Faculty Bibliography

Approximately 20% of all children in the United States live in poverty, which exists in rural, urban, and suburban areas. Thus, all child health clinicians need to be familiar with the effects of poverty on health and to understand associated, preventable, and modifiable social factors that impact health. Social determinants of health are identifiable root causes of medical problems. For children living in poverty, social determinants of health for which clinicians may play a role include the following: child maltreatment, child care and education, family financial support, physical environment, family social support, intimate partner violence, maternal depression and family mental illness, household substance abuse, firearm exposure, and parental health literacy. Children, particularly those living in poverty, exposed to adverse childhood experiences are susceptible to toxic stress and a variety of child and adult health problems, including developmental delay, asthma and heart disease. Despite the detrimental effects of social determinants on health, few child health clinicians routinely address the unmet social and psychosocial factors impacting children and their families during routine primary care visits. Clinicians need tools to screen for social determinants of health and to be familiar with available local and national resources to address these issues. These guidelines provide an overview of social determinants of health impacting children living in poverty and provide clinicians with practical screening tools and resources.

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Abstract Background: Although disparities in child obesity exist during infancy, the underlying mechanisms are unclear. Assessing dissimilarities in feeding practices, styles, and beliefs may provide a better understanding of these mechanisms. This study sought to identify modifiable maternal-infant feeding behaviors that may contribute to disparities in early child obesity. Methods: This study is a cross-sectional analysis comparing mothers with infants (2 weeks to 6 months old) in a low-risk group of high-income white mothers to a high-risk group of low-income Hispanic mothers. Regression analysis was used to explore relationships between each group and (1) infant feeding practices, including breastfeeding, giving juice, and adding cereal to bottles, (2) controlling feeding styles, (3) beliefs about infant hunger and satiety, and (4) infant weight status. Results: The sample included 412 mothers (low-risk group, n=208; high-risk group, n=204). The high-risk group was less likely to exclusively breastfeed (adjusted odds ratio [AOR], 0.43; 95% confidence interval [CI], 0.22-0.83), more likely to introduce juice (AOR, 12.25; 95% CI, 3.44-43.62), and add cereal to the bottle (AOR, 10.61; 95% CI, 2.74-41.0). The high-risk group exhibited greater restrictive and pressuring feeding styles and was more likely to believe that mothers can recognize infant hunger and satiety and less likely to believe that infants know their own hunger and satiety. High-risk infants were more likely to have a weight-for-length percentile >85th percentile (AOR, 2.66; 95% CI, 1.10-6.45). Conclusions: Differences in infant feeding behaviors may contribute to disparities in early child obesity. Longitudinal studies are needed to determine the effect of these differences on child obesity.

BACKGROUND: Di-2-ethylhexylphthalate (DEHP) is an ester of phthalic acid commonly found in processed foods. DEHP may contribute to obesity and insulin resistance in children and adolescents, yet dietary exposures have been not been studied in this vulnerable subpopulation. OBJECTIVE: To assess diet and its relation to urinary phthalates in a nationally representative sample of US children and adolescents. DESIGN: Cross-sectional analysis of 24-h dietary recall and urinary phthalate metabolites from 2743 6-19 year olds participating in the 2003-8 National Health and Nutrition Examination Surveys. Regression analyses examined relationships of food consumption with log-transformed metabolite concentrations, examined as low-molecular weight, high molecular weight and di-2-ethylhexylphthalate categories, controlling for urinary creatinine, age group, body mass index category, race/ethnicity, caloric intake and gender. RESULTS: We identified a -0.04% (95% CI: -0.08, -0.01) increment in di-2-ethylhexylphthalate metabolite concentration/additional gram fruit consumption, a +0.01% increment/additional calorie dietary intake (95% CI: +0.003, +0.02), and a +0.09% (95% CI: +0.02, +0.17) increment/additional gram meat/poultry/fish consumption. Soy consumption (-0.40% increment/additional gram consumed, 95% CI: -0.66, -0.14) was inversely associated with di-2-ethylhexylphthalate, while poultry (+0.23% increment/additional gram consumed, 95% CI: +0.12, +0.35) was positively associated. Findings were robust to examination of metabolite concentrations per unit body mass index and weight, and inclusion of fasting time. CONCLUSIONS: Diet contributes to urinary phthalate concentrations in children and adolescents. Further study is needed to examine the implications of di-2-ethylhexylphthalate exposure, especially earlier in life, when more permanent metabolic changes may occur.

OBJECTIVES: We explored the relationship between household food insecurity and maternal feeding styles, infant feeding practices, and perceptions and attitudes about infant weight in low-income mothers. METHODS: Mothers participating in the Special Supplemental Food Program for Women, Infants, and Children with infants aged between 2 weeks and 6 months were interviewed. By using regression analyses, the following relationships were examined between food insecurity and: (1) controlling feeding styles (restrictive and pressuring); (2) infant feeding practices, including breastfeeding, juice consumption, and adding cereal to the bottle; and (3) perceptions and attitudes about infant weight. Path analysis was used to determine if perceptions and attitudes about infant weight mediated the relationships between food insecurity and controlling feeding styles. RESULTS: The sample included 201 mother-infant pairs, with 35% reporting household food insecurity. Food-insecure mothers were more likely to exhibit restrictive (B [SE]: 0.18 [0.08]; 95% confidence interval [CI]: 0.02-0.34) and pressuring (B [SE]: 0.11 [0.06]; 95% CI: 0.001-0.22) feeding styles compared with food-secure mothers. No associations were found with feeding practices. Concern for their infant becoming overweight in the future was associated with food insecurity (adjusted odds ratio: 2.11 [95% CI: 1.02-4.38]). This concern mediated the relationship between food insecurity and both restrictive (P = .009) and pressuring (P = .01) feeding styles. CONCLUSIONS: Increased concern about future overweight and controlling feeding styles represent potential mechanisms by which food insecurity could be related to obesity. Obesity prevention should aim to decrease food insecurity and to reduce controlling feeding styles in families who remain food insecure.

This study sought to determine the relationship between maternal controlling feeding styles and maternal perception of their infant's ability to regulate feeding and infant weight. A cross-sectional survey of 208 mothers with infants between 2 weeks and 6 months old was performed in a private pediatric office. The authors assessed the relationship between restrictive and pressuring feeding styles with (a) maternal perception of the infant's ability to regulate feeding and (b) infant weight (both actual and perceived). Restrictive feeding style was associated with the perception that infants could not recognize their own hunger or satiety and with concern that the infant would become overweight in the future. Pressuring feeding style was associated with the perception that the baby's appetite is less than other babies and with concern that the infant would become underweight in the future. Maternal perceptions of infant feeding and weight should be incorporated into early obesity prevention strategies.

OBJECTIVE: Controlling feeding styles in which parents regulate feeding without responding to child cues have been associated with poor self-regulation of feeding and increased weight, but have not been well studied in infancy. We sought to assess maternal perception of infant feeding cues and pressuring feeding styles in an urban Latina Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) population. METHODS: Secondary analysis of a larger study of Latina mothers participating in New York City WIC programs. We examined maternal perception of infant feeding cues and pressuring feeding style. Using logistic regression, we assessed: 1) characteristics associated with perceptions of cues and pressuring to feed, including sociodemographics, breastfeeding, and maternal body mass index; and 2) whether perceptions of cues were associated with pressuring feeding style. RESULTS: We surveyed 368 mothers (84% response rate). Most mothers perceived that babies sense their own satiety. However, 72% believed that infant crying must indicate hunger. Fifty-three percent believed that mothers should always make babies finish the bottle ("pressure to feed"). Pressuring feeding style was associated with foreign maternal country of birth (adjusted odds ratio [AOR] 3.05; 95% confidence interval [CI], 1.66-5.60) and less than a high school education (AOR 1.81; 95% CI, 1.12-2.91). Two perceptions of feeding cues were related to pressuring feeding style: belief that infant crying must indicate hunger (AOR 2.59; 95% CI, 1.52-4.42) and infant hand sucking implies hunger (AOR 1.83; 95% CI, 1.10-3.03). CONCLUSIONS: Maternal characteristics influence perception of infant hunger and satiety. Interpretation of feeding cues is associated with pressuring feeding style. Improving responsiveness to infant cues should be a component of early childhood obesity prevention.

BACKGROUND: Physicians frequently report negative attitudes about obesity which is thought to affect patient care. However, little is known about how attitudes toward treating obese patients are formed. We conducted a cross-sectional survey of physicians in order to better characterize their attitudes and explore the relationships among attitudes, perceived competency in obesity care, including report of weight loss in patients, and other key physician, training, and practice characteristics. METHODS: We surveyed all 399 physicians from internal medicine, pediatrics, and psychiatry specialties at one institution regarding obesity care attitudes, competency, including physician report of percent of their patients who lose weight. We performed a factor analysis on the attitude items and used hierarchical regression analysis to explore the degree to which competency, reported weight loss, physician, training and practice characteristics explained the variance in each attitude factor. RESULTS: The overall response rate was 63%. More than 40% of physicians had a negative reaction towards obese patients, 56% felt qualified to treat obesity, and 46% felt successful in this realm. The factor analysis revealed 4 factors-Physician Discomfort/Bias, Physician Success/Self Efficacy, Positive Outcome Expectancy, and Negative Outcome Expectancy. Competency and reported percent of patients who lose weight were most strongly associated with the Physician Success/Self Efficacy attitude factor. Greater skill in patient assessment was associated with less Physician Discomfort/Bias. Training characteristics were associated with outcome expectancies with newer physicians reporting more positive treatment expectancies. Pediatric faculty was more positive and psychiatry faculty less negative in their treatment expectancies than internal medicine faculty. CONCLUSION: Physician attitudes towards obesity are associated with competency, specialty, and years since postgraduate training. Further study is necessary to determine the direction of influence and to explore the impact of these attitudes on patient care

BACKGROUND: Physicians must effectively evaluate and treat obesity. To design a needs-driven curriculum intended to improve patient outcomes, physicians were surveyed about their self-perceived knowledge and skills. OBJECTIVE: The objective of this study was to determine the expressed needs of residents and faculty regarding obesity care training across three specialties. DESIGN: The study used a survey given to faculty and residents in General Internal Medicine, Pediatrics, and Psychiatry. METHODS: Survey questions were generated from comprehensive nutrition curriculum and clinical recommendations, administered online, and then organized around a validated behavioral health framework-the 5As (assess, advise, agree, assist, arrange). Analyses were conducted to evaluate differences in perceived knowledge and skills between specialties and across training levels. RESULTS: From an overall response rate of 65% (65 residents and 250 faculty members), nearly 20% reported inadequate competency in every item with 48% of respondents reporting an inability to adequately counsel patients about common treatment options. Internists reported the lowest competency in arranging referrals and follow-up. Psychiatrists reported the lowest competency in assessment skills. CONCLUSIONS: This survey demonstrated a critical need for training in specific areas of obesity care. The proposed curriculum targets these areas taking into consideration observed differences across specialties