed a systematic search of English-language literature on WLS and pediatric, adolescent, gastric bypass, laparoscopic gastric banding, and extreme obesity published between April 2004 and May 2007 in PubMed, MEDLINE, and the Cochrane Library. Keywords were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. In light of evidence on the natural history of obesity and on outcomes of WLS in adolescents, guidelines for surgical treatment of obesity in this age group need to be updated. We recommend modification of selection criteria to include adolescents with BMI >or= 35 and specific obesity-related comorbidities for which there is clear evidence of important short-term morbidity (i.e., type 2 diabetes, severe steatohepatitis, pseudotumor cerebri, and moderate-to-severe obstructive sleep apnea). In addition, WLS should be considered for adolescents with extreme obesity (BMI >or= 40) and other comorbidities associated with long-term risks. We identified >1,085 papers; 186 of the most relevant were reviewed in detail. Regular updates of evidence-based recommendations for best practices in pediatric/adolescent WLS are required to address advances in technology and the growing evidence base in pediatric WLS. Key considerations in patient safety include carefully designed criteria for patient selection, multidisciplinary evaluation, choice of appropriate procedure, thorough screening and management of comorbidities, optimization of long-term compliance, and age-appropriate fully informed consent.

Weight loss surgery eligibility according to various BMI criteria among adolescents.

A BMI cutoff point at the 99th percentile for age and gender or at 40 kg/m(2) has been suggested for more aggressive treatment of adolescent obesity. The main objective of this study was to determine the proportion of adolescents eligible for weight loss surgery (WLS) based on various BMI cutoff points. Data was extracted from the electronic medical record database of an urban pediatric ambulatory care center over 4 years. National data were used to calculate BMI percentiles (Centers for Disease Control and Prevention (CDC), 2000). Eligibility for WLS was based on a BMI percentile criterion (>or=99th percentile) or the adult WLS cutoff point (>or=40 kg/m(2)). The sample consisted of 3,220 adolescents aged 12-17.9 years, of which 53% were female, 55% were of black race, and 17% of Hispanic ethnicity. Overall, 88 (3%) adolescents had a BMI >or=40 kg/m(2) and 236 (7%) had a BMI >or=99th percentile (P < 0.001). All adolescents with BMI >or=40 kg/m(2) had a BMI >or=99th percentile. A total of 159/2,007 (8%) of 12-14.9-year olds had a BMI >or=99th percentile compared with 77/1,213 (6%) 15-17.9-year olds (P = 0.10), whereas 43/2,007 (2%) of 12-14.9-year olds had a BMI >or=40 kg/m(2) compared with 45/1,213 (4%) 15-17.9-year olds (P = 0.003). In summary, a relatively large proportion of adolescents from a diverse urban population would qualify for WLS based on the percentile criterion. Fewer adolescents would be eligible based on the adult WLS criterion, and younger adolescents would be less likely to be eligible for WLS than older adolescents.

Self-assessment of height, weight, and sexual maturation: validity in overweight children and adolescents.

PURPOSE: To evaluate the validity of self-reported height, weight, and sexual maturation ratings among overweight children and adolescents. METHODS: This cross-sectional study included 77 overweight children and adolescents (39 girls, 38 boys) aged 8-18 years, with a mean body mass index (BMI) of 35.2 +/- 8.9 kg/m2 who visited the Optimal Weight for Life program at Boston Children's Hospital for weight management over a period of six months in 1999. Each patient's weight, height, and sexual maturation ratings were self-reported and measured. RESULTS: The intra-class correlation coefficients between measured and self-reported weights, heights, and BMI values ranged from .64 to .95 among boys, and from .49 to .84 among girls. The kappa statistics between measured and self-assessed Tanner stage ratings ranged from .21 to .50. The percentages of agreement for breast development and pubic hair ratings among girls were 37.8% and 61.1%, respectively. The percentages of agreement for pubic hair and genitalia ratings among boys were 51.7% and 40.0%, respectively. The self-assessed ratings by boys for pubic hair and genitalia were less likely to be correct with increased measured weight and height (p < .05). Boys aged 15 years or older were more likely to underestimate their pubic hair or genitalia stages than those younger than 15 years of age (p < .05). CONCLUSIONS: Among overweight children and adolescents aged 8-18 years, this pilot study suggests that self-reports of height, weight, and Tanner stages are not valid proxy measures for a physician's assessment.

Parental overweight as an indicator of childhood overweight: how sensitive?

This study determined the sensitivity and specificity of parental overweight from self-reported height and weight to identify families with overweight school age children. A cross sectional study was conducted among 3059 parents and their children (1558 boys and 1501 girls) aged 7-12 years in five primary schools of Busan, Korea. BMI was calculated from parental reported height and weight and from children's measured height and weight. Parents were considered overweight when their BMI was >25 kg/m2 (WHO, 2000). Children were considered overweight when their BMI was >95th percentile (CDC, 2000). Prevalence of overweight was calculated and logistic regressions were performed. The sensitivity and specificity of parental overweight were calculated. A total of 26% (805/3059) parents were overweight. Of the families with one overweight parent, 15% (N = 109) had an overweight child. When both parents were overweight, 17% (N = 9) had an overweight child. After adjusting for child's age and gender, parental education, family income, and spouse's BMI as required, the odds of having an overweight child were 2.5 [1.8, 3.3] for one overweight parent, and 3.2 [1.4, 7.1] for both overweight parents. While the sensitivity of one overweight parent to identify families with overweight school age children was 44%, specificity was 75%. The presence of both overweight parents provided a 3% sensitivity and 98% specificity for the identification of an overweight school age child. Although parental overweight was obtained from self-reported weight and height in Busan (Korea), it is a practical indicator to identify families with an overweight school age child, it has poor sensitivity.