Faculty Bibliography

BACKGROUND: Elevation in prepregnancy body mass index (BMI) has been linked to a host of perinatal complications, but increases in charges or costs associated with obesity during pregnancy have not been quantified. METHODS: To evaluate the economic impact of obesity as a diagnosis on hospitalizations of pregnant women, we performed descriptive, univariate, and multivariable analysis of the 1999 to 2005 Nationwide Inpatient Sample, a nationally representative sample of admissions to US community hospitals. RESULTS: Hospitalizations with a diagnosis of obesity were rare (0.7%), but when obesity was a diagnosis, it was associated with significant increases in length of stay (LOS), charges, and costs. Cesarean section was more frequent among women hospitalized with a diagnosis of obesity, with increases in this procedure across nearly every pregnancy-related diagnostic category. Controlled for cesarean section, diagnosed obesity was associated with significant increases in LOS (0.55 day), charges ($2015), and costs ($1805). Increases in LOS were sustained across nearly every diagnostic category when cesarean section was incorporated into the modeling, whereas increased cesarean section explained increases in costs for hemorrhage during pregnancy and abnormal glucose tolerance during pregnancy. DISCUSSION: Although these hospitalizations represent a relatively small sample of all obese pregnant women, diagnosed obesity seems to contribute heavily to increased costs among pregnant women. Further studies are needed to identify reasons increased health care costs of caring for women with obesity during pregnancy besides increased cesarean section. These data may encourage insurers to provide fiscal incentives to prevent complications of obesity during pregnancy

PURPOSE: Some have suggested that the criteria for weight loss surgery in adolescents be stricter than those currently recommended for adults by the National Institutes of Health (NIH). The aim of the current study is to define the characteristics of adolescents who meet NIH consensus criteria for bariatric surgery in adults to determine their level of morbidity. MATERIALS AND METHODS: Using the Medical Expenditure Panel Survey 2000-2004, children designated as meeting NIH criteria were 13 to 17 years of age with (1) a body mass index >or=40 or (2) a body mass index >35, and one or more comorbidity. We contrasted surgery candidates with noncandidates. We examined items that comprise a screener for identifying children with special health care needs. The Columbia Impairment Scale (CIS) was used to assess child functioning. RESULTS: There were 134 children identified as candidates for bariatric surgery and 4736 noncandidates in the same age range. Candidates were more likely to have special health care needs (36% vs 23%) and more likely to have a CIS above 16 (34% vs 16%). Candidates for weight loss surgery were 2.36 times as likely to have a CIS score of 16 or higher and 1.87 times as likely to be identified as a child with special health care needs (P <or= .001). CONCLUSIONS: We conclude that adolescents who meet NIH consensus criteria for weight loss surgery in adults require specialized health services and have functional impairment. Thus, we advocate the use of the standard adult criteria defined by the NIH as the initial screening requirements so that enhanced access to weight loss surgery for morbidly obese adolescents may be achieved

Childhood obesity is increasingly recognized as an epidemic, but the economic consequences have not been well quantified. We evaluated trends in obesity-associated hospitalizations, charges, and costs using 1999-2005 data from a nationally representative sample of admissions to U.S. hospitals. We detected a near-doubling in hospitalizations with a diagnosis of obesity between 1999 and 2005 and an increase in costs from $125.9 million to 237.6 million (in 2005 dollars) between 2001 and 2005. Medicaid appears to bear a large burden of hospitalizations for conditions that occur along with obesity, while private payers pay a greater portion of hospitalization costs to treat obesity itself

PURPOSE OF REVIEW: Food insecurity is a relatively new measure of household and child malnutrition. This paper reviews recent studies that have examined aspects of its etiology and adverse child health and development. RECENT FINDINGS: Smoking by adults in children's homes has recently been found to be highly associated with childhood food insecurity. Much recent research has also examined the relationship between food insecurity and childhood obesity, and thus far, whereas suggestive, results are conflicting. Some studies have found that parenting practices and parental depression are factors that link household food insecurity with childhood obesity. Other health outcomes recently shown to be associated with food insecurity include undernutrition, decreased mental proficiency, increased developmental risk, adverse pregnancy outcomes, and poor health status. Most of the studies of food insecurity to date have come from the USA. There is, however, absolutely no reason to believe that this measure, and the negative child health outcomes associated with it, does not apply to other developed nations. Similarly, it is likely that children and families living in developing countries suffer a greater prevalence and severity of food insecurity and its negative consequences. SUMMARY: Childhood food insecurity has numerous significant negative effects on childhood health and development, may be associated with obesity, and occurs much more often in impoverished homes with adult smokers

OBJECTIVE: Smoking behavior is strongly influenced by the social environment. More information is needed about how the composition of households with children is associated with adult smoking behavior so that more effective interventions to reduce children's secondhand smoke exposure can be devised and implemented. METHODS: Using data from the Medical Expenditure Panel Survey 2000-2004, we conducted cross-sectional analyses to assess how adult smoking behavior is associated with household characteristics, including the number of adults and smokers present, the relationship of the child to the head of household, and relationships between adult members of the household. RESULTS: More than one third (34.4%) of children lived with > or =1 adult smoker. Almost half (49.4%) of poor children lived with a smoker, and they were more likely to live with multiple smokers compared with those who lived at >400% of the federal poverty level (21.2% vs 7.8%). Approximately 5 million children lived in households headed by an adult other than their parent, and they were significantly more likely to live with smokers: 53.4% of children who lived in their grandparents' homes and 46.2% of children in homes of other adults lived with at least 1 adult smoker, compared with 33.3% who lived in their parents' home. A total of 59.4% of all children who lived with a smoker had a smoking mother, and 56.7% of those children lived with > or =2 smokers, whereas only 17.0% of children whose mother did not smoke had smoking adults in the home. CONCLUSIONS: These findings demonstrate the significant influence of household composition on children's likelihood to live in homes with adult smokers

The large number of adverse health outcomes associated with advanced paternal age is not widely recognized by the pediatric community. An exploration of the clinical and public health implications of this issue is required so as to develop appropriate policies. Included in this review are the clinically relevant conditions and diseases currently known to be associated with increasing paternal age, including diminutions in child IQ and social function [1], increased rates of low birth weight, certain childhood cancers, autistic spectrum disorders, schizophrenia, achondroplasia, Apert syndrome, Crouzon syndrome, and Multiple Endocrine Neoplasia (MEN). Other conditions for which there may be increased rates, but for which the data are still inconclusive, also are discussed. As men delay childbearing in the developed world, there is a need for pediatricians to be aware of the potential consequences. This paper provides pediatricians with a reference for conditions in children that are related to advanced paternal age, assisting them in maintaining a high index of suspicion, and for use in responding to questions from parents about this issue

OBJECTIVE: To investigate rates and severity of child and adult food insecurity (the inability to access enough food in a socially acceptable way for every day of the year) in households with and without smokers. DESIGN: Cross-sectional survey. SETTING: Nationally representative sample of the US population from 1999 to 2002. PARTICIPANTS: Households with children through age 17 years (n = 8817) in the National Health and Nutrition Examination Survey. Main Exposure Presence or absence of adult smokers in the household. Covariates included age, sex, and race/ethnicity of the child, and the poverty index ratio. Main Outcome Measure Rates and severity of food insecurity were ascertained using the US Department of Agriculture Food Security Survey Module. RESULTS: Food insecurity was more common and severe in children and adults in households with smokers. Of children in households with smokers, 17.0% were food insecure vs 8.7% in households without smokers (P < .001). Rates of severe child food insecurity were 3.2% vs 0.9% (P < .04), respectively. For adults, 25.7% in households with smokers and 11.6% in households without smokers were food insecure, and rates of severe food insecurity were 11.8% and 3.9%, respectively (P < .003 for each). Food insecurity was higher in low-income compared with higher income homes (P < .01). At multivariate analyses, smoking was independently associated with food insecurity and severe food insecurity in children (adjusted odds ratio, 2.0; 95% confidence interval, 1.5-2.7, and adjusted odds ratio, 3.1; 95% confidence interval, 1.4-6.9, respectively) and adults (adjusted odds ratio, 2.2; 95% confidence interval, 1.6-3.0, and adjusted odds ratio, 2.3; 95% confidence interval, 1.4-3.7, respectively). CONCLUSIONS: Living with adult smokers is an independent risk factor for adult and child food insecurity, associated with an approximate doubling of its rate and tripling of the rate of severe food insecurity

The importance of the public hospital system to medical education is often absent from the debate about its value. Best known as a core provider of services to the underserved, the safety net hospital system also plays a critical role in the education of future physicians. Particular strengths include its ability to imbue physicians in training with core professional values, to reveal through the enormous range of clinical experience provided many of the social forces shaping health, and to foster interest in and commitment to advancing population health. Faculty teaching in the public hospital system has unusual opportunities to reveal to learners the broader meanings of their diverse and rich experiences. Now, as an alarming array of pressures bearing down on the safety net system threaten its stability, the potential negative impact on medical education, were it to shrink or be forced to change its essential mission, must be considered. As advocates of the safety net system marshal forces to rationalize its funding and support, its tremendous contribution to the training of physicians and other health care professionals must be clearly set forth to ensure that support for the public hospital system's health is appropriately broad based

BACKGROUND: The prevalence of overweight children in the United States continues to increase. OBJECTIVES: To examine the relationship between being overweight and caries in primary and permanent dentition in a nationally representative sample of children. METHODS: Data from the NHANES III (1988-1994) were analyzed using logistic regression and controlling for potential confounders for 10 180 children 2-18 years of age and from the NHANES 1999-2002 for 7568 children 2-18 years of age. RESULTS: For children 2-5 years of age, there was no difference in caries experience among normal weight, at risk for overweight or overweight children for NHANES III and for NHANES 1999-2002. For children 6-11 years of age (NHANES III), at risk for overweight and overweight children were less likely to have caries experience in the primary dentition than normal weight children; overweight children were less likely to have caries experience in the permanent dentition than normal weight children. For children 12-18 years of age (NHANES III), overweight children were less likely to have caries experience in the permanent dentition than normal weight children. For children 6-11 years of age and 12-18 years of age (NHANES 1999-2002), there was no difference in having caries experience among normal, at risk for overweight and overweight children. CONCLUSIONS: The data from NHANES III and NHANES 1999-2002 provide no evidence to suggest that overweight children are at an increased risk for dental caries. Although no differences in caries rates by weight were found in younger children, interestingly results from NHANES III suggest that being overweight may be associated with decreased rates of caries in older children