Kumar, Seema

SummaryPaediatric weight management (PWM) programs in the United States (US) face challenges in providing sustainable multidisciplinary care for patients. The aim of this study was to report PWM program approaches to sustaining program delivery. A survey of 39 PWM programs was administered to identify challenges and solutions to program sustainability. Common and useful strategies for optimizing reimbursement for services included the use of applicable reimbursable diagnostic codes and management, billing for assessments and non‐medical personnel services, and the use of hospital outpatient department clinic billing. Increasing clinical breadth and capacity was achieved by offering telemedicine and other services, such as psychotherapy, pharmacotherapy, and metabolic and bariatric surgery, as well as active management of schedules. Securing institutional and extramural funding was also reported. One of the positive changes during the pandemic was the fast adoption of telemedicine services. Although delivering sustainable evidence‐based multidisciplinary PWM under the current US payment models has its challenges, PWM programs implement practical operational strategies to support this work.

Purpose of review Atherosclerosis and associated cardiovascular risk factors originate in childhood; hence, early management of dyslipidaemia is vital. However, hypercholesterolemia remains untreated or undertreated in many youths. We review current therapies, drugs under investigation and consider potential future directions for the management of paediatric dyslipidaemia to highlight the recent evidence and new therapeutic options for future use. Recent findings Cardiovascular disease (CVD) risk factors in childhood, including dyslipidaemia, are associated with CVD risk and clinical CVD events in adulthood. Recent data show that initiation of statin therapy in childhood in children with familial hypercholesterolemia reduces the risk of CVD in adulthood. Several well tolerated and efficacious treatment options have become available in recent times for the management of dyslipidaemia in youth. Many new lipid-lowering drugs are under investigation to widen the available choices. Some of these drugs are now available for use in paediatrics, while some remain targets for future use. Summary We review available treatment options for paediatric dyslipidaemia management, discuss potential limitations and propose future directions. We also acknowledge the need for continued research in paediatrics for optimal paediatric dyslipidaemia management.

Objective: This report describes data regarding the acceptability of delivering a family-based behavioral lifestyle intervention for adolescent obesity in a brief, intensive onsite program (initial 3 sequential days + 1 follow-up day) combined with telephonic wellness coaching (WC). Methods: Four cohorts consisting of 7 adolescents aged 15–17 years (self-identifying as 4 male, 2 female, 1 transgender male; 6 White, 1 African American and White) and thirteen parents participated in a new clinical intervention consisting of 3 days onsite programming, 3-months telephonic wellness coaching, and 1 day onsite follow up. Enrollment, attendance, and retention were recorded. Participants provided quantitative and qualitative feedback regarding acceptability of the program during postintervention interviews. Results: Of 11 families invited, 8 enrolled. Seven families participated, with 1 family lost to follow up. Adolescents completed an average 5.6/9 planned WC sessions. Adolescents rated the program positively overall and liked experiential sessions best. However, participants reported the onsite program was too long, they encountered barriers to sustained engagement during wellness coaching follow up, and parents desired greater guidance and structure for their involvement. Conclusions: Combining in-person sessions with telephonic wellness coaching was acceptable to participants, but intervention refinement is needed. Future program development and research investigating hybrid models should consist of briefer in-person sessions, emphasize skill practice, and include ongoing guidance to parents to provide developmentally appropriate support. Implications for Impact Statement This new clinical program evaluation found that extending onsite family-based behavioral lifestyle intervention for adolescent obesity with telephonic wellness coaching was acceptable to participants, but that program refinement is needed. Feedback highlighted the importance of keeping onsite sessions brief, engaging adolescents with hands-on skill practice, and providing ongoing guidance to parents to support sustained adolescent engagement in behavior change.

Background: Perinatal factors including gestational age, birthweight, size for gestational age, delivery route, maternal parity, maternal age, maternal education, socioeconomic status, race, and sex, are associated with the future risk of obesity and co-morbid conditions. This study evaluated the relationship of birthweight for gestational age and perinatal factors with severe obesity and dyslipidemia in adulthood. Methods: We conducted a population-based, retrospective birth cohort study of infants born to residents of Olmsted County, MN between 1976 and 1982. Outcomes were assessed after age 18 years until October 2020, including severe obesity (BMI ≥ 40 kg/m 2 ) and dyslipidemia (total cholesterol ≥200 mg/dL, non-high density lipoprotein [non-HDL] cholesterol ≥145 mg/dL or HDL cholesterol <40 mg/dL). We obtained mother’s age, education level, and parity as well as newborn sex, race, type of delivery, single/multiple birth, gestational age, and birthweight from birth certificate data. Individual-level socioeconomic status (SES) of the household at birth was determined with the HOUSES index. Results: Of 10 938 birth cohort subjects, 7394 had clinic visits after age 18 years and were included, with 2630 having severe obesity (n = 798) or dyslipidemia (n = 2357) as adults. In multivariable models, female sex, singleton birth, less maternal education, and lower SES defined by HOUSES were independently associated with an increased risk of severe obesity in adulthood. Non-white race, singleton birth, and lower birthweight were independently associated with adult dyslipidemia. Birthweight for gestational age was not associated with severe obesity or dyslipidemia. Conclusion: Perinatal factors were associated with both severe obesity and dyslipidemia in adulthood. Lower SES at birth was predictive of severe obesity in adulthood, highlighting the opportunity to investigate modifiable perinatal social determinants to reduce the risk of severe obesity.

Summary Objective To describe characteristics of paediatric weight management (PWM) programs across the United States and evaluate associations with program‐specific retention rates and body mass index (BMI) outcomes at 6 months. Methods A program profile survey was administered to 33 programs within the Paediatric Obesity Weight Evaluation Registry (POWER) to assess program staffing, services, and treatment format. Patient retention and percent of the 95th BMI percentile (%BMIp95) changes were assessed for each program. Results At 6 months program retention rates ranged from 15% to 74% (median: 41%), and program %BMIp95 changes ranged from −9.0 to +0.5 percentage points (median: −1.7). Percent of patients with ≥5 percentage‐point decrease in %BMIp95 ranged from 17% to 71% across programs (median: 29%). No associations were detected between program characteristics and retention or %BMIp95 changes. Conclusions Six‐month patient retention and BMI outcomes vary substantially in PWM programs across the United States. Yet, no associations were found between PWM treatment factors and these program‐level patient outcomes.

Abstract Context Identification of modifiable risk factors, including genetic and acquired disorders of lipid and lipoprotein metabolism, is increasingly recognized as an opportunity to prevent premature cardiovascular disease (CVD) in at-risk youth. Pediatric endocrinologists are at the forefront of this emerging public health concern and can be instrumental in beginning early interventions to prevent premature CVD-related events during adulthood. Aim In this article, we use informative case presentations to provide practical approaches to the management of pediatric dyslipidemia. Cases We present 3 scenarios that are commonly encountered in clinical practice: isolated elevation of low-density lipoprotein cholesterol (LDL-C), combined dyslipidemia, and severe hypertriglyceridemia. Treatment with statin is indicated when the LDL-C is ≥190 mg/dL (4.9 mmol/L) in children ≥10 years of age. For LDL-C levels between 130 and 189 mg/dL (3.4-4.89 mmol/L) despite dietary and lifestyle changes, the presence of additional risk factors and comorbid conditions would favor statin therapy. In the case of combined dyslipidemia, the primary treatment target is LDL-C ≤130 mg/dL (3.4 mmol/L) and the secondary target non-high-density lipoprotein cholesterol &lt;145 mg/dL (3.7 mmol/L). If the triglyceride is ≥400 mg/dL (4.5 mmol/L), prescription omega-3 fatty acids and fibrates are considered. In the case of triglyceride &gt;1000 mg/dL (11.3 mmol/L), dietary fat restriction remains the cornerstone of therapy, even though the landscape of medications is changing. Conclusion Gene variants, acquired conditions, or both are responsible for dyslipidemia during childhood. Extreme elevations of triglycerides can lead to pancreatitis. Early identification and management of dyslipidemia and cardiovascular risk factors is extremely important.

Mutations in the hepatocyte nuclear factor‐1‐beta (HNF1B) gene cause a variety of diseases in different organ systems. Mutations have been described as causing neonatal cholestasis, maturity‐onset diabetes of the young (type 5), cortical renal cysts, urogenital abnormalities, liver dysfunction, and atrophy of the pancreas. We describe a male patient who presented with cholestatic liver disease in infancy which progressed by age 14 to end‐stage liver disease due to HNF1B disease. He subsequently underwent liver transplantation at age 15 and then developed diabetes requiring insulin which did not resolve after cessation of corticosteroids. To our knowledge, this is the first case reported of liver transplantation for decompensated cirrhosis secondary to HNF1B disease.

AbstractBackgroundWe sought to evaluate the association between vitamin D deficiency and the severity of coronavirus disease 2019 (COVID‐19) infection.MethodsMultiple databases from 1 January 2019 to 3 December 2020 were searched for observational studies evaluating the association between vitamin D deficiency and severity of COVID‐19 infection. Independent reviewers selected studies and extracted data for the review. The main outcomes of interest were mortality, hospital admission, length of hospital stay and intensive care unit admission.ResultsSeventeen observational studies with 2756 patients were included in the analyses. Vitamin D deficiency was associated with significantly higher mortality (odds ratio [OR]: 2.47, 95% confidence interval [CI]: 1.50–4.05; 12 studies; hazard ratio [HR]: 4.11, 95% CI: 2.40–7.04; 3 studies), higher rates of hospital admissions (OR: 2.18, 95% CI: 1.48–3.21; 3 studies) and longer hospital stays (0.52 days; 95% CI: 0.25–0.80; 2 studies) as compared to nonvitamin D deficient status. Subgroup analyses based on different cut‐offs for defining vitamin D deficiency, study geographic locations and latitude also showed similar trends.ConclusionsVitamin D deficiency is associated with greater severity of COVID‐19 infection. Further studies are warranted to determine if vitamin D supplementation can decrease the severity of COVID‐19.

The study aim was to test hypotheses informed by self-determination theory (SDT) regarding associations of adolescent motivators for weight loss and family feeding practices on understanding adolescent weight management and dietary behaviors. Adolescents (n = 71) with obesity were recruited from a large medical center in the Midwest USA and completed questionnaire assessments via an online survey. Results supported hypotheses that endorsement of health motivators for weight loss, conceptualized as autonomous (intrinsic) motivation, and positive family support would be associated with healthier weight management practices and dietary behaviors. Nuanced findings related to social- and self-esteem-related motivators for weight loss indicated a need for further understanding of these weight-loss motivators in the context of SDT. The current study findings highlight the importance of addressing motivational factors and family influences in research and practice related to promoting healthy dietary habits and weight management strategies among adolescents with obesity.