The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

To revise 1998 recommendations on childhood obesity, an Expert Committee, comprised of representatives from 15 professional organizations, appointed experienced scientists and clinicians to 3 writing groups to review the literature and recommend approaches to prevention, assessment, and treatment. Because effective strategies remain poorly defined, the writing groups used both available evidence and expert opinion to develop the recommendations. Primary care providers should universally assess children for obesity risk to improve early identification of elevated BMI, medical risks, and unhealthy eating and physical activity habits. Providers can provide obesity prevention messages for most children and suggest weight control interventions for those with excess weight. The writing groups also recommend changing office systems so that they support efforts to address the problem. BMI should be calculated and plotted at least annually, and the classification should be integrated with other information such as growth pattern, familial obesity, and medical risks to assess the child’s obesity risk. For prevention, the recommendations include both specific eating and physical activity behaviors, which are likely to promote maintenance of healthy weight, but also the use of patient-centered counseling techniques such as motivational interviewing, which helps families identify their own motivation for making change. For assessment, the recommendations include methods to screen for current medical conditions and for future risks, and methods to assess diet and physical activity behaviors. For treatment, the recommendations propose 4 stages of obesity care; the first is brief counseling that can be delivered in a health care office, and subsequent stages require more time and resources. The appropriateness of higher stages is influenced by a patient’s age and degree of excess weight. These recommendations recognize the importance of social and environmental change to reduce the obesity epidemic but also identify ways healthcare providers and health care systems can be part of broader efforts.

/pdf/expert-committee-recommendations-regarding-the-prevention-38kyxmdgpa.pdf

Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report

Accurate appropriate assessment of overweight and obesity in children and adolescents is a critical aspect of contemporary medical care. However, physicians and other health care professionals may find this a somewhat thorny field to enter. The BMI has become the standard as a reliable indicator of overweight and obesity. The BMI is incomplete, however, without consideration of the complex behavioral factors that influence obesity.Because of limited time and resources, clinicians need to have quick, evidence-based interventions that can help patients and their families recognize the importance of reducing overweight and obesity and take action. In an era of fast food, computers, and DVDs, it is not easy to persuade patients to modify their diets and to become more physically active. Because research concerning effective assessment of childhood obesity contains many gaps, this report is intended to provide a comprehensive approach to assessment and to present the evidence available to support key aspects of assessment. The discussion and recommendations are based on 300 studies published since 1995, which examined an array of assessment tools. With this information, clinicians should find themselves better equipped to face the challenges of assessing childhood overweight and obesity accurately.

/pdf/assessment-of-child-and-adolescent-overweight-and-obesity-3x3r0o3ed0.pdf

Assessment of Child and Adolescent Overweight and Obesity

Importance Based on year 2000 Centers for Disease Control and Prevention growth charts, approximately 17% of children and adolescents aged 2 to 19 years in the United States have obesity, and almost 32% of children and adolescents are overweight or have obesity. Obesity in children and adolescents is associated with morbidity such as mental health and psychological issues, asthma, obstructive sleep apnea, orthopedic problems, and adverse cardiovascular and metabolic outcomes (eg, high blood pressure, abnormal lipid levels, and insulin resistance). Children and adolescents may also experience teasing and bullying behaviors based on their weight. Obesity in childhood and adolescence may continue into adulthood and lead to adverse cardiovascular outcomes or other obesity-related morbidity, such as type 2 diabetes. Subpopulation Considerations Although the overall rate of child and adolescent obesity has stabilized over the last decade after increasing steadily for 3 decades, obesity rates continue to increase in certain populations, such as African American girls and Hispanic boys. These racial/ethnic differences in obesity prevalence are likely a result of both genetic and nongenetic factors (eg, socioeconomic status, intake of sugar-sweetened beverages and fast food, and having a television in the bedroom). Objective To update the 2010 US Preventive Services Task Force (USPSTF) recommendation on screening for obesity in children 6 years and older. Evidence Review The USPSTF reviewed the evidence on screening for obesity in children and adolescents and the benefits and harms of weight management interventions. Findings Comprehensive, intensive behavioral interventions (≥26 contact hours) in children and adolescents 6 years and older who have obesity can result in improvements in weight status for up to 12 months; there is inadequate evidence regarding the effectiveness of less intensive interventions. The harms of behavioral interventions can be bounded as small to none, and the harms of screening are minimal. Therefore, the USPSTF concluded with moderate certainty that screening for obesity in children and adolescents 6 years and older is of moderate net benefit. Conclusions and Recommendation The USPSTF recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status. (B recommendation)

/pdf/screening-for-obesity-in-children-and-adolescents-us-5f8qnrvey1.pdf

Screening for obesity in children and adolescents us preventive services task force recommendation statement

https://www.cdc.gov/genomics/translation/file/print/translationGIM.pdf

The continuum of translation research in genomic medicine: how can we accelerate the appropriate integration of human genome discoveries into health care and disease prevention?

Background. Childhood and adolescent overweight and obesity are related to health risks, medical conditions, and increased risk of adult obesity, with its attendant effects on morbidity and mortality rates. The prevalence of childhood overweight and obesity has more than doubled in the past 25 years. Purpose. This evidence synthesis examines the evidence for the benefits and harms of screening and early treatment of overweight among children and adolescents in clinical settings. Methods. We developed an analytic framework and 7 key questions representing the logical evidence connecting screening and weight control interventions with changes in overweight and behavioral, physiologic, and health outcomes in childhood or adulthood. We searched the Cochrane Library from 1996 to April 2004. We searched Medline, PsycINFO, DARE, and CINAHL from 1966 to April 2004. One reviewer abstracted relevant information from each included article into standardized evidence tables, and a second reviewer checked key elements. Two reviewers quality-graded each article with US Preventive Services Task Force criteria. Results. Although BMI is a measure of relative weight rather than adiposity, it is recommended widely for use among children and adolescents to determine overweight and is the currently preferred measure. The risk of adult overweight from childhood overweight provides the best available evidence to judge the clinical validity of BMI as an overweight criterion for children and adolescents. BMI measures in childhood track to adulthood moderately or very well, with stronger tracking seen for children with ≥1 obese parent and children who are more overweight or older. The probability of adult obesity (BMI of >30 kg/m 2 ) is ≥50% among children >13 years of age whose BMI percentiles meet or exceed the 95th percentile for age and gender. BMI-based overweight categorization for individuals, particularly for racial/ethnic minorities with differences in body composition, may have limited validity because BMI measures cannot differentiate between increased weight for height attributable to relatively greater fat-free mass (muscle, bone, and fluids) and that attributable to greater fat. No trials of screening programs to identify and to treat childhood overweight have been reported. Limited research is available on effective, generalizable interventions for overweight children and adolescents that can be conducted in primary care settings or through primary care referrals. Conclusions. BMI measurements of overweight among older adolescents identify those at increased risk of developing adult obesity. Interventions to treat overweight adolescents in clinical settings have not been shown to have clinically significant benefits, and they are not widely available. Screening to categorize overweight among children under age 12 or 13 who are not clearly overweight may not provide reliable risk categorization for adult obesity. Screening in this age group is compromised by the fact that there is little generalizable evidence for primary care interventions. Because existing trials report modest short- to medium-term improvements (∼10–20% decrease in percentage of overweight or a few units of change in BMI), however, overweight improvements among children and adolescents seem possible.

https://pediatrics.aappublications.org/content/pediatrics/116/1/e125.full.pdf

Screening and interventions for childhood overweight: a summary of evidence for the US Preventive Services Task Force.

Primary Care Interventions to Prevent Motor Vehicle Occupant Injuries

Screening for Hereditary Hemochromatosis

We evaluated the representativeness of women approached and enrolled in a brief smoking cessation intervention conducted in Planned Parenthood clinics. In this effectiveness study, regular clinic staff were trained to identify, offer participation, and counsel willing smoking clients as part of their clinic visit. Chart audits were conducted to determine the percent of clients who had smoking status identified, as well as the percent and characteristics of potentially eligible clients who were not approached. Baseline and non-participant questionnaires were analyzed to determine participation rate and characteristics of those participating versus those not participating. Smoking status was documented in 99% of charts. Seventy percent of eligible smokers were approached about study participation and 74% of those approached participated. There were no significant differences between those approached and those not approached or between those who participated versus those who did not on a host of sociodemographic variables. This project was able to approach and attract a representative sample of young, lower income women to participate in a brief, clinic-based smoking cessation program.

Reaching those most in need: Participation in a Planned Parenthood smoking cessation program

Background Childhood and adolescent overweight and obesity are related to health risks, medical conditions, and an increased risk of adult obesity, with attendant impacts on morbidity and mortality. The prevalence of overweight has increased over the last 25 years among all American children and adolescents, but particularly among racial/ethnic minorities. The relatively greater increase in the upper body mass index (BMI) percentiles compared with the lower suggests that severity of overweight is increasing. Although obesity is the presumed condition impacting health, the use of the terms “at risk for overweight” and “overweight” are preferred when describing relative weight status based on age- and sex-specific BMI percentiles for children and adolescents, as these terms are more accurate and less pejorative. Purpose The focus of this evidence synthesis is to examine the evidence for the benefits and harms of screening and earlier treatment of overweight in children and adolescents in clinical settings. Data Sources We developed an analytic framework and seven key questions to represent the logical evidence connecting screening and weight control interventions with changes in overweight and behavioral, physiological, and health outcomes in childhood or adulthood. We searched the Cochrane Library from 1996 to April 2004. We searched MEDLINE®, PsycINFO, DARE, and CINAHL from 1966 to April 2004, using the Medical Subject Heading obesity and overweight and combining this term with predefined strategies to identify relevant English-language studies. We examined 2,162 abstracts related to screening, 312 related to screening harms, 949 related to treatment, and 864 related to treatment harms. We also contacted experts and checked bibliographies from review articles and selected trials. We found three recent, good-quality systematic reviews of interventions, one fair-to-good-quality systematic review relating screening measures to health outcomes, and a number of non-systematic, but comprehensive, review articles on screening, treatment, or other issues related to pediatric overweight. We relied on these as sources of relevant literature and, to a lesser extent, of synthesized information. When previous systematic reviews were incorporated in our results, we independently examined the individual studies to confirm or extend previous review findings. A bridge search between April 2004 and April 2005 did not identify any new intervention trials that would impact the findings of this report. Study Selection We included fair-to-good quality research (according to U.S. Preventive Services Task Force [USPSTF] criteria) in children and adolescents aged 2–18 years in the following categories: (1) the most current large, population-based, or nationally representative surveys of the prevalence of overweight and obesity to represent age- and, sex-specific prevalence for racial/ethnic subgroups (Mexican Americans, non-Hispanic blacks, Native Americans, Asians/Pacific Islanders, non-Hispanic whites); (2) prospective cohort studies conducted in the United States with clinically relevant childhood weight measures and adult health outcomes, including obesity; (3) randomized controlled trials (RCTs) or controlled clinical trials of screening; (4) RCTs of pharmacological agents or behavioral counseling interventions conducted in the United States or similarly industrialized countries, with at least six months' follow-up, reporting changes in overweight status with or without intermediate outcomes, health outcomes, or harms; (4) RCTs, controlled clinical trials, or controlled cohort studies of bariatric surgeries; and (5) prospective cohort studies and controlled clinical intervention trials with at least three months' follow-up for possible harms of screening or intervention. To confirm inclusion/exclusion status, two reviewers examined all abstracts (or a random subset in the case of the screening search) and included articles. Data Extraction One reviewer abstracted relevant information from each included article into standardized evidence tables, and a second reviewer checked key elements. Two reviewers quality graded each article using USPSTF criteria. Excluded articles were listed in tables. Data Synthesis No trials of screening programs to identify and treat overweight in children and adolescents have been reported. BMI (weight in kilograms [kg] divided by height in meters squared) is the preferred clinical measure for overweight. Although BMI is a measure of relative weight rather than of adiposity, it is widely recommended for use in children and adolescents to determine overweight, and correlates as well or better with measures of body fat in children and adolescents than other clinically feasible measures. Based on BMI criteria for overweight (BMI at or above the 95th percentile for age and sex), 10% of two- to five-year-olds and 16% of those six and older are overweight, with significantly higher prevalence in minority racial/ethnic and sex-specific subgroups beginning at age six. Age- and sex-specific BMI percentiles for use as references for U.S. children and adolescents (CDC 2000 growth charts) have been created from nationally representative datasets that primarily included black and non-Hispanic white children. The validity of BMI-based overweight categorization in racial/ethnic minorities with differences in body composition may be limited, since BMI measures can not differentiate between increased weight for height due to relatively greater fat-free mass (muscle, bone, fluids) and increased weight due to greater fat in either individuals or populations. BMI measures in childhood track to adulthood moderately or very well, with better tracking seen after age 12 to 13 (particularly when this age represents achieving sexual maturity), or in younger children (aged 6–12) with one or more obese parents or whose own BMI is above the 95th percentile. The risk of adult obesity in those with childhood overweight (BMI ≥ 95th percentile) provides the best available evidence by which to judge the clinical validity of BMI as an overweight criterion in children and adolescents. The probability of adult obesity in overweight adolescents is highest for 16–18 year-old white males (0.77–0.8) and white females (0.66–0.68), with little data on other race-ethnic groups in this age group available. Limited research is available on effective, generalizable interventions for overweight children and adolescents that can be conducted in primary care or to which primary care can make referrals. Most research has investigated intensive behavioral counseling interventions conducted by specialists with repeated contacts over 6 to 12 months, many using family-based comprehensive behavioral treatments. The largest single body of research addresses children aged 8–12 years. No current research is reported in children aged two-five. The number of studies addressing adolescents is small, but increasing. Overall, current trials are limited due to small—often-selective—samples; non-comparable interventions between trials; short-term (6 to 24 months) follow-up; reporting of overweight outcomes only with minimal reporting of health outcomes; and failing to report intention-to-treat analyses. Harms of screening and labeling children as overweight or obese theoretically include induced self-managed dieting with its sequelae, poorer self-concept, poorer health habits, disordered eating, or negative impacts of parental concern. Harms are not well reported in behavioral intervention trials. Limited good-quality evidence is available on pharmacological approaches as an adjunct to comprehensive behavioral treatment in adolescents, and no reasonable-quality evidence is available on bariatric surgery outcomes in adolescents. Conclusions BMI measurement to detect overweight in older adolescents could identify those at increased risk of developing adult obesity, and its consequent morbidities. Promising interventions to address overweight adolescents in clinical settings are beginning to be reported but are not yet proven to have clinically significant benefits; nor are they widely available. Screening for the purposes of overweight categorization in children under age 12 to 13 who are not clearly overweight may not provide reliable risk categorization for adult obesity. Theoretical harms may occur from overweight labeling or from induced individual and parental concern. Screening approaches are further compromised by the fact that there is little generalizable evidence for interventions that can be conducted in primary care or are widely available for primary care referral. Despite this, the fact that many trials report short- to medium-term modest improvements (approximately 10%–20% decrease in percent overweight or a few units' change in BMI) suggests that overweight improvements in children and adolescents are possible. Experts have identified pragmatic clinical recommendations for lifestyle changes that could be applied to all children and adolescents regardless of risk. While monitoring growth and development in children and adolescents through BMI documentation at visits is prudent, care should be taken not to unnecessarily label children and adolescents as overweight or at risk for overweight until more is known about BMI as a risk factor, and effective interventions are available.

Screening and Interventions for Childhood Overweight [Internet]

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