PURPOSE: To examine associations of adolescent body mass index (BMI), tobacco use, and physical activity with optimal physiologic cardiovascular health (CVH) in adulthood.
METHODS: Data were from 12,139 participants in Waves I (1995-1996) and IV (2007-2008) of the National Longitudinal Study of Adolescent Health. We defined optimal CVH as normal blood pressure, glucose, and cholesterol without diabetes or cardiovascular disease. We used logistic regression to estimate odds of having optimal CVH at ages 24-32 years (Wave IV) according to BMI category, smoking status, and physical activity at ages 11-19 years (Wave I).
RESULTS: Few young adults (16%) had optimal CVH. Adolescents with normal BMI were more than twice as likely to have optimal young adult CVH compared to those who were obese (adjusted odds ratio, 2.77; 95% confidence interval, 1.97-3.89). Adolescent smoking and physical activity did not predict young adult CVH.
CONCLUSIONS: Lower adolescent BMI is associated with young adult CVH.
PURPOSE: Guidelines recommend cholesterol screening for all adolescents and young adults (AYAs) ages 17-21 years. Little is known about how screening results impact perceptions of AYA health.
METHODS: We recruited 37 AYAs and 35 parents of AYAs with differing risk for abnormal cholesterol results: (1) familial hypercholesterolemia; (2) obesity; and (3) generally healthy. Participants completed quantitative health status ratings using visual analog scales (VASs) and semistructured interviews regarding three hypothetical cholesterol screening scenarios: (1) high likelihood of cardiovascular disease (CVD) before age 40 years ("high risk"); (2) some risk of CVD before age 70 years ("moderate risk"); and (3) low risk for CVD despite a strong family history of CVD ("low risk"). We analyzed VAS data with logistic regression and qualitative data with a priori and emergent coding using multiple coders.
RESULTS: Each group perceived all three cholesterol screening scenarios as comparatively less than perfect health; the high-risk result fell furthest from perfect health. Although there was no significant difference between AYAs and parents in VAS ratings, qualitative analyses revealed AYAs were more likely than parents to discount the impact of moderate-risk results because of longer length of time before predicted CVD.
CONCLUSIONS: AYAs' and parents' perceptions of the impact of cholesterol screening results on AYA health varied by presented scenario, ranging from mild to significant decreases in perceptions of AYA health. As universal cholesterol screening continues to be adopted in this age group, further studies of the real-life impact on AYA risk perceptions and subsequent behavior are warranted.
PROBLEM: Medical education academies play an important role in the recognition and career advancement of educators. However, hospital-based clinical faculty have unique professional development needs that may not be met by medical-school-based academies.
APPROACH: The Boston Children's Hospital Academy was founded in 2008 to serve the needs of its clinician-educators. It was open to junior faculty scholars and to senior faculty scholars and mentors, including interprofessional educators. To maintain membership, individuals must propose and work toward an education project or serve as a project mentor. In 2012, a survey was sent to all members, and annual project reports were reviewed to assess the academy's impact.
OUTCOMES: Sixty-five members completed the survey. The majority agreed that the academy created a community of educators, provided opportunities for networking and scholarship, contributed to their personal identity as an educator, and led to recognition by their chief. Projects addressed curriculum development, faculty development, learner assessment, program assessment, and resource development. They largely focused on graduate medical education and on patient safety and quality. During their tenure in the academy (mean length of membership = 2.4 years), members produced an average of 4.4 education presentations and 1.9 education publications, and 11 members were promoted.
NEXT STEPS: A hospital-based academy provides opportunities for interprofessional faculty development. Next steps include increasing interprofessional membership, wider dissemination of members' successes, better integration with the hospital's mission, specifically regarding graduate medical education and patient safety, and additional evaluation of the academy's impact on project completion and members' accomplishments.
PURPOSE: Adolescent health providers increasingly work in interprofessional environments. There is a lack of evidence regarding best educational practices for preparing the adolescent health care workforce of the future. We developed, implemented, and evaluated an interprofessional longitudinal case-based curriculum for postgraduate trainees in adolescent health.
METHODS: Faculty in an academic adolescent medicine division worked collaboratively with recent trainees to develop six teaching cases illustrative of interprofessional care of adolescents. During the 2013-2014 academic year, seven trainees (two social workers, two physicians, one nurse practitioner, one psychologist, and one dietician) completed the six month-long case modules while simultaneously working together in an interprofessional clinic. Trainees completed four-item pre- and post-case questionnaires that assessed confidence with assessment and diagnosis, comfort with counseling skills, ability to devise a treatment plan, and understanding of their colleagues' role for each of the six cases. Participants completed the 19-item Readiness for Interprofessional Learning Scale and the 12-item Interdisciplinary Education Perception Scale at three time points during the academic year and a 15-minute interview after their final session.
RESULTS: Confidence with assessment/diagnosis, comfort counseling adolescents, and the ability to devise treatment plans increased for most case topics, as did understanding of the role of others on the interprofessional team. Mean Readiness for Interprofessional Learning Scale and Interdisciplinary Education Perception Scale scores were high at baseline and similar at all three time points. Interviews highlighted the value of role clarity, communication, and learning within interprofessional teams along with modeling from interprofessional faculty.
CONCLUSIONS: Case-based learning in conjunction with collaborative practice provided a successful teaching strategy for interprofessionals in adolescent health.
OBJECTIVE: Childhood trauma is associated with hypertension in adults. It is unknown whether childhood trauma predicts elevated blood pressure earlier in development. We investigated whether the trauma of child abuse was associated with blood pressure in adolescents.
METHODS: The sample included 145 adolescents aged 13-17 years, 40% with exposure to child abuse. The mean age of participants was 14.93 years (SD = 1.33); 58% were female. The majority self-identified as non-Hispanic White (43%), with the remainder identifying as non-Hispanic Black (17%), Hispanic (17%), or other/mixed race (23%). We used established age/sex/height-specific cutoffs to determine the prevalence of prehypertension and hypertension in the sample. We used two-sample t tests to examine associations of abuse with resting systolic blood pressure (SBP) and diastolic blood pressure (DBP) and blood pressure reactivity to the Trier Social Stress Test and a frustration task. We used linear regression to adjust for potential confounders including sociodemographic variables, body mass index, smoking, and psychopathology.
RESULTS: Mean resting SBP and DBP were 114.07 mmHg and 61.35 mmHg in those with a history of abuse and 111.39 mmHg and 56.89 mmHg in those without a history of abuse. This difference was significant for DBP only. Twelve percent of participants met criteria for prehypertension or hypertension based on resting blood pressure values; this did not differ between those with and without an abuse history. Child abuse was associated with lower DBP and SBP reactivity to laboratory stress tasks and reduced DBP reactivity to frustration. These associations were robust to adjustment for potential confounders.
CONCLUSIONS: Child abuse is associated with higher resting DBP and blunted DBP and SBP reactivity to laboratory stress in adolescence. These findings suggest a potential pathway by which child abuse leads to hypertension.
This study aims to determine the association between weight misperception (considering oneself average or underweight) and depressive symptoms among youth with overweight/obesity. Linear regression models (adjusted for age, BMI, parental education, percent poverty) were used to examine cross-sectional (wave II, 1996, n = 3898, M age = 15.9, SD = 0.13) and longitudinal (from wave II to IV, 1996-2008/2009, n = 2738, M age = 28.5, SD = 0.06) associations between weight misperception and depressive symptoms (Center for Epidemiologic Studies-Depression Scale) in a subsample of White, Black, Asian, Hispanic, and Multi-racial male and female youth with overweight/obesity participating in the National Longitudinal Study of Adolescent Health. Average BMI was 29.0 (0.16) at wave II and 35.7 (0.23) at wave IV. Thirty-two percent misperceived their weight status as average weight (n = 1151, 30 %) or underweight (n = 99, 3 %). In fully adjusted cross-sectional models, White (β = -1.92, 95 % CI = -2.79, -1.06) and Multi-racial (β = -4.43, 95 % CI = -6.90, -1.95) youth who perceived themselves as average weight had significantly lower depressive symptoms compared to accurate weight-perceivers. In fully adjusted longitudinal models, White youth (β = -0.41, 95 % CI = -0.81, -0.004) who perceived themselves as average weight had significantly lower depressive symptoms 12 years later. Findings suggest that weight misperception may be protective against depression among White adolescents and young adults with overweight/obesity. Clinical and population interventions should consider potential harmful effects of correcting weight misperceptions on the mental health of youth with overweight/obesity.
BACKGROUND: Heterozygous familial hypercholesterolemia (FH) affects up to 1 in 200 individuals in the United States, but atherosclerotic cardiovascular disease (ASCVD) outcomes of FH in the general US population have not been described. We therefore sought to evaluate long-term coronary heart disease (CHD) and total ASCVD risks in US adults with an FH phenotype.
METHODS: Using individual pooled data from 6 large US epidemiological cohorts, we stratified participants by low-density lipoprotein cholesterol level at index ages from 20 to 79 years. For the primary analysis, low-density lipoprotein cholesterol levels ≥190 and <130 mg/dL defined the FH phenotype and referent, respectively. Sensitivity analyses evaluated the effects of varying the FH phenotype definition. We used Cox regression models to assess covariate-adjusted associations of the FH phenotype with 30-year hazards for CHD (CHD death or nonfatal myocardial infarction) and total ASCVD (CHD or stroke).
RESULTS: We included 68 565 baseline person-examinations; 3850 (5.6%) had the FH phenotype by the primary definition. Follow-up across index ages ranged from 78 985 to 308 378 person-years. After covariate adjustment, the FH phenotype was associated with substantially elevated 30-year CHD risk, with hazard ratios up to 5.0 (95% confidence interval, 1.1-21.7). Across index ages, CHD risk was accelerated in those with the FH phenotype by 10 to 20 years in men and 20 to 30 years in women. Similar patterns of results were found for total ASCVD risk, with hazard ratios up to 4.1 (95% confidence interval, 1.2-13.4). Alternative FH phenotype definitions incorporating family history, more stringent age-based low-density lipoprotein cholesterol thresholds, or alternative lipid fractions decreased the FH phenotype prevalence to as low as 0.2% to 0.4% without materially affecting CHD risk estimates (hazard ratios up to 8.0; 95% confidence interval, 1.0-61.6).
CONCLUSIONS: In the general US population, the long-term ASCVD burden related to phenotypic FH, defined by low-density lipoprotein cholesterol ≥190 mg/dL, is likely substantial. Our finding of CHD risk acceleration may aid efforts in risk communication.
AIM: Explore perspectives of adolescent and young adult (AYA) and parent stakeholders regarding their engagement in comparative effectiveness research (CER) evaluating cholesterol screening and treatment strategies for 17-21 year olds.
METHODS: All nine AYAs and parent stakeholders participating in a 20-member panel of AYAs, parents and professionals (i.e., clinicians, researchers, policy makers, payers), completed a quantitative survey and a semistructured interview at the completion of the core CER study.
RESULTS & CONCLUSION: AYAs and parents stakeholders emphasized the role of power differentials regarding shared knowledge, relationships and trust, and logistics. To mitigate power differentials, stakeholders recommended more materials, clearer definition of roles and in-person meetings. Perceived positive outcomes included diversity of perspectives provided, better understanding their own health and decision-making and improving CER.
BACKGROUND: The disruption in provider continuity caused by medical resident graduation may result in adverse patient outcomes.
OBJECTIVE: Our aim was to investigate whether resident graduation was associated with increased acute care utilization by residents' primary care patients.
DESIGN AND PARTICIPANTS: This was a retrospective cohort study of patients cared for by junior and senior residents finishing the academic year in 2010, 2011 and 2012.
MAIN MEASURES: We compared rates of clinic visits, emergency department (ED) visits, and hospitalizations between transitioning patients whose residents were graduating and non-transitioning patients whose residents were not graduating.
KEY RESULTS: Our study population comprised 90 residents, 4018 unique patients, and 5988 resident-patient dyads that transitioned (n = 3136) or did not transition (n = 2852). For transitioning patients, the clinic visit rate per 100 patients in the 4 months before and after graduation was 129 and 102, respectively; for non-transitioning patients, the clinic visit rate was 119 and 94, respectively (difference-in-differences, +2 per 100 patients; p = 0.12). For transitioning patients, the ED visit rate per 100 patients before and after graduation was 29 and 26, respectively; for non-transitioning patients, the ED visit rate was 28 and 25, respectively (difference-in-differences, 0; p = 0.49). For transitioning patients, the hospitalization rate per 100 patients before and after graduation was 14 and 13, respectively; for non-transitioning patients, the hospitalization rate was 15 and 12, respectively (difference-in-differences, -2; p = 0.20). In multivariable modeling there was no increased risk for transitioning patients for clinic visits (adjusted rate ratio [aRR], 1.03; 95 % confidence interval [CI], 0.97 to 1.10), ED visits (aRR, 1.05; 95 % CI, 0.92 to 1.20), or hospitalizations (aRR, 1.04; 95 % CI, 0.83 to 1.31).
CONCLUSIONS: Acute care utilization by residents' patients did not increase or decrease after graduation. Acute care utilization was high before and after graduation. Interventions to decrease the need for acute care should be employed throughout the year.
IMPORTANCE: Health care practitioners who care for adolescents transitioning to adulthood often face incongruent recommendations from pediatric and adult guidelines for treatment of lipid levels.
OBJECTIVE: To compare the proportion of young people aged 17 to 21 years who meet criteria for pharmacologic treatment of elevated low-density lipoprotein cholesterol (LDL-C) levels under pediatric vs adult guidelines.
DESIGN, SETTING, AND PARTICIPANTS: We performed a cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES) population. Surveys were administered from January 1, 1999, through December 31, 2012, and the analysis was performed from June through December 2014. Participants included 6338 individuals aged 17 to 21 years in the United States.
MAIN OUTCOMES AND MEASURES: To estimate the number and proportion of individuals aged 17 to 21 years in the NHANES population who were eligible for statin therapy, we applied treatment algorithms from the 2011 Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents of the National Heart, Lung, and Blood Institute and the 2013 Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults from the American College of Cardiology and American Heart Association. After imputing missing data and applying NHANES sampling weights, we extrapolated the results to 20.4 million noninstitutionalized young people aged 17 to 21 years living in the United States.
RESULTS: Of the 6338 young people aged 17 to 21 years in the NHANES population, 2.5% (95% CI, 1.8%-3.2%) would qualify for statin treatment under the pediatric guidelines compared with 0.4% (95% CI, 0.1%-0.8%) under the adult guidelines. Participants who met pediatric criteria had lower mean (SD) LDL-C levels (167.3 [3.8] vs 210.0 [7.1] mg/dL) but higher proportions of other cardiovascular risk factors, including hypertension (10.8% vs 8.4%), smoking (55.0% vs 23.9%), and obesity (67.7% vs 18.2%) compared with those who met the adult guidelines. Extrapolating to the US population of individuals aged 17 to 21 years represented by the NHANES sample, 483 500 (95% CI, 482 100-484 800) young people would be eligible for treatment of LDL-C levels if the pediatric guidelines were applied compared with only 78 200 (95% CI, 77 600-78 700) if the adult guidelines were applied.
CONCLUSIONS AND RELEVANCE: Application of pediatric vs adult guidelines for lipid levels, which consider additional cardiovascular risk factors beyond age and LDL-C concentration, might result in statin treatment for more than 400 000 additional adolescents and young adults.
BACKGROUND: Direct clinical observation is an essential component of medical trainee assessment, particularly in the era of milestone-based competencies. However, the adolescent patient's perspective on this practice is missing from the literature. Quality health care is patient centered, yet we did not know if our educational practices align with this clinical goal.
OBJECTIVE: We sought to better understand our adolescent/young adult patients' perspectives of the direct observation of our medical trainees in the outpatient clinical setting.
METHODS: As a quality improvement initiative, we surveyed adolescent/young adult patients, medical trainees, and physician observers in our outpatient clinical practice regarding their experience following a direct observation encounter. We performed descriptive analyses of the data.
RESULTS: During a 1-year period, responses were received from 23 adolescent/young adult patients, 8 family members, 14 trainees, and 6 faculty observers. Nearly all adolescent/young adult patients (n=22) and all surveyed family members (n=8) expressed comfort with direct observation, and all respondents felt the care they received was the same or better. All patient/family respondents preferred direct observation to the idea of remote observation, and most, but not all, trainees and faculty observers expressed similar opinions.
CONCLUSIONS: Adolescent/young adult patients and their family members found direct observation of their trainee providers to be comfortable and beneficial. Despite adolescent and young adults' facility and comfort with modern technologies, there was an expressed preference for direct versus remote observation.
To determine whether different types of childhood adversity are associated with body mass index (BMI) in adolescence, we studied 147 adolescents aged 13-17 years, 41% of whom reported exposure to at least one adversity (maltreatment, abuse, peer victimization, or witness to community or domestic violence). We examined associations between adversity type and age- and sex-specific BMI z-scores using linear regression and overweight and obese status using logistic regression. We adjusted for potential socio-demographic, behavioral, and psychological confounders and tested for effect modification by gender. Adolescents with a history of sexual abuse, emotional abuse, or peer victimization did not have significantly different BMI z-scores than those without exposure (p>0.05 for all comparisons). BMI z-scores were higher in adolescents who had experienced physical abuse (β=0.50, 95% CI 0.12-0.91) or witnessed domestic violence (β=0.85, 95% CI 0.30-1.40). Participants who witnessed domestic violence had almost 6 times the odds of being overweight or obese (95% CI: 1.09-30.7), even after adjustment for potential confounders. No gender-by-adversity interactions were found. Exposure to violence in childhood is associated with higher adolescent BMI. This finding highlights the importance of screening for violence in pediatric practice and providing obesity prevention counseling for youth.
OBJECTIVE: This research investigated factors associated with sexual orientation disparities in chronic pain frequency among youth.
METHOD: Data were analyzed from 4534 female and 3785 male youth from Waves I-IV (1995-2009) of the U.S. National Longitudinal Study of Adolescent to Adult Health. Gender-stratified weighted logistic regression models controlled for sociodemographic characteristics and included sexual orientation (primary predictor) and frequency of three types of chronic pain (outcomes). Models with sexual orientation only were compared to models with factors hypothesized to increase or decrease risk of pain. Significant odds ratios (OR) for chronic pain frequency (daily/weekly vs. rarely) with confidence intervals (CI) and associated factors are reported.
RESULTS: Compared to same-gender heterosexual females, mostly heterosexuals were more likely to report headaches (OR=1.40, CI=1.09, 1.79) and mostly heterosexuals and bisexuals were more likely to report muscle/joint pain (mostly heterosexual OR=1.69, CI=1.29, 2.20; bisexual OR=1.87, CI=1.03, 3.38). Compared to same-gender heterosexual males, gay males were more likely to report headaches (OR=2.00, CI=1.06, 3.82), but less likely to report muscle/joint pain (OR=0.28, CI=0.11, 0.74). Significant disparities were attenuated by up to 16% when associated factors were added to the model.
CONCLUSION: Sexual orientation disparities in chronic pain were partially explained by associated factors, but more research is needed to develop intervention and prevention strategies.
BACKGROUND: Middle-aged adults with ideal blood pressure, cholesterol, and glucose levels exhibit substantially lower cardiovascular mortality than those with unfavorable levels. Four healthy lifestyle components-optimal body weight, diet, physical activity, and not smoking-are recommended for cardiovascular health (CVH). This study quantified associations between combinations of healthy lifestyle components measured in young adulthood and loss of the ideal CVH profile into middle age.
METHODS AND RESULTS: Analyses included 2164 young adults in the Coronary Artery Risk Development in Young Adults study with the ideal CVH profile (defined as untreated blood pressure <120/80 mm Hg, total cholesterol <200 mg/dL, fasting blood glucose <100 mg/dL, and absence of cardiovascular disease) at baseline. Cox proportional hazards regression models estimated hazard ratios for loss of the ideal CVH profile over 25 years according to 4 individual and 16 combinations of optimal healthy lifestyle components measured in young adulthood: body mass index, physical activity, nonsmoking status, and diet quality. Models were adjusted for age, sex, race, education, study center, and baseline blood pressure, cholesterol, and glucose. Eighty percent (n=1737) of participants lost the ideal CVH profile by middle age; loss was greatest for young adults with no optimal healthy lifestyle components at baseline. Relative to young adults with no optimal healthy lifestyle components, those with all 4 were less likely to lose the ideal CVH profile (hazard ratio 0.59, 95% CI 0.44-0.80). Combinations that included optimal body mass index and nonsmoking status were each associated with lower risk.
CONCLUSIONS: Optimal body mass index and not smoking in young adulthood were protective against loss of the ideal CVH profile through middle age. Importance of diet and physical activity may be included through their effects on healthy weight.
OPINION STATEMENT: Approaches to the prevention and management of cardiovascular disease (CVD) are often too narrow in scope and initiated too late. While the majority of adolescents are free of CVD, far fewer are free of CVD risk factors, especially lifestyle factors such as poor exercise and dietary habits. Most clinicians are familiar with behavioral and pharmacologic strategies for modifying these and other traditional CVD risk factors such as hypertension, hypercholesterolemia, and diabetes. In this review, we highlight those strategies most applicable to teens and also propose fundamental reframing that recognizes the importance of early choices and life experiences to achieving cardiovascular health. Population- and individual-level approaches that support the establishment of positive health behaviors early in life are the foundation of preserving ideal cardiovascular health and promoting positive cardiovascular outcomes. The Positive Youth Development movement supports a frame shift away from seeing young people as merely the sum of their risk factors and instead as developmentally dynamic youth capable of making healthy choices. Informed by the Positive Youth Development framework, our approach to cardiovascular prevention among adolescents is both broad based and proactive, paying heed as early as possible to social, familial, and developmental factors that underlie health behaviors and employing evidence-based behavioral, pharmacologic, and surgical treatments when needed.
The American Heart Association's 2020 Strategic Impact Goal is "By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%." To monitor progress towards this goal, a new construct "ideal cardiovascular health" (iCVH) was defined that includes the simultaneous presence of optimal levels of seven health behaviors (physical activity, smoking, dietary intake, and body mass index) and factors (total cholesterol, blood pressure and fasting blood glucose). In this review, we present a summary of major concepts related to the concept of iCVH and an update of the literature in this area since publication of the 2020 Strategic Impact Goal, including trends in iCVH prevalence, new determinants and outcomes related to iCVH, strategies for maintaining or improving iCVH, policy implications of the iCVH model, and the remaining challenges to reaching the 2020 Strategic Impact Goal.
Adverse childhood experiences are associated with hypertension in older adults. This study assessed whether an association between child maltreatment and blood pressure is detectable in young adults and whether any association differs by sex or is modified by genetic polymorphisms known to be involved in stress sensitivity. We examined these patterns in a sample of 12,420 young adults ages 24-32 years who participated in Wave IV of the National Longitudinal Study of Adolescent Health. Participants retrospectively reported history of physical, emotional, or sexual abuse before age 18 years. Participants with a systolic blood pressure (SBP) ≥140 mmHg or a diastolic blood pressure (DBP) ≥90 mmHg were classified as hypertensive. We used sex-stratified linear and logistic regression models to assess associations between each type of childhood maltreatment and SBP, DBP, and hypertension. We created interaction terms to assess for effect modification of any relationship between maltreatment and blood pressure by sex or SLC64A genotype. Fifteen percent of females and 31.5% of males were hypertensive. Frequent physical abuse in childhood was reported by 5%, frequent emotional abuse by 12%, and any sexual abuse by 5%. No association was observed between abuse history and blood pressure in either males or females, nor was effect modification present by SLC64A genotype. Child maltreatment exposure was not associated with blood pressure or hypertension in young adults in this study. Future studies should investigate additional critical windows for the effect of child maltreatment on cardiovascular health.