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

D iabetes is a chronic illness that requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude clinical judgment or more extensive evaluation and management of the patient by other specialists as needed. For more detailed information about management of diabetes, refer to references 1–3. The recommendations included are screening, diagnostic, and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was used to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E. These standards of care are revised annually by the ADA multidisciplinary Professional Practice Committee, and new evidence is incorporated. Members of the Professional Practice Committee and their disclosed conflicts of interest are listed in the Introduction. Subsequently, as with all position statements, the standards of care are reviewed and approved by the Executive Committee of ADA’s Board of Directors.

Standards of Medical Care in Diabetes—2010

ContextClinical practice guidelines (CPGs) have been developed to improve the
quality of health care for many chronic conditions. Pay-for-performance initiatives
assess physician adherence to interventions that may reflect CPG recommendations.ObjectiveTo evaluate the applicability of CPGs to the care of older individuals
with several comorbid diseases.Data SourcesThe National Health Interview Survey and a nationally representative
sample of Medicare beneficiaries (to identify the most prevalent chronic diseases
in this population); the National Guideline Clearinghouse (for locating evidence-based
CPGs for each chronic disease).Study SelectionOf the 15 most common chronic diseases, we selected hypertension, chronic
heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes
mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis,
which are usually managed in primary care, choosing CPGs promulgated by national
and international medical organizations for each.Data ExtractionTwo investigators independently assessed whether each CPG addressed
older patients with multiple comorbid diseases, goals of treatment, interactions
between recommendations, burden to patients and caregivers, patient preferences,
life expectancy, and quality of life. Differences were resolved by consensus.
For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease,
type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, we aggregated
the recommendations from the relevant CPGs.Data SynthesisMost CPGs did not modify or discuss the applicability of their recommendations
for older patients with multiple comorbidities. Most also did not comment
on burden, short- and long-term goals, and the quality of the underlying scientific
evidence, nor give guidance for incorporating patient preferences into treatment
plans. If the relevant CPGs were followed, the hypothetical patient would
be prescribed 12 medications (costing her $406 per month) and a complicated
nonpharmacological regimen. Adverse interactions between drugs and diseases
could result.ConclusionsThis review suggests that adhering to current CPGs in caring for an
older person with several comorbidities may have undesirable effects. Basing
standards for quality of care and pay for performance on existing CPGs could
lead to inappropriate judgment of the care provided to older individuals with
complex comorbidities and could create perverse incentives that emphasize
the wrong aspects of care for this population and diminish the quality of
their care. Developing measures of the quality of the care needed by older
patients with complex comorbidities is critical to improving their care.

/pdf/clinical-practice-guidelines-and-quality-of-care-for-older-4dkwbw3b1x.pdf

Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance.

https://www.scienceopen.com/document_file/8305f7ff-79d5-49cd-b9e1-28a26f4ca691/PubMedCentral/8305f7ff-79d5-49cd-b9e1-28a26f4ca691.pdf

Standards of Medical Care in Diabetes—2009

OBJECTIVE: To review reliability, validity, and normative data from 7 different studies, involving a total of 1,988 people with diabetes, and provide a revised version of the Summary of Diabetes Self-Care Activities (SDSCA) measure. RESEARCH DESIGN AND METHODS: The SDSCA measure is a brief self-report questionnaire of diabetes self-management that includes items assessing the following aspects of the diabetes regimen: general diet, specific diet, exercise, blood-glucose testing, foot care, and smoking. Normative data (means and SD), inter-item and test-retest reliability, correlations between the SDSCA subscales and a range of criterion measures, and sensitivity to change scores are presented for the 7 different studies (5 randomized interventions and 2 observational studies). RESULTS: Participants were typically older patients, having type 2 diabetes for a number of years, with a slight preponderance of women. The average inter-item correlations within scales were high (mean = 0.47), with the exception of specific diet; test-retest correlations were moderate (mean = 0.40). Correlations with other measures of diet and exercise generally supported the validity of the SDSCA subscales (mean = 0.23). CONCLUSIONS: There are numerous benefits from standardization of measures across studies. The SDSCA questionnaire is a brief yet reliable and valid self-report measure of diabetes self-management that is useful both for research and practice. The revised version and its scoring are presented, and the inclusion of this measure in studies of diabetes self-management is recommended when appropriate.

https://care.diabetesjournals.org/content/diacare/23/7/943.full.pdf

The summary of diabetes self-care activities measure: results from 7 studies and a revised scale.

■ Abstract Given the growing attention on how environmental and policy interventions can affect chronic disease burden, our objectives are to describe (a) effective and promising interventions to address tobacco use, physical activity, and healthy eating and (b) lessons learned from the literature and practice experience in applying environmental and policy approaches. A total of 17 interventions were reviewed, organized across 3 domains affecting the physical environment/access, economic environment, and communication environment. Many of these interventions are effective. Several lessons are important to consider, such as the need to start with environmental and policy approaches, intervene comprehensively and across multiple levels, make use of economic evaluations, make better use of existing analytic tools, understand the politics and local context, address health disparities, and conduct sound policy research.

https://www.co.marion.or.us/HLT/PH/PS/chronicdisease/Documents/brownsonarphenvironpolicy.pdf

Shaping the context of health: a review of environmental and policy approaches in the prevention of chronic diseases.

The objective of this review is to summarize the literature on diabetes and smoking related to epidemiological risks, efficacy and cost-effectiveness of different cessation approaches, and implications for clinical practice. Over 200 studies were reviewed, with special emphasis placed on publications within the past 10 years. Intervention studies that included patients with diabetes but did not report results separately by disease are included. Diabetes-specific studies are highlighted. There are consistent results from both cross-sectional and prospective studies showing enhanced risk for micro- and macrovascular disease, as well as premature mortality from the combination of smoking and diabetes. The general cessation literature is extensive, generally well-designed, and encouraging regarding the impact of cost-effective practical office-based interventions. In particular, system-based approaches that make smoking a routine part of office contacts and provide multiple prompts, advice, assistance, and follow-up support are effective. Although there is minimal information on the effectiveness of cessation interventions specifically for people with diabetes, there is no reason to assume that cessation intervention would be more or less effective in this population. There is a clear need to increase the frequency of smoking cessation advice and counseling for patients with diabetes given the strong and consistent data on smoking prevalence; combined risks of smoking and diabetes for morbidity, mortality, and several complications; and the proven efficacy and cost-effectiveness of cessation strategies.

Smoking and diabetes.

Cultural tailoring for mammography and fruit and vegetable intake among low-income African-American women in urban public health centers

Smoking and Diabetes

Objective This article examines the relationship between the frequency with which African-American parents report modeling healthful dietary behaviors for their children and parental dietary intake. Design Cross-sectional, baseline data from a community-based dietary change study to reduce fat intake and increase fruit and vegetable consumption among African-American parents was analyzed to identify role-modeling behaviors. Subjects/setting Subjects were 456 African-American parents who participated in a dietary change study as part of a national parent education group. Participants completed the Parental Dietary Modeling Scale, an eating patterns questionnaire and a food frequency questionnaire. Statistical analyses performed Descriptive statistics and stepwise multiple linear regression analyses were conducted. Results Parental modeling of healthful dietary behavior was associated with the performance low-fat eating patterns ( r =0.48; P r =−0.30; P r =0.18; P Applications The frequency with which parents model healthful dietary behaviors may be associated with parental dietary intake and may have long-term implications for the development of childhood eating patterns. Dietetics professionals need to carefully assess parents' current dietary modeling behaviors and inform parents about how performance of these general behaviors may affect their child's ultimate nutrition health. J Am Diet Assoc. 2001;101:535-541 .

Debra Haire-Joshu

Papers

Shaping the context of health: a review of environmental and policy approaches in the prevention of chronic diseases.

Smoking and diabetes.

Cultural tailoring for mammography and fruit and vegetable intake among low-income African-American women in urban public health centers

Smoking and Diabetes

The relationship between parental modeling, eating patterns, and dietary intake among African-American parents