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OBJECTIVE To assess the use of a portable retinal camera in diabetic retinopathy (DR) screening in multiple settings and the presence of associated risk factors among children, adolescents, and young adults with type 1 diabetes. DESIGN AND METHODS Five hundred youth with type 1 diabetes of at least 1 year’s duration were recruited from clinics, diabetes camp, and a diabetes conference and underwent retinal imaging using a nonmydriatic fundus camera. Retinal characterization was performed remotely by a licensed ophthalmologist. Risk factors for DR development were evaluated by a patient-reported questionnaire and medical chart review. RESULTS Of the 500 recruited subjects aged 9–26 years (mean 14.9, SD 3.8), 10 cases of DR were identified (nine mild and one moderate nonproliferative DR) with 100% of images of gradable quality. The prevalence of DR was 2.04% (95% CI 0.78–3.29), at an average age of 20.2 years, with the youngest affected subject being 17.1 years of age. The rate of DR was higher, at 6.5%, with diabetes duration >10 years (95% CI 0.86–12.12, P = 0.0002). In subjects with DR, the average duration of diabetes was 12.1 years (SD 4.6, range 6.2–20.0), and in a subgroup of clinic-only subjects (n = 114), elevated blood pressure in the year before screening was associated with DR (P = 0.0068). CONCLUSION This study in a large cohort of subjects with type 1 diabetes demonstrates that older adolescents and young adults (>17 years) with longer disease duration (>6 years) are at risk for DR development, and screening using a portable retinal camera is feasible in clinics and other locations. Recent elevated blood pressure was a risk factor in an analyzed subgroup.

Early detection of diabetic retinopathy (DR) is imperative; however, adherence to screening guidelines is poor. We hypothesized that youth and young adults with type 1 diabetes (T1D) who met American Diabetes Association criteria for recommended DR screening at the time of the study (10 years old or greater with diabetes duration of 5 years or more) would report multiple barriers to screening and that targeted barriers and subpopulations could be identified to improve access to care. 271 youth aged 10 to 26 years with T1D of at least 5 years duration were recruited from clinic, diabetes camp, and a diabetes conference and completed a patient-reported questionnaire. 113 (41.7%) reported at least one barrier to DR screening, with missed school and work being the most common (20.7%). Older participants (P = 0.007) and those with a longer diabetes duration (P = 0.018) were more likely to report barriers to screening. Recruitment location, sex, race and ethnicity, HbA1c, insulin regimen, and clinic visit frequency were not associated with reporting at least one barrier. Slightly less than two-thirds (62.1%) of participants who responded (n = 235 out of 271) adhered to recommended screening guidelines of the time and reported having an eye exam within the past year, 24.7% 12-23 months ago, 9.8% 2 years ago or more, and 3.4% had never had a DR exam. As older patients and those with longer duration of diabetes are more likely to have DR, targeted interventions to address barriers to care, such as, missed school and work should be implemented in these groups.

Objective assessment of diabetes knowledge is essential to providing effective diabetes education. There is currently no such resource or instrument designed for pediatric clinical use and validated in the target population. We developed and validated the Knowledge Assessment in T1D (KAT-1) for this purpose. The KAT-1 has a total of 109 multiple choice items divided into 11 subscales designed to be taken individually. Following a pilot study to optimize the KAT-1, a validation study was performed with 200 participants (60% privately insured; 70% female; mean child A1c 8.2%; 10% African American, 11% Hispanic), including 50 parents of children with T1D Disclosure A. Albanese-O'Neill: None. J.W. MacInnes: None. N.T. Thomas: None. M.J. Haller: Advisory Panel; Self; Pancreum, SAB Biotherapeutics. D. Schatz: None. J. Silverstein: None. J. Adams: None. R. Oyetoro: None. B.A. Kershaw: None. K. Anderson: None. A. Bernier: None.

Objective To describe the clinical characteristics, treatment approaches, clinical outcomes, and co-morbidities of youth with type 2 diabetes (T2D) enrolled in the Pediatric Diabetes Consortium (PDC) T2D Registry. Methods PDC enrolled 598 youth

The incidence and prevalence of type 2 diabetes (T2D) in youth are steadily increasing. The Centers for Disease Control and Prevention recently published the projected prevalence of T2D in youth using the SEARCH for Diabetes in Youth Study database from 2001 for prevalence and 2002 for incidence. Based on these data and assuming a 2.3% increase annually, it is predicted that the prevalence of T2D in youth could quadruple in 40 years. 1 As in adults with T2D, adolescents develop macrovascular and microvascular complications, including albuminuria, hypertension, and dyslipidemia. These complications occur earlier and appear to be more rapidly progressive in youths than in adults. 2 Thus, prevention and treatment of T2D is paramount. Prevention begins with addressing known risk factors for developing T2D, the most important of which is obesity. Most youths with T2D have a body mass index (BMI) greater than the 85th percentile and are diagnosed between the ages of 10 and 16 years, around the time of puberty and the associated physiologic insulin resistance. 3 Occurrence is familial; 74%100% of adolescents with T2D have an affected first or second degreerelative. 4 OtherriskfactorsfordevelopingT2Darelarge forgestationalageorsmallforgestationalagebirthweightsand high risk ethnicities. American Indians are the most affected, followed in decreasing order by African Americans, Hispanics, Asian/Pacific Islanders, and non-Hispanic Whites. 3 Understanding the pathophysiology of diabetes has led to the development of novel treatments. T2D is due to insulin resistance and a relative insulin deficiency due to beta cell dysfunction with eventual beta cell failure. The time to beta cell failure in youth is more rapid than in adulthood, with the rate of beta cell function declining by � 20% per year in 6 youths who underwent clamp studies. 5 Explanations for the beta cell failure include beta cell exhaustion because of increased insulin secretion to compensate for insulin resistance, desensitization of the beta cell because of hyperglycemia (glucotoxicity), lipotoxicity, and a reduction of beta cell mass from amyloid deposition. 6 At diag

Examine whether unhealthy and extreme weight control behaviors (WCBs) mediate the relationship between youth weight status and disease-specific health-related quality of life (HRQOL) in treatment-seeking youth who are overweight and obese (OV/OB). 82 youth 10–17 years of age who were OV/OB and attending an outpatient obesity-related medical appointment completed measures assessing unhealthy and extreme WCBs and disease-specific HRQOL. Parents completed a demographic questionnaire and medical staff measured youth height and weight. Regression analyses revealed that unhealthy WCBs mediated the associations between youth weight status and emotional and social avoidance disease-specific HRQOL, such that higher body mass index (BMI) predicted unhealthy WCBs, which were ultimately associated with poorer emotional and social HRQOL. Mediation analyses were not significant for total, physical, teasing/marginalization, and positive attributes disease-specific HRQOL. In addition, extreme WCBs did not mediate the association between youth weight status and any subscales of the disease-specific HRQOL measure. Weight status is an important predictor of disease-specific HRQOL in OV/OB youth; however, the association with emotional and social HRQOL is partially accounted for by youth engagement in unhealthy WCBs. Clinicians and researchers should assess WCBs and further research should explore and evaluate appropriate intervention strategies to address unhealthy WCBs in pediatric weight management prevention and treatment efforts.

Patient-centered approaches to disease management are consistently recognized as valuable tools for improving health outcomes, yet studies are rarely designed to elicit adolescent perspectives. This study sought to better understand the perspectives of youths with type 1 diabetes according to key demographic variables. We conducted an exploratory study through which 40 youths were provided with disposable cameras and prompted to take five photographs each that captured what diabetes meant to them and to provide narratives to accompany their photo choices. Demographic variables examined included sex, age, disease duration, socioeconomic status (SES), race, and glycemic control (A1C). Content analysis was used for photos and open-ended responses to assign photo index scores, which were then analyzed by demographic variables using Mann-Whitney U tests for statistical significance. Analysis of photos/narratives (n = 202) revealed five main types of representations depicted by at least 50% of the young people. “Challenge” photos included diabetes supplies as tethering, food as a source of frustration, and the body as a territory for disease encroachment. “Resilience” photos included coping mechanisms and symbols of resistance. Overall, these representations were consistent across demographic categories with two exceptions. Males took more food depictions than females (P

IN BRIEF Low socioeconomic status (SES) is consistently identified as a major risk factor for poor health outcomes in youths with type 1 diabetes, yet little is known about the social factors that yield such disparities. This study used survey research to examine the role of SES by focusing on differential resourcing in social support systems for youths with type 1 diabetes and their parents/caregivers. We identified significant inequalities in social support systems and found that parents from lower-income households engage in few coping activities and rarely identify a primary care provider as the main point of contact when facing a diabetes-related problem. Our findings underscore the need to better connect low SES families to diabetes-specific professional resourcing and to raise awareness about the importance of extracurricular activities as a form of social support for youths.

The benefits of animal-companion ties to well-being are consistently documented, yet few studies use patient-centered methodologies to examine how youth living with chronic illnesses rely on domestic pets for support. Youth with type 1 diabetes (T1D) aged 12 to 19 years (N=40) completed surveys involving a prompt to take five photos of “what diabetes means to you,” with an accompanying narrative. Content analysis was conducted for photos/narratives and numeric variables analyzed including socio-economic status (SES: measured by total household income and years of parental education) and HbA1C. More than half of the youth participants took pictures of coping mechanisms, including pictures of their pets. In fact, pictures of pets outnumbered pictures of people three to one. Pet depictions were captured by youth from all SES levels. Youth with T1D identify pets as an important source of support. More research is needed to understand how pets may offset disease burden for youth with T1D.

Objective To examine the association between caregiver proxy report of executive function (EF) and dysregulated eating behavior in children with obesity. Methods Participants were 195 youth with obesity aged 8-17 years, and their legal guardians. Youth height, weight, demographics, depressive symptoms, eating behaviors, and EF were assessed cross-sectionally during a medical visit. Analyses of covariance, adjusted for child age, gender, race/ethnicity, standardized BMI, depressive symptoms, and family income were used to examine differences in youth EF across caregiver and youth self-report of eating behaviors. Results Youth EF differed significantly by caregiver report of eating behavior but not youth self-report. Post hoc analyses showed that youth with overeating or binge eating had poorer EF than youth without these eating behaviors. Conclusions Executive dysfunction, as reported by caregivers, in youth with obesity may be associated with dysregulated eating behaviors predictive of poor long-term psychosocial and weight outcomes. Further consideration of EF-specific targets for assessment and intervention in youth with obesity may be warranted.

Cosponsoring Associations:The European Society of Endocrinology and the Pediatric Endocrine Society. This guideline was funded by the Endocrine Society.Objective:To formulate clinical practice guidelines for the assessment, treatment, and prevention of pediatric obesity.Participants:The participants include an Endocrine Society–appointed Task Force of 6 experts, a methodologist, and a medical writer.Evidence:This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The Task Force commissioned 2 systematic reviews and used the best available evidence from other published systematic reviews and individual studies.Consensus Process:One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society committees and members and co-sponsoring organizations reviewed and commented on preliminary drafts of this guideline.Conclusion:Pediatric obesity remains an ongoing serious international health concern affecting ∼17% of US children and adolescents, threatening their adult health and longevity. Pediatric obesity has its basis in genetic susceptibilities influenced by a permissive environment starting in utero and extending through childhood and adolescence. Endocrine etiologies for obesity are rare and usually are accompanied by attenuated growth patterns. Pediatric comorbidities are common and long-term health complications often result; screening for comorbidities of obesity should be applied in a hierarchal, logical manner for early identification before more serious complications result. Genetic screening for rare syndromes is indicated only in the presence of specific historical or physical features. The psychological toll of pediatric obesity on the individual and family necessitates screening for mental health issues and counseling as indicated. The prevention of pediatric obesity by promoting healthful diet, activity, and environment should be a primary goal, as achieving effective, long-lasting results with lifestyle modification once obesity occurs is difficult. Although some behavioral and pharmacotherapy studies report modest success, additional research into accessible and effective methods for preventing and treating pediatric obesity is needed. The use of weight loss medications during childhood and adolescence should be restricted to clinical trials. Increasing evidence demonstrates the effectiveness of bariatric surgery in the most seriously affected mature teenagers who have failed lifestyle modification, but the use of surgery requires experienced teams with resources for long-term follow-up. Adolescents undergoing lifestyle therapy, medication regimens, or bariatric surgery for obesity will need cohesive planning to help them effectively transition to adult care, with continued necessary monitoring, support, and intervention. Transition programs for obesity are an uncharted area requiring further research for efficacy. Despite a significant increase in research on pediatric obesity since the initial publication of these guidelines 8 years ago, further study is needed of the genetic and biological factors that increase the risk of weight gain and influence the response to therapeutic interventions. Also needed are more studies to better understand the genetic and biological factors that cause an obese individual to manifest one comorbidity vs another or to be free of comorbidities. Furthermore, continued investigation into the most effective methods of preventing and treating obesity and into methods for changing environmental and economic factors that will lead to worldwide cultural changes in diet and activity should be priorities. Particular attention to determining ways to effect systemic changes in food environments and total daily mobility, as well as methods for sustaining healthy body mass index changes, is of importance.

This study compared quality of life (QOL) and psychosocial functioning of youth who are overweight and obese, with and without sleep troubles. A total of 80 youth (8-17 years) and their parents completed questionnaires assessing child QOL, psychosocial functioning, and sleep during an outpatient Obesity Clinic appointment. Twenty-nine percent of children reported sleep troubles. Youth with sleep troubles reported lower QOL and more internalizing problems than youth without sleep troubles. Longitudinal research with repeated measurement and use of validated measures of sleep is warranted. These preliminary data suggest improved sleep may help increase behavioral and psychosocial functioning in obese youth.

Patient Female, 11 FINAL DIAGNOSIS: Thyroid storm Symptoms: Diarrhea • tachycardia • tachypnea • tremor • wheezing Medication - Clinical Procedure: - Specialty: - Objective Rare disease. Background A growing number of pediatric endocrinologists treat Graves disease with radioactive iodine (RAI) therapy due to the typically definitive nature of I-131 therapy. Given the published benefits and perceived low risks of RAI when compared to surgery or long-term anti-thyroid medication, the trend towards therapy with RAI is likely to continue. Nevertheless, RAI is not without significant risk. Case report An 11-year-old girl with newly diagnosed Graves disease received RAI for definitive treatment of her hyperthyroidism. Within 24 hours of receiving I-131, she developed increasing sleepiness and eventually became unresponsive. Upon arrival at the emergency department she had a tonic-clonic seizure and was diagnosed with thyroid storm. Despite best efforts to manage her hyperthyroidism, she suffered a stroke of the left cerebral hemisphere that left her with persistent neurological deficits. Conclusions Although thyroid storm after thyroid ablation is rare, the significant morbidity and potential mortality of pediatric thyroid storm warrant further studies to determine if children with markedly elevated thyroid hormone concentrations at diagnosis should receive prolonged pretreatment with anti-thyroid drugs. While such an approach may reduce the efficacy of I-131 ablation, it can also reduce and hopefully eliminate the risk of post-ablative thyroid storm.

This study examined relations among diabetes-specific family factors, adherence to medical regimen, quality of life (QOL), and glycemic control in youth and adolescents with type 1 diabetes. During an endocrinologist visit, patient and parent–caregiver dyads (n = 70) completed family factors and QOL measures and participated in a structured interview to assess medical regimen compliance, and the patient's glycemic control was assessed by a medical professional. Combined measures accounted for 42% of the variance in glycemic control. QOL partially mediated adherence and glycemic control. Ethnic minority status was associated with poorer glycemic control.

To better elucidate the experiences and perspectives of youth and families living with type 1 diabetes mellitus (T1D), we conducted survey research with 40 youth and their parents/caregivers. Youth were provided with disposable cameras and prompted to take 5 pictures that captured what diabetes meant to them accompanied by narratives explaining their photo choices. Demographic data were collected to examine possible variations in photos/representations, including gender, age, disease duration, socioeconomic status, race, and glycemic control (measured with glycated hemoglobin). Qualitative content analysis was conducted for photos and open-ended survey responses. Quantitative analysis included a comparison of means through Mann-Whitney U tests for statistical significance. In all, 68% of youth took at least 1 photograph of food, and 90% of parents/caregivers addressed food-specific issues, demonstrating 3 broad categories of representation: food as off limits, food as laborious, and food as exclusionary. The only demographic variable that proved to be significant was gender: male participants took more food-specific photos than their female counterparts (P ≤ .005). Food-specific issues signify challenging and negative aspects of living with T1D, and these experiences are particularly intense for male participants. The inclusion of patient perspectives through nontraditional methodologies such as photography could provide greater insight into adolescent perspectives.

Objective To identify determinants of HbA1c levels one year after the diagnosis of type 1 diabetes (T1D) in participants in the Pediatric Diabetes Consortium (PDC) T1D New Onset (NeOn) Study.

The CHIRP study is a two-arm, pilot randomized controlled trial assessing the effectiveness of a behavioral family weight management intervention in an important and at-risk population, overweight young children, 3 to 6 years of age, and their parents from underserved rural counties. Participants will include 96 parent–child dyads living in rural counties in north central Florida. Families will be randomized to one of two conditions: (a) behavioral family based intervention or (b) a waitlist control. Child and parent participants will be assessed at baseline (month 0), post-treatment (month 4), and follow-up (month 10). Assessments and intervention sessions will be held at the Cooperative Extension office in each participating rural county. The primary outcome measure is change in child body mass index (BMI) z-score. Additional key outcome measures include child dietary intake, physical activity, and parent BMI. This study is unique because (1) it is one of the few randomized controlled trails examining a behavioral family intervention to address healthy habits and improved weight status in young overweight and obese children, (2) addresses health promotion in rural settings, and (3) examines intervention delivery in real world community settings through the Cooperative Extension Service offices. If successful, this research has potential implications for medically underserved rural communities and preventative health services for young children and their families.

OBJECTIVE:Over the last 3 decades, the prevalence of childhood obesity has increased dramatically in North America, ushering in a variety of health problems, including type 2 diabetes mellitus (T2DM), which previously was not typically seen until much later in life. This technical report describes, in detail, the procedures undertaken to develop the recommendations given in the accompanying clinical practice guideline, “Management of Type 2 Diabetes Mellitus in Children and Adolescents,” and provides in-depth information about the rationale for the recommendations and the studies used to make the clinical practice guideline’s recommendations.METHODS:A primary literature search was conducted relating to the treatment of T2DM in children and adolescents, and a secondary literature search was conducted relating to the screening and treatment of T2DM’s comorbidities in children and adolescents. Inclusion criteria were prospectively and unanimously agreed on by members of the committee. An article was eligible for inclusion if it addressed treatment (primary search) or 1 of 4 comorbidities (secondary search) of T2DM, was published in 1990 or later, was written in English, and included an abstract. Only primary research inquiries were considered; review articles were considered if they included primary data or opinion. The research population had to constitute children and/or adolescents with an existing diagnosis of T2DM; studies of adult patients were considered if at least 10% of the study population was younger than 35 years. All retrieved titles, abstracts, and articles were reviewed by the consulting epidemiologist.RESULTS:Thousands of articles were retrieved and considered in both searches on the basis of the aforementioned criteria. From those, in the primary search, 199 abstracts were identified for possible inclusion, 58 of which were retained for systematic review. Five of these studies were classified as grade A studies, 1 as grade B, 20 as grade C, and 32 as grade D. Articles regarding treatment of T2DM selected for inclusion were divided into 4 major subcategories on the basis of type of treatment being discussed: (1) medical treatments (32 studies); (2) nonmedical treatments (9 studies); (3) provider behaviors (8 studies); and (4) social issues (9 studies). From the secondary search, an additional 336 abstracts relating to comorbidities were identified for possible inclusion, of which 26 were retained for systematic review. These articles included the following: 1 systematic review of literature regarding comorbidities of T2DM in adolescents; 5 expert opinions presenting global recommendations not based on evidence; 5 cohort studies reporting natural history of disease and comorbidities; 3 with specific attention to comorbidity patterns in specific ethnic groups (case-control, cohort, and clinical report using adult literature); 3 reporting an association between microalbuminuria and retinopathy (2 case-control, 1 cohort); 3 reporting the prevalence of nephropathy (cohort); 1 reporting peripheral vascular disease (case series); 2 discussing retinopathy (1 case-control, 1 position statement); and 3 addressing hyperlipidemia (American Heart Association position statement on cardiovascular risks; American Diabetes Association consensus statement; case series). A breakdown of grade of recommendation shows no grade A studies, 10 grade B studies, 6 grade C studies, and 10 grade D studies. With regard to screening and treatment recommendations for comorbidities, data in children are scarce, and the available literature is conflicting. Therapeutic recommendations for hypertension, dyslipidemia, retinopathy, microalbuminuria, and depression were summarized from expert guideline documents and are presented in detail in the guideline. The references are provided, but the committee did not independently assess the supporting evidence. Screening tools are provided in the Supplemental Information.

Objective Current data are limited on the course of type 1 diabetes (T1D) in children and adolescents through the first few years of diabetes. The Pediatric Diabetes Consortium T1D new onset (NeOn) Study was undertaken to prospectively assess natural history and clinical outcomes in children treated at 7 US diabetes centers from the time of diagnosis. This paper describes clinical outcomes in the T1D NeOn cohort during the first 3 years postdiagnosis. Results A total of 1048 participants (mean age 9.2 years, 49% female, 65% non-Hispanic White) were enrolled between July 2009 and April 2011. Mean glycated hemoglobin (HbA1c) (±SD) was 7.2% (55 mmol/mol) at 3 months, followed by a progressive rise to 8.4% (68 mmol/mol) at 36 months postdiagnosis, with only 30% of participants achieving target HbA1c

The US market for organic foods has grown from $3.5 billion in 1996 to $28.6 billion in 2010, according to the Organic Trade Association. Organic products are now sold in specialty stores and conventional supermarkets. Organic products contain numerous marketing claims and terms, only some of which are standardized and regulated. In terms of health advantages, organic diets have been convincingly demonstrated to expose consumers to fewer pesticides associated with human disease. Organic farming has been demonstrated to have less environmental impact than conventional approaches. However, current evidence does not support any meaningful nutritional benefits or deficits from eating organic compared with conventionally grown foods, and there are no well-powered human studies that directly demonstrate health benefits or disease protection as a result of consuming an organic diet. Studies also have not demonstrated any detrimental or disease-promoting effects from an organic diet. Although organic foods regularly command a significant price premium, well-designed farming studies demonstrate that costs can be competitive and yields comparable to those of conventional farming techniques. Pediatricians should incorporate this evidence when discussing the health and environmental impact of organic foods and organic farming while continuing to encourage all patients and their families to attain optimal nutrition and dietary variety consistent with the US Department of Agriculture’s MyPlate recommendations. This clinical report reviews the health and environmental issues related to organic food production and consumption. It defines the term “organic,” reviews organic food-labeling standards, describes organic and conventional farming practices, and explores the cost and environmental implications of organic production techniques. It examines the evidence available on nutritional quality and production contaminants in conventionally produced and organic foods. Finally, this report provides guidance for pediatricians to assist them in advising their patients regarding organic and conventionally produced food choices.

This study examined agreement and disagreement between child and caregiver reports of healthy, unhealthy, and extreme weight control behaviors (WCBs) in overweight and obese children.Participants were 93 youth 10-17 years old [M = 12.9; standard deviation (SD) = 2.1] attending an outpatient pediatric obesity clinic and their caregivers. Children and caregivers completed a measure examining child use of healthy, unhealthy, and extreme WCBs. Caregivers also completed a demographic questionnaire.Significant differences between child and caregiver reports were found for child engagement in healthy, t(88) = 2.13, p0.05, and unhealthy WCBs, t(91) = 2.19, p0.05. Children endorsed using more WCBs to lose or maintain weight within the past year compared to caregiver report. No differences were found for extreme WCBs t(92) = 1.72, p = 0.09. Agreement between child and caregiver reports of WCBs ranged from slight to moderate (Cohen kappa = 0.11 to 0.43) for healthy WCBs, fair to moderate (0.25 to 0.44) for unhealthy WCBs, and fair to substantial (0.36 to 0.66) for extreme WCBs.Comparing child and caregiver reports of different WCBs used by children is important due to the differences and ranges of agreement found. Agreement between child and caregiver reports of WCBs in this sample was higher than in previous research. These findings highlight the importance of including both child and caregiver reports of healthy, unhealthy, and extreme WCBs in future research.

The European Society of Endocrinology and the Pediatric Endocrine Society. This guideline was funded by the Endocrine Society.To formulate clinical practice guidelines for the assessment, treatment, and prevention of pediatric obesity.The participants include an Endocrine Society-appointed Task Force of 6 experts, a methodologist, and a medical writer.This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The Task Force commissioned 2 systematic reviews and used the best available evidence from other published systematic reviews and individual studies.One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society committees and members and co-sponsoring organizations reviewed and commented on preliminary drafts of this guideline.Pediatric obesity remains an ongoing serious international health concern affecting ∼17% of US children and adolescents, threatening their adult health and longevity. Pediatric obesity has its basis in genetic susceptibilities influenced by a permissive environment starting in utero and extending through childhood and adolescence. Endocrine etiologies for obesity are rare and usually are accompanied by attenuated growth patterns. Pediatric comorbidities are common and long-term health complications often result; screening for comorbidities of obesity should be applied in a hierarchal, logical manner for early identification before more serious complications result. Genetic screening for rare syndromes is indicated only in the presence of specific historical or physical features. The psychological toll of pediatric obesity on the individual and family necessitates screening for mental health issues and counseling as indicated. The prevention of pediatric obesity by promoting healthful diet, activity, and environment should be a primary goal, as achieving effective, long-lasting results with lifestyle modification once obesity occurs is difficult. Although some behavioral and pharmacotherapy studies report modest success, additional research into accessible and effective methods for preventing and treating pediatric obesity is needed. The use of weight loss medications during childhood and adolescence should be restricted to clinical trials. Increasing evidence demonstrates the effectiveness of bariatric surgery in the most seriously affected mature teenagers who have failed lifestyle modification, but the use of surgery requires experienced teams with resources for long-term follow-up. Adolescents undergoing lifestyle therapy, medication regimens, or bariatric surgery for obesity will need cohesive planning to help them effectively transition to adult care, with continued necessary monitoring, support, and intervention. Transition programs for obesity are an uncharted area requiring further research for efficacy. Despite a significant increase in research on pediatric obesity since the initial publication of these guidelines 8 years ago, further study is needed of the genetic and biological factors that increase the risk of weight gain and influence the response to therapeutic interventions. Also needed are more studies to better understand the genetic and biological factors that cause an obese individual to manifest one comorbidity vs another or to be free of comorbidities. Furthermore, continued investigation into the most effective methods of preventing and treating obesity and into methods for changing environmental and economic factors that will lead to worldwide cultural changes in diet and activity should be priorities. Particular attention to determining ways to effect systemic changes in food environments and total daily mobility, as well as methods for sustaining healthy body mass index changes, is of importance.

This pilot study examined the efficacy of a behavioral family intervention (BFI) to address weight management in obese children from economically disadvantaged backgrounds. Forty children, ages 6 to 12, and their parents enrolled in Medicaid were assigned to a BFI or an individual standard of care condition. Assessments were completed at baseline, posttreatment, and 9-month follow up. There were no differences in weight outcomes across treatment conditions. However, there were trends to suggest differences in weight change by child race. Specifically, children identified as African American benefited less from the BFI than Caucasian children. Implications for practice and research are discussed.

Graziano PA, Geffken GR, Williams LB, Lewin AB, Duke DC, Storch EA, Silverstein JH. Gender differences in the relationship between parental report of self-regulation skills and adolescents' management of type 1 diabetes. Objective: To examine the extent to which self-regulation skills of adolescents with type 1 diabetes (T1D), including executive functioning and emotion regulation, relate to treatment adherence and glycemic control. Method: Participants were 109 adolescents aged 12–18 yr with TID and their primary caregiver who attended an outpatient appointment at a pediatric endocrinology clinic. Parents and adolescents completed a measure of treatment adherence. Parents completed a self-regulation measure while a glycemic control measure [i.e., hemoglobin A1c (HbA1c)] was collected. Results: For boys, executive functioning and emotion regulation deficits were significantly associated with worse treatment adherence and glycemic control. Further analyses indicated that emotion regulation was the primary self-regulation measure related to treatment adherence and glycemic control. No significant associations were found for girls. Conclusion: For adolescent boys, the ability to cope with various stressors and emotions may be as important as higher-order thinking skills for maximizing treatment adherence and diabetes control. Clinical implications and potential mechanisms by which emotion regulation skills relate to adolescent boys' diabetes treatment management are discussed.

This study examined whether social support moderates the relation between peer victimization and depressive symptoms in children who are obese. Participants were 96 children 8 to 17 years of age (M = 12.8, SD = 1.8) attending a pediatric obesity clinic. Children completed self-report measures. Results indicated that for obese girls peer social support significantly moderated the association between peer victimization and depression, but this result was not found for obese boys. Partial support was found that peer social support buffered the relation between peer victimization and depressive symptoms in obese children. However, important gender differences were found.

The objective of this research is to determine the direct impact of family variables on initial status of a glycosylated hemoglobin A1c test (HbA1c) and HbA1c rate of change, and to determine the indirect effects of family variables on HbA1c through adherence. Study participants were 224 children and their parents who completed baseline measures of diabetes-specific family functioning and separate parent- and child-structured adherence interviews. HbA1c assays were performed at baseline, Year 1, and Year 2. Latent growth curve modeling indicated that, together, disagreement about responsibility for diabetes regimen, critical parenting, parental guidance, and parental warmth predicted initial status of HbA1c through adherence. Individually, critical parenting indirectly predicted initial status of HbA1c. Family variables did not directly predict initial status or rate of change in HbA1c, and did not indirectly predict rate of change in HbA1c over 2 years. Risk for high HbA1c remains elevated over time for ...

The objective of this research was to develop and validate the Diabetes Family Adherence Measure (D–FAM), a comprehensive and up-to-date tool designed for the assessment of adherence-related parenting behaviors for youth with type 1 diabetes (T1D). Further, this article outlines an empirical approach for scale design. First, experts reviewed a battery of potential items to create a preliminary version of the D–FAM. Subsequently, 165 youth with T1D and their families completed an initial administration. A parsimonious measure resulted, consisting of 19 items with 4 additional validity items. Factor analysis identified supportive, coercive, control, and monitoring subscales. D–FAM factors were generally associated with both adherence and health status (HbA1c [glycosolated hemoglobin]), as well as with extant scales of family functioning. Strong internal consistency, test–retest reliability, and construct-convergent reliability were obtained. This initial evaluation of the D–FAM suggests utility for efficien...

Background: Poor management of type 1 diabetes mellitus (T1DM) may result in serious medical complications. Psychological intervention may improve adherence to medical regimens; however, access to trained professionals is limited, particularly in rural communities. Telehealth interventions may address this by allowing families to access services at home; however, little is known about the efficacy of such services. Method: This study presents results from a pilot trial of a randomized waitlist controlled trial of Telehealth Behavioral Therapy (TBT) for youths with T1DM. Primary outcome measures were adherence to the diabetes regimen, glycemic control, and level of family discord. Thirty-two youths (23 female) with T1DM (aged 9 to 17 years) and one parent or caregiver participated. Telehealth Behavioral Therapy sessions were conducted thrice weekly for 12 weeks by phone and lasted an average of 15 min each. Results: Results indicated that youths in treatment decreased their hemoglobin A1c by 0.74 compared to 0.09 in the waitlist, though this was not statistically significant. Youths in treatment reported increased unsupportive and decreased caring parental behaviors. Conclusion: Telehealth Behavioral Therapy improves access to knowledgeable providers and results in a clinically significant improvement in glycemic control. Despite some youths experiencing an increase in unsupportive parental behaviors, TBT is a promising method of service delivery that warrants further investigation.

Current diabetes regimens require more effort than ever before. The level of diabetes control students are able to maintain is affected greatly by their ability to care for their diabetes during the school day. This article reviews use of School Health Plans and Diabetes Medical Management Plans in schools. Students with diabetes, their families, health care providers and school personnel all have responsibilities that should be outlined in these plans. School nurses coordinate school-based diabetes care, provide training to school staff members, advocate for students and monitor implementation of students’ school plans. Normal growth and development, prevention of complications and full participation in academic and social opportunities should be possible for students with diabetes. A variety of resources that support students with diabetes are described and referenced.

The 1993 Diabetes Complications and Control Trial (DCCT) showed that controlling blood glucose prevents and delays the progression of long term complications of diabetes. New diabetes technologies can make control of diabetes possible and safer. This paper reviews these technologies used to monitor blood glucose, administer insulin and evaluate effectiveness of therapy. Self-monitoring of blood glucose has been a standard of care for several decades. Today, patients and practitioners can gain great benefit from data that can be provided by using Continuous Glucose Monitoring (CGM). Current physiologic insulin therapy regimens have improved blood glucose control capabilities. Insulin therapy devices; including pens and pumps are reviewed. Advantages of insulin pump therapy and features of the latest ‘smart’ pumps are described. Children with diabetes, and their families, have many challenges as well as many opportunities to employ new technologies in diabetes management plans. The ability of school...

Objective This study provides normative data, divided by age and gender, for the Diabetes Self-Management Profile (DSMP), an empirically supported structured interview that assesses adherence with the type 1 diabetes treatment regimen. Despite wide use, normative data on the DSMP have yet to be reported. Methods The sample included 444 parents and 275 youth with type 1 diabetes. The DSMP was administered by a trained clinician. Results For both child and parent ratings of adherence, means and standard deviations for the overall sample and subdivision by gender and three age groups are presented for normative comparisons. Subscale data (e.g., glucose monitoring, diet, exercise) are similarly presented. Lower adherence scores were reported among older adolescents relative to preadolescents. Conclusions The literature has lacked normative data on pediatric diabetes adherence. These data present means and standard deviations for parent and child ratings of regimen adherence from a relatively large sample of youth with diabetes that can be utilized for normative comparisons for clinical and research purposes.

The dissemination of effective interventions to address the pediatric obesity epidemic is critical. There is also a growing recognition of the need for health investments to be informed by the best available cost and outcome data.1 Such data are essential as researchers, policy makers, and public health officials attempt to implement interventions that yield the greatest gains for the dollars spent.2 Behavioral interventions for overweight children lead to significant improvements in weight and health status.3 Most group interventions utilize a family-based approach including both children and their parents in group treatment sessions.4,5 However, research has demonstrated that parent-only group interventions to may lead to similar improvements in weight status compared to family-based models.6 Recently, we reported that both parent-only and family-based group interventions for overweight and obese children in medically underserved rural counties led to greater improvements in weight status than a control condition.7 While data are accumulating on the relative effectiveness of these 2 models, little attention has been paid to the differential costs of these interventions. Children in medically underserved rural areas are at greater risk for obesity than their non-rural peers.8,9 To our knowledge, there is only 1 published randomized clinical trial7 addressing weight management for children in rural settings. This is a significant concern, as one of the greatest challenges facing health promotion is translating research into evidence-based public health and clinical practices that are actively disseminated and widely adopted.10 Given the limited resources (eg, health care resources, health promotion programs, funds for corrlrrltwity health programs) often experienced in rural areas,11-14 examining the costs of interventions that can be disseminated to medically underserved areas has vital public health implications.10,15 The aim of this study was to compare the costs of parent-only and family-based group interventions for overweight and obese children in medically underserved rural communities. We hypothesized that parent-only group interventions would demonstrate lower costs and greater change in weight per dollar spent to conduct the treatment than family-based interventions.

Purpose Loss of participants in randomized clinical trials threatens the validity of study findings. The purpose of this study was to determine pre-randomization predictors of study completion status throughout the course of a randomized clinical trial involving young children with type 1 diabetes and their primary caregivers. Methods An intervention to improve adherence to the diabetes treatment regimen was delivered as part of the child's regular 3-month diabetes clinic visit. The study protocol involved 7 clinic visits across 18 months for the Immediate Treatment group and 9 clinic visits across 24 months for the Delayed Treatment group. Among those who completed the study and regardless of treatment group, participants were categorized into two groups: On-Time Completers ( n = 41) and Late Completers ( n = 39). Demographic, disease, and psychosocial characteristics of children and their primary caregivers measured prior to study randomization were tested for their association with the participants' completion status (i.e., On-Time Completers, Late Completers, or Withdrawals). Results Of the 108 participants, 28 (25.9%) withdrew and 80 (74.1%) completed the study. On-Time Completers (i.e., study completed within 4 months of expected date) were more likely to have private insurance and primary caregivers with some college education. Late Completers (i.e., study completion took longer than 4 months) were more likely to be boys and to have primary caregivers who reported mild to moderate levels of depression. Children who subsequently withdrew from the study reported poorer diabetes-related quality of life and poorer school-related quality of life at study inception and were more likely to have primary caregivers who did not work outside the home. Conclusions Pre-randomization screening of participants on both demographic and psychological variables may help identify those at greatest risk for study withdrawal or poor study protocol adherence, permitting the investigators to develop retention strategies aimed at this high-risk group.

Management of type 1 diabetes (T1D) involves balancing several components including diet, exercise, and medication. Peer involvement in management tasks is an important, but understudied, issue in T1D. This study presents results of a preliminary examination of perceptions of disease management in youth with T1D and their peers. Data were collected using a mixed methods (qualitative and quantitative data) approach during medical education time at a camp for youth with T1D and their peers. Results suggest that both youth with T1D and their peers believe that peers need more information about medical consequences of having diabetes. Further, youth with T1D and their peers would like coaching on how peers may help the child with T1D manage their illness better. Results provide preliminary ideas for intervention (i.e., including peers, assessing social support) in the medical setting as well as ideas for future research (i.e., examining relationships among perceptions and gender, time since diagnosis).

Management of type 1 diabetes (T1D) involves a complex regimen. Adherence may improve glycemic control and health outcomes. Accurately assessing adherence is critical. A parent and child self-report measure of regimen adherence was developed: Assessment of Diabetes Adherence, Parent and Child (ADA–P/–C). One hundred sixty-five youth with T1D and parents completed the Diabetes Self-Management Profile (DSMP), psychosocial measures, and the ADA–P/–C. Results revealed good psychometric properties. Parent and child agreement was adequate. Although not intended to replace the DSMP, the ADA–P/–C may be used for multiple adherence measurements, as part of a larger assessment battery, and when a trained clinician is not available.

Noncompliance with medical regimens for type 1 diabetes (T1D) may lead to serious consequences. The most life-threatening is diabetic ketoacidosis (DKA). Little is known about how DKA affects cognitive abilities in youth with T1D. We examined the impact of multiple DKA episodes and gender differences on cognitive abilities. Sixty-four youth (aged 8–16) who experienced at least two DKA episodes participated. Participants had lower index and subtest scores relative to norms. Gender differences on index scores were found with boys scoring higher. Results suggest DKA episodes may impact cognitive abilities. Researchers should continue to examine the link between DKA and intellectual ability.

This study examined rates of teacher victimization and relationships between teacher victimization, adherence and metabolic control in 167 young people with type-1 diabetes. Questions that assessed diabetes-related victimization from teachers were administered to young people with type-1 diabetes. Metabolic control was measured with HbA1c values and diabetes self-management was assessed using the parent version of the Diabetes Self-Management Profile (DSMP). The results indicated that teacher victimization was associated significantly and negatively with the DSMP Diet Subscale ( p = .03), DSMP Insulin Adherence Subscale ( p = .00) and overall adherence ( p = .01) for younger children (aged 8—11 years), but not for older youth (12—17 years). The implications and recommendations for practitioners are discussed.

Objective This study examined predictive and mediated relationships among youth perception of critical parenting, Child Behavior Checklist Externalizing Subscale (CBCL) externalizing problem scores, adherence, and (hemoglobin A1c HbA1c), in youth with type 1 diabetes from low socioeconomic status families. Methods Caregiver/youth dyads (n ¼120) completed diabetes specific measures of family functioning regarding diabetes management and structured adherence interviews. Parents completed the CBCL, while assays of youth HbA1c were performed. Analyses were conducted using hierarchical linear regression. Results Combined measures predicted 44% of the variance in HbA1c. Adherence partially mediated critical parenting and HbA1c, while critical parenting and adherence mediated CBCL externalizing problem scores and HbA1c. CBCL externalizing problem scores did not mediate critical parenting and HbA1c. Conclusions The presence of youth perceptions of critical parenting and youth externalizing behavior problems may interfere with adherence, leading to increases in HbA1c.

Objective: With the prevalence of childhood overweight reaching epidemic proportions, there is an increased need to identify factors which may aid in the development of successful weight intervention pro- grams. Given that lower levels of physical activity are inversely correlated with weight status in children, research has focused on identifying and addressing reported barriers to physically activity. A relationship exists between the number of reported barriers and weight status such that children who are overweight report more barriers to being physically active. However, important demographic and psychosocial correlates of barriers have not been examined. Methods: This study investigates the relationship among parent distress, peer victim- ization, childhood depression, barriers to physical activity, and physical activity among a sample of 95 clinically overweight children and adolescents. Higher levels of parent distress, peer victimization, and childhood de- pression are predictive of a variety of barriers to physical activity, with peer victimization emerging as the strongest predictor of barriers. Barriers to physical activity mediate the relationships between peer victimiza- tion, parent distress, child depression and physical activity. Results: These findings have significant implications for the development/design of weight intervention programs. Interventions targeting increases in physical activity should not only focus on the barriers children report, but should also include a psycho-emotional component to address factors such as parent distress, peer victimization and child mood that may contribute to barrier formation/maintenance. Conclusion: Future interventions may benefit from the identification of addi- tional factors that impact barrier formation and physical activity levels among children. (J Dev Behav Pediatr 29:26-33, 2008) Index terms: childhood obesity, physical activity barriers.