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Anorexia nervosa in adolescent patients: What pediatricians need to know
Eating disorders are among the most prevalent, disabling, and potentially fatal psychiatric illnesses, and the COVID-19 pandemic has exacerbated their burden, with a 15.3% increase in incidence in 2020 compared with previous years.1 This increase was almost solely among adolescent girls with anorexia nervosa (AN), which is often insidious in onset and more difficult to treat as it advances. Adolescents with AN are most likely to present to their pediatricians, so awareness and early recognition of the symptoms is critical. Pediatricians are also an integral part of the treatment team in AN and can offer monitoring for serious complications, alongside valuable guidance to parents, who are central to treatment and the reestablishment of healthy eating habits in their children. Here we will review the epidemiology, diagnosis, and treatment of anorexia, with an emphasis on what pediatricians need to know to screen and to facilitate treatment.
Epidemiology
AN is marked by a fear of gaining weight or behaviors that interfere with weight gain and a self-evaluation unduly influenced by weight and body shape. Youth with AN often deny the seriousness of their malnutrition, although that is not required for diagnosis. AN can be of a restrictive or binge-purge subtype, and amenorrhea is no longer a requirement for diagnosis. There is not a specific weight or body mass index cutoff for the diagnosis, but the severity of AN is determined by the BMI percentile normed to age and sex. The average age of onset is 18, and the prepandemic prevalence of AN was about 1% of the population. It affects about 10 times as many females as males. It is quite rare prior to puberty, affecting about 0.01% of that age group. There is a heritable component, with a fivefold relative risk in youth with a parent with AN, and twin studies suggest heritability rates as high as 75%. Youth with rigid cognitive styles appear more vulnerable, as do those who participate in activities such as ballet, gymnastics, modeling, and wrestling because of the role of appearance and weight in performance. More than half of patients with AN will have another psychiatric illness, most commonly anxiety disorders, depression, or obsessive-compulsive disorder. AN becomes chronic in up to 15% of sufferers and the mortality rate is close to 10%, with approximately half dying from medical complications and half dying by suicide.
Screening
Parents and pediatricians are usually the first to notice that a child has started to lose weight or is falling off the growth curve. But weight changes usually emerge after feelings of preoccupation with weight, body shape, and body satisfaction. If parents report escalating pickiness around food, increased or compulsive exercise, persistent self-consciousness and self-criticism around weight and body shape, it is worth starting with screening questions.
If you notice preoccupation or anxiety around being weighed, even if the weight or growth curve are still normal, it is worthwhile to screen. Screening questions, such as the SCOFF questionnaire with five simple questions, can be very sensitive for both AN and bulimia nervosa.2 There are also many validated screening instruments, such as the Eating Disorder Inventory or Eating Attitudes Test (for adolescents) and the Kids Eating Disorder Survey and the Child Eating Attitudes Test (for younger children), that are short self-reports that you can have your patients fill out when you have a higher index of suspicion. Weight loss or growth failure without a preoccupation around weight or appearance needs a thorough a medical workup, and could be a function of other psychiatric problems, such as depression.
If a child screens positive for an eating disorder, your full physical examination, growth curves, and longitudinal growth charts are critical for diagnosis. Percentile BMIs must be used, given the inaccuracy of standard BMI calculations in this age group. (Centers for Disease Control and Prevention age and sex growth charts include methods for this calculation). Laboratory assessment, including metabolic, kidney, pancreatic, and thyroid function, and an EKG can illuminate if there are consequences of restricting or purging. Of course, you want to evaluate for significant medical symptoms, including bradycardia, orthostasis, and hypokalemia. These medical symptoms are not limited to the severely underweight and merit referral to an emergency department and possible medical admission.
Then, a referral to a clinician who is expert in the assessment and treatment of eating disorders is needed. This may be a child psychiatrist, psychologist, or a colleague pediatrician with this specialization. It is also very important to begin the conversation with the family to introduce your concerns, describe what you have noticed, and discuss the need for further assessment and possibly treatment.
Be mindful that discussing this in front of your patient may heighten the patient’s anxiety or distress. Be prepared to offer support and understanding for your patient’s anxiety, while steadfastly providing absolute clarity for the parents about the necessity of further evaluation and treatment. Many parents will be concerned and ready to do whatever is needed to get their child’s eating and growth back on track. But some parents may have more difficulty. They may have their own history with an eating disorder. They may be avoiding a sense of shame or alarm. They may be eager to avoid adding to their child’s stress. They may be tired of engaging in power struggles with the child. They may be proud of their ambitious, accomplished young athlete. Their trust in you makes you uniquely positioned to complicate their thinking. And treatment will hinge on them, so this is a critical bridge to care.
Beyond telling parents that they will need to bring more structure and supervision to mealtimes to begin addressing their child’s nutrition, you might offer guidance on other strategies. Empower parents to limit their child’s use of social media sites such as Instagram, YouTube, and TikTok, where they may be immersed in comparing themselves to idealized (and airbrushed) influencers. Empower them to make their child’s participation in beloved sports contingent on eating meals together and completely or on a stabilized weight (as will be common in treatment). Remind them that there are no bad foods, that the goal is health, and that they are not in a power struggle with their child, but instead allied with their child to treat AN. Remind them to also look for chances to have fun with their child, to help everyone remember what matters.
Treatment
Family-based therapy (FBT) is the first-line treatment of shorter-duration AN in children and adolescents. It focuses on the parents, helping them to calmly and effectively manage their child’s eating behaviors until their weight and behaviors have normalized. As a patient’s nutritional status improves, so does cognitive function, emotional flexibility, and mood. Individual therapy and psychopharmacologic treatment can be very effective for comorbid anxiety, mood, attentional, and thought disorders. Family-based work does include the child and is often done in group-based settings with clinicians from multiple disciplines. Dietitians provide education and guidance about healthy nutrition to the child and parents. Therapists may work with the child, parents, or full family to focus on behavior modification and managing distress. Most academic medical centers provide access to FBT, but there are many regions with no providers of this evidence-based treatment. One of the silver linings of the COVID-19 pandemic is that several online services have emerged offering FBT, working with families to manage mealtimes and treatment entirely at home.3 Pediatricians provide regular medical checks to measure progress and help with decisions about when it is safe to permit exercise or advance privileges and independence around eating. Some pediatricians have discovered a deep interest in this area of pediatrics and built their practices on it. Given the surge in prevalence of AN and the needs for adolescent mental health services, we hope more will do so.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
References
1. Taquet M et al. Br J Psychiatry. 2022;220:262-4.
2. Morgan JF et al. West J Med. 2000 Mar;172(3):164-5.
3. Matheson BE et al. Int J Eat Disord. 2020 Jul;53(7):1142-54.
Eating disorders are among the most prevalent, disabling, and potentially fatal psychiatric illnesses, and the COVID-19 pandemic has exacerbated their burden, with a 15.3% increase in incidence in 2020 compared with previous years.1 This increase was almost solely among adolescent girls with anorexia nervosa (AN), which is often insidious in onset and more difficult to treat as it advances. Adolescents with AN are most likely to present to their pediatricians, so awareness and early recognition of the symptoms is critical. Pediatricians are also an integral part of the treatment team in AN and can offer monitoring for serious complications, alongside valuable guidance to parents, who are central to treatment and the reestablishment of healthy eating habits in their children. Here we will review the epidemiology, diagnosis, and treatment of anorexia, with an emphasis on what pediatricians need to know to screen and to facilitate treatment.
Epidemiology
AN is marked by a fear of gaining weight or behaviors that interfere with weight gain and a self-evaluation unduly influenced by weight and body shape. Youth with AN often deny the seriousness of their malnutrition, although that is not required for diagnosis. AN can be of a restrictive or binge-purge subtype, and amenorrhea is no longer a requirement for diagnosis. There is not a specific weight or body mass index cutoff for the diagnosis, but the severity of AN is determined by the BMI percentile normed to age and sex. The average age of onset is 18, and the prepandemic prevalence of AN was about 1% of the population. It affects about 10 times as many females as males. It is quite rare prior to puberty, affecting about 0.01% of that age group. There is a heritable component, with a fivefold relative risk in youth with a parent with AN, and twin studies suggest heritability rates as high as 75%. Youth with rigid cognitive styles appear more vulnerable, as do those who participate in activities such as ballet, gymnastics, modeling, and wrestling because of the role of appearance and weight in performance. More than half of patients with AN will have another psychiatric illness, most commonly anxiety disorders, depression, or obsessive-compulsive disorder. AN becomes chronic in up to 15% of sufferers and the mortality rate is close to 10%, with approximately half dying from medical complications and half dying by suicide.
Screening
Parents and pediatricians are usually the first to notice that a child has started to lose weight or is falling off the growth curve. But weight changes usually emerge after feelings of preoccupation with weight, body shape, and body satisfaction. If parents report escalating pickiness around food, increased or compulsive exercise, persistent self-consciousness and self-criticism around weight and body shape, it is worth starting with screening questions.
If you notice preoccupation or anxiety around being weighed, even if the weight or growth curve are still normal, it is worthwhile to screen. Screening questions, such as the SCOFF questionnaire with five simple questions, can be very sensitive for both AN and bulimia nervosa.2 There are also many validated screening instruments, such as the Eating Disorder Inventory or Eating Attitudes Test (for adolescents) and the Kids Eating Disorder Survey and the Child Eating Attitudes Test (for younger children), that are short self-reports that you can have your patients fill out when you have a higher index of suspicion. Weight loss or growth failure without a preoccupation around weight or appearance needs a thorough a medical workup, and could be a function of other psychiatric problems, such as depression.
If a child screens positive for an eating disorder, your full physical examination, growth curves, and longitudinal growth charts are critical for diagnosis. Percentile BMIs must be used, given the inaccuracy of standard BMI calculations in this age group. (Centers for Disease Control and Prevention age and sex growth charts include methods for this calculation). Laboratory assessment, including metabolic, kidney, pancreatic, and thyroid function, and an EKG can illuminate if there are consequences of restricting or purging. Of course, you want to evaluate for significant medical symptoms, including bradycardia, orthostasis, and hypokalemia. These medical symptoms are not limited to the severely underweight and merit referral to an emergency department and possible medical admission.
Then, a referral to a clinician who is expert in the assessment and treatment of eating disorders is needed. This may be a child psychiatrist, psychologist, or a colleague pediatrician with this specialization. It is also very important to begin the conversation with the family to introduce your concerns, describe what you have noticed, and discuss the need for further assessment and possibly treatment.
Be mindful that discussing this in front of your patient may heighten the patient’s anxiety or distress. Be prepared to offer support and understanding for your patient’s anxiety, while steadfastly providing absolute clarity for the parents about the necessity of further evaluation and treatment. Many parents will be concerned and ready to do whatever is needed to get their child’s eating and growth back on track. But some parents may have more difficulty. They may have their own history with an eating disorder. They may be avoiding a sense of shame or alarm. They may be eager to avoid adding to their child’s stress. They may be tired of engaging in power struggles with the child. They may be proud of their ambitious, accomplished young athlete. Their trust in you makes you uniquely positioned to complicate their thinking. And treatment will hinge on them, so this is a critical bridge to care.
Beyond telling parents that they will need to bring more structure and supervision to mealtimes to begin addressing their child’s nutrition, you might offer guidance on other strategies. Empower parents to limit their child’s use of social media sites such as Instagram, YouTube, and TikTok, where they may be immersed in comparing themselves to idealized (and airbrushed) influencers. Empower them to make their child’s participation in beloved sports contingent on eating meals together and completely or on a stabilized weight (as will be common in treatment). Remind them that there are no bad foods, that the goal is health, and that they are not in a power struggle with their child, but instead allied with their child to treat AN. Remind them to also look for chances to have fun with their child, to help everyone remember what matters.
Treatment
Family-based therapy (FBT) is the first-line treatment of shorter-duration AN in children and adolescents. It focuses on the parents, helping them to calmly and effectively manage their child’s eating behaviors until their weight and behaviors have normalized. As a patient’s nutritional status improves, so does cognitive function, emotional flexibility, and mood. Individual therapy and psychopharmacologic treatment can be very effective for comorbid anxiety, mood, attentional, and thought disorders. Family-based work does include the child and is often done in group-based settings with clinicians from multiple disciplines. Dietitians provide education and guidance about healthy nutrition to the child and parents. Therapists may work with the child, parents, or full family to focus on behavior modification and managing distress. Most academic medical centers provide access to FBT, but there are many regions with no providers of this evidence-based treatment. One of the silver linings of the COVID-19 pandemic is that several online services have emerged offering FBT, working with families to manage mealtimes and treatment entirely at home.3 Pediatricians provide regular medical checks to measure progress and help with decisions about when it is safe to permit exercise or advance privileges and independence around eating. Some pediatricians have discovered a deep interest in this area of pediatrics and built their practices on it. Given the surge in prevalence of AN and the needs for adolescent mental health services, we hope more will do so.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
References
1. Taquet M et al. Br J Psychiatry. 2022;220:262-4.
2. Morgan JF et al. West J Med. 2000 Mar;172(3):164-5.
3. Matheson BE et al. Int J Eat Disord. 2020 Jul;53(7):1142-54.
Eating disorders are among the most prevalent, disabling, and potentially fatal psychiatric illnesses, and the COVID-19 pandemic has exacerbated their burden, with a 15.3% increase in incidence in 2020 compared with previous years.1 This increase was almost solely among adolescent girls with anorexia nervosa (AN), which is often insidious in onset and more difficult to treat as it advances. Adolescents with AN are most likely to present to their pediatricians, so awareness and early recognition of the symptoms is critical. Pediatricians are also an integral part of the treatment team in AN and can offer monitoring for serious complications, alongside valuable guidance to parents, who are central to treatment and the reestablishment of healthy eating habits in their children. Here we will review the epidemiology, diagnosis, and treatment of anorexia, with an emphasis on what pediatricians need to know to screen and to facilitate treatment.
Epidemiology
AN is marked by a fear of gaining weight or behaviors that interfere with weight gain and a self-evaluation unduly influenced by weight and body shape. Youth with AN often deny the seriousness of their malnutrition, although that is not required for diagnosis. AN can be of a restrictive or binge-purge subtype, and amenorrhea is no longer a requirement for diagnosis. There is not a specific weight or body mass index cutoff for the diagnosis, but the severity of AN is determined by the BMI percentile normed to age and sex. The average age of onset is 18, and the prepandemic prevalence of AN was about 1% of the population. It affects about 10 times as many females as males. It is quite rare prior to puberty, affecting about 0.01% of that age group. There is a heritable component, with a fivefold relative risk in youth with a parent with AN, and twin studies suggest heritability rates as high as 75%. Youth with rigid cognitive styles appear more vulnerable, as do those who participate in activities such as ballet, gymnastics, modeling, and wrestling because of the role of appearance and weight in performance. More than half of patients with AN will have another psychiatric illness, most commonly anxiety disorders, depression, or obsessive-compulsive disorder. AN becomes chronic in up to 15% of sufferers and the mortality rate is close to 10%, with approximately half dying from medical complications and half dying by suicide.
Screening
Parents and pediatricians are usually the first to notice that a child has started to lose weight or is falling off the growth curve. But weight changes usually emerge after feelings of preoccupation with weight, body shape, and body satisfaction. If parents report escalating pickiness around food, increased or compulsive exercise, persistent self-consciousness and self-criticism around weight and body shape, it is worth starting with screening questions.
If you notice preoccupation or anxiety around being weighed, even if the weight or growth curve are still normal, it is worthwhile to screen. Screening questions, such as the SCOFF questionnaire with five simple questions, can be very sensitive for both AN and bulimia nervosa.2 There are also many validated screening instruments, such as the Eating Disorder Inventory or Eating Attitudes Test (for adolescents) and the Kids Eating Disorder Survey and the Child Eating Attitudes Test (for younger children), that are short self-reports that you can have your patients fill out when you have a higher index of suspicion. Weight loss or growth failure without a preoccupation around weight or appearance needs a thorough a medical workup, and could be a function of other psychiatric problems, such as depression.
If a child screens positive for an eating disorder, your full physical examination, growth curves, and longitudinal growth charts are critical for diagnosis. Percentile BMIs must be used, given the inaccuracy of standard BMI calculations in this age group. (Centers for Disease Control and Prevention age and sex growth charts include methods for this calculation). Laboratory assessment, including metabolic, kidney, pancreatic, and thyroid function, and an EKG can illuminate if there are consequences of restricting or purging. Of course, you want to evaluate for significant medical symptoms, including bradycardia, orthostasis, and hypokalemia. These medical symptoms are not limited to the severely underweight and merit referral to an emergency department and possible medical admission.
Then, a referral to a clinician who is expert in the assessment and treatment of eating disorders is needed. This may be a child psychiatrist, psychologist, or a colleague pediatrician with this specialization. It is also very important to begin the conversation with the family to introduce your concerns, describe what you have noticed, and discuss the need for further assessment and possibly treatment.
Be mindful that discussing this in front of your patient may heighten the patient’s anxiety or distress. Be prepared to offer support and understanding for your patient’s anxiety, while steadfastly providing absolute clarity for the parents about the necessity of further evaluation and treatment. Many parents will be concerned and ready to do whatever is needed to get their child’s eating and growth back on track. But some parents may have more difficulty. They may have their own history with an eating disorder. They may be avoiding a sense of shame or alarm. They may be eager to avoid adding to their child’s stress. They may be tired of engaging in power struggles with the child. They may be proud of their ambitious, accomplished young athlete. Their trust in you makes you uniquely positioned to complicate their thinking. And treatment will hinge on them, so this is a critical bridge to care.
Beyond telling parents that they will need to bring more structure and supervision to mealtimes to begin addressing their child’s nutrition, you might offer guidance on other strategies. Empower parents to limit their child’s use of social media sites such as Instagram, YouTube, and TikTok, where they may be immersed in comparing themselves to idealized (and airbrushed) influencers. Empower them to make their child’s participation in beloved sports contingent on eating meals together and completely or on a stabilized weight (as will be common in treatment). Remind them that there are no bad foods, that the goal is health, and that they are not in a power struggle with their child, but instead allied with their child to treat AN. Remind them to also look for chances to have fun with their child, to help everyone remember what matters.
Treatment
Family-based therapy (FBT) is the first-line treatment of shorter-duration AN in children and adolescents. It focuses on the parents, helping them to calmly and effectively manage their child’s eating behaviors until their weight and behaviors have normalized. As a patient’s nutritional status improves, so does cognitive function, emotional flexibility, and mood. Individual therapy and psychopharmacologic treatment can be very effective for comorbid anxiety, mood, attentional, and thought disorders. Family-based work does include the child and is often done in group-based settings with clinicians from multiple disciplines. Dietitians provide education and guidance about healthy nutrition to the child and parents. Therapists may work with the child, parents, or full family to focus on behavior modification and managing distress. Most academic medical centers provide access to FBT, but there are many regions with no providers of this evidence-based treatment. One of the silver linings of the COVID-19 pandemic is that several online services have emerged offering FBT, working with families to manage mealtimes and treatment entirely at home.3 Pediatricians provide regular medical checks to measure progress and help with decisions about when it is safe to permit exercise or advance privileges and independence around eating. Some pediatricians have discovered a deep interest in this area of pediatrics and built their practices on it. Given the surge in prevalence of AN and the needs for adolescent mental health services, we hope more will do so.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
References
1. Taquet M et al. Br J Psychiatry. 2022;220:262-4.
2. Morgan JF et al. West J Med. 2000 Mar;172(3):164-5.
3. Matheson BE et al. Int J Eat Disord. 2020 Jul;53(7):1142-54.
One in four obese teens don’t know they’re obese
New research from 10 countries around the globe, including 1,164 participants from the United Kingdom, presented at this year’s European Congress on Obesity shows that nearly one-quarter (24%) of adolescents living with obesity (ALwO) do not know they have obesity.
“The impact of obesity – in children and adults – on individuals, society, and our health care systems should not be underestimated,” said lead author Professor Jason C.G. Halford, PhD, C.Psychol, AFBPS, head of the school of psychology, University of Leeds (England), and president of the European Association for the Study of Obesity.
The new findings come from the ACTION teens global survey study, a quantitative survey-based study that collected data in 10 countries (Australia, Colombia, Italy, Korea, Mexico, Saudi Arabia, Spain, Taiwan, Turkey, and the United Kingdom) and included ALwO, their caregivers, and health care professionals (HCPs) who had direct, recent experience of clinical obesity management in adolescents.
Included in the survey were:
- 5,275 ALwO aged 12-17 years with current body mass index–for-age (based on self-reported sex, age, height, and weight) in the top 5% (≥95th percentile) for age and sex.
- 5,389 caregivers aged 25 years and over, who were the parent or legal guardian of an ALwO who lived in the same household at least 50% of the time and were involved in their ALwO’s health care decisions.
- 2,323 HCP, primary care physicians, pediatricians, or other specialists, who had been in clinical practice for at least 2 years, spent at least 50% of their time in direct patient care, and treated at least 10 ALwO in a typical month
An online panel, telephone calls, and in-person meetings were utilized to survey participants on a wide range of topics, including attitudes towards obesity and its impact, number of weight-loss attempts, and motivations/barriers to weight loss.
Many believe losing weight is their sole responsibility
The authors reported that around 9 out of 10 (89%) HCPs indicated that obesity has a strong impact on a person’s overall health and wellbeing. Fewer ALwO and caregivers, however, had similar views about this (72% and 67% respectively). In addition, the authors said that “most participants thought obesity was at least as, or more, impactful than heart disease, cancer, or diabetes.”
Despite many ALwO not recognizing being obese, most surveyed (85%) were worried about the impact of their weight on their future health, with two-thirds (65%) feeling it was their sole responsibility to deal with their excess weight. This compared to 37% of caregivers and around one in four HCPs (27%) feeling that losing weight was solely the ALwO’s responsibility.
Study coauthor Vicki Mooney, chairwoman of the Irish Coalition for People Living with Obesity and executive director of the European Coalition for People living with Obesity, said: “It is hard to fathom the pressure for these teenagers, especially as two-thirds believe it is their sole responsibility to lose weight, with many of their parents/caregivers struggling to know how to best care for their child.”
Teenagers unable to speak to parents about losing weight
Many ALwO said they struggled to talk to those closest to them about their weight, with 1 in 3 saying they couldn’t talk to either parent about their weight, and alarmingly 1 in 10 feeling they couldn’t talk to anyone about their weight. However, around one in three could talk to their doctor, and 74% said that they trusted the advice of a HCP about weight management.
Ms. Mooney said: “The results show us teenagers want to lose weight and improve their health, however, one in three teenagers feel unable to speak to their parents about it and many revert to social media for guidance.”
When it came to sources of information YouTube (34%), social media (28%), family and friends (25%), search engines (25%), and doctors (24%) were the most popular.
Motivation, barriers, and attempts
Weight-loss attempts by ALwO appeared to be underestimated by HCPs, the authors explained, while caregivers tended to underestimate both the impact of obesity on health and wellbeing, and ALwO’s weight-loss attempts.
Efforts had been made to try and lose weight in the past year by more than half (58%) of ALwO, with three-quarters (75%) being somewhat/very likely to attempt to lose weight in the next 6 months. However, fewer (41%) caregivers reported that their ‘linked’ ALwO attempted weight loss over the past year or that their ALwO was somewhat/very likely (63%) to attempt to lose weight in the next 6 months. Amongst HCPs, only about two out of five (38%) responded that their ALwO patients had made a serious weight loss attempt in the past year.
Motivation is a key component of successful weight reduction and wanting to be more fit/in better shape (40%), not being happy with their weight (37%), and wanting to feel more confident (35%) were the most common motivators for ALwO, and also the most common motivators reported by caregivers for their ALwO. For HCPs, though, things were somewhat different, with the top three motivators they reported for ALwO to lose weight were wanting the have more confidence/self-esteem (69%), improved social life and popularity (69%), and wanting to look like peers their age (65%).
The top three barriers to losing weight reported by ALwO and by caregivers for their ALwO were not being able to control hunger (38%), lack of motivation (34%), and enjoying eating unhealthy food (32%). For HCPs, the top three barriers they reported for ALwO losing weight were unhealthy eating habits (93%), lack of exercise (92%), and enjoying eating unhealthy food (91%).
“Key motivations and barriers for weight loss were not aligned between ALwO and HCPs,” said the authors. They pointed out that these disconnects may “negatively impact the level of support and effectiveness” of obesity care ALwO receive from caregivers and HCPs.
Prof. Halford said: “There is urgent need for governments and society to recognize and treat obesity as a disease, so that more teens can get the right support to help them live happier and healthier lives.”
The conference posters have yet to be published in a journal but were peer reviewed by the ECO selection committee.
The studies were sponsored by Novo Nordisk A/S.
A version of this article first appeared on Univadis.
New research from 10 countries around the globe, including 1,164 participants from the United Kingdom, presented at this year’s European Congress on Obesity shows that nearly one-quarter (24%) of adolescents living with obesity (ALwO) do not know they have obesity.
“The impact of obesity – in children and adults – on individuals, society, and our health care systems should not be underestimated,” said lead author Professor Jason C.G. Halford, PhD, C.Psychol, AFBPS, head of the school of psychology, University of Leeds (England), and president of the European Association for the Study of Obesity.
The new findings come from the ACTION teens global survey study, a quantitative survey-based study that collected data in 10 countries (Australia, Colombia, Italy, Korea, Mexico, Saudi Arabia, Spain, Taiwan, Turkey, and the United Kingdom) and included ALwO, their caregivers, and health care professionals (HCPs) who had direct, recent experience of clinical obesity management in adolescents.
Included in the survey were:
- 5,275 ALwO aged 12-17 years with current body mass index–for-age (based on self-reported sex, age, height, and weight) in the top 5% (≥95th percentile) for age and sex.
- 5,389 caregivers aged 25 years and over, who were the parent or legal guardian of an ALwO who lived in the same household at least 50% of the time and were involved in their ALwO’s health care decisions.
- 2,323 HCP, primary care physicians, pediatricians, or other specialists, who had been in clinical practice for at least 2 years, spent at least 50% of their time in direct patient care, and treated at least 10 ALwO in a typical month
An online panel, telephone calls, and in-person meetings were utilized to survey participants on a wide range of topics, including attitudes towards obesity and its impact, number of weight-loss attempts, and motivations/barriers to weight loss.
Many believe losing weight is their sole responsibility
The authors reported that around 9 out of 10 (89%) HCPs indicated that obesity has a strong impact on a person’s overall health and wellbeing. Fewer ALwO and caregivers, however, had similar views about this (72% and 67% respectively). In addition, the authors said that “most participants thought obesity was at least as, or more, impactful than heart disease, cancer, or diabetes.”
Despite many ALwO not recognizing being obese, most surveyed (85%) were worried about the impact of their weight on their future health, with two-thirds (65%) feeling it was their sole responsibility to deal with their excess weight. This compared to 37% of caregivers and around one in four HCPs (27%) feeling that losing weight was solely the ALwO’s responsibility.
Study coauthor Vicki Mooney, chairwoman of the Irish Coalition for People Living with Obesity and executive director of the European Coalition for People living with Obesity, said: “It is hard to fathom the pressure for these teenagers, especially as two-thirds believe it is their sole responsibility to lose weight, with many of their parents/caregivers struggling to know how to best care for their child.”
Teenagers unable to speak to parents about losing weight
Many ALwO said they struggled to talk to those closest to them about their weight, with 1 in 3 saying they couldn’t talk to either parent about their weight, and alarmingly 1 in 10 feeling they couldn’t talk to anyone about their weight. However, around one in three could talk to their doctor, and 74% said that they trusted the advice of a HCP about weight management.
Ms. Mooney said: “The results show us teenagers want to lose weight and improve their health, however, one in three teenagers feel unable to speak to their parents about it and many revert to social media for guidance.”
When it came to sources of information YouTube (34%), social media (28%), family and friends (25%), search engines (25%), and doctors (24%) were the most popular.
Motivation, barriers, and attempts
Weight-loss attempts by ALwO appeared to be underestimated by HCPs, the authors explained, while caregivers tended to underestimate both the impact of obesity on health and wellbeing, and ALwO’s weight-loss attempts.
Efforts had been made to try and lose weight in the past year by more than half (58%) of ALwO, with three-quarters (75%) being somewhat/very likely to attempt to lose weight in the next 6 months. However, fewer (41%) caregivers reported that their ‘linked’ ALwO attempted weight loss over the past year or that their ALwO was somewhat/very likely (63%) to attempt to lose weight in the next 6 months. Amongst HCPs, only about two out of five (38%) responded that their ALwO patients had made a serious weight loss attempt in the past year.
Motivation is a key component of successful weight reduction and wanting to be more fit/in better shape (40%), not being happy with their weight (37%), and wanting to feel more confident (35%) were the most common motivators for ALwO, and also the most common motivators reported by caregivers for their ALwO. For HCPs, though, things were somewhat different, with the top three motivators they reported for ALwO to lose weight were wanting the have more confidence/self-esteem (69%), improved social life and popularity (69%), and wanting to look like peers their age (65%).
The top three barriers to losing weight reported by ALwO and by caregivers for their ALwO were not being able to control hunger (38%), lack of motivation (34%), and enjoying eating unhealthy food (32%). For HCPs, the top three barriers they reported for ALwO losing weight were unhealthy eating habits (93%), lack of exercise (92%), and enjoying eating unhealthy food (91%).
“Key motivations and barriers for weight loss were not aligned between ALwO and HCPs,” said the authors. They pointed out that these disconnects may “negatively impact the level of support and effectiveness” of obesity care ALwO receive from caregivers and HCPs.
Prof. Halford said: “There is urgent need for governments and society to recognize and treat obesity as a disease, so that more teens can get the right support to help them live happier and healthier lives.”
The conference posters have yet to be published in a journal but were peer reviewed by the ECO selection committee.
The studies were sponsored by Novo Nordisk A/S.
A version of this article first appeared on Univadis.
New research from 10 countries around the globe, including 1,164 participants from the United Kingdom, presented at this year’s European Congress on Obesity shows that nearly one-quarter (24%) of adolescents living with obesity (ALwO) do not know they have obesity.
“The impact of obesity – in children and adults – on individuals, society, and our health care systems should not be underestimated,” said lead author Professor Jason C.G. Halford, PhD, C.Psychol, AFBPS, head of the school of psychology, University of Leeds (England), and president of the European Association for the Study of Obesity.
The new findings come from the ACTION teens global survey study, a quantitative survey-based study that collected data in 10 countries (Australia, Colombia, Italy, Korea, Mexico, Saudi Arabia, Spain, Taiwan, Turkey, and the United Kingdom) and included ALwO, their caregivers, and health care professionals (HCPs) who had direct, recent experience of clinical obesity management in adolescents.
Included in the survey were:
- 5,275 ALwO aged 12-17 years with current body mass index–for-age (based on self-reported sex, age, height, and weight) in the top 5% (≥95th percentile) for age and sex.
- 5,389 caregivers aged 25 years and over, who were the parent or legal guardian of an ALwO who lived in the same household at least 50% of the time and were involved in their ALwO’s health care decisions.
- 2,323 HCP, primary care physicians, pediatricians, or other specialists, who had been in clinical practice for at least 2 years, spent at least 50% of their time in direct patient care, and treated at least 10 ALwO in a typical month
An online panel, telephone calls, and in-person meetings were utilized to survey participants on a wide range of topics, including attitudes towards obesity and its impact, number of weight-loss attempts, and motivations/barriers to weight loss.
Many believe losing weight is their sole responsibility
The authors reported that around 9 out of 10 (89%) HCPs indicated that obesity has a strong impact on a person’s overall health and wellbeing. Fewer ALwO and caregivers, however, had similar views about this (72% and 67% respectively). In addition, the authors said that “most participants thought obesity was at least as, or more, impactful than heart disease, cancer, or diabetes.”
Despite many ALwO not recognizing being obese, most surveyed (85%) were worried about the impact of their weight on their future health, with two-thirds (65%) feeling it was their sole responsibility to deal with their excess weight. This compared to 37% of caregivers and around one in four HCPs (27%) feeling that losing weight was solely the ALwO’s responsibility.
Study coauthor Vicki Mooney, chairwoman of the Irish Coalition for People Living with Obesity and executive director of the European Coalition for People living with Obesity, said: “It is hard to fathom the pressure for these teenagers, especially as two-thirds believe it is their sole responsibility to lose weight, with many of their parents/caregivers struggling to know how to best care for their child.”
Teenagers unable to speak to parents about losing weight
Many ALwO said they struggled to talk to those closest to them about their weight, with 1 in 3 saying they couldn’t talk to either parent about their weight, and alarmingly 1 in 10 feeling they couldn’t talk to anyone about their weight. However, around one in three could talk to their doctor, and 74% said that they trusted the advice of a HCP about weight management.
Ms. Mooney said: “The results show us teenagers want to lose weight and improve their health, however, one in three teenagers feel unable to speak to their parents about it and many revert to social media for guidance.”
When it came to sources of information YouTube (34%), social media (28%), family and friends (25%), search engines (25%), and doctors (24%) were the most popular.
Motivation, barriers, and attempts
Weight-loss attempts by ALwO appeared to be underestimated by HCPs, the authors explained, while caregivers tended to underestimate both the impact of obesity on health and wellbeing, and ALwO’s weight-loss attempts.
Efforts had been made to try and lose weight in the past year by more than half (58%) of ALwO, with three-quarters (75%) being somewhat/very likely to attempt to lose weight in the next 6 months. However, fewer (41%) caregivers reported that their ‘linked’ ALwO attempted weight loss over the past year or that their ALwO was somewhat/very likely (63%) to attempt to lose weight in the next 6 months. Amongst HCPs, only about two out of five (38%) responded that their ALwO patients had made a serious weight loss attempt in the past year.
Motivation is a key component of successful weight reduction and wanting to be more fit/in better shape (40%), not being happy with their weight (37%), and wanting to feel more confident (35%) were the most common motivators for ALwO, and also the most common motivators reported by caregivers for their ALwO. For HCPs, though, things were somewhat different, with the top three motivators they reported for ALwO to lose weight were wanting the have more confidence/self-esteem (69%), improved social life and popularity (69%), and wanting to look like peers their age (65%).
The top three barriers to losing weight reported by ALwO and by caregivers for their ALwO were not being able to control hunger (38%), lack of motivation (34%), and enjoying eating unhealthy food (32%). For HCPs, the top three barriers they reported for ALwO losing weight were unhealthy eating habits (93%), lack of exercise (92%), and enjoying eating unhealthy food (91%).
“Key motivations and barriers for weight loss were not aligned between ALwO and HCPs,” said the authors. They pointed out that these disconnects may “negatively impact the level of support and effectiveness” of obesity care ALwO receive from caregivers and HCPs.
Prof. Halford said: “There is urgent need for governments and society to recognize and treat obesity as a disease, so that more teens can get the right support to help them live happier and healthier lives.”
The conference posters have yet to be published in a journal but were peer reviewed by the ECO selection committee.
The studies were sponsored by Novo Nordisk A/S.
A version of this article first appeared on Univadis.
Most at-home STI testing kits fail to meet young people’s needs
The wide majority of at-home sexually transmitted infection testing kits in the United States appear to be limited to use by adults, a new study finds, and many have limitations that make them less than ideal for young people to use.
While at-home kits do allow more access to STI testing, “we need to create programs that are specific for youth because they have extra needs,” said lead author Saumya Sao, a research assistant at the department of gynecology & obstetrics at Johns Hopkins University, Baltimore, in an interview. “The only platform that did meet our needs was the program that we developed specifically.”
The findings were released ahead of the study’s scheduled presentation at the 2022 annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists (Session A117).
According to Ms. Sao, companies began to offer more at-home testing kits during the pandemic as in-person STI clinics shut down. Still, “the fact that we only found 13 self-collect mail-in STI programs shows you that this is pretty new,” she said. “There are not too many companies that do it. We found a lot more platforms that allow users to place orders for testing online, but you’re still required to go into a lab and actually do the testing.”
The researchers gathered information about 13 programs, including the one that they developed at Johns Hopkins known as Violet. Of those, seven limited testing to adults aged 18 and up, and one didn’t list an age requirement. The rest had some age requirements (such as 14 and up) or no age requirements.
The lack of full access for teens is problematic, Ms. Sao said. According to the study, “access to testing among young people is especially important because youth (ages 13-24) bear a disproportionate burden of sexually transmitted infection, accounting for 50% of cases but only 25% of the sexually active population.”
Research has suggested that young people are often wary of visiting STI clinics because they fear stigma from medical professionals or worry about being seen there, Ms. Sao said.
Tests are free in only three of the programs analyzed in the new study. Among the other programs, tests for Chlamydia trachomatis and Neisseria gonorrhoeae cost $45-$179; only two accepted insurance. “These out-of-pocket costs are really high in regard to what a young person might be able to afford for testing, especially if they would need to do repeat testing between partners, or 3 months after testing positive,” Ms. Sao said.
Most of the programs will link users to medical professionals if they test positive. This is a key feature, Ms. Sao said, in order to make sure young people have support.
As for location, most of the programs – including all those that offer free testing – are limited to certain states. Planned Parenthood, for example, only offers at-home STI testing in Maine, New Hampshire, and Vermont. The program charges patients on a sliding scale, accepts insurance, and is available for ages 14 and up. It connects users who test positive to physicians.
Another free program, TakeMeHome, is restricted to 16 states. It includes an HIV panel for ages 17+ (although it doesn’t have vaginal swab testing). It recommends that patients who are positive consult a doctor.
The researchers also found that some, but not all, of the programs send testing material in discreet packaging. This is important to young people because they may not want their parents to know that they’re getting tested.
Some of the testing programs analyzed don’t make it clear on their web sites whether their packaging is discreet, Ms. Sao said.
At Johns Hopkins, Ms. Sao has helped develop the Violet Project, which is designed to meet the needs of young people and offers free STI testing to residents of Maryland of any age for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Mailing packages are discreet, and physicians reach out to those who test positive. Fees are covered.
“We don’t have money yet to expand beyond Maryland, but we’re hopeful,” she said.
In an interview, Loma Linda (Calif.) University Health maternal-fetal medicine specialist Sarah Smithson, DO, MS, praised the study and said she supports optimizing at-home testing for young people. It may be useful for youths who first get tested in a clinic but then need follow-up testing or testing of their partners, she said.
Dr. Smithson added that transportation is often a challenge for young people. At her pregnancy clinic in California’s Inland Empire, she said, some patients live in remote areas and make virtual doctor visits because of the distance. STI testing is crucial for pregnant women, she said, “and this could be a game changer for them.”
The wide majority of at-home sexually transmitted infection testing kits in the United States appear to be limited to use by adults, a new study finds, and many have limitations that make them less than ideal for young people to use.
While at-home kits do allow more access to STI testing, “we need to create programs that are specific for youth because they have extra needs,” said lead author Saumya Sao, a research assistant at the department of gynecology & obstetrics at Johns Hopkins University, Baltimore, in an interview. “The only platform that did meet our needs was the program that we developed specifically.”
The findings were released ahead of the study’s scheduled presentation at the 2022 annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists (Session A117).
According to Ms. Sao, companies began to offer more at-home testing kits during the pandemic as in-person STI clinics shut down. Still, “the fact that we only found 13 self-collect mail-in STI programs shows you that this is pretty new,” she said. “There are not too many companies that do it. We found a lot more platforms that allow users to place orders for testing online, but you’re still required to go into a lab and actually do the testing.”
The researchers gathered information about 13 programs, including the one that they developed at Johns Hopkins known as Violet. Of those, seven limited testing to adults aged 18 and up, and one didn’t list an age requirement. The rest had some age requirements (such as 14 and up) or no age requirements.
The lack of full access for teens is problematic, Ms. Sao said. According to the study, “access to testing among young people is especially important because youth (ages 13-24) bear a disproportionate burden of sexually transmitted infection, accounting for 50% of cases but only 25% of the sexually active population.”
Research has suggested that young people are often wary of visiting STI clinics because they fear stigma from medical professionals or worry about being seen there, Ms. Sao said.
Tests are free in only three of the programs analyzed in the new study. Among the other programs, tests for Chlamydia trachomatis and Neisseria gonorrhoeae cost $45-$179; only two accepted insurance. “These out-of-pocket costs are really high in regard to what a young person might be able to afford for testing, especially if they would need to do repeat testing between partners, or 3 months after testing positive,” Ms. Sao said.
Most of the programs will link users to medical professionals if they test positive. This is a key feature, Ms. Sao said, in order to make sure young people have support.
As for location, most of the programs – including all those that offer free testing – are limited to certain states. Planned Parenthood, for example, only offers at-home STI testing in Maine, New Hampshire, and Vermont. The program charges patients on a sliding scale, accepts insurance, and is available for ages 14 and up. It connects users who test positive to physicians.
Another free program, TakeMeHome, is restricted to 16 states. It includes an HIV panel for ages 17+ (although it doesn’t have vaginal swab testing). It recommends that patients who are positive consult a doctor.
The researchers also found that some, but not all, of the programs send testing material in discreet packaging. This is important to young people because they may not want their parents to know that they’re getting tested.
Some of the testing programs analyzed don’t make it clear on their web sites whether their packaging is discreet, Ms. Sao said.
At Johns Hopkins, Ms. Sao has helped develop the Violet Project, which is designed to meet the needs of young people and offers free STI testing to residents of Maryland of any age for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Mailing packages are discreet, and physicians reach out to those who test positive. Fees are covered.
“We don’t have money yet to expand beyond Maryland, but we’re hopeful,” she said.
In an interview, Loma Linda (Calif.) University Health maternal-fetal medicine specialist Sarah Smithson, DO, MS, praised the study and said she supports optimizing at-home testing for young people. It may be useful for youths who first get tested in a clinic but then need follow-up testing or testing of their partners, she said.
Dr. Smithson added that transportation is often a challenge for young people. At her pregnancy clinic in California’s Inland Empire, she said, some patients live in remote areas and make virtual doctor visits because of the distance. STI testing is crucial for pregnant women, she said, “and this could be a game changer for them.”
The wide majority of at-home sexually transmitted infection testing kits in the United States appear to be limited to use by adults, a new study finds, and many have limitations that make them less than ideal for young people to use.
While at-home kits do allow more access to STI testing, “we need to create programs that are specific for youth because they have extra needs,” said lead author Saumya Sao, a research assistant at the department of gynecology & obstetrics at Johns Hopkins University, Baltimore, in an interview. “The only platform that did meet our needs was the program that we developed specifically.”
The findings were released ahead of the study’s scheduled presentation at the 2022 annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists (Session A117).
According to Ms. Sao, companies began to offer more at-home testing kits during the pandemic as in-person STI clinics shut down. Still, “the fact that we only found 13 self-collect mail-in STI programs shows you that this is pretty new,” she said. “There are not too many companies that do it. We found a lot more platforms that allow users to place orders for testing online, but you’re still required to go into a lab and actually do the testing.”
The researchers gathered information about 13 programs, including the one that they developed at Johns Hopkins known as Violet. Of those, seven limited testing to adults aged 18 and up, and one didn’t list an age requirement. The rest had some age requirements (such as 14 and up) or no age requirements.
The lack of full access for teens is problematic, Ms. Sao said. According to the study, “access to testing among young people is especially important because youth (ages 13-24) bear a disproportionate burden of sexually transmitted infection, accounting for 50% of cases but only 25% of the sexually active population.”
Research has suggested that young people are often wary of visiting STI clinics because they fear stigma from medical professionals or worry about being seen there, Ms. Sao said.
Tests are free in only three of the programs analyzed in the new study. Among the other programs, tests for Chlamydia trachomatis and Neisseria gonorrhoeae cost $45-$179; only two accepted insurance. “These out-of-pocket costs are really high in regard to what a young person might be able to afford for testing, especially if they would need to do repeat testing between partners, or 3 months after testing positive,” Ms. Sao said.
Most of the programs will link users to medical professionals if they test positive. This is a key feature, Ms. Sao said, in order to make sure young people have support.
As for location, most of the programs – including all those that offer free testing – are limited to certain states. Planned Parenthood, for example, only offers at-home STI testing in Maine, New Hampshire, and Vermont. The program charges patients on a sliding scale, accepts insurance, and is available for ages 14 and up. It connects users who test positive to physicians.
Another free program, TakeMeHome, is restricted to 16 states. It includes an HIV panel for ages 17+ (although it doesn’t have vaginal swab testing). It recommends that patients who are positive consult a doctor.
The researchers also found that some, but not all, of the programs send testing material in discreet packaging. This is important to young people because they may not want their parents to know that they’re getting tested.
Some of the testing programs analyzed don’t make it clear on their web sites whether their packaging is discreet, Ms. Sao said.
At Johns Hopkins, Ms. Sao has helped develop the Violet Project, which is designed to meet the needs of young people and offers free STI testing to residents of Maryland of any age for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Mailing packages are discreet, and physicians reach out to those who test positive. Fees are covered.
“We don’t have money yet to expand beyond Maryland, but we’re hopeful,” she said.
In an interview, Loma Linda (Calif.) University Health maternal-fetal medicine specialist Sarah Smithson, DO, MS, praised the study and said she supports optimizing at-home testing for young people. It may be useful for youths who first get tested in a clinic but then need follow-up testing or testing of their partners, she said.
Dr. Smithson added that transportation is often a challenge for young people. At her pregnancy clinic in California’s Inland Empire, she said, some patients live in remote areas and make virtual doctor visits because of the distance. STI testing is crucial for pregnant women, she said, “and this could be a game changer for them.”
FROM ACOG 2022
Supreme Court appears ready to overturn Roe
to the news outlet Politico.
The draft opinion, written by Justice Samuel Alito, outlines ways a presumed majority of the nine justices believes the 1973 ruling in Roe v. Wade was incorrect. If signed by a majority of the court, the ruling would eliminate the protections for abortion rights that Roe provided and give the 50 states the power to legislate abortion.
“We hold that Roe and Casey must be overruled,” Justice Alito writes in the draft. “It is time to heed the Constitution and return the issue of abortion to the people’s elected representatives.”
While a final ruling was not expected from the court until June, the leaked draft – a nearly unprecedented breach of the court’s internal workings – gives a strong signal of the court’s five most conservative members’ decisions. During oral arguments in the case in December, conservative justices appeared prepared to undo at least part of the country’s abortion protections.
President Joe Biden said his administration was already preparing for a potential ruling that struck down federal abortion protections.
The White House, he said in a statement, is working on a “response to the continued attack on abortion and reproductive rights, under a variety of possible outcomes in the cases pending before the Supreme Court. We will be ready when any ruling is issued.”
But if the draft opinion becomes final, he said the fight will move to the states.
“It will fall on our nation’s elected officials at all levels of government to protect a woman’s right to choose,” he said. “And it will fall on voters to elect pro-choice officials this November.”
With more pro-abortion rights members of Congress, it would be possible to pass federal legislation protecting abortion rights, “which I will work to pass and sign into law.”
Should the Alito draft become law, its first impact would be to allow a Mississippi law that bans abortions after 15 weeks to take effect.
But quickly after that, abortions would become illegal in many states. Several conservative-leaning states, mostly in the South and Midwest, have already passed laws severely restricting abortions well beyond what Roe allowed. Should Roe be overturned then, those laws would take effect without the threat of lengthy lawsuits or rulings from lower-court judges who have blocked them.
Nearly half of the states, mostly in the Northeast and West, would likely allow abortion to continue in some way. In fact, several states, including Colorado and Vermont, have already passed laws granting the right to an abortion into state law.
The leaked draft, however, is still a draft, meaning it remains possible Roe survives. Anthony Kreis, PhD, a professor of law at Georgia State University, says that could have been the point of whoever leaked the draft.
“It suggests to me that whoever leaked it knew that public outrage was the last resort to stopping the court from overturning Roe v. Wade and letting states ban all abortions,” Dr. Kreis said. “The danger that abortions won’t be legal in most of the country is very real.”
A version of this article first appeared on WebMD.com.
This article was updated 5/3/22.
to the news outlet Politico.
The draft opinion, written by Justice Samuel Alito, outlines ways a presumed majority of the nine justices believes the 1973 ruling in Roe v. Wade was incorrect. If signed by a majority of the court, the ruling would eliminate the protections for abortion rights that Roe provided and give the 50 states the power to legislate abortion.
“We hold that Roe and Casey must be overruled,” Justice Alito writes in the draft. “It is time to heed the Constitution and return the issue of abortion to the people’s elected representatives.”
While a final ruling was not expected from the court until June, the leaked draft – a nearly unprecedented breach of the court’s internal workings – gives a strong signal of the court’s five most conservative members’ decisions. During oral arguments in the case in December, conservative justices appeared prepared to undo at least part of the country’s abortion protections.
President Joe Biden said his administration was already preparing for a potential ruling that struck down federal abortion protections.
The White House, he said in a statement, is working on a “response to the continued attack on abortion and reproductive rights, under a variety of possible outcomes in the cases pending before the Supreme Court. We will be ready when any ruling is issued.”
But if the draft opinion becomes final, he said the fight will move to the states.
“It will fall on our nation’s elected officials at all levels of government to protect a woman’s right to choose,” he said. “And it will fall on voters to elect pro-choice officials this November.”
With more pro-abortion rights members of Congress, it would be possible to pass federal legislation protecting abortion rights, “which I will work to pass and sign into law.”
Should the Alito draft become law, its first impact would be to allow a Mississippi law that bans abortions after 15 weeks to take effect.
But quickly after that, abortions would become illegal in many states. Several conservative-leaning states, mostly in the South and Midwest, have already passed laws severely restricting abortions well beyond what Roe allowed. Should Roe be overturned then, those laws would take effect without the threat of lengthy lawsuits or rulings from lower-court judges who have blocked them.
Nearly half of the states, mostly in the Northeast and West, would likely allow abortion to continue in some way. In fact, several states, including Colorado and Vermont, have already passed laws granting the right to an abortion into state law.
The leaked draft, however, is still a draft, meaning it remains possible Roe survives. Anthony Kreis, PhD, a professor of law at Georgia State University, says that could have been the point of whoever leaked the draft.
“It suggests to me that whoever leaked it knew that public outrage was the last resort to stopping the court from overturning Roe v. Wade and letting states ban all abortions,” Dr. Kreis said. “The danger that abortions won’t be legal in most of the country is very real.”
A version of this article first appeared on WebMD.com.
This article was updated 5/3/22.
to the news outlet Politico.
The draft opinion, written by Justice Samuel Alito, outlines ways a presumed majority of the nine justices believes the 1973 ruling in Roe v. Wade was incorrect. If signed by a majority of the court, the ruling would eliminate the protections for abortion rights that Roe provided and give the 50 states the power to legislate abortion.
“We hold that Roe and Casey must be overruled,” Justice Alito writes in the draft. “It is time to heed the Constitution and return the issue of abortion to the people’s elected representatives.”
While a final ruling was not expected from the court until June, the leaked draft – a nearly unprecedented breach of the court’s internal workings – gives a strong signal of the court’s five most conservative members’ decisions. During oral arguments in the case in December, conservative justices appeared prepared to undo at least part of the country’s abortion protections.
President Joe Biden said his administration was already preparing for a potential ruling that struck down federal abortion protections.
The White House, he said in a statement, is working on a “response to the continued attack on abortion and reproductive rights, under a variety of possible outcomes in the cases pending before the Supreme Court. We will be ready when any ruling is issued.”
But if the draft opinion becomes final, he said the fight will move to the states.
“It will fall on our nation’s elected officials at all levels of government to protect a woman’s right to choose,” he said. “And it will fall on voters to elect pro-choice officials this November.”
With more pro-abortion rights members of Congress, it would be possible to pass federal legislation protecting abortion rights, “which I will work to pass and sign into law.”
Should the Alito draft become law, its first impact would be to allow a Mississippi law that bans abortions after 15 weeks to take effect.
But quickly after that, abortions would become illegal in many states. Several conservative-leaning states, mostly in the South and Midwest, have already passed laws severely restricting abortions well beyond what Roe allowed. Should Roe be overturned then, those laws would take effect without the threat of lengthy lawsuits or rulings from lower-court judges who have blocked them.
Nearly half of the states, mostly in the Northeast and West, would likely allow abortion to continue in some way. In fact, several states, including Colorado and Vermont, have already passed laws granting the right to an abortion into state law.
The leaked draft, however, is still a draft, meaning it remains possible Roe survives. Anthony Kreis, PhD, a professor of law at Georgia State University, says that could have been the point of whoever leaked the draft.
“It suggests to me that whoever leaked it knew that public outrage was the last resort to stopping the court from overturning Roe v. Wade and letting states ban all abortions,” Dr. Kreis said. “The danger that abortions won’t be legal in most of the country is very real.”
A version of this article first appeared on WebMD.com.
This article was updated 5/3/22.
Hospital readmission remains common for teens with nonfatal drug overdose
Approximately 1 in 5 adolescents hospitalized for nonfatal drug overdoses were readmitted within 6 months, based on data from more than 12,000 individuals.
Previous studies suggest that many adolescents fail to receive timely treatment for addiction after a nonfatal overdose, but the rates of hospital readmission in this population have not been examined, according to Julie Gaither, PhD, of Yale University, New Haven, Conn.
In a study presented at the annual meeting of the Pediatric Academic Societies, Dr. Gaither and her colleague, John M. Leventhal, MD, also of Yale University, used data from the 2016 Nationwide Readmissions Database to examine incidence and recurrent hospitalizations for nonfatal drug overdoses in adolescents. The study population included 12,952 patients aged 11-21 years who were admitted to a hospital after a nonfatal drug overdose in 2016. Of these, 15% were younger than 15 years, and 52.1% were females.
Overall, 76.2% of the overdoses involved opioids; 77.9% involved a prescription opioid, 15.3% involved heroin, and 7.9% involved fentanyl.
Across all drug overdoses, the majority (86.5%) were attributed to accidental intent and 11.8% were attributed to self-harm. Notably, females were nearly four times more likely than males to attempt suicide (odds ratio, 3.57). After the initial hospitalization, 79.3% of the patients were discharged home, and 11.5% went to a short-term care facility.
The 6-month hospital readmission rate was 21.4%. Of the patients readmitted for any cause, 18.2% of readmissions were for recurrent overdoses, and 92.1% of these were attributed to opioids.
The median cost of the initial hospital admission was $23,705 (ranging from $11,902 to $54,682) and the median cost of the first readmission was $25,416 (ranging from $13,905 to $48,810). In 42.1% of all hospitalizations, Medicaid was the primary payer.
The study findings were limited by the relatively high number of Medicaid patients, which may limit generalizability, but is strengthened by the large sample size.
The findings highlight not only the need for prevention efforts to limit opioid use among adolescents, but also “speak to the need for timely evidenced-based addiction treatment and appropriate follow-up care for teens following hospitalization for a nonfatal drug overdose,” the researchers wrote in their abstract.
Potential for postpandemic surge in drug use
Interestingly, some recent research has shown a decline in teens’ substance use during the pandemic, Kelly Curran, MD, of the University of Oklahoma Health Sciences Center, Oklahoma City, said in an interview.
“However, as the world begins ‘opening up’ again, I suspect rates of drug use will rise – especially with the significant burden of mental health issues adolescents have struggled with during the last few years,” said Dr. Curran, who was not involved with the current study.
“Sadly, I am not surprised by this study’s findings. Too often, teens with substance abuse issues are not connected to effective, evidenced-based treatment, and for those who are, the wait list can be long,” she said.
“Teens who are misusing drugs – either to get high or to attempt suicide – who are admitted for nonfatal overdose have a high rate of readmission for recurrent drug overdose,” Dr. Curran said. “This high rate of readmission has serious social and financial implications,” she added. “This study is part of a growing body of literature that supports the importance of getting adolescents into effective, evidence-based substance abuse treatment, such as medication-assisted treatment in opioid abuse. However, we also should be advocating for improved funding for and access to these treatments for all individuals.”
The study received no outside funding. Dr. Gaither had no financial conflicts to disclose. Dr. Curran had no financial conflicts to disclose and serves on the editorial advisory board of Pediatric News.
Approximately 1 in 5 adolescents hospitalized for nonfatal drug overdoses were readmitted within 6 months, based on data from more than 12,000 individuals.
Previous studies suggest that many adolescents fail to receive timely treatment for addiction after a nonfatal overdose, but the rates of hospital readmission in this population have not been examined, according to Julie Gaither, PhD, of Yale University, New Haven, Conn.
In a study presented at the annual meeting of the Pediatric Academic Societies, Dr. Gaither and her colleague, John M. Leventhal, MD, also of Yale University, used data from the 2016 Nationwide Readmissions Database to examine incidence and recurrent hospitalizations for nonfatal drug overdoses in adolescents. The study population included 12,952 patients aged 11-21 years who were admitted to a hospital after a nonfatal drug overdose in 2016. Of these, 15% were younger than 15 years, and 52.1% were females.
Overall, 76.2% of the overdoses involved opioids; 77.9% involved a prescription opioid, 15.3% involved heroin, and 7.9% involved fentanyl.
Across all drug overdoses, the majority (86.5%) were attributed to accidental intent and 11.8% were attributed to self-harm. Notably, females were nearly four times more likely than males to attempt suicide (odds ratio, 3.57). After the initial hospitalization, 79.3% of the patients were discharged home, and 11.5% went to a short-term care facility.
The 6-month hospital readmission rate was 21.4%. Of the patients readmitted for any cause, 18.2% of readmissions were for recurrent overdoses, and 92.1% of these were attributed to opioids.
The median cost of the initial hospital admission was $23,705 (ranging from $11,902 to $54,682) and the median cost of the first readmission was $25,416 (ranging from $13,905 to $48,810). In 42.1% of all hospitalizations, Medicaid was the primary payer.
The study findings were limited by the relatively high number of Medicaid patients, which may limit generalizability, but is strengthened by the large sample size.
The findings highlight not only the need for prevention efforts to limit opioid use among adolescents, but also “speak to the need for timely evidenced-based addiction treatment and appropriate follow-up care for teens following hospitalization for a nonfatal drug overdose,” the researchers wrote in their abstract.
Potential for postpandemic surge in drug use
Interestingly, some recent research has shown a decline in teens’ substance use during the pandemic, Kelly Curran, MD, of the University of Oklahoma Health Sciences Center, Oklahoma City, said in an interview.
“However, as the world begins ‘opening up’ again, I suspect rates of drug use will rise – especially with the significant burden of mental health issues adolescents have struggled with during the last few years,” said Dr. Curran, who was not involved with the current study.
“Sadly, I am not surprised by this study’s findings. Too often, teens with substance abuse issues are not connected to effective, evidenced-based treatment, and for those who are, the wait list can be long,” she said.
“Teens who are misusing drugs – either to get high or to attempt suicide – who are admitted for nonfatal overdose have a high rate of readmission for recurrent drug overdose,” Dr. Curran said. “This high rate of readmission has serious social and financial implications,” she added. “This study is part of a growing body of literature that supports the importance of getting adolescents into effective, evidence-based substance abuse treatment, such as medication-assisted treatment in opioid abuse. However, we also should be advocating for improved funding for and access to these treatments for all individuals.”
The study received no outside funding. Dr. Gaither had no financial conflicts to disclose. Dr. Curran had no financial conflicts to disclose and serves on the editorial advisory board of Pediatric News.
Approximately 1 in 5 adolescents hospitalized for nonfatal drug overdoses were readmitted within 6 months, based on data from more than 12,000 individuals.
Previous studies suggest that many adolescents fail to receive timely treatment for addiction after a nonfatal overdose, but the rates of hospital readmission in this population have not been examined, according to Julie Gaither, PhD, of Yale University, New Haven, Conn.
In a study presented at the annual meeting of the Pediatric Academic Societies, Dr. Gaither and her colleague, John M. Leventhal, MD, also of Yale University, used data from the 2016 Nationwide Readmissions Database to examine incidence and recurrent hospitalizations for nonfatal drug overdoses in adolescents. The study population included 12,952 patients aged 11-21 years who were admitted to a hospital after a nonfatal drug overdose in 2016. Of these, 15% were younger than 15 years, and 52.1% were females.
Overall, 76.2% of the overdoses involved opioids; 77.9% involved a prescription opioid, 15.3% involved heroin, and 7.9% involved fentanyl.
Across all drug overdoses, the majority (86.5%) were attributed to accidental intent and 11.8% were attributed to self-harm. Notably, females were nearly four times more likely than males to attempt suicide (odds ratio, 3.57). After the initial hospitalization, 79.3% of the patients were discharged home, and 11.5% went to a short-term care facility.
The 6-month hospital readmission rate was 21.4%. Of the patients readmitted for any cause, 18.2% of readmissions were for recurrent overdoses, and 92.1% of these were attributed to opioids.
The median cost of the initial hospital admission was $23,705 (ranging from $11,902 to $54,682) and the median cost of the first readmission was $25,416 (ranging from $13,905 to $48,810). In 42.1% of all hospitalizations, Medicaid was the primary payer.
The study findings were limited by the relatively high number of Medicaid patients, which may limit generalizability, but is strengthened by the large sample size.
The findings highlight not only the need for prevention efforts to limit opioid use among adolescents, but also “speak to the need for timely evidenced-based addiction treatment and appropriate follow-up care for teens following hospitalization for a nonfatal drug overdose,” the researchers wrote in their abstract.
Potential for postpandemic surge in drug use
Interestingly, some recent research has shown a decline in teens’ substance use during the pandemic, Kelly Curran, MD, of the University of Oklahoma Health Sciences Center, Oklahoma City, said in an interview.
“However, as the world begins ‘opening up’ again, I suspect rates of drug use will rise – especially with the significant burden of mental health issues adolescents have struggled with during the last few years,” said Dr. Curran, who was not involved with the current study.
“Sadly, I am not surprised by this study’s findings. Too often, teens with substance abuse issues are not connected to effective, evidenced-based treatment, and for those who are, the wait list can be long,” she said.
“Teens who are misusing drugs – either to get high or to attempt suicide – who are admitted for nonfatal overdose have a high rate of readmission for recurrent drug overdose,” Dr. Curran said. “This high rate of readmission has serious social and financial implications,” she added. “This study is part of a growing body of literature that supports the importance of getting adolescents into effective, evidence-based substance abuse treatment, such as medication-assisted treatment in opioid abuse. However, we also should be advocating for improved funding for and access to these treatments for all individuals.”
The study received no outside funding. Dr. Gaither had no financial conflicts to disclose. Dr. Curran had no financial conflicts to disclose and serves on the editorial advisory board of Pediatric News.
FROM PAS 2022
Firearm counseling in the ED could be lifesaving for teens
Caregivers who brought suicidal adolescents to the emergency department reported safer gun storage practices after firearm counseling – a crucial way to cut gun deaths among children, according to researchers from Cincinnati Children’s Hospital.
In the study, which took place between June 2021 and Feb 2022, gun safety counseling and handouts were provided to 99 families of children who had come to the ED with mental health problems. A separate set of 101 families in similar situations received counseling and handouts, along with two cable-style gun locks.
Four weeks later, parents in both groups reported an increase in safe storage practices in which they locked away all guns in the household. Those offered only counseling increased safe storage by 7.2% – from 89.9% to 97.1%.
The gains were greater for families that received locks in addition to counseling. The number of those who locked away all guns rose from 82.2% to 98.5% – a 16.3% increase. (Roughly one-third of families in both arms of the study were lost to follow-up, according to the researchers, which left 68 families in each group for analysis.)
Several caregivers in each group reported that guns had been removed entirely from the home, and more than 60% in each group said they had bought additional gun locks to secure their weapons.
“The main point of our study is that just-in-time counseling is very effective in helping these families of children with mental health concerns in securing all their guns, and an emergency department visit is a great time to do that,” said Bijan Ketabchi, MD, a clinical fellow in the division of emergency medicine at Cincinnati Children’s Hospital Medical Center, who presented the findings at the Pediatric Academic Societies annual meeting.
Dr. Ketabchi said his department sees 500-700 children each month with mental health concerns, most commonly depression. The mean age of adolescent patients in the study was 14 years.
Suicide is the second-leading cause of death among children in the United States. Both pediatric suicides and firearm suicides have increased in the past 2 decades, Dr. Ketabchi said. The number of youth suicides who use guns has risen 90% since 2008. One in three U.S. families own a firearm, and 4.6 million children live in a home with loaded, unlocked guns.
Among children aged 17 years and younger who die by firearm suicide, 82% used guns belonging to a family member.
The right time for the message
Interventions to encourage safe gun storage – at a time when caregivers are really listening – can be lifesaving, Dr. Ketabchi said.
“We know that counseling is really helpful for these families, because when they come to the emergency department with a concern, they can have a teachable moment,” he said in an interview. “It resonates with them a lot more than it normally would because they have experienced something traumatic.”
The importance of safe gun storage in households with adolescents can’t be overstated, even if the children are not at risk of suicide, said Naoka Carey, a doctoral candidate at Boston College.
Ms. Carey authored an article on the prevalence of handguns among adolescents that will be published in May in Pediatrics.
“Three kinds of harm for adolescents with access to guns are accidental injury, homicide, and suicide,” she said. “Families who own guns don’t always know their teens have access to the guns.”
The problem is getting worse. Ms. Carey and colleagues found that, between 2002 and 2019, the rate of children aged 12-17 who reported carrying handguns increased 41%. Most of them were White, and their families were in high-income brackets. New data show that firearm injuries have become the leading cause of death among youth in the United States, eclipsing auto accidents for the first time.
“Preventing tragedy in your family is more than reason enough to secure guns you have,” she said.
Dr. Ketabchi disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Caregivers who brought suicidal adolescents to the emergency department reported safer gun storage practices after firearm counseling – a crucial way to cut gun deaths among children, according to researchers from Cincinnati Children’s Hospital.
In the study, which took place between June 2021 and Feb 2022, gun safety counseling and handouts were provided to 99 families of children who had come to the ED with mental health problems. A separate set of 101 families in similar situations received counseling and handouts, along with two cable-style gun locks.
Four weeks later, parents in both groups reported an increase in safe storage practices in which they locked away all guns in the household. Those offered only counseling increased safe storage by 7.2% – from 89.9% to 97.1%.
The gains were greater for families that received locks in addition to counseling. The number of those who locked away all guns rose from 82.2% to 98.5% – a 16.3% increase. (Roughly one-third of families in both arms of the study were lost to follow-up, according to the researchers, which left 68 families in each group for analysis.)
Several caregivers in each group reported that guns had been removed entirely from the home, and more than 60% in each group said they had bought additional gun locks to secure their weapons.
“The main point of our study is that just-in-time counseling is very effective in helping these families of children with mental health concerns in securing all their guns, and an emergency department visit is a great time to do that,” said Bijan Ketabchi, MD, a clinical fellow in the division of emergency medicine at Cincinnati Children’s Hospital Medical Center, who presented the findings at the Pediatric Academic Societies annual meeting.
Dr. Ketabchi said his department sees 500-700 children each month with mental health concerns, most commonly depression. The mean age of adolescent patients in the study was 14 years.
Suicide is the second-leading cause of death among children in the United States. Both pediatric suicides and firearm suicides have increased in the past 2 decades, Dr. Ketabchi said. The number of youth suicides who use guns has risen 90% since 2008. One in three U.S. families own a firearm, and 4.6 million children live in a home with loaded, unlocked guns.
Among children aged 17 years and younger who die by firearm suicide, 82% used guns belonging to a family member.
The right time for the message
Interventions to encourage safe gun storage – at a time when caregivers are really listening – can be lifesaving, Dr. Ketabchi said.
“We know that counseling is really helpful for these families, because when they come to the emergency department with a concern, they can have a teachable moment,” he said in an interview. “It resonates with them a lot more than it normally would because they have experienced something traumatic.”
The importance of safe gun storage in households with adolescents can’t be overstated, even if the children are not at risk of suicide, said Naoka Carey, a doctoral candidate at Boston College.
Ms. Carey authored an article on the prevalence of handguns among adolescents that will be published in May in Pediatrics.
“Three kinds of harm for adolescents with access to guns are accidental injury, homicide, and suicide,” she said. “Families who own guns don’t always know their teens have access to the guns.”
The problem is getting worse. Ms. Carey and colleagues found that, between 2002 and 2019, the rate of children aged 12-17 who reported carrying handguns increased 41%. Most of them were White, and their families were in high-income brackets. New data show that firearm injuries have become the leading cause of death among youth in the United States, eclipsing auto accidents for the first time.
“Preventing tragedy in your family is more than reason enough to secure guns you have,” she said.
Dr. Ketabchi disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Caregivers who brought suicidal adolescents to the emergency department reported safer gun storage practices after firearm counseling – a crucial way to cut gun deaths among children, according to researchers from Cincinnati Children’s Hospital.
In the study, which took place between June 2021 and Feb 2022, gun safety counseling and handouts were provided to 99 families of children who had come to the ED with mental health problems. A separate set of 101 families in similar situations received counseling and handouts, along with two cable-style gun locks.
Four weeks later, parents in both groups reported an increase in safe storage practices in which they locked away all guns in the household. Those offered only counseling increased safe storage by 7.2% – from 89.9% to 97.1%.
The gains were greater for families that received locks in addition to counseling. The number of those who locked away all guns rose from 82.2% to 98.5% – a 16.3% increase. (Roughly one-third of families in both arms of the study were lost to follow-up, according to the researchers, which left 68 families in each group for analysis.)
Several caregivers in each group reported that guns had been removed entirely from the home, and more than 60% in each group said they had bought additional gun locks to secure their weapons.
“The main point of our study is that just-in-time counseling is very effective in helping these families of children with mental health concerns in securing all their guns, and an emergency department visit is a great time to do that,” said Bijan Ketabchi, MD, a clinical fellow in the division of emergency medicine at Cincinnati Children’s Hospital Medical Center, who presented the findings at the Pediatric Academic Societies annual meeting.
Dr. Ketabchi said his department sees 500-700 children each month with mental health concerns, most commonly depression. The mean age of adolescent patients in the study was 14 years.
Suicide is the second-leading cause of death among children in the United States. Both pediatric suicides and firearm suicides have increased in the past 2 decades, Dr. Ketabchi said. The number of youth suicides who use guns has risen 90% since 2008. One in three U.S. families own a firearm, and 4.6 million children live in a home with loaded, unlocked guns.
Among children aged 17 years and younger who die by firearm suicide, 82% used guns belonging to a family member.
The right time for the message
Interventions to encourage safe gun storage – at a time when caregivers are really listening – can be lifesaving, Dr. Ketabchi said.
“We know that counseling is really helpful for these families, because when they come to the emergency department with a concern, they can have a teachable moment,” he said in an interview. “It resonates with them a lot more than it normally would because they have experienced something traumatic.”
The importance of safe gun storage in households with adolescents can’t be overstated, even if the children are not at risk of suicide, said Naoka Carey, a doctoral candidate at Boston College.
Ms. Carey authored an article on the prevalence of handguns among adolescents that will be published in May in Pediatrics.
“Three kinds of harm for adolescents with access to guns are accidental injury, homicide, and suicide,” she said. “Families who own guns don’t always know their teens have access to the guns.”
The problem is getting worse. Ms. Carey and colleagues found that, between 2002 and 2019, the rate of children aged 12-17 who reported carrying handguns increased 41%. Most of them were White, and their families were in high-income brackets. New data show that firearm injuries have become the leading cause of death among youth in the United States, eclipsing auto accidents for the first time.
“Preventing tragedy in your family is more than reason enough to secure guns you have,” she said.
Dr. Ketabchi disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM PAS 2022
Pandemic prompts spike in eating disorder hospitalization for adolescents
Hospital admission for children with eating disorders approximately tripled during the COVID-19 pandemic, based on data from 85 patients.
Eating disorders are common among adolescents and often require hospital admission for nutritional restoration, according to May Shum of Yale University, New Haven, Conn., and colleagues
During the COVID-19 pandemic, the volume of hospital admissions for adolescents with eating disorders has increased, the researchers wrote in a poster presented at the annual meeting of the Pediatric Academic Societies. This increase may be driven both by interruptions in medical care and increased psychological distress, but data on changes in patient characteristics and hospitalization course are lacking, they said.
The researchers reviewed charts from patients with eating disorders admitted to a single center between Jan. 1, 2017, and June 30, 2021. The majority of the patients were female (90.6%), and White (78.8%), had restrictive eating behaviors (97.2%), and had private insurance (80.0%).
Overall, the number of monthly admissions increased from 1.4 before the onset of the pandemic to 3.6 during the pandemic (P < .001).
Length of stay increased significantly from before to during pandemic cases (12.8 days vs. 17.3 days, P = .04) and age younger than 13 years was significantly associated with a longer length of stay (P < .001).
The number of patients for whom psychotropic medications were initiated or changed increased significantly (12.5% vs. 28.3%, P = .04); as did the proportion of patients discharged to partial hospitalization, residential, or inpatient psychiatric treatment rather than discharged home with outpatient therapy (56.2% vs. 75.0%, P = .04).
No significant differences were noted in demographics, comorbidities, admission parameters, EKG abnormalities, electrolyte repletion, or tube feeding.
The study findings were limited by the use of data from a single center. However, the results suggest an increase in severity of hospital admissions that have implications for use of hospital resources, the researchers said.
“In addition to an increase in hospital admissions for eating disorder management during the pandemic, longer inpatient stays of younger children with higher acuity at discharge is an added strain on hospital resources and warrants attention,” they concluded.
Considerations for younger patients
The current study is especially important at this time, Margaret Thew, DNP, FNP-BC, medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee, said in an interview. “There have been reports of the rising numbers in eating disorders, but until research has been conducted, we cannot quantify the volumes,” said Ms. Thew, who was not involved in the study. “There have been many reports of the rise in mental health issues during the pandemic, so it seems accurate that the rate of eating disorders would rise,” she said. “Additionally, from a clinical perspective there seemed to be many younger-age patients with eating disorders presenting to the inpatient units who seemed sicker,” she noted.
Ms. Thew said she was not surprised by the study findings. “Working with adolescents with eating disorders we saw the increased numbers of both hospitalizations and outpatient referrals during the pandemic,” said Ms. Thew. “Length of stay was higher across the nation regarding admissions for concerns of eating disorders. These patients are sicker and fewer went home after medical stabilization,” she emphasized.
“Clinicians should be more aware of the rise in patients presenting with eating disorders at younger ages to their clinics and provide early interventions to prevent severe illness and medical instability,” said Ms. Thew. Clinicians also should be more proactive in managing younger children and adolescents who express mood disorders, disordered eating, or weight loss, given the significant rise in eating disorders and mental health concerns, she said.
Additional research is needed to continue following the rate of eating disorders into 2022, said Ms. Thew. More research is needed on early interventions and recognition of eating disorders for preteens and teens to prevent severe illness, as is research on how the younger patient with an eating disorder may present differently to the primary care doctor or emergency department, she said.
“We may need to study treatment of the younger population, as they may not do as well with admissions into behavioral health facilities,” Ms. Thew added.
The study received no outside funding. The researchers had no financial conflicts to disclose. Ms. Thew had no financial conflicts to disclose and serves on the editorial advisory board of Pediatric News.
Hospital admission for children with eating disorders approximately tripled during the COVID-19 pandemic, based on data from 85 patients.
Eating disorders are common among adolescents and often require hospital admission for nutritional restoration, according to May Shum of Yale University, New Haven, Conn., and colleagues
During the COVID-19 pandemic, the volume of hospital admissions for adolescents with eating disorders has increased, the researchers wrote in a poster presented at the annual meeting of the Pediatric Academic Societies. This increase may be driven both by interruptions in medical care and increased psychological distress, but data on changes in patient characteristics and hospitalization course are lacking, they said.
The researchers reviewed charts from patients with eating disorders admitted to a single center between Jan. 1, 2017, and June 30, 2021. The majority of the patients were female (90.6%), and White (78.8%), had restrictive eating behaviors (97.2%), and had private insurance (80.0%).
Overall, the number of monthly admissions increased from 1.4 before the onset of the pandemic to 3.6 during the pandemic (P < .001).
Length of stay increased significantly from before to during pandemic cases (12.8 days vs. 17.3 days, P = .04) and age younger than 13 years was significantly associated with a longer length of stay (P < .001).
The number of patients for whom psychotropic medications were initiated or changed increased significantly (12.5% vs. 28.3%, P = .04); as did the proportion of patients discharged to partial hospitalization, residential, or inpatient psychiatric treatment rather than discharged home with outpatient therapy (56.2% vs. 75.0%, P = .04).
No significant differences were noted in demographics, comorbidities, admission parameters, EKG abnormalities, electrolyte repletion, or tube feeding.
The study findings were limited by the use of data from a single center. However, the results suggest an increase in severity of hospital admissions that have implications for use of hospital resources, the researchers said.
“In addition to an increase in hospital admissions for eating disorder management during the pandemic, longer inpatient stays of younger children with higher acuity at discharge is an added strain on hospital resources and warrants attention,” they concluded.
Considerations for younger patients
The current study is especially important at this time, Margaret Thew, DNP, FNP-BC, medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee, said in an interview. “There have been reports of the rising numbers in eating disorders, but until research has been conducted, we cannot quantify the volumes,” said Ms. Thew, who was not involved in the study. “There have been many reports of the rise in mental health issues during the pandemic, so it seems accurate that the rate of eating disorders would rise,” she said. “Additionally, from a clinical perspective there seemed to be many younger-age patients with eating disorders presenting to the inpatient units who seemed sicker,” she noted.
Ms. Thew said she was not surprised by the study findings. “Working with adolescents with eating disorders we saw the increased numbers of both hospitalizations and outpatient referrals during the pandemic,” said Ms. Thew. “Length of stay was higher across the nation regarding admissions for concerns of eating disorders. These patients are sicker and fewer went home after medical stabilization,” she emphasized.
“Clinicians should be more aware of the rise in patients presenting with eating disorders at younger ages to their clinics and provide early interventions to prevent severe illness and medical instability,” said Ms. Thew. Clinicians also should be more proactive in managing younger children and adolescents who express mood disorders, disordered eating, or weight loss, given the significant rise in eating disorders and mental health concerns, she said.
Additional research is needed to continue following the rate of eating disorders into 2022, said Ms. Thew. More research is needed on early interventions and recognition of eating disorders for preteens and teens to prevent severe illness, as is research on how the younger patient with an eating disorder may present differently to the primary care doctor or emergency department, she said.
“We may need to study treatment of the younger population, as they may not do as well with admissions into behavioral health facilities,” Ms. Thew added.
The study received no outside funding. The researchers had no financial conflicts to disclose. Ms. Thew had no financial conflicts to disclose and serves on the editorial advisory board of Pediatric News.
Hospital admission for children with eating disorders approximately tripled during the COVID-19 pandemic, based on data from 85 patients.
Eating disorders are common among adolescents and often require hospital admission for nutritional restoration, according to May Shum of Yale University, New Haven, Conn., and colleagues
During the COVID-19 pandemic, the volume of hospital admissions for adolescents with eating disorders has increased, the researchers wrote in a poster presented at the annual meeting of the Pediatric Academic Societies. This increase may be driven both by interruptions in medical care and increased psychological distress, but data on changes in patient characteristics and hospitalization course are lacking, they said.
The researchers reviewed charts from patients with eating disorders admitted to a single center between Jan. 1, 2017, and June 30, 2021. The majority of the patients were female (90.6%), and White (78.8%), had restrictive eating behaviors (97.2%), and had private insurance (80.0%).
Overall, the number of monthly admissions increased from 1.4 before the onset of the pandemic to 3.6 during the pandemic (P < .001).
Length of stay increased significantly from before to during pandemic cases (12.8 days vs. 17.3 days, P = .04) and age younger than 13 years was significantly associated with a longer length of stay (P < .001).
The number of patients for whom psychotropic medications were initiated or changed increased significantly (12.5% vs. 28.3%, P = .04); as did the proportion of patients discharged to partial hospitalization, residential, or inpatient psychiatric treatment rather than discharged home with outpatient therapy (56.2% vs. 75.0%, P = .04).
No significant differences were noted in demographics, comorbidities, admission parameters, EKG abnormalities, electrolyte repletion, or tube feeding.
The study findings were limited by the use of data from a single center. However, the results suggest an increase in severity of hospital admissions that have implications for use of hospital resources, the researchers said.
“In addition to an increase in hospital admissions for eating disorder management during the pandemic, longer inpatient stays of younger children with higher acuity at discharge is an added strain on hospital resources and warrants attention,” they concluded.
Considerations for younger patients
The current study is especially important at this time, Margaret Thew, DNP, FNP-BC, medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee, said in an interview. “There have been reports of the rising numbers in eating disorders, but until research has been conducted, we cannot quantify the volumes,” said Ms. Thew, who was not involved in the study. “There have been many reports of the rise in mental health issues during the pandemic, so it seems accurate that the rate of eating disorders would rise,” she said. “Additionally, from a clinical perspective there seemed to be many younger-age patients with eating disorders presenting to the inpatient units who seemed sicker,” she noted.
Ms. Thew said she was not surprised by the study findings. “Working with adolescents with eating disorders we saw the increased numbers of both hospitalizations and outpatient referrals during the pandemic,” said Ms. Thew. “Length of stay was higher across the nation regarding admissions for concerns of eating disorders. These patients are sicker and fewer went home after medical stabilization,” she emphasized.
“Clinicians should be more aware of the rise in patients presenting with eating disorders at younger ages to their clinics and provide early interventions to prevent severe illness and medical instability,” said Ms. Thew. Clinicians also should be more proactive in managing younger children and adolescents who express mood disorders, disordered eating, or weight loss, given the significant rise in eating disorders and mental health concerns, she said.
Additional research is needed to continue following the rate of eating disorders into 2022, said Ms. Thew. More research is needed on early interventions and recognition of eating disorders for preteens and teens to prevent severe illness, as is research on how the younger patient with an eating disorder may present differently to the primary care doctor or emergency department, she said.
“We may need to study treatment of the younger population, as they may not do as well with admissions into behavioral health facilities,” Ms. Thew added.
The study received no outside funding. The researchers had no financial conflicts to disclose. Ms. Thew had no financial conflicts to disclose and serves on the editorial advisory board of Pediatric News.
FROM PAS 2022
How gender-affirming care is provided to adolescents in the United States
“Texas investigates parents of transgender teen.” “Court did not force dad to allow chemical castration of son.” Headlines such as these are becoming more common as transgender adolescents and young adults, as well as their families, continue to come under attack from state and local governments. In the 2021 state legislative sessions, more than 100 anti-trans bills were filed across 35 state legislatures. Texas alone saw 13 anti-trans bills, covering everything from sports participation to criminalization of best-practice medical care.1 Many of these bills are introduced under the guise of “protecting” these adolescents and young adults but are detrimental to their health. They also contain descriptions of gender-affirming care that do not reflect the evidence-based standards of care followed by clinicians across the country. Below is scientifically accurate information on gender-affirming care.
Gender identity development
Trajectories of gender identity are diverse. In a large sample of transgender adults (n = 27,715), 10% started to realize they were transgender at age 5 or younger, 16% between ages 6 and 10, 28% between 11 and 15, 29% between 16 and 20, and 18% at age 21 or older.2 In childhood, cross-gender play and preferences are a normal part of gender expression and many gender-nonconforming children will go on to identify with the sex they were assigned at birth (labeled cisgender). However, some children explicitly identify with a gender different than the sex they were assigned at birth (labeled transgender). Children who are consistent, insistent, and persistent in this identity appear likely to remain so into adolescence and adulthood. It is important to note that there is no evidence that discouraging gender nonconformity decreases the likelihood that a child will identify as transgender. In fact, this practice is no longer considered ethical, as it can have damaging effects on self-esteem and mental health. In addition, not all transgender people are noticeably gender nonconforming in childhood and that lack of childhood gender nonconformity does not invalidate someone’s transgender identity.
Gender-affirming care
For youth who identify as transgender, all steps in transition prior to puberty are social. This includes steps like changing hairstyles or clothing and using a different (affirmed) name and/or pronouns. This time period allows youth to explore their gender identity and expression. In one large study of 10,000 LGBTQ youth, among youth who reported “all or most people” used their affirmed pronoun, 12% reported a history of suicide attempt.3 In comparison, among those who reported that “no one” used their affirmed pronoun, the suicide attempt rate was 28%. Further, 14% of youth who reported that they were able to make changes in their clothing and appearance reported a past suicide attempt in comparison to 26% of those who were not able to. Many of these youth also are under the care of mental health professionals during this time.
At the onset of puberty, transgender youth are eligible for medical management, if needed, to address gender dysphoria (i.e., distress with one’s sex characteristics that is consistent and impairing). It is important to recognize that not all people who identify as transgender experience gender dysphoria or desire a medical transition. For those who do seek medical care, puberty must be confirmed either by breast/testicular exam or checking gonadotropin levels. Standards of care suggest that prior to pubertal suppression with GnRH agonists, such as leuprolide or histrelin, adolescents undergo a thorough psychosocial evaluation by a qualified, licensed clinician. After this evaluation, pubertal suppression may be initiated. These adolescents are monitored by their physicians every 3-6 months for side effects and continuing evaluation of their gender identity. GnRH agonists pause any further pubertal development while the adolescent continues to explore his/her/their gender identity. GnRH agonists are fully reversible and if they are stopped, the child’s natal puberty would recommence.
If an adolescent desires to start gender-affirming hormones, these are started as early as age 14, depending on their maturity, when they desire to start, and/or their ability to obtain parental consent. If a patient has not begun GnRH agonists and undergone a previous psychosocial evaluation, a thorough psychosocial evaluation by a qualified, licensed clinician would take place prior to initiating gender-affirming hormones. Prior to initiating hormones, a thorough informed-consent process occurs between the clinician, patient, and family. This process reviews reversible versus irreversible effects, as well of any side effects of the medication(s). Adolescents who begin hormonal treatment are then monitored every 3-6 months for medication side effects, efficacy, satisfaction with treatment, and by continued mental health assessments. Engagement in mental health therapy is not required beyond the initial evaluation (as many adolescents are well adjusted), but it is encouraged for support during the adolescent’s transition.4 It is important to note that the decision to begin hormones, or not, as well as how to adjust dosing over time, is nuanced and is individualized to each patient’s particular goals for his/her/their transition.
Care for transmasculine identified adolescents (those who were assigned female at birth) typically involves testosterone, delivered via subcutaneous injection, transdermal patch, or transdermal gel. Care for transfeminine individuals (those who were assigned male at birth) typically involves estradiol, delivered via daily pill, weekly or twice weekly transdermal patch, or intramuscular injection, as well as an androgen blocker. This is because estradiol by itself is a weak androgen inhibitor. Antiandrogen medication is delivered by daily oral spironolactone, daily oral bicalutamide (an androgen receptor blocker), or GnRH agonists similar to those used for puberty blockade.
Outcomes
At least 13 studies have documented an improvement in gender dysphoria and/or mental health for adolescents and young adults after beginning gender affirming medical care.5 A recent study by Turban et al. showed that access to gender affirming hormones during adolescence or early adulthood was associated with decreased odds of past month suicidal ideation than for those who did not have access to gender-affirming hormones.6 Tordoff et al. found that receipt of gender-affirming care, including medications, led to a 60% decrease in depressive symptoms and a 73% decrease in suicidality.7 One other question that often arises is whether youth who undergo medical treatment for their transition regret their transition or retransition back to the sex they were assigned at birth. In a large study at a gender clinic in the United Kingdom, they found a regret rate of only 0.47% (16 of 3,398 adolescents aged 13-20).8 This is similar to other studies that have also found low rates of regret. Regret is often due to lack of acceptance in society rather than lack of transgender identity.
The care of gender diverse youth takes place on a spectrum, including options that do not include medical treatment. By supporting youth where they are on their gender journey, there is a significant reduction in adverse mental health outcomes. Gender-affirming hormonal treatment is individualized and a thorough multidisciplinary evaluation and informed consent are obtained prior to initiation. There are careful, nuanced discussions with patients and their families to individualize care based on individual goals. By following established evidence-based standards of care, physicians can support their gender-diverse patients throughout their gender journey. Just like other medical treatments, procedures, or surgeries, gender-affirming care should be undertaken in the context of the sacred patient-physician relationship.
Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.
References
1. Equality Texas. Legislative Bill Tracker.
2. James SE et al. The Report of the 2015 U.S. Transgender Survey. 2016. Washington, DC: National Center for Transgender Equality.
3. The Trevor Project. 2020. National Survey on LGBTQ Mental Health.
4. Lopez X et al. Curr Opin Pediatrics. 2017;29(4):475-80.
5. Turban J. The evidence for trans youth gender-affirming medical care. Psychology Today. 2022 Jan 24.
6. Turban J et al. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLOS ONE. 2022;17(1).
7. Tordoff DM et al. Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA Network Open. 2022;5(2).
8. Davies S et al. Detransition rates in a national UK gender identity clinic. Inside Matters. On Law, Ethics, and Religion. 2019 Apr 11.
“Texas investigates parents of transgender teen.” “Court did not force dad to allow chemical castration of son.” Headlines such as these are becoming more common as transgender adolescents and young adults, as well as their families, continue to come under attack from state and local governments. In the 2021 state legislative sessions, more than 100 anti-trans bills were filed across 35 state legislatures. Texas alone saw 13 anti-trans bills, covering everything from sports participation to criminalization of best-practice medical care.1 Many of these bills are introduced under the guise of “protecting” these adolescents and young adults but are detrimental to their health. They also contain descriptions of gender-affirming care that do not reflect the evidence-based standards of care followed by clinicians across the country. Below is scientifically accurate information on gender-affirming care.
Gender identity development
Trajectories of gender identity are diverse. In a large sample of transgender adults (n = 27,715), 10% started to realize they were transgender at age 5 or younger, 16% between ages 6 and 10, 28% between 11 and 15, 29% between 16 and 20, and 18% at age 21 or older.2 In childhood, cross-gender play and preferences are a normal part of gender expression and many gender-nonconforming children will go on to identify with the sex they were assigned at birth (labeled cisgender). However, some children explicitly identify with a gender different than the sex they were assigned at birth (labeled transgender). Children who are consistent, insistent, and persistent in this identity appear likely to remain so into adolescence and adulthood. It is important to note that there is no evidence that discouraging gender nonconformity decreases the likelihood that a child will identify as transgender. In fact, this practice is no longer considered ethical, as it can have damaging effects on self-esteem and mental health. In addition, not all transgender people are noticeably gender nonconforming in childhood and that lack of childhood gender nonconformity does not invalidate someone’s transgender identity.
Gender-affirming care
For youth who identify as transgender, all steps in transition prior to puberty are social. This includes steps like changing hairstyles or clothing and using a different (affirmed) name and/or pronouns. This time period allows youth to explore their gender identity and expression. In one large study of 10,000 LGBTQ youth, among youth who reported “all or most people” used their affirmed pronoun, 12% reported a history of suicide attempt.3 In comparison, among those who reported that “no one” used their affirmed pronoun, the suicide attempt rate was 28%. Further, 14% of youth who reported that they were able to make changes in their clothing and appearance reported a past suicide attempt in comparison to 26% of those who were not able to. Many of these youth also are under the care of mental health professionals during this time.
At the onset of puberty, transgender youth are eligible for medical management, if needed, to address gender dysphoria (i.e., distress with one’s sex characteristics that is consistent and impairing). It is important to recognize that not all people who identify as transgender experience gender dysphoria or desire a medical transition. For those who do seek medical care, puberty must be confirmed either by breast/testicular exam or checking gonadotropin levels. Standards of care suggest that prior to pubertal suppression with GnRH agonists, such as leuprolide or histrelin, adolescents undergo a thorough psychosocial evaluation by a qualified, licensed clinician. After this evaluation, pubertal suppression may be initiated. These adolescents are monitored by their physicians every 3-6 months for side effects and continuing evaluation of their gender identity. GnRH agonists pause any further pubertal development while the adolescent continues to explore his/her/their gender identity. GnRH agonists are fully reversible and if they are stopped, the child’s natal puberty would recommence.
If an adolescent desires to start gender-affirming hormones, these are started as early as age 14, depending on their maturity, when they desire to start, and/or their ability to obtain parental consent. If a patient has not begun GnRH agonists and undergone a previous psychosocial evaluation, a thorough psychosocial evaluation by a qualified, licensed clinician would take place prior to initiating gender-affirming hormones. Prior to initiating hormones, a thorough informed-consent process occurs between the clinician, patient, and family. This process reviews reversible versus irreversible effects, as well of any side effects of the medication(s). Adolescents who begin hormonal treatment are then monitored every 3-6 months for medication side effects, efficacy, satisfaction with treatment, and by continued mental health assessments. Engagement in mental health therapy is not required beyond the initial evaluation (as many adolescents are well adjusted), but it is encouraged for support during the adolescent’s transition.4 It is important to note that the decision to begin hormones, or not, as well as how to adjust dosing over time, is nuanced and is individualized to each patient’s particular goals for his/her/their transition.
Care for transmasculine identified adolescents (those who were assigned female at birth) typically involves testosterone, delivered via subcutaneous injection, transdermal patch, or transdermal gel. Care for transfeminine individuals (those who were assigned male at birth) typically involves estradiol, delivered via daily pill, weekly or twice weekly transdermal patch, or intramuscular injection, as well as an androgen blocker. This is because estradiol by itself is a weak androgen inhibitor. Antiandrogen medication is delivered by daily oral spironolactone, daily oral bicalutamide (an androgen receptor blocker), or GnRH agonists similar to those used for puberty blockade.
Outcomes
At least 13 studies have documented an improvement in gender dysphoria and/or mental health for adolescents and young adults after beginning gender affirming medical care.5 A recent study by Turban et al. showed that access to gender affirming hormones during adolescence or early adulthood was associated with decreased odds of past month suicidal ideation than for those who did not have access to gender-affirming hormones.6 Tordoff et al. found that receipt of gender-affirming care, including medications, led to a 60% decrease in depressive symptoms and a 73% decrease in suicidality.7 One other question that often arises is whether youth who undergo medical treatment for their transition regret their transition or retransition back to the sex they were assigned at birth. In a large study at a gender clinic in the United Kingdom, they found a regret rate of only 0.47% (16 of 3,398 adolescents aged 13-20).8 This is similar to other studies that have also found low rates of regret. Regret is often due to lack of acceptance in society rather than lack of transgender identity.
The care of gender diverse youth takes place on a spectrum, including options that do not include medical treatment. By supporting youth where they are on their gender journey, there is a significant reduction in adverse mental health outcomes. Gender-affirming hormonal treatment is individualized and a thorough multidisciplinary evaluation and informed consent are obtained prior to initiation. There are careful, nuanced discussions with patients and their families to individualize care based on individual goals. By following established evidence-based standards of care, physicians can support their gender-diverse patients throughout their gender journey. Just like other medical treatments, procedures, or surgeries, gender-affirming care should be undertaken in the context of the sacred patient-physician relationship.
Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.
References
1. Equality Texas. Legislative Bill Tracker.
2. James SE et al. The Report of the 2015 U.S. Transgender Survey. 2016. Washington, DC: National Center for Transgender Equality.
3. The Trevor Project. 2020. National Survey on LGBTQ Mental Health.
4. Lopez X et al. Curr Opin Pediatrics. 2017;29(4):475-80.
5. Turban J. The evidence for trans youth gender-affirming medical care. Psychology Today. 2022 Jan 24.
6. Turban J et al. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLOS ONE. 2022;17(1).
7. Tordoff DM et al. Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA Network Open. 2022;5(2).
8. Davies S et al. Detransition rates in a national UK gender identity clinic. Inside Matters. On Law, Ethics, and Religion. 2019 Apr 11.
“Texas investigates parents of transgender teen.” “Court did not force dad to allow chemical castration of son.” Headlines such as these are becoming more common as transgender adolescents and young adults, as well as their families, continue to come under attack from state and local governments. In the 2021 state legislative sessions, more than 100 anti-trans bills were filed across 35 state legislatures. Texas alone saw 13 anti-trans bills, covering everything from sports participation to criminalization of best-practice medical care.1 Many of these bills are introduced under the guise of “protecting” these adolescents and young adults but are detrimental to their health. They also contain descriptions of gender-affirming care that do not reflect the evidence-based standards of care followed by clinicians across the country. Below is scientifically accurate information on gender-affirming care.
Gender identity development
Trajectories of gender identity are diverse. In a large sample of transgender adults (n = 27,715), 10% started to realize they were transgender at age 5 or younger, 16% between ages 6 and 10, 28% between 11 and 15, 29% between 16 and 20, and 18% at age 21 or older.2 In childhood, cross-gender play and preferences are a normal part of gender expression and many gender-nonconforming children will go on to identify with the sex they were assigned at birth (labeled cisgender). However, some children explicitly identify with a gender different than the sex they were assigned at birth (labeled transgender). Children who are consistent, insistent, and persistent in this identity appear likely to remain so into adolescence and adulthood. It is important to note that there is no evidence that discouraging gender nonconformity decreases the likelihood that a child will identify as transgender. In fact, this practice is no longer considered ethical, as it can have damaging effects on self-esteem and mental health. In addition, not all transgender people are noticeably gender nonconforming in childhood and that lack of childhood gender nonconformity does not invalidate someone’s transgender identity.
Gender-affirming care
For youth who identify as transgender, all steps in transition prior to puberty are social. This includes steps like changing hairstyles or clothing and using a different (affirmed) name and/or pronouns. This time period allows youth to explore their gender identity and expression. In one large study of 10,000 LGBTQ youth, among youth who reported “all or most people” used their affirmed pronoun, 12% reported a history of suicide attempt.3 In comparison, among those who reported that “no one” used their affirmed pronoun, the suicide attempt rate was 28%. Further, 14% of youth who reported that they were able to make changes in their clothing and appearance reported a past suicide attempt in comparison to 26% of those who were not able to. Many of these youth also are under the care of mental health professionals during this time.
At the onset of puberty, transgender youth are eligible for medical management, if needed, to address gender dysphoria (i.e., distress with one’s sex characteristics that is consistent and impairing). It is important to recognize that not all people who identify as transgender experience gender dysphoria or desire a medical transition. For those who do seek medical care, puberty must be confirmed either by breast/testicular exam or checking gonadotropin levels. Standards of care suggest that prior to pubertal suppression with GnRH agonists, such as leuprolide or histrelin, adolescents undergo a thorough psychosocial evaluation by a qualified, licensed clinician. After this evaluation, pubertal suppression may be initiated. These adolescents are monitored by their physicians every 3-6 months for side effects and continuing evaluation of their gender identity. GnRH agonists pause any further pubertal development while the adolescent continues to explore his/her/their gender identity. GnRH agonists are fully reversible and if they are stopped, the child’s natal puberty would recommence.
If an adolescent desires to start gender-affirming hormones, these are started as early as age 14, depending on their maturity, when they desire to start, and/or their ability to obtain parental consent. If a patient has not begun GnRH agonists and undergone a previous psychosocial evaluation, a thorough psychosocial evaluation by a qualified, licensed clinician would take place prior to initiating gender-affirming hormones. Prior to initiating hormones, a thorough informed-consent process occurs between the clinician, patient, and family. This process reviews reversible versus irreversible effects, as well of any side effects of the medication(s). Adolescents who begin hormonal treatment are then monitored every 3-6 months for medication side effects, efficacy, satisfaction with treatment, and by continued mental health assessments. Engagement in mental health therapy is not required beyond the initial evaluation (as many adolescents are well adjusted), but it is encouraged for support during the adolescent’s transition.4 It is important to note that the decision to begin hormones, or not, as well as how to adjust dosing over time, is nuanced and is individualized to each patient’s particular goals for his/her/their transition.
Care for transmasculine identified adolescents (those who were assigned female at birth) typically involves testosterone, delivered via subcutaneous injection, transdermal patch, or transdermal gel. Care for transfeminine individuals (those who were assigned male at birth) typically involves estradiol, delivered via daily pill, weekly or twice weekly transdermal patch, or intramuscular injection, as well as an androgen blocker. This is because estradiol by itself is a weak androgen inhibitor. Antiandrogen medication is delivered by daily oral spironolactone, daily oral bicalutamide (an androgen receptor blocker), or GnRH agonists similar to those used for puberty blockade.
Outcomes
At least 13 studies have documented an improvement in gender dysphoria and/or mental health for adolescents and young adults after beginning gender affirming medical care.5 A recent study by Turban et al. showed that access to gender affirming hormones during adolescence or early adulthood was associated with decreased odds of past month suicidal ideation than for those who did not have access to gender-affirming hormones.6 Tordoff et al. found that receipt of gender-affirming care, including medications, led to a 60% decrease in depressive symptoms and a 73% decrease in suicidality.7 One other question that often arises is whether youth who undergo medical treatment for their transition regret their transition or retransition back to the sex they were assigned at birth. In a large study at a gender clinic in the United Kingdom, they found a regret rate of only 0.47% (16 of 3,398 adolescents aged 13-20).8 This is similar to other studies that have also found low rates of regret. Regret is often due to lack of acceptance in society rather than lack of transgender identity.
The care of gender diverse youth takes place on a spectrum, including options that do not include medical treatment. By supporting youth where they are on their gender journey, there is a significant reduction in adverse mental health outcomes. Gender-affirming hormonal treatment is individualized and a thorough multidisciplinary evaluation and informed consent are obtained prior to initiation. There are careful, nuanced discussions with patients and their families to individualize care based on individual goals. By following established evidence-based standards of care, physicians can support their gender-diverse patients throughout their gender journey. Just like other medical treatments, procedures, or surgeries, gender-affirming care should be undertaken in the context of the sacred patient-physician relationship.
Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.
References
1. Equality Texas. Legislative Bill Tracker.
2. James SE et al. The Report of the 2015 U.S. Transgender Survey. 2016. Washington, DC: National Center for Transgender Equality.
3. The Trevor Project. 2020. National Survey on LGBTQ Mental Health.
4. Lopez X et al. Curr Opin Pediatrics. 2017;29(4):475-80.
5. Turban J. The evidence for trans youth gender-affirming medical care. Psychology Today. 2022 Jan 24.
6. Turban J et al. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLOS ONE. 2022;17(1).
7. Tordoff DM et al. Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA Network Open. 2022;5(2).
8. Davies S et al. Detransition rates in a national UK gender identity clinic. Inside Matters. On Law, Ethics, and Religion. 2019 Apr 11.
Gun violence now leading cause of death for U.S. children
In 2020, 4,357 children aged 1-19, or approximately 6 in 100,000, died from a gun-related injury, the researchers reported, modestly exceeding the number for auto accidents (3,913) and greatly exceeding deaths caused by suffocation (1,411) or drowning (966).
To observers of gun violence in this country, the grim statistical marker has been all but inevitable. Gunshots were the second-leading cause of death in 2016 among children aged 1-19, the researchers reported. But sharp rises in such fatalities since then, especially in 2020 as the COVID-19 pandemic began, pushed the death toll above all other causes among Americans in this age group.
Guns accounted for more than 45,000 deaths among all age groups in 2020, also a record, according to the U.S. Centers for Disease Control and Prevention.
Although gun deaths rose across nearly every racial and ethnic group, the increase was greatest among Black children. In this group, firearms accounted for more than 15 deaths per 100,000 children in 2020 – up from about 12 such deaths in 2019.
Homicide was the leading cause of gun deaths, followed by suicide and then accidental shootings, although the reason for some deaths could not be determined, according to the researchers.
The researchers reported their findings in the New England Journal of Medicine.
Gun deaths among children are preventable, both researchers and advocates said.
“There are ways to reduce injuries without banning guns,” said Jason Goldstick, PhD, a statistician at the University of Michigan, Ann Arbor, who led the study.
Dr. Goldstick pointed to significant investments in car vehicle safety as a model for policy makers to follow today for making gun injuries less frequent and deadly.
“More people drive today than in the 1970s, and motor vehicle–related injury rates are much lower,” Dr. Goldstick said. Innovations like seatbelt laws and changes in how cars are built have made them less deadly during a crash. Similar innovations are possible in how guns are managed.
More than 4.6 million U.S. children live in homes with unsecured firearms, according to Shannon Watts of the advocacy organization Moms Demand Action. “Securely storing firearms unloaded, locked and separate from ammunition is a simple yet lifesaving action that all gun owners should follow – and lawmakers should require,” she said in a statement to this news organization.
“The effects of gun violence ripple far beyond the child who was struck by a bullet,” said Sarah Burd-Sharps, the senior director of research for the advocacy organization Everytown for Gun Safety. Children might grieve their friends who are now lost or worry that they will be next.
The data in this study aren’t surprising, Ms. Burd-Sharps said, given the large number of homes in which guns are unsecured and the sharp rise in gun sales during the pandemic. On average one child per day in the United States accesses an unsecured gun that ends up injuring or killing themself or someone else.
“Gun owners want to be responsible. These deaths are really preventable,” Ms. Burd-Sharps said. In addition to securing ammunition and firearms separately, she recommended wider use of biometric guns that can only be used by someone with a specific fingerprint. If a young person got ahold of such a gun, even if it was loaded, they couldn’t use it.
The researchers reported no relevant financial conflicts of interest.
A version of this article first appeared on Medscape.com.
In 2020, 4,357 children aged 1-19, or approximately 6 in 100,000, died from a gun-related injury, the researchers reported, modestly exceeding the number for auto accidents (3,913) and greatly exceeding deaths caused by suffocation (1,411) or drowning (966).
To observers of gun violence in this country, the grim statistical marker has been all but inevitable. Gunshots were the second-leading cause of death in 2016 among children aged 1-19, the researchers reported. But sharp rises in such fatalities since then, especially in 2020 as the COVID-19 pandemic began, pushed the death toll above all other causes among Americans in this age group.
Guns accounted for more than 45,000 deaths among all age groups in 2020, also a record, according to the U.S. Centers for Disease Control and Prevention.
Although gun deaths rose across nearly every racial and ethnic group, the increase was greatest among Black children. In this group, firearms accounted for more than 15 deaths per 100,000 children in 2020 – up from about 12 such deaths in 2019.
Homicide was the leading cause of gun deaths, followed by suicide and then accidental shootings, although the reason for some deaths could not be determined, according to the researchers.
The researchers reported their findings in the New England Journal of Medicine.
Gun deaths among children are preventable, both researchers and advocates said.
“There are ways to reduce injuries without banning guns,” said Jason Goldstick, PhD, a statistician at the University of Michigan, Ann Arbor, who led the study.
Dr. Goldstick pointed to significant investments in car vehicle safety as a model for policy makers to follow today for making gun injuries less frequent and deadly.
“More people drive today than in the 1970s, and motor vehicle–related injury rates are much lower,” Dr. Goldstick said. Innovations like seatbelt laws and changes in how cars are built have made them less deadly during a crash. Similar innovations are possible in how guns are managed.
More than 4.6 million U.S. children live in homes with unsecured firearms, according to Shannon Watts of the advocacy organization Moms Demand Action. “Securely storing firearms unloaded, locked and separate from ammunition is a simple yet lifesaving action that all gun owners should follow – and lawmakers should require,” she said in a statement to this news organization.
“The effects of gun violence ripple far beyond the child who was struck by a bullet,” said Sarah Burd-Sharps, the senior director of research for the advocacy organization Everytown for Gun Safety. Children might grieve their friends who are now lost or worry that they will be next.
The data in this study aren’t surprising, Ms. Burd-Sharps said, given the large number of homes in which guns are unsecured and the sharp rise in gun sales during the pandemic. On average one child per day in the United States accesses an unsecured gun that ends up injuring or killing themself or someone else.
“Gun owners want to be responsible. These deaths are really preventable,” Ms. Burd-Sharps said. In addition to securing ammunition and firearms separately, she recommended wider use of biometric guns that can only be used by someone with a specific fingerprint. If a young person got ahold of such a gun, even if it was loaded, they couldn’t use it.
The researchers reported no relevant financial conflicts of interest.
A version of this article first appeared on Medscape.com.
In 2020, 4,357 children aged 1-19, or approximately 6 in 100,000, died from a gun-related injury, the researchers reported, modestly exceeding the number for auto accidents (3,913) and greatly exceeding deaths caused by suffocation (1,411) or drowning (966).
To observers of gun violence in this country, the grim statistical marker has been all but inevitable. Gunshots were the second-leading cause of death in 2016 among children aged 1-19, the researchers reported. But sharp rises in such fatalities since then, especially in 2020 as the COVID-19 pandemic began, pushed the death toll above all other causes among Americans in this age group.
Guns accounted for more than 45,000 deaths among all age groups in 2020, also a record, according to the U.S. Centers for Disease Control and Prevention.
Although gun deaths rose across nearly every racial and ethnic group, the increase was greatest among Black children. In this group, firearms accounted for more than 15 deaths per 100,000 children in 2020 – up from about 12 such deaths in 2019.
Homicide was the leading cause of gun deaths, followed by suicide and then accidental shootings, although the reason for some deaths could not be determined, according to the researchers.
The researchers reported their findings in the New England Journal of Medicine.
Gun deaths among children are preventable, both researchers and advocates said.
“There are ways to reduce injuries without banning guns,” said Jason Goldstick, PhD, a statistician at the University of Michigan, Ann Arbor, who led the study.
Dr. Goldstick pointed to significant investments in car vehicle safety as a model for policy makers to follow today for making gun injuries less frequent and deadly.
“More people drive today than in the 1970s, and motor vehicle–related injury rates are much lower,” Dr. Goldstick said. Innovations like seatbelt laws and changes in how cars are built have made them less deadly during a crash. Similar innovations are possible in how guns are managed.
More than 4.6 million U.S. children live in homes with unsecured firearms, according to Shannon Watts of the advocacy organization Moms Demand Action. “Securely storing firearms unloaded, locked and separate from ammunition is a simple yet lifesaving action that all gun owners should follow – and lawmakers should require,” she said in a statement to this news organization.
“The effects of gun violence ripple far beyond the child who was struck by a bullet,” said Sarah Burd-Sharps, the senior director of research for the advocacy organization Everytown for Gun Safety. Children might grieve their friends who are now lost or worry that they will be next.
The data in this study aren’t surprising, Ms. Burd-Sharps said, given the large number of homes in which guns are unsecured and the sharp rise in gun sales during the pandemic. On average one child per day in the United States accesses an unsecured gun that ends up injuring or killing themself or someone else.
“Gun owners want to be responsible. These deaths are really preventable,” Ms. Burd-Sharps said. In addition to securing ammunition and firearms separately, she recommended wider use of biometric guns that can only be used by someone with a specific fingerprint. If a young person got ahold of such a gun, even if it was loaded, they couldn’t use it.
The researchers reported no relevant financial conflicts of interest.
A version of this article first appeared on Medscape.com.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Young and older athletes show similar arrhythmia patterns with fQRS
The prevalence of exercise-induced arrhythmias in young athletes with fragmented QRS (fQRS) patterns in lead V1 was 27%, similar to that seen in adult athletes, based on data from nearly 700 individuals.
Recent data suggest that fQRS complex in lead V1 (fQRSV1) in healthy athletes may promote arrhythmias in the context of training-induced right ventricular remodeling, but the prevalence and significance in young athletes has not been well studied, Guilia Quinto, MD, of the University of Padova (Italy) said in a presentation at the annual congress of the European Association of Preventive Cardiology.
Dr. Quinto and colleagues assessed data from of young athletes on ventricular arrhythmias during exercise tests.
The study population included 684 young athletes with a mean age of 15 years; 64% were male. Baseline data collection included medical history, physical exam, resting ECG, standardized maximum exercise tolerance, and echocardiography evaluation.
The overall prevalence of fQRSV1 was 27%. Individuals with fQRSV1 were significantly less likely than those without fQRSV1 to be female (22% vs. 43%), and to present with a lower resting heart rate (66.98 beats per minute vs. 70.08 beats per minute).
Echocardiographic data showed that individuals with fQRSV1 had significantly different morphological and functional right ventricular characteristics.
Notably, right ventricular end-diastolic diameter was 20.42 mm/m2 among individuals with fQRSV1 and 19.81 mm/m2 in those without, a significant difference (P = .019), Dr. Quinto said. Tricuspid annulus plain systolic excursion also differed significantly; 24.33 mm and 23.75 mm for individuals with and without fQRSV1, respectively (P = .013).
However, the individuals with fQRSV1 showed no increased occurrence of any type of exercise-induced arrhythmias regardless of morphology or complexity, said Dr. Quinto.
The prevalence of common and uncommon arrhythmias among individuals with and without fQRSV1 was 31% versus 34% and 13% versus 11%, respectively; these differences were not significant.
The study findings were limited by the relatively small size, but were strengthened by the review of echocardiographic data by two independent physicians, she said.
The results show that the overall prevalence of fQRSV1 in young athletes is comparable with patterns seen in studies of adult athletes, and no differences in exercise-induced arrhythmias occurred despite differences in right ventricular characteristics, she concluded.
Expanded insight into evaluation
The ECG pattern identified in the current study is often encountered in the evaluation of athletes, but its importance was unknown, Matthew Martinez, MD, a sports cardiologist at the Atlantic Health System in Morristown, N.J., said in an interview.
“Studies of ECG findings in athletes continues to inform us about which findings are important to evaluate. This study furthers our understanding of how to proceed,” and will serve as a guide for additional testing to reduce athlete risk, he said.
Looking ahead, “this study should guide clinicians about additional testing and evaluation when fQRS is present in adolescent athletes compared to adults,” Dr. Martinez noted. However, additional research is needed to determine which is the next best test, and whether the patient requires ongoing surveillance, or whether a single evaluation is sufficient, he said. “Further study should focus on best practices after fQRS is identified and whether outcomes can be linked to this finding.”
The study received no outside funding. Dr. Quinto and Dr. Martinez had no financial conflicts to disclose.
The prevalence of exercise-induced arrhythmias in young athletes with fragmented QRS (fQRS) patterns in lead V1 was 27%, similar to that seen in adult athletes, based on data from nearly 700 individuals.
Recent data suggest that fQRS complex in lead V1 (fQRSV1) in healthy athletes may promote arrhythmias in the context of training-induced right ventricular remodeling, but the prevalence and significance in young athletes has not been well studied, Guilia Quinto, MD, of the University of Padova (Italy) said in a presentation at the annual congress of the European Association of Preventive Cardiology.
Dr. Quinto and colleagues assessed data from of young athletes on ventricular arrhythmias during exercise tests.
The study population included 684 young athletes with a mean age of 15 years; 64% were male. Baseline data collection included medical history, physical exam, resting ECG, standardized maximum exercise tolerance, and echocardiography evaluation.
The overall prevalence of fQRSV1 was 27%. Individuals with fQRSV1 were significantly less likely than those without fQRSV1 to be female (22% vs. 43%), and to present with a lower resting heart rate (66.98 beats per minute vs. 70.08 beats per minute).
Echocardiographic data showed that individuals with fQRSV1 had significantly different morphological and functional right ventricular characteristics.
Notably, right ventricular end-diastolic diameter was 20.42 mm/m2 among individuals with fQRSV1 and 19.81 mm/m2 in those without, a significant difference (P = .019), Dr. Quinto said. Tricuspid annulus plain systolic excursion also differed significantly; 24.33 mm and 23.75 mm for individuals with and without fQRSV1, respectively (P = .013).
However, the individuals with fQRSV1 showed no increased occurrence of any type of exercise-induced arrhythmias regardless of morphology or complexity, said Dr. Quinto.
The prevalence of common and uncommon arrhythmias among individuals with and without fQRSV1 was 31% versus 34% and 13% versus 11%, respectively; these differences were not significant.
The study findings were limited by the relatively small size, but were strengthened by the review of echocardiographic data by two independent physicians, she said.
The results show that the overall prevalence of fQRSV1 in young athletes is comparable with patterns seen in studies of adult athletes, and no differences in exercise-induced arrhythmias occurred despite differences in right ventricular characteristics, she concluded.
Expanded insight into evaluation
The ECG pattern identified in the current study is often encountered in the evaluation of athletes, but its importance was unknown, Matthew Martinez, MD, a sports cardiologist at the Atlantic Health System in Morristown, N.J., said in an interview.
“Studies of ECG findings in athletes continues to inform us about which findings are important to evaluate. This study furthers our understanding of how to proceed,” and will serve as a guide for additional testing to reduce athlete risk, he said.
Looking ahead, “this study should guide clinicians about additional testing and evaluation when fQRS is present in adolescent athletes compared to adults,” Dr. Martinez noted. However, additional research is needed to determine which is the next best test, and whether the patient requires ongoing surveillance, or whether a single evaluation is sufficient, he said. “Further study should focus on best practices after fQRS is identified and whether outcomes can be linked to this finding.”
The study received no outside funding. Dr. Quinto and Dr. Martinez had no financial conflicts to disclose.
The prevalence of exercise-induced arrhythmias in young athletes with fragmented QRS (fQRS) patterns in lead V1 was 27%, similar to that seen in adult athletes, based on data from nearly 700 individuals.
Recent data suggest that fQRS complex in lead V1 (fQRSV1) in healthy athletes may promote arrhythmias in the context of training-induced right ventricular remodeling, but the prevalence and significance in young athletes has not been well studied, Guilia Quinto, MD, of the University of Padova (Italy) said in a presentation at the annual congress of the European Association of Preventive Cardiology.
Dr. Quinto and colleagues assessed data from of young athletes on ventricular arrhythmias during exercise tests.
The study population included 684 young athletes with a mean age of 15 years; 64% were male. Baseline data collection included medical history, physical exam, resting ECG, standardized maximum exercise tolerance, and echocardiography evaluation.
The overall prevalence of fQRSV1 was 27%. Individuals with fQRSV1 were significantly less likely than those without fQRSV1 to be female (22% vs. 43%), and to present with a lower resting heart rate (66.98 beats per minute vs. 70.08 beats per minute).
Echocardiographic data showed that individuals with fQRSV1 had significantly different morphological and functional right ventricular characteristics.
Notably, right ventricular end-diastolic diameter was 20.42 mm/m2 among individuals with fQRSV1 and 19.81 mm/m2 in those without, a significant difference (P = .019), Dr. Quinto said. Tricuspid annulus plain systolic excursion also differed significantly; 24.33 mm and 23.75 mm for individuals with and without fQRSV1, respectively (P = .013).
However, the individuals with fQRSV1 showed no increased occurrence of any type of exercise-induced arrhythmias regardless of morphology or complexity, said Dr. Quinto.
The prevalence of common and uncommon arrhythmias among individuals with and without fQRSV1 was 31% versus 34% and 13% versus 11%, respectively; these differences were not significant.
The study findings were limited by the relatively small size, but were strengthened by the review of echocardiographic data by two independent physicians, she said.
The results show that the overall prevalence of fQRSV1 in young athletes is comparable with patterns seen in studies of adult athletes, and no differences in exercise-induced arrhythmias occurred despite differences in right ventricular characteristics, she concluded.
Expanded insight into evaluation
The ECG pattern identified in the current study is often encountered in the evaluation of athletes, but its importance was unknown, Matthew Martinez, MD, a sports cardiologist at the Atlantic Health System in Morristown, N.J., said in an interview.
“Studies of ECG findings in athletes continues to inform us about which findings are important to evaluate. This study furthers our understanding of how to proceed,” and will serve as a guide for additional testing to reduce athlete risk, he said.
Looking ahead, “this study should guide clinicians about additional testing and evaluation when fQRS is present in adolescent athletes compared to adults,” Dr. Martinez noted. However, additional research is needed to determine which is the next best test, and whether the patient requires ongoing surveillance, or whether a single evaluation is sufficient, he said. “Further study should focus on best practices after fQRS is identified and whether outcomes can be linked to this finding.”
The study received no outside funding. Dr. Quinto and Dr. Martinez had no financial conflicts to disclose.
FROM ESC PREVENTIVE CARDIOLOGY 2022