Recent Research in Child & Adolescent Health
Addressing Health Literacy and Numeracy to Prevent Childhood Obesity
Chronic Disease Management for Adolescents with T2DM
Maternal & Infant Effects of Treated and Untreated Depression during Pregnancy
National Children’s Study
Obesity Prevention in Youth Using Dental Settings
Weight Gain Prevention in Hispanic Girls
Addressing Health Literacy and Numeracy to Prevent Childhood Obesity
In 2003, Surgeon General Richard Carmona stated that low health literacy was "one of the largest contributors to our nation´s epidemic of overweight and obesity." This assertion is supported by recent studies which have found that low health literacy or numeracy is associated with poorer caregiver breastfeeding knowledge, incorrect mixing of infant formula, difficulty understanding food labels and portion sizes, and higher Body Mass Index (BMI) in adults and children. Of particular concern is the impact of the obesity epidemic on our youngest children. Over 26 percent of preschool children are now overweight (BMI>85 percent) or obese (BMI>95 percent) (based on 2007 HHS/CDC Expert panel definitions). Rates of obesity in preschool children have doubled over the past decade, with the highest increases among low income and minority children-- the same communities most affected by low health literacy. To date, clinical efforts to prevent or treat childhood obesity have had limited efficacy. Efforts need to start early, because children who are overweight by age two are five times as likely to become overweight adolescents, and subsequently at higher risk for obesity-related complications, including early-onset Type-2 Diabetes and cardiovascular disease. No published clinical studies have rigorously addressed obesity prevention prior to age 2 with a specific low-literacy and numeracy focus. Addressing caregiver health literacy in early childhood is an innovative strategy to promote healthy nutrition and activity among these families and prevent unhealthy weight gain across the child´s life, which would have great public health significance by preventing both child and adult chronic illness. The proposed study is a multi-site randomized, controlled trial to assess the efficacy of a low- literacy/numeracy-oriented intervention designed to promote healthy family lifestyles and to prevent early childhood obesity. The intervention will be delivered through pediatric resident physicians in primary care settings in under-resourced communities. Four academic medical centers will be randomized: Vanderbilt University, the University of Miami, the University of North Carolina at Chapel Hill, and New York University. Two centers will receive the intervention while the other two centers will receive an active control. At each site, a cohort of 250 English- or Spanish-speaking caregiver-child dyads will be enrolled and followed from the child´s 4-6 month well-child visit through the 24-month well-child visit. The intervention will include a low- literacy-oriented toolkit for pediatric residents to use with families and clear health communication training for the pediatric residents. At control sites, pediatric residents will provide "usual care" with respect to lifestyle counseling, but they will also receive an injury-prevention education program to act as an attention control. The primary hypotheses are that the intervention will improve family dietary and physical activity behaviors and that it will reduce the rate of childhood overweight (BMI > 85 percent) at age 24 months. Funded by the National Institute of Child Health and Human Development Investigators: Russell L. Rothman, M.D., M.P.P. (PI); Bettina Beech, Dr.P.H., M.P.H.; Shari Barkin, M.D.; Sunil Kripalani, M.D. M.S.; Lisa Rawn, M.S.; Ayumi Shintani, Ph.D., M.P.H.; Shonna Yin, M.D., M.S.
Chronic Disease Management for Adolescents with T2DM
Type 2 diabetes (T2DM) is recognized as a growing problem among adolescents, particularly in minority populations. While T2DM previously represented less than 5% of new diabetes diagnoses in pediatrics, it now accounts for as much as 50% of new diagnoses. The treatment of T2DM in adolescents requires comprehensive care that includes behavioral and pharmacologic interventions. Studies show that approximately 50% of adolescents with chronic problems do not comply with care recommendations. This non-adherence can be exacerbated by patient, provider and system attributes. Addressing patient, provider and system barriers to care are crucial in the development of a successful comprehensive program for the treatment of T2DM in adolescents. This proposal will advance current knowledge about T2DM in adolescents through emphasis on identifying barriers to care, and applying this information to the development and evaluation of a comprehensive intervention to improve adolescent diabetes care. To accomplish these goals I will work with Dr. Robert Dittus, Director of the Vanderbilt Center for Health Services Research, Dr. William Russell, Division Chief of Pediatric Endocrinology, and Dr. David Schlundt, Co-director of the Behavioral Core of the Vanderbilt Diabetes Research and Training Center (DRTC) to further my career development in (1) adolescent diabetes, (2) methods for identifying and measuring psychosocial determinants of adolescent behavior, and (3) designing and evaluating interventions to improve self-management behaviors and treatment adherence in adolescents with T2DM. The specific aims of this research will be to: (1) perform surveys and focus groups to identify patient/parent barriers to care for adolescents with T2DM and strategies for addressing these barriers (2) examine provider and system barriers to proper management of adolescent T2DM, and (3) to use this information to develop and implement a randomized controlled trial of a new comprehensive diabetes management program for adolescents with T2DM. The process and results of this research will provide valuable insights into adolescent diabetes, and will accelerate my future independent investigation in adolescent T2DM. Funded by the National Institute of Diabetes and Digestive and Kidney Diseases Investigators: Russell L. Rothman, M.D., M.P.P. (PI); Shelagh Mulvaney, Ph.D.; David Schlundt, Ph.D.; William E. Russell, M.D.; Robert Dittus, M.D., M.P.H.
Maternal & Infant Effects of Treated and Untreated Depression during Pregnancy
This proposal is in response to a National Institute of Mental Health program announcement on women’s mental health in pregnancy and the postpartum period and addresses several goals of the program by investigating the epidemiology, risk factors, and effects of treatment on depression during pregnancy. Ten to fifteen percent of women experience some degree of depression during pregnancy and these women are at higher risk of depression following childbirth and later in life. Maternal depression during pregnancy may have adverse effect on pregnancy and neonatal outcomes, and on-going maternal depression is known to have adverse effects on parenting and family function. To help determine the best course of treatment for depression among pregnant women, this study will analyze provider, pharmacy, and hospital claims data from the Tennessee Medicaid (TennCare) population from 1994-2003. This large population includes over half of all Tennessee births during the study period. The proposed study makes efficient use of existing data and infrastructure to study the relationship of treated and untreated depression on maternal and infant outcomes, which will help guide both future clinical research and current medical practice. The central hypothesis is that there are no measurable harmful effects of pharmacotherapy for depression during pregnancy with regards to specific pregnancy, perinatal, and depression outcomes. To determine whether women who take antidepressants during pregnancy have increased rates of adverse pregnancy and perinatal outcomes, we will perform a retrospective cohort analysis in otherwise healthy pregnant women to evaluate pregnancy and perinatal outcomes by exposure to specific antidepressant medications. We will perform a second retrospective cohort study of women with recognized depression prior to pregnancy. Women will be classified as exposed or unexposed to antidepressants and we will quantify the risks of adverse pregnancy, perinatal, and depression outcomes by antidepressant treatment status after adjusting for markers of depression severity. The second proposed retrospective cohort is an innovative analysis that will use a subset of the very large population to evaluate the relative risks of treating depression during pregnancy. Results of the proposed analysis will help women and their health care providers decide how to manage depression during pregnancy and guide future research. Understanding the impact of treated and untreated depression during pregnancy is very important to public and maternal health, specifically the well being of the mother, healthy fetal development, and the development of a healthy mother-infant relationship. Funded by the National Institute of Mental Health Investigators: Tina V. Hartert, M.D., M.P.H. (PI)
National Children’s Study
This proposal is offered by the Davidson Partners for Children’s Health, a collaborative formed to seek and facilitate large-scale research that will advance maternal and child health. The Partners include community and academic care providers; all six childbirth facilities in the county; stakeholder organizations; related government offices; and resources such as a media liaison. As a study center we will 1) provide center leadership and senior staff who are experienced researchers skilled at effectively leading large scale enterprises, are trusted in the community, and will have longevity with the study; 2) establish a high-performing study center that can agilely draw on the experience of the entire local organizational structure to efficiently plan, implement, tailor, and launch the Davison study center; 3) serve the National Children´s Study (NCS) leadership and steering committee; assure timely and accurate data transfer and reporting to the NCS-CC; and share lessons-learned with the larger NCS study community; 4) fully integrate expertise and staffing capabilities to deploy an exceptionally well-prepared field operations team for recruitment, household visits, and data and specimen collections; 5) initiate study activities on schedule and precisely implement all aspects of study protocol, including sample evaluation with adjustments as needed to achieve enrollment of 1,000 mother-child dyads; 6) achieve top performance in tracking and retaining participants in follow-up; and 7) dedicate ourselves to participant satisfaction, successful community engraftment, and the highest ethical standards as steward of the national reputation and visibility of the NCS. Funded by the National Institutes of Health Investigators: Katherine E. Hartmann, M.D., Ph.D. (PI); Judy Aschner, M.D.; Shari Barkin, M.D., M.S.H.S.; Gordon Bernard, M.D.; William Blot, Ph.D.; Clarence Creech, M.D., M.P.H.; Robert Dittus, M.D., M.P.H.; Elizabeth Dykens, Ph.D.; Kathryn Edwards, M.D.; Jonathan Gitlin, M.D.; Tina Hartert, M.D., M.P.H.; Elizabeth Heitman, Ph.D.; Lynne Hutchison, B.S.; Howard Jones, M.D.; Yvonne Joosten, M.P.H.; Lynda Lane, R.N.; Melanie Lutenbacher, Ph.D.; Russell Rothman, M.D.; Charles Rush, M.D.; Glynis Sacks, M.D.; David Schlundt, Ph.D.; Martha Shrubsole, Ph.D.; Paul Speer, Ph.D.; Wendy Stone, Ph.D.; Richard Urbano, Ph.D.; Deborah Wage, M.S.N., F.N.P., C.N.M.; Allison Woodworth, Ph.D.
Obesity Prevention in Youth Using Dental Settings
The prevalence of obesity among children in the United States increased 130% between 1970 and 2000. Current estimates indicate that 15.3% of 6 to11 year olds and 15.5% of 12 to 19 year olds are overweight, with even higher rates (23%) among African American and Hispanic adolescents. Control of obesity among youth will require multiple interventions society-wide in order to provide cumulative and synergistic effects that can result in sustained health practices. One step in this approach is to encourage clinicians of all specialties to provide appropriate health promotion advice and counseling to their patients during routine office visits. Dentists and dental hygienists are in a unique position to provide such advice in the context of routine dental care. This seems particularly promising in light of the role of sugar consumption in both dental caries and weight gain. Further, consistent exposure to food advertising, particularly during television viewing, can lead to increased consumption of sugar-sweetened beverages and snacks among children and adolescents. Effective behavioral interventions are needed to reduce these behaviors, and dental offices offer an excellent channel in which to conduct such interventions. The objective of this research is to develop and test the feasibility of a dental office intervention to reduce the consumption of sugar-sweetened beverages and snacks and TV viewing among youth ages 9 to 14. We believe these changes will decrease the risk of dental caries, excessive caloric intake leading to weight gain, and exposure to TV advertisements and messages that encourage the consumption of sugar-sweetened beverages and snacks. The specific aims of this project are to use formative assessment methods including focus groups with youth 9 to14 years of age, parents, and dental professionals (dentists and dental hygienists) to obtain feedback regarding the proposed intervention materials and recruitment and retention strategies. We will then use intervention development methods to develop a repeated contact counseling intervention with dentists and dental hygienists based on Social Cognitive Theory (SCT) and modeled after successful tobacco control interventions conducted in dental offices. Funded by the National Institute of Dental and Craniofacial Research Investigators: Jay H. Fowke, M.P.H., Ph.D. (PI); Ayumi Shintani, M.P.H., Ph.D.; Heidi Silver, M.S., Ph.D.
Weight Gain Prevention in Hispanic Girls
Over the past 30 years obesity has reached epidemic proportions in the United States (Ogden et al, 2006). While this epidemic affects all socioeconomic levels, certain racial/ethnic groups such as Hispanics are disproportionately affected by obesity and diabetes. The age of onset of excess obesity in Hispanic females, formerly young adulthood, is now younger. Childhood obesity poses intermediate and long-term health risks, including: type 2 diabetes, hyperlipidemia, elevated blood pressure and metabolic syndrome. Although biological factors may influence a child´s risk for becoming overweight, the home environment has been shown to be a predisposing and reinforcing contextual factor for unhealthy eating and exercise behaviors. Since parents are the primary transmitters of Hispanic cultural practices and significantly influence their children´s diet and physical activity behaviors from preschool through high school, family-based weight-gain prevention interventions are likely to b. effective. The goal of this implementation study is to contribute to the reduction of racial/ethnic disparities in obesity and risk of type 2 diabetes by tailoring a successful childhood obesity, prevention program originally developed for African American girls, to implement and evaluate with preadolescent Hispanic girls. Funded by the State of Tennessee Investigators: Jay H. Fowke, M.P.H., Ph.D. (PI); Shari Barkin, M.D., M.P.H.; Thomas Cook, B.S.N., M.S.N., F.N.P, Ph.D.; Roger Zoorob, M.D., M.P.H.