Faculty Bibliography

BACKGROUND: The metabolic syndrome predicts future coronary artery disease and type II diabetes and often emerges in childhood. Tobacco smoke potentially contributes to insulin resistance in this syndrome. This study evaluates the association of environmental tobacco smoke (ETS) exposure and active smoking with the prevalence of the metabolic syndrome in US adolescents. METHODS AND RESULTS: Data from 2273 subjects 12 to 19 years of age were examined from the National Health and Nutrition Examination Survey III (NHANES III, 1988 to 1994). Serum cotinine levels, presence of household smokers, and self-report of smoking were used to determine ETS exposure and active smoking. The metabolic syndrome was defined as having > or =3 criteria from the National Cholesterol Education Panel definition. Bivariate and multivariable analyses were conducted. Among adolescents, 5.6% met the criteria for metabolic syndrome, and prevalence increased with tobacco exposure: 1.2% for nonexposed, 5.4% for those exposed to ETS, and 8.7% for active smokers (P<0.001). In adolescents at risk for overweight and overweight adolescents (body mass index above the 85th percentile), a similar relationship was observed: 5.6% for nonexposed, 19.6% for those exposed to ETS, and 23.6% for active smokers (P=0.01). In multivariable logistic regression analyses among all adolescents, ETS exposure was independently associated with the metabolic syndrome (ETS exposure: odds ratio, 4.7, 95% CI, 1.7 to 12.9; active smoking: odds ratio, 6.1; 95% CI, 2.8 to 13.4). CONCLUSIONS: Considering that tobacco and obesity are the 2 leading causes of preventable death in the United States, these findings of a dose-response, cotinine-confirmed relationship between tobacco smoke and metabolic syndrome among adolescents may have profound implications for the future health of the public

CONTEXT: Both maternal smoking and depression are common and can adversely impact child health and functioning, yet few studies have explored their co-occurrence among mothers. OBJECTIVE: To determine the prevalence and associations of depression and smoking among mothers in the United States. DESIGN: Random-digit-dial national telephone survey of 1530 households conducted in 2002. Respondents were asked about their sociodemographic characteristics, smoking status, and their children's receipt of Medicaid. A validated 3-item depression screen was administered. Bivariate and multiple regression analyses for maternal smoking and a positive depression screen were performed. SETTING: National sample. PARTICIPANTS: Seven hundred two mothers with children aged less than 19 years living in their homes. RESULTS: The response rate was 61%. Among mothers, 24.3% were smokers, 24.4% had a positive depression screen, 8.1% had both, and 40.6% were smokers and/or had a positive depression screen. All rates were greater among mothers whose children receive Medicaid (37.6%, 47.5%, 20.6%, and 64.5%) than those whose children do not receive Medicaid (21.1%, 19.0%, 4.8%, and 35.3%) (P < .001) for each. In multivariate analyses, maternal smoking was independently associated with a 70% increased risk of depressive symptoms (odds radio, 1.7; 95% confidence interval, 1.1-2.6). CONCLUSIONS: This study highlights both the frequency and the co-occurrence of maternal smoking and maternal depressive symptoms, two negative influences on children's health and development, as well as their increased prevalence among mothers whose children receive Medicaid, thereby highlighting the economic disparities associated with both. These findings have significant implications for our nation's children, health care clinicians, and health care payers

PURPOSE: To evaluate factors that independently predict counseling for diet, exercise, sexually transmitted diseases (STDs), pregnancy, smoking, and injuries at adolescent well visits, and compare these rates to the frequency of counseling at adolescent acute visits. METHODS: The 1997-2000 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys were combined for patients aged 11-21 years. Acute visits were identified by ICD-9 code for: sexual health, obesity, asthma, injury, and well care. Bivariate analyses were used to determine differences in relevant counseling provided at acute visits compared with well visits. Logistic regression was used to assess factors that predict counseling on each of the above topics at well adolescent visits. RESULTS: Of 23,378 adolescent ambulatory visits, 1508 (6.5%) were for well care. Only 0.8% of visits were for obesity, 3.7% for sexual health, 2.6% for asthma, and 13% for injuries. Counseling was more frequent at acute than well visits for diet (72% vs. 28%), exercise (52% vs. 23%), human immunodeficiency virus/sexually transmitted diseases (HIV/STD; 14% vs. 6.2%), and family planning (FP) (24% vs. 10%), (all p values < .05). Pediatric clinicians were more likely than other specialists to provide counseling for diet (OR 2.3), HIV/STD (OR 2.7), FP (OR 2.9), tobacco use (OR 2.8), and injury prevention (OR 4.7). Blacks received less exercise counseling than Whites (OR 0.4), and counseling about sensitive issues (STDs, family planning) occurred more often in older adolescents (OR 1.3). CONCLUSIONS: Despite recommendations, more counseling occurs at acute rather than well visits, and still does not reach all those adolescents in need. There remains much room for improvement in physicians' adherence to national guidelines for adolescent care

BACKGROUND: Childhood iron deficiency is associated with behavioral and cognitive delays. Few studies have explored the relationship between prolonged bottle-feeding and iron-deficiency anemia among toddlers. OBJECTIVE: To examine the association between prolonged bottle-feeding and iron deficiency in a nationally representative sample of children ages 1 to 3 years. DESIGN AND METHODS: The National Health and Nutrition Examination Survey III provides data on the feeding practices of children 1 to 3 years old and contains measures of iron status including transferrin saturation, free erythrocyte protoporphyrin, and serum ferritin. The prevalence of iron deficiency and duration of bottle-feeding were determined for black, white, and Mexican American toddlers. Bivariate and multivariate analyses were performed to examine the association between bottle-feeding duration and iron deficiency. RESULTS: Among 2121 children ages 1 to 3 years, the prevalence of iron deficiency was 6% among whites, 8% among blacks, and 17% among Mexican Americans (P< .001). With increasing duration of bottle-feeding, the prevalence of iron deficiency among all children increased (3.8%, bottle-fed < or =12 months; 11.5%, bottle-fed 13-23 months; and 12.4%, bottle-fed 24-48 months [P< .001]). At 24 to 48 months of age, 36.8% of Mexican American children were still bottle-fed, compared with 16.9% of white and 13.8% of black children. In multivariate analyses, bottle-feeding for 24 to 48 months and Mexican ethnicity were associated with iron deficiency (odds ratio, 2.8; 95% confidence interval, 1.3-6.0; and odds ratio, 2.9; 95% confidence interval, 1.5-5.6, respectively). CONCLUSIONS: Children with prolonged bottle-feeding and Mexican American children are at higher risk for iron deficiency. Screening practices and nutritional counseling should be targeted at these high-risk groups

OBJECTIVE: To examine clinician-reported diagnosis of obesity and frequency of blood pressure assessment and diet and exercise counseling during ambulatory visits made by children and adolescents. METHODS: The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey 1997 to 2000 were combined for visits to clinicians of 2- to 18-year-olds. Well-child visits (WCVs) were examined for frequencies of obesity diagnosis, blood pressure screening, and diet and exercise counseling in relation to patient and clinician characteristics. Multivariate models examined the relationship of patient and visit characteristics with diet and exercise counseling. RESULTS: Of the 32 930 ambulatory visits made by 2- to 18-year-olds in 1997-2000, obesity was diagnosed at 0.78% of all visits and 0.93% of WCVs. Blood pressure assessment was reported in 61.1% of WCVs with obesity diagnosis compared with 43.9% of WCVs without obesity diagnosis. WCVs with obesity diagnosis had higher diet counseling rates (88.4% vs 35.7%) and higher exercise counseling rates (69.2% vs 18.6%). Diet counseling was reported for 88.4% and exercise counseling was reported for 69.2% of visits with an obesity diagnosis compared with 35.7% and 18.6% during WCVs without a diagnosis of obesity. In multivariate analyses, factors associated with diet counseling at WCVs were diagnosis of obesity (odds ratio [OR]: 12.9; 95% confidence interval [CI]: 3.0-55.3), being seen by pediatricians (OR: 2.5; 95% CI: 1.6-3.9), 2- to 5-year-olds compared with 12- to 18-year-olds (OR: 0.7; 95% CI: 0.5-1.0), and self-pay compared with private insurance visits (OR: 0.6; 95% CI: 0.4-0.9). Associations with exercise counseling were similar to those for diet counseling, but exercise counseling occurred less frequently in visits by black youths compared with white youths (OR: 0.5; 95% CI: 0.3-0.8). CONCLUSIONS: Clinicians may overlook obesity during WCVs. Programs to increase obesity diagnosis could improve diet and exercise counseling rates, but even with diagnosis of obesity, significant opportunities for screening and intervention are missed

BACKGROUND: Smokers who use cessation medications when they attempt to quit double their likelihood of success. No prior survey has assessed the acceptability to parents of receiving smoking cessation medication prescriptions in the context of their child's primary care visits. OBJECTIVE: To assess acceptability to parents of receiving smoking cessation medication prescriptions and to compare that with the reported rate of actually receiving smoking cessation medication prescriptions in the context of the child's health care visit. METHODS: Data were collected through a national random-digit dial telephone survey of households from July to September 2003. The sample was weighted according to race and gender, on the basis of the 2002 US Census, to be representative of the US population. RESULTS: Of 3990 eligible respondents contacted, 3010 (75%) completed surveys; 1027 (34%) of those were parents. Of those parents, 211 (21%) were self-identified smokers. One half would consider using a smoking cessation medication and, of those, 85% said that it would be acceptable if the child's doctor prescribed or recommended it to them. In contrast, of the 143 smoking parents who accompanied their child to the doctor, only 15% had pharmacotherapy recommended and only 8% received a prescription for a smoking cessation medication. These results did not vary according to parent age, gender, race, or child age. CONCLUSIONS: Child health care clinicians have low rates of recommending and prescribing cessation therapies that have proved effective in other settings. The recommendation or provision of cessation medications would be acceptable to the majority of parents in the context of their child's health care visit