AFP Journal Review Vol 78, No. 9 11/1/08

1. AFP Journal ReviewVol 78, No. 9 11/1/08 Samantha Brown-Parks, MD, MPH 12/4/2008

2. Overview • Supplements and Sports • Obesity and CV risks in Children • Toilet Training • Probiotics

3. Supplements and Sports • GOAL: to be able to effectively counsel patients on the use of supplements with respect to • Safety • Effectiveness • Legality • 4/5 users are non-athletes • 2-7% HS students admit to anabolic steroids

6. 16 yo HS student has Q’s about sports supplements. Which one of the following has had life-threatening adverse effects? Amino Acids Sodium Bicarbonate C. Anabolic Steroids D. Creatine Questions

7. Includes all synthetic derivatives of Testosterone Increases muscle protein synthesis Short term Increased strength and lean body mass Schedule III controlled substance HDL BP Gynecomastia Aggressive Behavior Azospermia Virilization of Women Premature Death Suicide Acute MI Answer: C (Anabolic Steroids)

8. Which one of the following is true about caffeine? A. Increases sprint times B. Shown to improve cycling & rowing times C. Prohibited by IOC and NCAA >10mcg/ml urine D. Increases oxygen delivery Question #2

9. Stimulant Performance enhancing- faster times in rowing and cycling Decreased fatigue/ increased endurance Anxiety Dependency CNS withdrawal effects Prohibited by IOC/NCAA at >12 and >15 mcg/ml urinary concentration Answer: B (decreased times)

10. Evaluating Obesity and CV Risk in Kids • 17% of 2-19 yo are overweight • Numbers have increased 3X in 2 decades • Increased: • HTN • DM • Hyperlipidemia • Metabolic Syndrome

11. USPSTF No evidence to suggest screening kids for obesity or CV RFs AAP and AHA More aggressive based on consensus Screening Children

12. OBESITY <7yo, >95th% BMI with complications >7yo, >95th BMI Weight to <85th% BMI Control food intake >60 min vigorous activity/day <2h of sedentary activity HYPERTENSION Diastolic or Systolic >95th% AAP screen >3yo Appropriate cuff Normal for sex, height, age Elevated levels in >10yo Treated as Essential HTN related to Obesity (RR=3.3) Screening guidelines

13. DIABETES ADA screen >85th% + 2: Family Hx of DMII Native Am, Hispanic, Asian/So. Pacific Islander Insulin Resist/conditions Acanthosis nigricans HTH Hyperlipidemia PCOS FBG q other year at 10 AHA: glucose & insulin HYPERLIPIDEMIA 10% of 2-19yo TC>200 AAP- selective screening algorithm No clinical outcomes In overweight, screen annually 2-10yo Screening Guidelines, cont’d

14. Prevention & Management • Start interventions EARLY • Actively support Breast Feeding • No food as rewards • Look for Satiety signs • No “supersized” portions • Consider cultural preferences • Become community advocates for physical activity in daily life

15. Questions • Which one of the following is correct? A. The ADA rec’s screening in children with BMI >85th % and 2 additional Risk Factors B. The USPSTF rec ‘s screening all overweight adolescents annually C. ADA does not rec screening because it has not been proven to improve clinical outcomes D. According the AAP, blood glucose & insulin levels are not necessary when screening at risk children

16. Answer: A • The American Diabetic Association recommends screening children with a body mass index at or above the 85th percentile and two additional risk factors for diabetes every other year.

17. Toilet Training • Impacts families with small children • ALL healthy children will eventually be trained • Age of onset has increased over 40 yrs from 18mo -> 21-36mo

18. Training Basics • Mastery of necessary developmental skills usually at 24 months • Girls complete training earlier than boys • Family physicians should provide guidance and identify children who do not meet developmental milestones

19. Select Toilet Training Methods • Child-oriented • Brazelton • AAP guidelines • Dr. Spock’s • Operant conditioning • Azrin & Fox;s “Toilet Training in a Day” • Others • Assisted infant training • Elimination Communication Trains without force, praise success, begin when signs of readiness and when child shows interest

20. Toilet Training Complications • Stool Toileting refusal • Affects 22% • More likely to become constipated • Treated with dietary changes, stool softners, and positive reinforcement • Usually resolves without intervention • Stool Withholding • Increase fiber • May return to diapers • Hiding • Usually begins at 22 months • More likely to have Stool refusal and constipation

21. Tips for parents • Signs of readiness • Can copy what you do • Shows an interest in the potty • Can walk, sit, and follow simple directions • Can indicate when they are about to eliminate • Can pull pants up and down • Never refer to waste as “yucky”, “stinky” • Tell your doctor if the child withholds stool, hides during bowel movements, or becomes constipated

22. Question (multiple answers) Which of the following statements about current trends in toilet training in the US is/are correct? • The avg age training begins has increased over the past 4 decades • Boys usually train earlier than girls • Mastery of developmental skills required for training usually occur after 24 months • Convenience of disposable diapers likely leads some parents to delay toilet training

23. Correct Answers: A, C, D

24. Probiotics • Microorganisms with potential health benefits in food, pill, capsule form • Can prevent/treat antibiotic-assoctd diarrhea and acute infectious diarrhea • Useful for irritable bowel syndrome and possible atopic dermatitis

27. Questions?