Fouzi Benboujja, Elizabeth Hartnick, Evelyn Zablah, Cheryl Hersh, Kevin Callans, Perla Villamor, Phoebe H Yager, Christopher Hartnick
Overcoming language barriers in pediatric care: a multilingual, AI-driven curriculum for global healthcare education
Frontiers in public health
homecirculationvol 119 15american heart association childhood obesity research summit free accessreview articlepdfepubaboutview pdfview epubsections toolsadd favoritesdownload citationstrack citationspermissions shareshare onfacebooktwitterlinked inmendeleyreddit jump tofree accessreview articlepdfepubamerican heart association childhood obesity research summitexecutive summary stephen r daniels md phd faha chair marc jacobson md faha brian w mccrindle md mph faha robert h eckel md faha brigid mchugh sanner bs stephen r danielsstephen r daniels marc jacobsonmarc jacobson brian w mccrindlebrian w mccrindle robert h eckelrobert h eckel brigid mchugh sannerbrigid mchugh sanner originally published30 mar 2009httpsdoiorg101161circulationaha109192215circulation 200911921142123other versions articleyou viewing recent version article previous versions march 30 2009 previous version 1 childhood obesity one pressing health threats facing united states today one third american children adolescents obese overweight past 30 years prevalence obesity nearly tripled children 2 5 years age youth 12 19 years age quadrupled children 6 11 years old1the problem childhood obesitya burgeoning epidemicoverweight children adolescents risk significant health problems youth adults overweight children adolescents likely children adolescents risk factors associated cardiovascular disease eg high blood pressure high cholesterol type 2 diabetes mellitus2overweight children adolescents likely become obese adults34studies document link obesity poor school performance unhealthy risky behaviors alcohol use tobacco use premature sexual behavior inappropriate dieting practices physical inactivity56overweight children adolescents may experience health conditions associated increased weight include asthma hepatic steatosis sleep apnea type 2 diabetes mellitusobesity puts children longterm higher risk chronic conditions stroke breast colon kidney cancers musculoskeletal disorders gall bladder diseaseas part strategic focus childhood obesity particularly prevention childhood obesity american heart association convened childhood obesity research summit examine research opportunities obesity epidemic intersects healthcare system childhood obesity research summit provided overview childhood obesity participants identified key questions need answered well recommendations future work areas education public policy research recommendations outcomes conference help inform american heart association alliance healthy generation broadly terms help focus ongoing research public policy initiativesmedical consequences childhood obesitythe increasing prevalence severity obesity children adolescents resulted higher prevalence comorbid conditions including high blood pressure early development atherosclerosis type 2 diabetes mellitus nonalcoholic fatty liver disease polycystic ovary disorder disordered breathing sleep7 complications occur shortterm longterm complications type 2 diabetes mellitus previously thought occur adulthood shown occur children adolescents raised concerns whether obesity epidemic might shorten lifespan current generation children still much learned mechanisms obesity development related comorbid conditions translational research perhaps lead information help identify children higher risk excessive weight gain development specific adverse outcomes due obesity type mechanistic research could also inform specific strategies treatment comorbidities weight management cannot accomplished less adequatepsychosocial societal consequences childhood obesityhistorically studies evaluate psychosocial consequences pediatric overweight focused primarily comparing functioning overweight children adolescents nonoverweight peers dimensions healthrelated quality life selfconcept body image depressive symptomology peer relationships studies demonstrate decreased healthrelated quality life associated increasing weight lower body satisfaction lower physical appearancerelated selfconcept overweight children adolescents8 well decreases selfesteem childhood early adolescence among overweight children9 evidence indicating increased risk development obesity among depressed adolescents10 overweight children experience teasing weight status predictive vulnerability bullying peer relationships1112 studies document relationship overweight status decreased probability employment less financial support college among women lower household incomes men womenlifestyle assessment diet physical activitylifestyle assessment opportunity identify potential targets prevention increase families selfawareness current behaviors situation may differ routine wellchild care visits visits aimed addressing specific health issue childhood obesity lifestyle assessment requiring specific indepth questionshow assessment conducted critical dietary physical activity assessments typically taught medical healthprofession schools wide variability exists performed primary care assessment methods standardized remains unclear often standardized assessment methods usedseveral tools developed research setting assess dietary intake potentially could used primary care setting addition emerging technologies may provide novel methods diet physical activity assessment may prove helpful primary care settingclinical assessmentevaluation obesity begins calculation body mass index bmi clinical validity correlates adiposity13 adult adiposity14 cardiovascular risk factors15 longterm mortality16 unfortunately perfect cutpoint bmi identifies children elevated body fat bmi norms change age differ boys girls absolute bmi appropriate screen children practitioners need plot bmi centers disease control preventions percentile curves identify bmi percentile category wwwcdcgovgrowthchartsclinicians assess obesity risk children integrating information patients bmi medical risk current eating physical activity behaviors attitudes assessment guide initiation preventive treatment strategiespsychosocialbehavioral assessmentcurrent practices psychosocial screening assessments include qualityoflife assessments readiness assessments family context assessments available data indicate greater depressive symptoms baseline associated higher dropout rates clinical weightloss programs17 greater parent distress child social problems baseline associated poorer weightloss outcomes18 existence fewer social problems baseline predicted better longterm maintenance weight loss 2 years19 improvements weight status shown associated improvements childs social problems psychological adjustment reduction maternal distress20 participation intervention alone positive effect selfesteem21to help clinicians tailor treatment approaches randomized clinical trials needed relation appropriateness psychological treatment clinical treatment referral concurrent psychological clinical treatment treatment psychosocial issues within weightmanagement model addition understanding readiness change family useful currently wellvalidated measures widespread use evaluate readiness change studies potential harm intervention family ready intervention also neededthe final area requires evaluation family structure family assessment recommended determine providingmonitoring care favored parenting style family functionsimplementing effective prevention treatment options dietprevention treatment obesity usually require decrease energy consumption increase energy expenditure improve energy balance dietary interventions may help reduce prevent childhood obesity include breastfeeding infants highfiber diet calcium intakedietary factors promote obesity include highcalorie beverages sugared soft drinks fruit juice energydense foods excess refined carbohydrates excess dietary fat large portion sizes22 increase prevalence obesity coincided increase portion sizes foods inside outside home suggests larger portions may play role obesity epidemic23to outline dietary treatment plan provide adequate education counseling health professional expertise dietary management often required use qualified experienced health professional preferably registered dietitian dietary counseling implement optimal dietary plan achieving maintaining healthy body weight recommendedimplementing effective prevention treatment options exercise sedentary behaviorseven specific recommendations intensity duration frequency modality exercise management pediatric obesity implementation may difficult time consistent exercise result multitude metabolic physiological benefits promoting weight loss increased energy expenditure possibly inhibition food intake24 physical activity also facilitates maintenance desirable weight helps reduce risk factors cardiovascular disease children25 frequent vigorous exercise periods shown associated decreased abdominal fat youth26 strength training shown independent predictor lower insulin resistance children27 unfortunately positive effects exercise training realized overweight child complies prescribed physical activities careful consideration must given selecting appropriate intensity frequency duration modality exercise overweight childoverweight children may experience negative consequences participation activities considered appropriate normalweight children activities easily mastered considered recommendations based clear attainable goals gradually increase volume intensity time established structuring help ensure overweight children experience initial success overweight children expend energy performing exercise intensity normalweight children prescribed running activities must compete normalweight youth resistive weightlifting exercise activity performed close supervision trained personnelimplementing effective prevention treatment options family behavioral approachesfamily involvement important part childhood overweightprevention programs common focus family parental involvement prevention programs peripheral inclusion parents school communitybased programs usually takes form newsletters postcards sent parents occasional familybased events held school communityin contrast childhood overweightprevention programs childhood overweight treatment often takes form familybased behavioral intervention parents intricately involved treatment2829 familybased behavioral interventions widely studied type intervention evidence longterm success among 8 12yearold children30 interventions consistently successful treatment educationonly interventions21 core behavioral skills intervention programs including monitoring contingency management environmental control help already overweight children make eating activity changes highly dependent caregivers implementationbehavioral managementthe family lifestyle overweight prevention study flow suggested schoolbased treatment sufficient intensity effective means promoting initial weight loss study findings indicate nutrition elements programs simple easily integrated lifestyle physical activity components focus fun activities31some promising studies management childhood overweight performed homogenous samples data use behavioral management minorities children lowincome families significantly overweight children given increased rates overweight minority lowincome children increased health emotional problems overweight adolescents methods strategies effective groups must developed recruitment adherence retention need better understood culturally economically appropriate behaviorbased interventions necessary meet unique needs various populationsmedical pharmacological managementrecommendations national heart lung blood institute nhlbi adults emphasize addition antiobesity drugs regimen lifestyle modification produce weight loss lifestyle modification alone nhlbi guidelines note antiobesity drugs given part comprehensive program lifestyle modification different antiobesity agents combined risks associated longterm pharmacotherapy must balanced increasing risks continued weight gainstudies shown weightloss drugs sibutramine orlistat together behavioral therapy similar magnitude bmilowering effects 4 effects drugs additive behavioral therapy 6 12month studies sibutramine overweight adolescents designed provide information weight maintenance currently possible determine whether adolescents require chronic treatment weightloss medications adulthood beyond whether weight loss 12month period sufficient result consistent behavior change time studies tested orlistat sibutramine adjunctive therapy complement wellknown effects behavior modification patients received dietary exercise lifestyle modification instructions counseling32surgical managementthe 40year evidence base bariatric surgery adolescents small research methodology quality studies vary studies provide 3 years followup data outcomes clearly demonstrate weightloss effectiveness compared weight loss achieved intensive dietarybehavioral interventions severe pediatric obesity3334 limited data suggest important comorbidities improve bariatric surgery adolescents perhaps youth adults given pediatric comorbidities shorter duration analysis perioperative complications indicates bariatric surgical procedures generally safe complications similar seen adults insufficient data permit assessment longterm risks recidivism young patientsseveral unique concerns raised bariatric surgery pediatric populations including questions timing intervention costs informed consent risktaking behaviors successful weight loss compliance durability weight loss comorbidity resolution35 questions point importance welldesigned prospective research efforts better inform important decisionspreparedness providersdespite identification specific risk behaviors related overweight primary care systems often ineffective developing methods implement guidelines assessment children adolescents overweight obese36 reluctance fully implement screening measures may due lack welldefined validated preventive therapeutic interventions could given children adolescents families given series studies demonstrate effectiveness screening health risk behaviors initiated adolescence incumbent healthcare systems learn decade preventive interventions embraced screening measures clinical practice efforts need coordinated public policy interventions target reimbursement practices public private levelmodels coverage careimportant gaps exist done prevent treat childhood obesity covered health insurance especially true light guidelines published centers disease control prevention american heart association see httpwwwamericanheartorgpresenterjhtmlidentifier3054245 healthcare organizations able promote continuity coordination encourage quality leadership incentives organize equip healthcare teams use information systems support selfmanagement prevention overweight obesity community organizations need focus raising awareness mobilizing resources policy plays role types activities creating supporting environments leadership advocacy childhood obesity provided crosssector partnerships eg health care schools transportation networks developed sustained policy support developed implemented monitoring benchmarking reporting progress neededchallenges barriers addressed include program recruitment retention financing apathy policy level clinical apathy addition healthcare stakeholder organizations vary terms priority place childhood obesityuninsurance underinsurance among children familiescurrently 1 5 children rely medicaid state childrens health insurance program coverage numbers higher among children lowincome families37 uninsured children eligible medicaid state childrens health insurance program getting enrolled although 85 lowincome parents say would enroll children told child eligible fewer half would eligible aware fact despite 8 states set eligibility 200 federal poverty levels parents indicate concerns medicaid extent state childrens health insurance program enrollment processes complicatedemployersponsored coverage predominant form healthcare coverage children united states38 fewer parents obtain coverage employers coverage diminishes childrenhealthcare providers settings role modelshealthcare providers poor job identifying managing childhood obesity clinicians appear selective morbidities receive focus medical history taken physical examination performed one study pediatricians showed 27 overweight pediatric patients identified whereas 86 obese children identified such39 yet overweight obesity identified growth charts kept current bmi plotted activities would lead increased odds patients would receive counseling diet physical activityhealthcare providers perceive number barriers affect obesity identification treatment basis primarily selfreported data practitioners indicated belief although childhood adolescent obesity treatment needed treatment probably ineffective another issue may impact engagement healthcare providers many instances healthcare providers may minimally healthier patients studies shown physicians personal weight status health habits influence counseling practices patients perceive counseling40 additionally healthcare institutions subject market forces driving obesity epidemic leads institutions poor role modelsmotivational interviewing pediatric obesitymotivational interviewing clientcentered directive method enhancing intrinsic motivation change behaviors exploring resolving ambivalence applied successfully obesity management41 technique involves active listening advising informing asking barriers motivational interviewing clinicians perspective combination time limitations sense treatment futility belief patients parents wont listen concerns efficacy belief really work42psychosocial factors influencing behavior changerecent research suggests 3 psychosocial variables may negatively influence quality life obese children also barriers adoption healthier diet healthier physical activity patterns weightrelated teasing social isolation depression issues coexist daily life certain obese children although may reluctant discuss parents healthcare providersenvironmental factors influencing behavioral changeit critical understand major environmental determinants healthy eating physical activity effective intervention points improve behaviors among children ecological framework well suited understanding behaviors developing public health interventions policies improve healthy eating physical activity among children four broad levels influenceindividual social environment physical environment macrolevel environmentsall interact directly indirectly impact eating physical activity behaviors research determinants eating physical activity behaviors children adolescents focused predominantly individuallevel determinants behaviors example attitudes preferences intentions selfefficacy recently shift attention environmental determinants eating behavior built environment empirical evidence environmental factors scant especially food environmentmodels disciplines adult chronic care modelimproving chronic illness care national program robert wood johnson foundation presents chronic care model framework management conditions obesity43 improving chronic illness care program supported robert wood johnson foundation directional technical assistance provided group healths maccoll institute healthcare innovation wwwimprovingchroniccareorgthe chronic care model identifies essential elements healthcare system encourage highquality chronic disease care figure chronic care model applied variety chronic illnesses healthcare settings target populations produce healthier patients satisfied providers cost savings chronic care model evaluated diabetes mellitus asthma congestive heart failure depression mixed results however application chronic care model provision obesity care remains untested download figuredownload powerpointfigure population health outcomesfunctional clinical outcomes reprinted permission american college physicians wagner eh chronic disease management take improve care chronic illness eff clin pract 1998124models disciplines treatment heart failuremany studies indicate multidisciplinary teams incorporate disease management strategies lead improved outcomes heart failure thus fewer hospitalizations improved adherence medications improved adherence lifestyle changes improved mortality likely treatment depression greater likelihood overcoming barriersmodels disciplines treatment type 2 diabetes mellitusresearch shows diabetes selfmanagement effective improving metabolic control quality life patients diabetes mellitus4445 diabetes initiative robert wood johnson foundation sought show diabetes selfmanagement could implemented successfully settings neighborhood health centers community organizations46 based learned diabetes initiative well american academy family physicians foundation program peers progress supported eli lilly company foundation implications approaches childhood obesity follows selfmanagement works realworld settings sustained behavior change requires varied intervention modes ongoing supportchoice key reaching audiences engaging diverse needs preferences program planning identify implement many good practices rather obsess identifying limiting offerings best practicesidentification key program ingredients approaches provides base individual programs flexibly developed ensure best fit settings organizational community strengths population needs perspectivesmodels disciplines treatment childhood asthmamany different initiatives undertaken improve childhood asthma outcomes including rand corporation report improving childhood asthma outcomes47 national asthma education prevention program report key clinical activities48 expert panel report 3 guidelines implementation panel ongoing 3 documents demonstrate importance distilling information detailed documents activities messages likely produce significant impact asthma care processes outcomes related ongoing project asthma iq project demonstrates technological approach improving asthma care specialists officepublic health measures childhood obesitythere notable public health successes respect certain threats health questions arisen regarding whether public health efforts control tobacco might provide insight prevent childhood obesity tobacco control aspects similar different obesity public health problem problems guidelines clinical care policy interventionsfor evidence base interventions less robust children youth adults interventions adolescence adulthood poorly definedprogress tobacco control required still requires sustained advocacy political leadership progress addressing obesity require samethere also important differences nicotine highly addictive safe level use exposure whereas food deadly product people need eat every day one reason public health response overnutrition focused strategies rely need individuals change behavior however approach may ineffective companies spend substantial resources advertising influence eaten food industry often resistant public health attempts change current practices thus comprehensive response may needed similar used tobacco industry experience tobacco control suggests broad wellnetworked coalitions along strong leadership needed help develop sustain range strategies needed address obesity public health problemspecifying priorities context complex multifactorial problempatients often receive comorbidityspecific medical care comprehensive care understanding may limited lack coordination result patient needs may identified treated may affect care planning staffing reimbursement