Showing papers in "Adolescent medicine (Philadelphia) in 2003"

Eating disorders in children and young adolescents: etiology, classification, clinical features, and treatment.

Abstract: Eating disorders in children and young adolescents are increasing in prevalence and occurring at ever-earlier ages. Eating disorders in this age group differ from the traditional eating disorders seen in older adolescents and young adults in that they frequently present atypically, they are suspected less often, they are more difficult to diagnose definitively, and there is less evidence to guide informed treatment decisions. Classification of eating disorders in this population also presents unique challenges. A high index of suspicion and aggressive screening will help to prevent delays in diagnosis. Treatment should include attention to nutritional, medical, and psychological issues. Family therapy has emerged as the treatment modality with the greatest evidence for its efficacy. Prognosis has been poorly studied, but good outcomes are common, particularly with early intervention.

Obesity and eating disorder prevention: an integrated approach?

Abstract: This article provides a rationale for interventions aimed at the prevention of eating disorders and obesity, an overview of some of the questions and controversies currently facing the fields of eating disorder and obesity prevention, and a discussion of the potential for integrated prevention approaches that address the broad spectrum of weight-related disorders. A rationale for utilizing an integrated approach, the challenges inherent to developing such an approach, and suggestions for working toward integrated approaches aimed at preventing the broad spectrum of weight-related disorders are discussed.

The worldwide epidemic of obesity in adolescents.

Abstract: There is an epidemic of obesity affecting adolescents worldwide. Both in developing and in developed countries adolescents are increasingly becoming more obese. The number of adolescents exceeding previously identified "cut-points" as well as the weight and "fatness" of the most obese individuals is increasing at a progressive rate. Despite their benign appearance epidemics of noncommunicable disease (or their risk factors) are no less devastating to the health of populations. The two key responses to any epidemic are to discover the causes of the epidemic disease and to characterize the epidemic. The latter needs to occur in relation to prevalence distribution across the populations (are some population groups more likely to be affected than others?) and secular trends. This chapter reviews what is currently known about the epidemiology of overweight and obesity among adolescents throughout the world. To clarify terms of epidemiology this chapter first identifies what are considered the most appropriate measures of adiposity and defines how much fat is too much fat. (authors)

The course and outcome of eating disorders in adults and in adolescents: a review.

Abstract: Over 100 studies have been published in the literature to date on the course and outcome of eating disorders. These have generally shown that approximately 50% of patients do well over time, approximately 30% do reasonably well but continue to have symptoms, and approximately 20% do poorly. In this article, the literature on the course and outcome of eating disorders is reviewed from two perspectives. The first is an analysis of studies in adults, looking in depth at a range of issues (weight, eating behaviors, menstrual function, psychosocial functioning, psychosexual function, mortality, bulimia nervosa, long-term follow-up, comorbidity, and prognostic factors) and reviewing the difficulties inherent to the performance of all eating disorders follow-up studies. The second is an analysis of whether adolescents with eating disorders have a better prognosis than adults, as has been considered in the literature. It is concluded that adolescents do, in fact, have a somewhat better prognosis than adults, with the differences seeming to be greater with a longer duration of follow-up.

Brain structure and function in adolescents with anorexia nervosa.

Abstract: Anorexia nervosa (AN) commonly arises during adolescence and is associated with significant medical morbidity Abnormalities in brain structure and function are among the most common, early, and concerning physical consequences Advances in neuroimaging technology have played an important role in delineating the structural and functional changes found in patients with AN Studies using computed tomography and magnetic resonance imaging have demonstrated changes in brain structure in the low-weight stages of AN In addition, functional neuroimaging techniques have demonstrated altered brain metabolism Debate continues as to whether these brain abnormalities are fully reversible with weight restoration Neuropsychological research has demonstrated that cognitive dysfunction is also a common feature of AN Multiple studies have indicated deficits in various neuropsychological domains Whether the reported cognitive deficits are reversible with weight gain remains unknown To date, some preliminary evidence suggests that reported cognitive deficits in patients with AN may be associated with structural brain abnormalities This chapter reviews the current literature about neuroimaging studies and cognitive function in adolescents with AN, discusses the possible underlying mechanisms causing these changes, and explores the possible association between them

Osteopenia and osteoporosis in anorexia nervosa.

Abstract: Osteopenia is a frequent and severe complication of anorexia nervosa. Once established, it is difficult to treat and is only partially reversible. Osteoporosis is a preventable disease, and intervention should begin during childhood and adolescence. Optimizing peak bone mass accrual during adolescence is essential, and an episode of anorexia nervosa during adolescence interferes with that process. In anorexia nervosa, results with hormone replacement therapy have been disappointing. Calcium and vitamin D supplementation should be prescribed where necessary. Excessive exercise should be avoided and moderate weight-bearing exercise encouraged. Ongoing research studying newer modalities such as IGF-1, DHEA, and bisphosphonates looks promising. Until more effective treatment regimens become available, the mainstay of treatment remains weight gain, nutritional rehabilitation, and spontaneous resumption of menses.

Physical activity, exercise, and sedentary activity: relationship to the causes and treatment of obesity.

Abstract: Lack of physical activity is a known determinant of obesity. Unfortunately, children become less and less active as they reach and progress through adolescence. This behavior leads to detrimental effects on body composition and other components of health-related physical fitness. Various types of exercise and activities have different effects on fitness, body composition, and metabolic state. For a physician to recommend activities or sports and exercise type, he or she should examine and discuss the patients fitness and physique goals to maintain their enthusiasm and promote lifelong physical activity benefits.

Psychosexual development and eating disorders.

Abstract: The relationship among eating disorders (EDs), psychosexual and identity development, and physical maturation (puberty) is reviewed. The developmental tasks of adolescence are summarized, and research from both community studies and clinical samples on the association between the development of an ED and putative risk factors that include pubertal development and psychosexual behaviors and attitudes for children and adolescents is reviewed. Specific issues explored include the role of child and adolescent abuse and EDs in males. Overall evidence suggests the following: there are inconsistent findings regarding early pubertal development as a risk factor; there is some support for differences between the ED subtypes in sexual attitudes, behaviors, and experiences; sexual abuse is not a specific risk factor; and gender identity issues may play more of a role for adolescent males than females. However, psychosexual issues are neither sufficient nor necessary for the development of an ED in a young person. It should be considered as only one factor in the multidimensional, multifactorial framework needed to clarify this complex and still poorly understood set of disorders.

The female athlete triad.

Abstract: The female athlete triad is a syndrome consisting of disordered eating, amenorrhea, and osteoporosis. The syndrome is increasing in prevalence as more women are participating in sports at a competitive level. Behaviors such as intense exercise or disordered eating patterns can lead to dysregulation of the hypothalamic-pituitarian-ovarian (HPO) axis, resulting in amenorrhea. Hypothalamic amenorrhea can lead to osteoporosis and increased fracture risk. Adolescents may particularly be at risk because it is during this crucial time that females attain their peak bone mass. Prevention of the female athlete triad through education and identification of athletes at risk may decrease the incidence of long-term deleterious consequences. Treatment of the female athlete triad is initially aimed at increasing caloric intake and decreasing physical activity until there is resumption of normal menses. Treatment of decreased bone mineral density and osteoporosis in the adolescent population, however, is controversial, with new treatment modalities currently being investigated in order to aid in the management of this disorder.

Cognitive-behavioral approaches in the management of obesity.

Abstract: Many of the behavioral interventions designed to promote dietary change in individuals include medical assessment, initial assessment of diet history, assessing readiness, establishing dietary goals, self-monitoring, stimulus control training, training in problem solving, relapse prevention training, enlisting social support, nutrition education, dietary therapy, and ongoing contact to maintain progress. The comprehensive nature of a cognitive-behavioral weight management program is of value in modifying behaviors that are linked to adverse health effects and psychological distresses, without necessarily causing a drastic weight loss in obese individuals. The behavioral treatments for overweight and obesity directly modify behaviors that bear on health and illness, such as improving dietary choices, decreasing sedentary behaviors, and increasing habitual physical activity and exercises. Cognitive-behavioral treatment can be used to help overweight adolescents become more assertive in coping with the adverse social stigma of being overweight, enhance their self-esteem, and reduce their dissatisfaction with body image regardless of their weight loss. Cognitive-behavioral treatments seem to be more effective in children when delivered before puberty than they are for adults.

Not all adolescents are the same: addressing the unique needs of gay and bisexual male youth.

Abstract: Adolescent males who self-identify as gay or bisexual come from all walks of life all socioeconomic backgrounds all religious denominations and all racial and ethnic groups. They live in urban centers suburban communities and small rural towns. Providing health care to this subpopulation of youth can be challenging to health care providers because of a pervasive societal stigma surrounding same gender sexual activity and sexual minority youth. Although gay and bisexual male youth share many of the same adolescent struggles as their heterosexual peers growing up in a society that often rejects and disapproves of them creates unique challenges to healthy physical and psychological development. Here we discuss the role of sexual identity formation in the lives of gay and bisexual male adolescents review some of the greatest challenges to their overall health and well-being and provide guidance for clinicians wishing to improve the delivery of health care services to this vulnerable population of youth. (excerpt)

Health care of adolescent males: overview, rationale, and recommendations.

Abstract: Overlooked amid the advances made in womens health over the past decade strategies for improving the health status of men and the quality of health care that they receive are now emerging. The importance of this is made clear from national data indicating that at birth the life expectancy for men is an average 5.4 years less than that for women (5.2 years for non-Hispanic Caucasians and 6.7 for African Americans). The age adjusted death rates for leading causes of premature mortality such as heart disease malignant neoplasm and motor vehicle crashes are also substantially greater for men than for women (32% 32% and 56% greater respectively). Greater emphasis on the value of prevention is also emerging. In the medical model attention is directed traditionally toward early detection and treatment of conditions such as heart disease hypertension cancer and hyperlipidemia. Using the public health model of prevention attention is directed toward antecedent factors that contribute to disease. The need for this approach was made clear in a seminal study which concluded that personal behaviors such as tobacco diet and physical activity alcohol firearms sexual behavior motor vehicles and illicit use of drugs accounted for approximately 42% of the 2.148 millions deaths during 1990. (excerpt)

The use of indirect calorimetry in the clinical management of adolescents with nutritional disorders.

Abstract: Indirect calorimetry is a noninvasive, inexpensive technique used to determine resting energy expenditure. Its use provides the clinician with objective information that can be used to design, implement, and evaluate efficacy of treatment in the nutritional management of adolescents with anorexia nervosa, bulimia nervosa, chronic dieting behavior, and obesity. This chapter outlines the theoretical framework, interpretation of data, and clinical applications of indirect calorimetry and presents case examples to underscore its utility in adolescents with eating disorders.

Bulimia nervosa and binge-eating disorder in adolescents.

Abstract: Bulimia nervosa (BN) and binge-eating disorder (BED) are separate entities with the common denominator of binge eating. In this chapter, Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for BN are reviewed, including both recurrent episodes of binge eating and inappropriate compensatory behaviors to prevent weight gain in one whose self-evaluation is unduly influenced by body weight and shape. Two percent of adolescent females and 0.3% of adolescent males fulfill criteria for BN. Risk factors, medical complications of binge eating (vomiting, use of ipecac, diet pills, diuretics, and laxatives), physical and laboratory findings, and treatment options and outcome are discussed. BED is seen in 1-2% of adolescents. The DSM-IV lists BED under Eating Disorder Not Otherwise Specified. DSM-IV research criteria for BED is reviewed, including binge eating, distress over binge eating, and absence of regular extreme compensatory behaviors. The mean age of onset is 17.2 years. Up to 30% of obese patients have BED. Risk factors are discussed. Because most patients with BED are obese, medical evaluation is similar to that for obesity. Treatment goals must be geared not only toward decreased binge eating but toward weight loss. Outcome is discussed.

Anogenital human papillomavirus infection in males.

Abstract: Human papillomaviruses (HPVs) are members of the Papillomaviridae family of DNA viruses. More than 100 types have been identified; some HPV types cause nongenital cutaneous infection and other HPV types cause anogenital mucocutaneous infection. Based on their association with cervical cancer anogenital HPV types have been classified further: low-risk types (e.g. 6 11) are associated with anogenital warts and mild dysplasias and high-risk types (e.g. 16 18 31 45) are associated with anogenital cancers and high-grade dysplasias. In contrast to other sexually transmitted pathogens HPV cannot be cultured and no serologic test is available for clinical use. HPV infection is assessed clinically and by detection of HPV DNA. Anogenital HPV infections are estimated to be the most common sexually transmitted infection; an estimated 5.5 million adults are infected with HPV annually. In one study cumulative annual incidence in young women was 43%. It is unclear whether the high prevalence of genital HPV infection is because the virus is easily transmitted remains infectious on the genital mucosa for long periods or both. (excerpt)

Connecting the adolescent male with health care.

Abstract: Starting in adolescence males use health care services less than females Younger adolescent males who use existing services rely on access to their primary clinician: pediatricians adolescent medicine physicians family physicians internists or nurse practitioners Older adolescent and young adult males obtain medical care from hospital emergency departments more often than primary care clinicians Many adolescent males who do have contact with clinicians receive limited medical examinations whether for injuries or for sports physicals There are few opportunities for preventive health messages or discussions with male adolescents; only one third report talking with a clinician about a reproductive health topic Unfortunately utilization of health services decreases further as males leave high school and become increasingly disconnected from traditional venues that provide preventive health care services and education to young people (excerpt)

The role of the primary care practitioner in the treatment of eating disorders.

Abstract: This article addresses practical issues facing the primary care practitioner caring for an adolescent with an eating disorder. It is grounded in the four elements of successful treatment noted by Comerci: (1) recognizing the disorder and restoring physiologic stability early in its course, (2) establishing a trusting, therapeutic partnership with the adolescent, (3) involving the family in treatment, and (4) using an interdisciplinary team approach. Although primary care practitioners often have an established relationship with their patients, adolescents with eating disorders present special challenges. These adolescents tend to be bright, strong-willed, and wary of any recommendations to change their weight-control practices for fear that they will lose control. Their families are often distraught by the conflicts that arise as a result of the disordered eating behaviors and the fear that the condition is associated with significant morbidity and mortality. The article provides primary care clinicians with pragmatic ways to diagnose and initiate treatment and engage the patient and parents as active participants and members of the therapeutic team in the early phases of treatment. In addressing these principles, the authors combine the nurturant-authoritative approach described by Levenkron with the biopsychosocial model proposed by Engel.

Medical nutrition therapy of overweight adolescents.

Abstract: The long-term goal of medical nutrition therapy for adolescents who are overweight or at risk for becoming overweight is to promote healthy lifestyle behaviors These behaviors will, in turn, improve metabolic parameters and self-esteem while helping the adolescent achieve and maintain a desirable body weight The identification of anthropometric, metabolic, nutritional, and environmental risk factors present in the child and family will help formulate the medical nutrition intervention A well-balanced diet that supports growth and development, aerobic exercise, and cognitive behavioral strategies are essential components of an intervention program Frequent and long-term monitoring by a registered dietitian and pediatrician will reinforce lifestyle changes and support the adolescent and family in achieving realistic goals of weight loss or weight maintenance This article covers the assessment and interventions necessary for successful nutrition therapy for obese and superobese adolescents

Genitourinary problems in adolescent males.

Abstract: In most aspects of life the adolescent is at an awkward transition between childhood and adult life In medicine and especially urology this gray zone pertains often to the disadvantage of these individuals--too big to consider themselves children but clearly not adults The genitourinary problems of adolescent males perhaps a unique species unto themselves span a wide range from undetected congenital anomalies to developmental and environmentally acquired problems Most genitourinary anomalies are detected in infancy if not before by virtue of antenatal ultrasonography and careful newborn examination Many children do not receive these examinations however and only later in childhood are the problems identified (excerpt)

Adolescent male sexuality.

Abstract: Adolescence is a transition period between childhood and adulthood. During this time the body develops into an adult and reproductively mature body. For many adolescents it is the time of completion of high school finding first jobs leaving home and beginning college. It is a stage to discover and establish an identity independent of the family. It is a time of exploration of romantic relationships including the initiation of sexual relations. All adolescents are sexual beings whether they are sexually active or not. Adolescents are often sexually active—a fact supported by data from many developed countries. Most adolescent males have their first sexual experience during their teenage years. Health care providers are not always comfortable addressing their sexual activity however. Only one third of adolescent males report talking with their clinician about a reproductive health topic. It is essential for health care providers caring for adolescents to understand male sexuality during the teenage period. This article provides an overview of heterosexual adolescent male sexuality. Another article in this issue gives an overview of gay bisexual and questioning youth. (authors)

Male puberty: physical, psychological, and emotional issues.

Abstract: Pubertal changes generally commence in males between 9.8 and 14.2 years with a mean of 11.8 years. Although there are a number of diseases that can lead to delayed puberty in males the vast majority of boys who experience delayed puberty have no underlying clinical pathologic condition. In a large case series of patients with delayed puberty 63% of males were found to have a constitutional delay. Of the remaining males with delayed puberty 19% had functional hypogonadotropic hypogonadism (FHH) and went into spontaneous pubertal development albeit late. Conditions leading to FHH in males included growth hormone deficiency hypothyroidism Crohns disease celiac disease sickle cell anemia seizure disorders and severe asthma. Males are much less likely than females to have a clinical pathologic condition as a basis of delayed onset of puberty; in fact most boys who enter puberty late have a family history of delayed pubertal development. (excerpt)

Providing anticipatory guidance and counseling to the adolescent male.

Abstract: During a clinical day a health care provider may find it refreshing to see an adolescent male because he will be quick and easy to see with an uncomplicated physical examination and clinical history. This attitude may be in part due to the fact that adolescent males have the reputation of being nontalkative difficult to engage or not interested when it comes to clinical care. Yet adolescent males experience many preventable health issues that place them at significant risk for morbidity and mortality (see earlier article). Also despite their reputation adolescent males do want to discuss their health. The primary care provider should not shortchange the adolescent male during his medical encounter but instead should take the time to engage him in anticipatory guidance and counseling. The fact that adolescent males are seen in a variety of clinical settings including ambulatory care emergency department school-based and juvenile detention makes it important for all types of care providers to become familiar with how to counsel adolescent males and to use counseling approaches that work. To provide a rationale for effective counseling a framework is first presented to enhance the understanding of the adolescent male in context of his development family friends and community/school. Equipped with the right set of tools clinicians of either gender can have much success communicating with and counseling adolescent male patients. (excerpt)

Condoms: the basics and beyond.

Abstract: Used properly and consistently condoms have a dual role in the prevention of STIs and unintended pregnancy. Condoms remain the only method of STI prevention and birth control available for use by the sexually active male. They are relatively inexpensive available without a prescription easy to obtain easy to carry and disposable after single use. Condoms also may prolong erection and male sexual response and reduce anxiety about STIs and pregnancy in both partners. Condoms require an erection to be applied must be applied before genital contact may reduce sensation significantly and may interfere with spontaneity when sexual activity is interrupted to put on the condom. Condoms are free of side effects except for individuals with latex allergy. Of U.S. adults 5–7% report latex allergy and these rates may reach 8–17% among hospital employees. Polyurethane condoms provide a latex-free alternative. Some individuals of either gender also may be sensitive to a specific condom lubricant and partners may need to experiment with alternative brands. (excerpt)