Weight Stigmatization in Childhood Obesity

Childhood obesity represents a growing public health concern and a leading cause of morbidity among children. Multiple efforts have been implemented to curb obesity including educating parents to encourage dietary changes, physical activity, limiting screen time, and behavioral modification. However, relatively few strategies explore the social and psychological impact of the stigmatization of obesity in children, which represents a significant gap in our ability to provide care. It is important for pediatricians to model the approach to patients with unhealthy weight by realizing its stigma, using sensitive language, and engaging in motivational interview.

Weight stigmatization, which is defined as discrimination and stereotyping based on a person’s weight, has largely been cultivated and tolerated in our society. It is perceived as a way of motivating overweight children to lose weight. However, this approach generates negative psychological consequences on children as well as adults (Puhl et al. 2015). It is also ineffective at preventing further weight gain, social isolation, or eating disorders. Weight stigmatization creates a barrier for children to actively engage in healthy behaviors or to seek healthcare intervention. Multiple studies have shown that weight-based teasing correlates with an increased risk of worsening obesity (Haines et al. 2010).

Overweight children suffer from poor body image due to the weight teasing they encounter in their everyday lives. Weight stigmatization and victimization can arise not only from school friends but also from educators and parents. A study demonstrated that about 46% obese individuals experience greater weight victimization from members of their family than from others (Puhl et al. 2008).  This shows how weight stigmatization has become normalized in our society: family members are concerned with their loved ones’ health and have a misconception that pushing their children harder will make them want to lose weight. This also creates a long-lasting emotional effect on a child when the weight stigmatization comes from a parent or a family member. 

With childhood obesity remaining a public health crisis, pediatricians can display model behaviors with parents by educating families and society about the complexity of obesity (genetics, SES, environmental factors). This helps take away the assumption that the overweight individuals are to blame for their excess weight. Pediatricians can model sensitive communication, using more neutral terms for describing obesity such as “unhealthy weight” or saying “child with obesity” instead of “obese child”.  Engaging in motivational interviewing is also more effective for pediatricians to encourage behavioral changes. They can counsel parents to consider the effect of weight stigmatization on their children and ensure that they are actively addressing weight victimization at their children’s schools.  

Carine Halaby, M.D.

References:

AAP- Stigma Experienced by Children and Adolescents With Obesity. https://pediatrics.aappublications.org/content/140/6/e20173034#xref-ref-28-1

Haines J, Kleinman KP, Rifas-Shiman SL, Field AE, Austin SB. Examination of shared risk and protective factors for overweight and disordered eating among adolescents. Arch Pediatr Adolesc Med. 2010;164(4):336–343pmid:20368486

Puhl R, Suh Y. Health consequences of weight stigma: Implications for obesity prevention and treatment. Curr Obes Rep. 2015;4(2):182–190pmid:26627213

Puhl RM, Moss-Racusin CA, Schwartz MB, Brownell KD. Weight stigmatization and bias reduction: perspectives of overweight and obese adults. Health Educ Res. 2008;23(2):347–358pmid:17884836

Advertisements

Children’s Social Media Consumption and Eating Behavior

With the advancements in technology and the introduction of high-speed internet, our societies have been facing a whole new set of issues and concerns especially when it comes to the role and impact of social media on the development and health of our children.  Pediatricians should educate parents about the influence of social media on their children’s eating habits and share resources to counteract the effects of unhealthy foods digital marketing.

A decade ago I never thought I would have to include restricted social media use and modified Facebook or YouTube home content as part of my diet plan. Nowadays, our exposure to social media influencers significantly impacts our subconscious decisions even when it comes to snack choices. This is also true for our young children and adolescents.

Is it true that our children are following social media influencers when it comes to food consumption.? And is social media contributing to the obesity epidemic?

A randomized trial study published in Pediatrics by Anna E. Coates et al. included 176 children between 9 and 11 years old.  The children were assigned to view mock Instagram profiles of two popular YouTube vloggers and influencers promoting healthy or unhealthy snacks or nonfood products.  The results of this study indicated that children who viewed unhealthy snacks content had a statistically significant increase in food intake compared to those who viewed the influencers promoting healthy snacks. Thus, the study concluded that marketing of unhealthy foods through social media influencers increased children’s food intake of 26% more kilocalories compared to children who viewed healthy food behavior.

With childhood obesity remaining a major health epidemic, it is crucial for pediatricians to recognize the impact of digital marketing on the health and eating behavior of children exposed to thousands and thousands of social media influencers on a daily basis. Methods for restricting social media food marketing content should be implemented to protect the health of the new generation of children and adolescents.

Parents can be advised to have a family media use framework to control the content of social media that their children view. Parents should start the conversation early about social media influence with their children, explaining the risks of the promoted unhealthy foods on their children’s health.

Sonia Allouch, MD

References:

  • AAP COUNCIL ON COMMUNICATIONS AND MEDIA.  Media and Young Minds. Pediatrics. 2016;138(5):e20162591

https://pediatrics.aappublications.org/content/138/5/e20162591

  • Coates AE, Hardman CA, Halford JCG, et al. Social Media Influencer Marketing and Children’s Food Intake: A Randomized Trial. Pediatrics. 2019;143(4):e20182554

https://pediatrics.aappublications.org/content/pediatrics/143/4/e20182554.full.pdf

  • Coyne S, Radesky J, Collier KM, Gentile DA, Ruh Linder J, Nathanson AI, Rasmussen EE, Reich SM, Rogers J.  Parenting and Digital Media. Pediatrics 2017;140;S112

https://pediatrics.aappublications.org/content/140/Supplement_2/S112

  • Robinson TN, Banda JA, Hale L, Shirong Lu A, Fleming-Milici F, Calvert SL, Wartella E.

Screen Media Exposure and Obesity in Children and Adolescents. Pediatrics 2017;140;S97

https://pediatrics.aappublications.org/content/140/Supplement_2/S97

Be Kind to the Brain

“I could not leave the team behind. I needed to get back in. They told me I had to keep going and move.” These harrowing words send chills down my spine. Why all the upset? These statements represent the sentiment often carried by those who subsequently suffer from a concussion. During one of my hospital shifts, I met a young man who arrived in agony from a severe headache. He was hit in the head several times throughout the week during football practice. He was hit not 2, not 3, but 4 times before he sought help. Each impact led to worsening headache, blurry vision, and dizziness, but it was ignored.

Concussion is a group of symptoms representing a type of traumatic brain injury that results in chemical damage to the brain. Brain damage can result from a direct blow to the head or an indirect hit to the body that results in the head and brain shaking. This type of damage is frequent in children who participate in sports, especially football and soccer [1]. It, however, can occur several other ways. The CDC estimates that as many as 3.8 million suffer from a concussion annually, with females suffering more frequently.

It is imperative that parents, coaches, teachers and medical professionals recognize the signs. These can include: headache, vomiting, light sensitivity, sound sensitivity, slurred speech, emotional changes, memory issues, and problems with sleep. Loss of consciousness may or may not occur. There are several scoring systems that can help aid in a child or adolescent that you suspect experienced a concussion [2]. When in doubt, set them out! The CDC offers wonderful information and training online to become familiar with the condition [2].

As the pediatrician or concussion specialist, you can work to structure a schedule that will allow the patient to get better. This will involve a graduated program that increases their activity level as the individual improves [3]. The school should provide the student with the necessary accommodations to ensure full recovery. Rest is a crucial component of this process. Without it, the child or young adult may risk developing long term memory problems, behavior issues, and significant depression [4]. Most patients recover after two weeks but some take months to regain their baseline health. You are encouraged to follow the child or adolescent and perform the necessary exams to assess progress.

My patient spent several days in pain, unable to move from his hospital bed. He explained with great detail that he was not his normal self. He felt angrier, sadder, and unable to cope with daily activities. I have seen worse outcomes; thus, I end with a message to pass to all those who seek your care. It is okay to step out of a game when you are hurt. It takes courage to tell someone you need help. We are proud that you recognize it. You are a rock star and the game is not worth gambling your life. Also, missing one game, does not mean missing an entire season. Allow the brain the time to heal; it will love you for it!

References

1. Meehan III, W. P., & O’ Brien, M. J. (2018, November 14). Concussion in children and adolescents: Clinical manifestations and diagnosis. Retrieved from UptoDate: https://www.uptodate.com/contents/concussion-in-children-and-adolescents-clinical-manifestations-and-diagnosis?source=history_widget

2. US Department of Health and Human Services. (2017, June 22). Heads Up. Retrieved from The Centers for Disease Control and Prevention: https://www.cdc.gov/headsup/index.html

3. Centers for Disease Control and Prevention. (n.d.). Cole’s Story: Coach Saves a Wrestler’s Life by Knowing Concussion Signs and Symptoms. Retrieved from https://www.cdc.gov/headsup/pdfs/stories/coles_story_one_pager-a.pdf

4. Forgrave, R. (2017, January 10). The Concussion Diaries: One High School Football Player’s Secret Struggle with CTE. Retrieved from GQ Magazine: https://www.gq.com/story/the-concussion-diaries-high-school-football-cte

Abdelrahim Abdel, MD

What We Can Do to Continue to Improve Babies’ Health Outcomes

Infant mortality is defined as the death of an infant prior to his or her first birthday. The infant mortality rate represents number of infant deaths for every 1,000 live births. In the United States, infant mortality rate was 5.9 deaths per 1,000 live births as of 2016. However, of the developed countries, the United States persistently has among one of the highest rates of infant mortality. Despite the overall decline in mortality rate, there remains significant disparities among populations that are likely attributed to multiple barriers to health care, from prenatal to postnatal care. Therefore, it is imperative as pediatricians to identify and address these barriers in order to improve maternal health care and subsequently reduce infant mortality.

The Center for Disease Control and Prevention (CDC) reported over 23,000 infant deaths in 2016. The leading causes of infant deaths include birth defects, preterm births and low birth weight, sudden infant death syndrome (SIDS), maternal pregnancy complications, and injuries (i.e. suffocation). The rates of deaths also vary based on multiple factors, such as socioeconomic status, education, neighborhood safety, race and ethnicity, and access to transportation. Non-Hispanic black infants remain disproportionately affected by infant mortality. Nationwide, the mortality rate of non-Hispanic black infants is 11.4 compared to 4.9 among non-Hispanic white infants in 2016. In the state of Texas, significant variability in mortality rates are even found within a particular group among different communities. Race and ethnicity alone are unlikely to create significant differences in rates.

The alarming rates of infant mortality have fortunately caught the public’s attention, and through the years actions have been taken to improve birth outcomes. Notably, overall infant mortality rate had a greater than 10% decline, from 6.86 deaths in 2005 to 5.9 deaths per 1,000 in 2015. With the development of safe sleep practices in the 1990s, there has been dramatic decline in the rates of SIDS across the country.

Armed with awareness that infant mortality rates in the United States are higher than many developed countries (i.e. Canada, France, Switzerland, and Australia), Congressman Steve Cohen (D-TN) recently introduced H.R.117 in Congress, the Nationally Enhancing the Wellbeing of Babies through Outreach and Research Now (NEWBORN) Act. This proposed legislation focuses on implementing pilot programs in high risk metropolitan areas to provide maternal care and address the leading causes of infant deaths. This could aid the targeted areas in the country that are subject to highest risk of infant mortality.

While there are no definitive measures to prevent many of the leading causes of infant mortality, there are ways to lower the risks. Providing maternal education prior to and during pregnancy, such as the importance of receiving adequate folic acid supplementation can prevent neural tube defects. To address preterm birth and low birth weight with their associated outcomes, our communities must  provide adequate and accessible prenatal care for mothers.

Pediatricians should continue to advise safe sleep practices in households throughout the first year of life during clinic visits to reduce SIDS.  We must continue to counsel parents on infant care, feeding and parenting in addition to postpartum care during well baby visits.

Consistent parental counseling and education at the local clinical setting along with advocacy at the legislative level will further contribute to nationwide efforts to seek solutions to improve birth outcomes and wellbeing of mothers and infants.

Melody Chiu, M.D.

References

https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm

https://www.cnn.com/2018/01/04/health/infant-mortality-by-state-study/index.html

https://www.congress.gov/bill/116th-congress/house-bill/117/text?q=%7B%22search%22%3A%5B%22infant%22%5D%7D&r=2&s=1

http://www.utsystempophealth.org/imr-texas/

Building Your Vaccine Conversation Toolkit

We, as pediatricians, have the incredible opportunity and privilege of providing life-savingmedicine to children in the form of immunizations. Overall vaccination coverage remains high nationally, but the percentage of young children who have received no vaccines has increased over the past several years. This fact has recently gained significant attention both in the medical community and in the political arena. Of course, many factors may be contributing to lack of immunization in some communities, including lack of access to healthcare or health insurance, but the discussion about causality is most often focused on vaccine hesitancy among parents. As physicians who are interacting daily with parents who may be hesitant about vaccines (or simply parents who have questions about immunizations in general), pediatricians must be prepared to participate in discussions about vaccines in a productive and meaningful way.  

Certainly, there is need for advocacy regarding immunizations at a population level. However, there is also an immense opportunity for advocacy at the individual patient level. A 2013 survey conducted by the AAP showed that 87% of pediatricians have encountered parents who refuse a vaccine. Studies have shown that howproviders initiate and pursue vaccine recommendations with parents is associated with parental vaccine acceptance. In other words, it is not simply our responsibility as pediatricians to provide the recommendation to immunize – it is our responsibility to engage parents in discussion about vaccines, answer their questions, address their concerns, and help them feel confident in choosing to immunize their children. 

In order to participate successfully in these discussions with families, we must stock our proverbial toolkits with a plethora of skills and strategies. We all have our own unique communication style, but incorporating some key (and proven) tools into our everyday practice is essential to our effort to increase vaccination uptake while maintaining partnerships with families.

  • Using a presumptive approach– We are taught in medical school and residency to use open-ended questions when obtaining a history. When discussing vaccines with parents, using the opposite approach has actually been shown to be more effective. It is important to remember that most parents areplanning to vaccinate, and we can introduce the topic with that assumption. Using a presumptive approach means using language such as, “Johnny is due for 3 shots today,” as opposed to “What do you think about Johnny’s shots today?” One study showed that, among all parents, more parents chose to vaccinate their children when providers used a presumptive approach.
  • Debunking myths – Families may have questions about some of the commonly publicized concerns about vaccines, and we must take time to appropriately address them. The goal is to increase families’ familiarity with the facts while avoiding making the misinformation more familiar. Minimizing the influence of misinformation is a difficult and complex challenge, but one which pediatricians can be well-equipped to handle with practice. In a resource called “The Debunking Handbook” by J. Cook and S. Lewandowsky, the authors state that there are 3 key elements to debunking: 
  • Focus on the facts rather than the myth.
  • If the myth is mentioned, it should be preceded by the warning that the information is false.
  • The debunking should include an alternative explanation that addresses the important qualities of the misinformation in question. 

Using this debunking strategy has been demonstrated to be effective. This video from the CDC is a concrete example of a pediatrician answering difficult questions from parents using some of these debunking techniques: https://www.cdc.gov/cdctv/diseaseandconditions/vaccination/get-picture-childhood-immunization.html

  • Motivational interviewing– Studies have shown that only providing facts and information to vaccine hesitant parents is an ineffective method to increase parents’ intention to vaccinate. Motivational interviewing (MI) is a patient-centered approach focusing on enhancing a person’s ownmotivation for change. It employs the techniques of using open-ended questions to explore concerns (if any are encountered after using a presumptive approach), providing affirmations and reflective listening, and summarizing what the person has expressed to you. One study showed that MI training for providers was effective at increasing uptake of the HPV vaccine. Here is an example of an MI-style interview (borrowed from an MI training module through Denver Metro Alliance for HPV Prevention):

Parent: “I think Mary is way too young for an HPV vaccine. I mean, she’s only 11 years old. I think you doctors are pushing this too soon. Someday, she may consider getting vaccinated, but not now.” 

Provider: “It’s really hard for you to believe that the HPV vaccine is right for Mary when she’s so young. That just doesn’t make any sense at all.” 

Parent: “Exactly!”

Provider: “Well I can certainly understand why you would feel that way (affirmation). May I share the reasoning behind vaccinating early (autonomy, supportive education) – then you can tell me what you think?” (collaboration)

Becoming comfortable with MI can take time. There is an abundance of training videos and modules for providers online, but the best way to practice is in daily conversations with our patients and families. Using MI when we encounter vaccine hesitancy allows parents to feel heard and respected, encourages them to share their honest concerns and thoughts without pressure or judgement, and may lead them to form new conclusions about vaccines. 

We cannot depend on any one of these tools in isolation and must be prepared to call on them in tandem as questions and concerns from parents arise. Remember that our responsibility is to build trust with families and to be able to have honest and thoughtful conversations about decisions that affect their child’s health. Encountering vaccine hesitancy can seem overwhelming, frustrating, and discouraging at times. However, we must realize that success comes in many forms and that the conversations will be ongoing. Stocking our toolkits with strategies like these is a simple way to take advantage of the precious time we spend with families and the immense opportunity to advocate for every one of our patients. 

Gaylan Dascanio, MD

Resources:

Opel, D. J., MD, MPH. (2015). The Influence of Provider Communication Behaviors on Parental Vaccine Acceptance and Visit Experience. The American Journal of Public Health, 105(10), 1998-2004.

Cook, J., Lewandowsky, S. (2011), The Debunking Handbook. St. Lucia, Australia: University of Queensland. November 5. ISBN 978-0-646-56812-6. [http://sks.to/debunk] 

Reno JE et al. Improving Provider Communication about HPV Vaccines for Vaccine-Hesitant Parents Through the Use of Motivational Interviewing. J Health Commun. 2018;23(4):313-320. 

https://www.cdc.gov/vaccines/hcp/conversations/index.html

E-cigarettes: the pediatrician’s role in an epidemic

The Surgeon General issued an advisory to warn about the rising use of vaping in minors (middle and high school children). E-cigarettes were introduced to the US market in the mid-2000s, and the market has expanded rapidly. In 2011, only 5% of high schoolers had used or experimented with them at some point, but only 4 years later in 2015, that percentage had grown to 13% of middle school and 39% of high schoolers. Because the use of electronic delivery systems for nicotine is a rising danger, pediatricians should include a routine discussion with teenagers as part of patient visits.

The dangers of vaping have been suspected by the medical community since its introduction, and evidence is accumulating to validate those fears. Evidence does support the suspicion that nicotine predisposes the adolescent brain to more severe tobacco addictions. Biological studies (animal models and human population data) indicate that the teenage brain is more susceptible to addictions–earlier exposure leads to stronger addictions and increased likelihood of experimenting with other substances. Thus, the fear that nicotine delivery systems are a bridge (rather than just an alternative) to more serious tobacco addictions is validated by the data so far.

Conversely, it is also true that electronic nicotine systems can help current smokers wean the nicotine addiction. However, from a public standpoint, this could be far outweighed by the number of younger non-smokers who are led to develop a habit they might have otherwise avoided. The solvents and flavors in e-cigarettes are not benign either. While they are safer (by current estimates) than traditional tobacco smoke, they do cause inflammation of the airways. For example, two common additives (diacetyl and acetyl propionyl) have been shown to cause popcorn lung/bronchiolitis obliterans. Like other consumable additives, the FDA has long considered them safe for ingestion, but the aerosolized form can still cause damage to lung tissue.

The toxicity of nicotine itself forms the most obvious risk to young people. First of all, nicotine has been shown to irreversibly decrease attention and processing speed and to increase the fear response mechanism. In other words, teenage nicotine exposure will impair memory and attention span for life and increase the likelihood of anxiety and depression. This risk decreases when exposure is delayed until adulthood, so the teenage years represent a critical window.

Second, nicotine is very toxic in utero. It increases the risk of SIDS, hearing impairment, language delays, ADHD, and possibly obesity. It may begins disrupting the normal development of brain circuitry as early as 5 weeks gestation, and even secondhand exposure to vaping can result in significant serum nicotine levels. These facts should be strongly emphasized to adolescent girls who may wish to be mothers someday, as well as to anyone who lives in proximity to women of childbearing age.

Finally, nicotine has long been known to acutely increase heart rate and blood pressure. Its long-term cardiovascular consequences are still unknown. Other nicotine-replacement  systems (nicotine patches, etc) have not been shown to cause cardiovascular toxicity, but the prolonged, irregular doses from vaping have not yet been sufficiently studied.

This is a prominent issue among young people in our country independent of racial or economic demographics, and pediatricians should give it a proportionate level of attention. Parents should be informed of its dangers during well child visits and given data about the specific risks. Given its prevalence, this should be a routine topic of anticipatory guidance for middle-school children and older. Also, local governments and schools should be encouraged to aggressively regulate teenage access to these devices and limit marketing to that audience. Evidence shows that regulation does prevent a large fraction of teenage vaping, and pediatricians should play an active role in voicing the importance of this legislation. As health care providers, we have the opportunity now to intervene in our communities and forestall some of the long-term consequences of this new epidemic among young people in our country.   

Natasha Varughese, MD

E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General. US Health and Human Services 2016.

Examining the relationship of vaping to smoking initiation among US youth and young adults: a reality check. Levy DT, et al. Tob Control 2018;0:1–7

The impact of local regulation on reasons for electronic cigarette use among Southern California young adults. Hong H, et al. Addictive Behaviors, 2018 (ahead of print).

Transforming the Lives of Children with Asthma

Asthma continues to be a major public health concern affecting 26.5 million Americans nationwide.  Currently, it is the most common chronic condition among children with approximately 6.1 million children under the age of 18 diagnosed with asthma, and the third leading cause of hospitalizations in children. Asthma also has a significant financial impact, as it is currently responsible for an annual expenditure of $50.3 billion in healthcare costs and leads to numerous missed school and work days approximating $3 billion.  Fortunately, asthma symptoms and costs can be controlled when affected individuals have access to appropriate care and education.  Therefore, there is an increasing need to provide proper asthma education to patients and their families in order to prevent recurrent ER visits, hospitalizations, and even death.  (more…)

Addressing TB in Pediatric Patients

Cases of tuberculosis (TB), an airborne bacterial disease,  in the US have been steadily decreasing, thanks to improved socioeconomic conditions, focused screening efforts, and thorough follow-up. 9,272 TB cases were found in the US in 2016, down from about 21,210 cases in 1996 [1]. Pediatric TB cases have also been on the decline. In 2016, about 4% of the TB cases were pediatric. However, data from the past several years shows the incident caseload has remained steady [2]. (more…)

Sports: Healthy Competition vs Performance Anxiety

With school back in full swing, kids are joining their friends and classmates in school sports. Sports can be a great way for growing children to develop fine and gross motor skills. However, it can also be an area of stress and pressure to perform. (more…)

Helping Your Child Succeed at School

A new school year is once again upon us! And for those with children who may need a little extra help in their classes, this may be a stressful time. Children with disabilities or impairments may be eligible for modifications or accommodations at school to help them learn and succeed.

Knowing if your child has a disability impacting their learning can be challenging. Usually a student will begin to have poor, down trending grades.  He/she may have difficulty remembering to do homework or may struggle to complete it.  If this is not brought up by your child’s teacher, you may need to speak up. An evaluation may need to be performed by the school in order to test for certain learning disabilities or other issues. Additionally, you should speak with your child’s pediatrician for developmental, vision, and hearing screens.

Some students qualify for special education services under the federal law, Individuals with Disabilities Education Act. If eligible, an individualized education plan (IEP) is developed to lay out goals for the school year and describe any services or supports the student may need.  Any child age 3 or older with a suspected disability can request a free full individual evaluation from the local public school district.  Several categories of eligibility exist, including specific learning disability, hearing/visual impairment, and “other health impairment.”

Other students may qualify for accommodations under Section 504 of the Rehabilitation Act of 1973. These can include supports such as reminders to stay on task, preferential seating in the classroom, shortened assignments, and other items.  You can ask your child’s teacher or school counselor for a “504 meeting.”

It is vital to know that your child will only receive services if it has been shown that your child’s learning has been affected by these issues and problems with functioning at school exist. If this is the case, a meeting for either special education or 504 accommodations will involve a plethora of staff (classroom teachers, diagnostician or school psychologist, special education teacher, campus administrator, and others).  The group, along with you the parent, decides what the child needs. You, as a parent, will have the option to review the proposals and agree or disagree. Do this to make sure your child is getting all the services he/she may need. Make sure to discuss any changes you would like to be made.

The 504 plan or IEP should be reviewed annually. If you are not seeing appropriate changes to your child’s performance or learning goals – speak up.  Ask your child’s pediatrician for any suggestions or recommendations for your child.   You are the best advocate for your child!

To learn more, visit:

https://sites.ed.gov/idea/

https://www2.ed.gov/about/offices/list/ocr/504faq.html

Kristina Ciaglia, MD