Lifestyle intervention and support preferences to maximize health outcomes in adolescent bariatric surgery patients.

Introduction: Metabolic and bariatric surgery (MBS) is safe and efficacious for adolescents with severe obesity. Pairing MBS with behavioral lifestyle interventions may be effective for optimizing treatment outcomes. However, no standardized program exists. Adolescent perspectives are critical to understanding how to design interventions to enhance engagement, sustain motivation, and meet informational needs for pre- and post-MBS self-management behaviors. The aim of this study was to develop an MBS lifestyle support intervention built on evidence-based content with input from adolescents and their families. Methods: A mixed-methods design identified adolescent preferences for MBS lifestyle support. Data were collected from a racially and ethnically diverse sample of adolescents (N = 17, 76% females, 24% males 41.2% non-Hispanic Black, 41.2% Hispanic/Latino, 11.8% non-Hispanic White, 5.8% Other) and their mothers (N = 13, 38.4% Hispanic) recruited from an MBS clinic. Quantitative surveys and qualitative interviews assessed preferred types of pre-post MBS content, modality, frequency, and delivery platforms to inform the design of the intervention. Mixed methods data were triangulated to provide a comprehensive understanding of adolescent/parent preferences. Results: Adolescents prioritized eating well, managing stress, and maintaining motivation as desired support strategies. Parents identified parental support groups and nutrition guidance as priorities. Peer support and social media platforms were identified as key approaches for boosting motivation and engagement. Conclusions: The patient voice is an important first step in understanding how, and whether behavioral lifestyle programs combined with MBS for weight management can be optimized. Adolescent preferences may enhance program fit and identify health behavior supports needed to sustain behavior change.

Factors associated with elevated SARS-CoV-2 immune response in children and adolescents.

Background: Understanding the distinct immunologic responses to SARS-CoV-2 infection among pediatric populations is pivotal in navigating the COVID-19 pandemic and informing future public health strategies. This study aimed to identify factors associated with heightened antibody responses in children and adolescents to identify potential unique immune dynamics in this population. Methods: Data collected between July and December 2023 from the Texas Coronavirus Antibody REsponse Survey (Texas CARES), a statewide prospective population-based antibody survey among 1-to-19-year-old participants, were analyzed. Each participant had the following data available for analysis: (1) Roche Elecsys® Anti-SARS-CoV-2 Immunoassay for Nucleocapsid protein antibodies (Roche N-test), (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 health status. Statistical analysis identified associations between participant characteristics and spike antibody quartile group. Results: The analytical sample consisted of 411 participants (mean age 12.2 years, 50.6% female). Spike antibody values ranged from a low of 6.3 U/ml in the lowest quartile to a maximum of 203,132.0 U/ml in the highest quartile in the aggregate sample. Older age at test date (OR = 1.22, 95% CI: 1.12, 1.35, p < .001) and vaccination status (primary series/partially vaccinated, one or multiple boosters) showed significantly higher odds of being in the highest spike antibody quartile compared to younger age and unvaccinated status. Conversely, fewer days since the last immunity challenge showed decreased odds (OR = 0.98, 95% CI: 0.96, 0.99, p = 0.002) of being in the highest spike antibody quartile vs. more days since last immunity challenge. Additionally, one out of every three COVID-19 infections were asymptomatic. Conclusions: Older age, duration since the last immunity challenge (vaccine or infection), and vaccination status were associated with heightened spike antibody responses, highlighting the nuanced immune dynamics in the pediatric population. A significant proportion of children/adolescents continue to have asymptomatic infection, which has important public health implications.

Child maltreatment and behavioral health outcomes in child welfare: Exploring the roles of severity and polyvictimization.

BACKGROUND: Child maltreatment and polyvictimization are known risk factors for long-term detrimental health and development outcomes, including behavioral health challenges. However, effects from specific types and combinations of maltreatments are unclear. This study examined the association between maltreatment or polyvictimization and behavioral health in a child welfare sample. PARTICIPANTS AND SETTING: Medical records of children with child welfare involvement with at least one behavioral health condition (i.e., mental, behavioral or neurodevelopmental disorder, ICD-10 F01-F99) between 1/1/2018-12/31/2021 were extracted from a large, academic hospital system. METHODS: Behavioral health complexity was categorized as non-chronic, non-complex chronic, or complex chronic using the Pediatric Medical Complexity Algorithm. Partial proportional logistic regression models adjusted for age, sex, race/ethnicity, caregiver type, and physical health complexity generated odds of behavioral health complexity by maltreatment type (physical abuse, sexual abuse, neglect) and maltreatment combinations. RESULTS: The analytic sample included 3992 participants (mean age 7.6 (Standard Deviation, 5.0) 44 % female, 29 % white, 32 % black, 22 % Hispanic). Participants who experienced physical abuse (Odds Ratio [OR]: 1.79, 95 % Confidence Interval [CI]: 1.10-2.91), or neglect (OR: 1.69, 95 % CI: 1.38-2.07) were more likely to have increasing behavioral health complexity versus those without maltreatment. Participants with both physical abuse and neglect were over twice as likely (OR: 2.44, 95 % CI: 1.88-3.16) to have increasing behavioral health complexity versus those who did not experience maltreatment. CONCLUSION: Results emphasize the differential impacts of maltreatment and polyvictimization exposures on behavioral health complexity among children with child welfare involvement that can guide risk assessment and clinical care.

Impact of the Physical Activity Environment on Change in Body Mass Index Percentile in Child Care Centers Serving Children with Disabilities.

Childcare centers (CCCs) can provide opportunities to implement physical activity (PA) via health promotion interventions to prevent obesity and associated chronic disease risk factors in young children. This study evaluated the impact of the Healthy Caregivers-Healthy Children (HC2) intervention on body mass index percentile (PBMI) and the PA environment in CCCs serving children with disabilities (CWD) over one school year. Ten CCCs were cluster-randomized to either (1) an intervention arm that received the HC2 curriculum adapted for CWD or (2) an attention control arm. Mixed-effect linear regression models analyzed the relationship between change in child PBMI and CCC childcare center PA environment by experimental condition and child disability status over one school year. Findings showed a significant decrease in PBMI among children in the HC2 centers (-6.74, p = 0.007) versus those in control centers (-1.35, p = 0.74) over one school year. Increased PA staff behaviors (mean change 3.66, p < 0.001) and PA policies (mean change 6.12, p < 0.001) were shown in intervention centers during the same period. Conversely, there was a significant increase in sedentary opportunities (mean change 4.45, p < 0.001) and a decrease in the portable play environment (mean change -3.16, p = 0.03) and fixed play environment (mean change -2.59, p = 0.04) in control centers. No significant differences were found in PBMI changes between CWD and children without disabilities (beta = 1.62, 95% CI [-7.52, 10.76], p = 0.73), suggesting the intervention's efficacy does not differ by disability status. These results underscore the importance of (1) including young CWD and (2) PA and the supporting environment in CCC health promotion and obesity prevention interventions.

Prevalence of Metabolic Syndrome Among Emerging Adult Cannabis Users by Race/Ethnicity: Analysis of the 2009-2018 National Health and Nutrition Examination Surveys.

Background: Association between cannabis use and metabolic syndrome (MetS) has been documented; yet variation by race/ethnicity is understudied. We examined cannabis use and MetS by race/ethnicity among emerging adults (18-25 years old), the age group with the highest prevalence of cannabis use. Methods: Data from 18- to 25-year-olds who completed the National Health and Nutrition Examination Survey (2009-2018) were analyzed. Current cannabis use was defined as ≥1 day of use in the last 30 days. MetS was defined using standardized guidelines as ≥3 of the following: elevated fasting glucose, triglycerides, systolic (SBP) and/or diastolic blood pressure (DPB), waist circumference, and/or low high-density lipoprotein (HDL) cholesterol. Logistic regression was used to examine the association between current cannabis use (CCU) and MetS, adjusting for covariates. Results: Of 3974 respondents, 48.8% were female, mean age 21.1 years (SD = 2.4), 56.7% non-Hispanic white, 20.4% Hispanic, and 14.0% non-Hispanic black (NHB). Hispanics had the highest MetS prevalence (7.9%) and lowest CCU prevalence (23.5%). NHB had highest CCU prevalence (33.4%, P < .0001) and lowest MetS prevalence (4.8%, P = .2543). CCUs had a higher mean SBP (P = .020) and Hispanics (P = .002) than never users. Conversely, NHB CCUs exhibited lower mean SBP than NHB never users (P = .008). CCUs had 42% reduced odds of MetS than never users (AOR: 0.58, 95% CI: 0.35-0.95). Among NHB, CCUs had 78% lower likelihood of having MetS than never users (AOR: 0.22, 95% CI: 0.06-0.81). Conclusions: Cannabis use impacts MetS and blood pressure differently by race/ethnicity. Current cannabis use was associated with lower odds of MetS overall and among NHB. Further research is warranted to investigate how administration routes, dosages, and usage duration affect MetS.

Anthropometry for predicting cardiometabolic disease risk factors in adolescents.

OBJECTIVE: Early screening prevents chronic diseases by identifying at-risk adolescents through anthropometric measurements, but predictive value in diverse groups is uncertain. METHODS: A cross-sectional analysis of 12- to 19-year-old individuals from the 2017-2018 National Health and Nutrition Examination Survey (NHANES) assessed the predictive ability of BMI percentile, total body fat percentage, waist circumference (WC), and waist-hip ratio (WHR) for four cardiometabolic risk factors across race and ethnicity groups using receiver operating characteristic curves. RESULTS: The unweighted sample (N = 1194; 51.2% male individuals; 23.7% Hispanic, 13.2% non-Hispanic Black [NHB], 51.1% non-Hispanic White [NHW], 12.0% other/multirace) had a weighted prevalence of elevated blood pressure of 2.7%, hyperglycemia of 36.8%, hypertriglyceridemia of 4.8%, and low high-density lipoprotein (HDL) cholesterol of 15%. WHR (area under the curve [AUC] = 0.77), WC (AUC = 0.77), and BMI percentile (AUC = 0.73) outperformed total body fat percentage (AUC = 0.56) in predicting elevated blood pressure (p < 0.001 for all). BMI percentile was more accurate than total body fat percentage in predicting hypertriglyceridemia (AUC = 0.70 vs. 0.59; p = 0.02) and low HDL cholesterol (AUC = 0.69 vs. 0.59; p < 0.001). Race and ethnicity-based predictions varied: NHW adolescents had the highest AUC (0.89; p < 0.01) for elevated blood pressure prediction compared with Hispanic and NHB adolescents (AUC = 0.77 for both). Total body fat percentage was more accurate in predicting low HDL cholesterol among Hispanic versus NHW adolescents (AUC = 0.73 vs. 0.58; p = 0.04). CONCLUSIONS: WHR, WC, and BMI percentile are better predictors of cardiometabolic risk factors in adolescents than total body fat percentage. Predictive abilities differed by race and ethnicity, highlighting the importance of tailored risk assessment strategies.

Association of Social Support and Metabolic and Bariatric Surgery Completion Among Racially and Ethnically Diverse Patients.

PURPOSE: Metabolic and bariatric surgery (MBS) is presently the most evidence-based, effective treatment of obesity. Nevertheless, only half of the eligible individuals who are referred for this procedure complete it. This study aims to investigate the association between social support and MBS completion, considering race and ethnicity. METHODS: In this prospective cohort study, 413 participants were enrolled between 2019 and 2022. Using the 19-item Brief Family Relationship Scale, which comprises three subscales (eight-item Cohesion subscale, four-item Expressiveness subscale, and seven-item Conflict subscale), the quality of family relationship functioning was assessed. Multivariable logistic regression models were used to determine the association between MBS completion and social support status, adjusting for variables including race, ethnicity, age, gender, body mass index, and insurance. RESULTS: The mean age of the sample was 47.55 years (SD 11.57), with 87% of the participants being female and 39% non-Hispanic White. Nearly 35% of participants (n = 145) completed MBS. Multivariable logistic regression analysis showed overall cohesion (adjusted odds ratio [aOR], 1.52 [95% CI, 1.15-2.00]; p = .003) and overall expressiveness (aOR, 1.58 [95% CI, 1.22-2.05]; p < .001) were associated with higher odds of pursuing MBS. There was no significant interaction between overall cohesion, expressiveness, conflict, and race/ethnicity (p = .61, p = .63, p = .25, respectively). CONCLUSION: The findings indicated that there is a link between family-based social support and MBS completion, regardless of race and ethnicity. Future research should continue to explore the complex interplay between family dynamics and MBS outcomes, considering cultural variations to enhance the effectiveness of obesity interventions within diverse communities.

Child Care Center Staff Readiness to Change in an Early Childhood Obesity Prevention Program.

CONTEXT: The childcare center (CCC) setting has the potential to be a strong foundation that supports the introduction of sustainable healthy lifestyle behaviors to prevent childhood obesity. It is important to assess barriers and facilitators to healthy weight development initiatives via program evaluation, including measuring CCC staff readiness to change. OBJECTIVE: The overall goal of this study was to assess the readiness level over 1 school year among CCC staff who participated in "Healthy Caregivers-Healthy Children" (HC2), a cluster randomized controlled trial that evaluated the effectiveness of a childhood obesity prevention program from 2015 to 2018 in 24 low-income, racially/ethnically diverse centers. A secondary outcome was to assess how a CCC's stage of readiness to change was associated with CCC nutrition and physical activity environment, measured via the Environment and Policy Assessment and Observation (EPAO) tool. DESIGN: Mixed-models analysis with the CCC as the random effect assessed the impact of readiness to change over time on EPAO outcomes. PARTICIPANTS: Eighty-eight CCC teachers and support staff completed the HC2 readiness to change survey in August 2015 and 68 in August 2016. Only teachers and staff randomized to the treatment arm of the trial were included. MAIN OUTCOME: Readiness to change and the EPAO. RESULTS: Results showed the majority of CCC staff in advanced stages of readiness to change at both time points. For every increase in readiness to change stage over 1 year (eg, precontemplation to contemplation), there was a 0.28 increase in EPAO nutrition scores (95% confidence interval [CI], 0.04-0.53; P = .02) and a 0.52 increase in PA score (95% CI, 0.09-0.95; P = .02). CONCLUSIONS: This analysis highlights the importance between CCC staff readiness to change and the CCC environment to support healthy weight development. Future similar efforts can include consistent support for CCC staff who may not be ready for change to support successful outcomes.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Pediatric weight management research focused on primary care centers for children ages 6­12 in the USA has typically focused on assessing the effectiveness of the intervention rather than how to translate and disseminate such interventions into different settings for diverse populations, or external validity. Using the Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, we conducted a systematic review to report how existing research reports external validity.