Jennifer Carlson, MD, is a Clinical Professor of Pediatrics in the division of Adolescent Medicine at Stanford. During her time at Stanford, she has served in a range of both clinical roles (providing care in the ambulatory, inpatient, and consultative services) and educational roles (serving as rotation director, pediatric resident coach, program director for Adolescent Medicine fellowship, member of the Fellows in Adolescent Medicine Learning Initiative (FAMLI)). She has led/collaborated on program initiatives with the goal of improving health access, particularly for the adolescent-aged population. These programs have included the Virtual PrEP clinic, inpatient Reproductive Consultation service, outpatient Joint Reproductive Health clinics, and Eating Disorders Telehealth program.

In addition to Adolescent Medicine, Dr. Carlson is board-certified in Clinical Informatics. She has served as the Medical Director of Patients Portals since 2016 and is a member of the Epic Adolescent Medicine Steering Board/BrainTrust. In her role as Clinical Informaticist, she has worked to expand and enhance information access for patients and families and published widely on novel approaches to portal development and management of confidentiality within the electronic health record (EHR). She has collaborated on the Epic White paper for managing confidentiality within the EHR and co-authored a multi-organization position statement on the topic.

Operationally, Dr. Carlson has held positions as physician-at-large for the LPCH Executive committee, Medical Director of the South Bay clinics, and member of the Operations Leadership Steering committee for the hospital.

Specific areas of interest and scholarship include:
1)Improving health equity and health access for the pediatric population- particularly for the adolescent and young adult age range- through novel program development (such as Virtual PrEP clinic).
2)Developing foundational and systemic approaches to managing health information within the EHR to allow for optimal health care for all patients. This includes ensuring that private and confidential information is protected within the electronic health record and non-private information is easily accessible to patients and families.
3)Improving systems for screening and management of psychosocial factors that affect the health of youth and families (ie, social determinants of health, universal depression screening, etc).

Clinical Focus

  • Adolescent Medicine
  • Clinical Informatics

Administrative Appointments

  • Portal Medical Director, Clinical Informatics, Stanford Medicine Children's Health (2016 - Present)
  • Medical Site Director, South Bay clinics, Stanford Medicine Children's Health (2021 - Present)
  • Fellowship Program Director, Adolescent Medicine, Stanford University School of Medicine (2018 - 2023)

Honors & Awards

  • Normal Schlossberger Research grant, UC San Francisco (2006)
  • Honor Roll for Teaching, Stanford University Medical Center (2008-2010, 2013)
  • Fuji Apple Mentoring Award, Stanford University, Department of Pediatrics (2017)

Boards, Advisory Committees, Professional Organizations

  • Fellow, American Academy of Pediatrics (2000 - Present)
  • Member, Society for Adolescent Health and Medicine (2003 - Present)
  • Member, Academy of Eating Disorders (2007 - Present)
  • Member, Athlete Triad Coalition (2013 - Present)
  • Member, Epic Adolescent Medicine Steering Board (2018 - Present)
  • Member, Adolescent Medicine Subboard, American Board of Pediatrics (2022 - Present)
  • Member, COCIT, American Academy of Pediatrics (2023 - Present)
  • Member, American Pediatric Society (2024 - Present)

Professional Education

  • Board-certified, ABPM: Clinical Informatics (2023)
  • Fellowship: UCSF Adolescent Medicine (2006) CA
  • Residency: Vermont Children's Hospital (UVMC) Pediatric Residency Program (2003) VT
  • Internship: Vermont Children's Hospital (UVMC) Pediatric Residency Program (2001) VT
  • M.D., Georgetown University, Medicine (2000)
  • B.S., University of California, Davis, Biological Sciences (1996)

Community and International Work

  • Yael's Running Club, Mountain View


    After school running club for middle school girls.

    Partnering Organization(s)

    Graham Middle School

    Populations Served

    Female adolescents


    Bay Area

    Ongoing Project


    Opportunities for Student Involvement


2023-24 Courses

Graduate and Fellowship Programs

  • Adolescent Medicine (Fellowship Program)

All Publications

  • Medical Considerations and Consequences of Eating Disorders. Focus (American Psychiatric Publishing) Carlson, J. L., Lemly, D. C. 2024; 22 (3): 301-306


    Eating disorders may result in medical complications that affect every body system with both acute and chronic consequences. Although some medical complications may require acute medical hospitalization to manage, other complications, such as low bone mineral density, may not present until malnutrition has become chronic. It is critical for team members to be aware of the early clinical signs of malnutrition and disordered eating behaviors, as well as longer-term complications that may affect their patients. When identifying eating disorder concerns, appropriate colleagues from the medical, nutrition, and psychiatric fields can be engaged in order to collaborate on stabilizing and improving the health of patients.

    View details for DOI 10.1176/appi.focus.20230042

    View details for PubMedID 38988462

    View details for PubMedCentralID PMC11231475

  • The association between overuse and musculoskeletal injuries and the female athlete triad in Division I collegiate athletes. PM & R : the journal of injury, function, and rehabilitation Miller Olson, E., Sainani, K. L., Dyrek, P., Bakal, D., Miller, K., Carlson, J. L., Fredericson, M., Tenforde, A. S. 2024


    Although the female athlete triad (Triad) has been associated with increased risk of bone-stress injuries (BSIs), limited research among collegiate athletes has addressed the associations between the Triad and non-BSI injuries.To elucidate the relationship between Triad and both BSI and non-BSI in female athletes.Retrospective cohort study.Primary and tertiary care student athlete clinic.National Collegiate Athletic Association Division I female athletes at a single institution.Participants completed a pre-participation questionnaire and dual-energy x-ray absorptiometry, which was used to generate a Triad cumulative risk assessment score (Triad score). The number of overuse musculoskeletal injuries that occurred while the athletes were still competing collegiately were identified through chart review.BSI and non-BSI were treated as count variables. The association between BSI, non-BSI, and Triad score was measured using Poisson regression to calculate rate ratios.Of 239 athletes, 43% of athletes (n = 103) sustained at least one injury. Of those, 40% (n = 95) sustained at least one non-BSI and 10% (n = 24) sustained at least one BSI over an average follow-up 2.5 years. After accounting for sport type (non-lean, runner, other endurance sport, or other lean advantage sport) and baseline age, we found that every additional Triad score risk point was associated with a significant 17% increase in the rate of BSI (rate ratio [RR] 1.17, 95% confidence interval [CI] 1.03-1.33; p = .016). However, Triad score was unrelated to non-BSI (1.00, 95% CI 0.91-1.11; p = .99). Compared with athletes in non-lean sports (n = 108), athletes in other lean advantage sports (n = 30) had an increased rate of non-BSI (RR: 2.09, p = .004) whereas distance runners (n = 46) had increased rates of BSI (RR: 7.65, p < .001) and non-BSI (RR: 2.25, p < .001).Higher Triad score is associated with an increased risk of BSI but not non-BSI in collegiate athletes.

    View details for DOI 10.1002/pmrj.13201

    View details for PubMedID 38837318

  • Evaluation of a Large Language Model to Identify Confidential Content in Adolescent Encounter Notes. JAMA pediatrics Rabbani, N., Brown, C., Bedgood, M., Goldstein, R. L., Carlson, J. L., Pageler, N. M., Morse, K. E. 2024

    View details for DOI 10.1001/jamapediatrics.2023.6032

    View details for PubMedID 38252434

    View details for PubMedCentralID PMC10804277

  • Provider Perspectives on Adolescent Confidentiality and the Electronic Health Record Postimplementation of the 21st Century Cures Act Final Rule. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Goldstein, R. L., Mermelstein, S. J., Sisk, B. A., Carlson, J. L. 2023


    PURPOSE: The 21st Century Cures Act Final Rule mandates increased transparency and accessibility of the Electronic Health Record (EHR). This mandate has exacerbated tensions in adolescent healthcare between transparency and confidentiality. This study evaluates clinicians' perspectives on how well the EHR maintains confidentiality for adolescents in the post-Cures Act era.METHODS: A web-based survey was distributed via the national listserv of the Society for Adolescent Health and Medicine in March-April 2022. English-speaking members practicing in the Unites States who used an EHR to document clinical visits with minors were eligible. The survey included questions about EHR training, features, and approach to information sharing with adolescent patients and proxies.RESULTS: Participants included 97 respondents from 32 states. Most participants were physicians (98%) and identified themselves as attending (89%). Several EHR vendors were represented, although the majority used Epic (76%). As has been seen in prior studies, there remains significant variability in approaches to patient portal access for adolescent patients and their adult proxies. Respondents report that training around adolescent-specific privacy issues remains infrequent and is perceived as inadequate. Adolescent providers, despite feeling confident in navigating the EHR generally, continue to report low rates of confidence in how well their EHR may protect adolescent privacy.DISCUSSION: Clinicians have persistent concerns about adolescent confidentiality postimplementation of the 21st Century Cures Act. Sharing sufficient information while protecting adolescent confidentiality might require standardization by EHR vendors to improve granularity of proxy information sharing. Healthcare institutions must also commit to training providers on management of adolescent confidentiality.

    View details for DOI 10.1016/j.jadohealth.2023.11.006

    View details for PubMedID 38099899

  • A Natural Language Processing Model to Identify Confidential Content in Adolescent Clinical Notes. Applied clinical informatics Rabbani, N., Bedgood, M., Brown, C., Steinberg, E., Goldstein, R., Carlson, J., Pageler, N., Morse, K. 2023


    BACKGROUND: The 21st Century Cures Act mandates the immediate, electronic release of health information to patients. However, in the case of adolescents, special consideration is required to ensure that confidentiality is maintained. The detection of confidential content in clinical notes may support operational efforts to preserve adolescent confidentiality while implementing information sharing.OBJECTIVE: Determine if a natural language processing (NLP) algorithm can identify confidential content in adolescent clinical progress notes.METHODS: 1,200 outpatient adolescent progress notes written between 2016 and 2019 were manually annotated to identify confidential content. Labeled sentences from this corpus were featurized and used to train a two-part logistic regression model, which provides both sentence-level and note-level probability estimates that a given text contains confidential content. This model was prospectively validated on a set of 240 progress notes written in May 2022. It was subsequently deployed in a pilot intervention to augment an ongoing operational effort to identify confidential content in progress notes. Note-level probability estimates were used to triage notes for review and sentence-level probability estimates were used to highlight high-risk portions of those notes to aid the manual reviewer.RESULTS: The prevalence of notes containing confidential content was 21% (255/1200) and 22% (53/240) in the train/test and validation cohorts. The ensemble logistic regression model achieved an AUROC of 90% and 88% in the test and validation cohorts. Its use in a pilot intervention identified outlier documentation practices and demonstrated efficiency gains over completely manual note review.DISCUSSION: An NLP algorithm can identify confidential content in progress notes with high accuracy. Its human-in-the-loop deployment in clinical operations augmented an ongoing operational effort to identify confidential content in adolescent progress notes. These findings suggest NLP may be used to support efforts to preserve adolescent confidentiality in the wake of the information blocking mandate.

    View details for DOI 10.1055/a-2051-9764

    View details for PubMedID 36898410

  • The Prevalence of Confidential Content in Adolescent Progress Notes Prior to the 21st Century Cures Act Information Blocking Mandate. Applied clinical informatics Bedgood, M., Rabbani, N., Brown, C., Goldstein, R., Carlson, J. L., Steinberg, E., Powell, A., Pageler, N. M., Morse, K. 2023; 14 (2): 337-344


    The 21st Century Cures Act information blocking final rule mandated the immediate and electronic release of health care data in 2020. There is anecdotal concern that a significant amount of information is documented in notes that would breach adolescent confidentiality if released electronically to a guardian.The purpose of this study was to quantify the prevalence of confidential information, based on California laws, within progress notes for adolescent patients that would be released electronically and assess differences in prevalence across patient demographics.This is a single-center retrospective chart review of outpatient progress notes written between January 1, 2016, and December 31, 2019, at a large suburban academic pediatric network. Notes were labeled into one of three confidential domains by five expert reviewers trained on a rubric defining confidential information for adolescents derived from California state law. Participants included a random sampling of eligible patients aged 12 to 17 years old at the time of note creation. Secondary analysis included prevalence of confidentiality across age, gender, language spoken, and patient race.Of 1,200 manually reviewed notes, 255 notes (21.3%) (95% confidence interval: 19-24%) contained confidential information. There was a similar distribution among gender and age and a majority of English speaking (83.9%) and white or Caucasian patients (41.2%) in the cohort. Confidential information was more likely to be found in notes for females (p < 0.05) as well as for English-speaking patients (p < 0.05). Older patients had a higher probability of notes containing confidential information (p < 0.05).This study demonstrates that there is a significant risk to breach adolescent confidentiality if historical progress notes are released electronically to proxies without further review or redaction. With increased sharing of health care data, there is a need to protect the privacy of the adolescents and prevent potential breaches of confidentiality.

    View details for DOI 10.1055/s-0043-1767682

    View details for PubMedID 37137339

    View details for PubMedCentralID PMC10156443

  • Adolescent Privacy and the Electronic Health Record - Creating a Guardrail System to Ensure Appropriate Activation of Adolescent Portal Accounts. Applied clinical informatics Xie, J., Hogan, A., McPherson, T., Pageler, N., Lee, T. C., Carlson, J. 2023


    CASE PRESENTATION: The parent of an adolescent patient noticed an upcoming appointment in the patient's portal account that should have remained confidential to the parent. As it turned out, this parent was directly accessing their child's adolescent patient portal account instead of using a proxy account. After investigation of this case, it was found that the adolescent account had been activated with the parent's demographic information. This case illustrates the challenges of using adult-centric electronic health record (EHR) systems and how our institution addressed the problem of incorrect portal account activations.BACKGROUND: Confidentiality is fundamental to providing healthcare to adolescents. To comply with the 21st Century Cures Act's information blocking rules, confidential information must be released to adolescent patients when appropriate while also remaining confidential from their guardians. While complying with this national standard, systems of care must also account for interstate variability in which services allow for confidential adolescent consent. Unfortunately, there are high rates of guardian access to adolescent portal accounts. Therefore, measures must be taken to minimize the risk of inadvertent confidentiality breaches via adolescent patient portals. Solutions and Lessons Learned: Our institution implemented a guardrail system that checks the adolescent patient's contact information against the contact information of their parent/guardian/guarantor. This guardrail reduced the rate of account activation errors after implementation. However, the guardrail can be bypassed when demographic fields are missing. Thus, ongoing efforts to create pediatric-appropriate demographic fields in the EHR and workflows for registration of proxy accounts in the patient portal are needed.

    View details for DOI 10.1055/a-2015-0964

    View details for PubMedID 36652961

  • Providing Online Portal Access to Families of Adolescents and Young Adults with Diminished Capacity at an Academic Children's Hospital: A Case Report. Applied clinical informatics Carlson, J. L., Pageler, N., McPherson, T., Anoshiravani, A. 2023; 14 (1): 128-133


     For caregivers of adolescents and young adults with severe cognitive deficits, or "diminished capacity," access to the medical record can be critical. However, this can be a challenge when utilizing the electronic health record (EHR) as information is often restricted in order to protect adolescent confidentiality. Having enhanced access for these proxies would be expected to improve engagement with the health system for the families of these medically complex adolescents and young adults. To describe a process for granting full EHR access to proxies of adolescents with diminished capacity and young adults who are legally conserved while respecting regulations supporting adolescent confidentiality. The first step in this initiative was to define the "diminished capacity" access class for both adolescents and young adults. Once defined, workflows utilizing best practice alerts were developed to support clinicians in providing the appropriate documentation. In addition, processes were developed to minimize the possibility of erroneously activating the diminished capacity access class for any given patient. To enhance activation, a support tool was developed to identify patients who might meet the criteria for diminished capacity proxy access. Finally, outreach and educations were developed for providers and clinics to make them aware of this initiative. Since activating this workflow, proxies of 138 adolescents and young adults have been granted the diminished capacity proxy access class. Approximately 54% are between 12 and 17 years with 46% 18 years and older. Proxies for both age groups have engaged with portal functionality at higher rates when compared to institutional rates of use by proxies of the general pediatric population. With this quality improvement initiative, we were able to enhance EHR access and engagement of families of some of the most complex adolescent and young adult patients without inadvertently compromising adolescent confidentiality.

    View details for DOI 10.1055/s-0043-1760847

    View details for PubMedID 36792056

  • Clinician confidence and practices for evaluating bone health in male and female adolescents and young adults with an eating disorder. Eating disorders Nelson, L. R., Carlson, J. L., Halpern-Felsher, B. L., Nagata, J. M. 2022: 1-9


    Extensive literature exists on bone health in females with an eating disorder, yet few have studied males. Our study assessed clinician confidence and current practices for assessing bone health in patients with an eating disorder. We also aimed to identify any differences in practice based on patient sex. Our 31-item survey, distributed to adolescent clinicians in the United States via the Society for Adolescent Health and Medicine (SAHM) listserv, assessed clinician confidence and practices for assessing bone mineral density in both male and female adolescents with an eating disorder. Findings showed that clinicians (n=104) were less confident in assessing bone mineral density in males compared to females (p<.001), yet there was no significant difference in rates of obtaining a DXA (p=.390). Although clinicians are less confident assessing bone health in males with an eating disorder than females, this does not appear to result in screening differences.

    View details for DOI 10.1080/10640266.2022.2141714

    View details for PubMedID 36404478

  • Usability and Utility of HIV Pre-exposure Prophylaxis (PrEP) Clinical Decision Support to Increase Knowledge and PrEP Initiations among Pediatric Providers. Applied clinical informatics Chan, C. T., Carlson, J., Lee, T. C., Vo, M., Nasr, A., Hart-Cooper, G. 2022


    OBJECTIVES: An effective clinical decision support system (CDSS) may address the current provider training barrier to offering pre-exposure prophylaxis (PrEP) to youth at risk for human immunodeficiency virus (HIV) infection. This study evaluated change in provider knowledge and likelihood to initiate PrEP after exposure to a PrEP CDSS. A secondary objective explored perceived provider utility of the CDSS and suggestions for improving CDSS effectiveness.METHODS: This was a prospective study using survey responses from a convenience sample of pediatric providers who launched the interruptive PrEP CDSS when ordering an HIV test. McNemar's test evaluated change in provider PrEP knowledge and likelihood to initiate PrEP. Qualitative responses on CDSS utility and suggested improvements were analyzed using Framework Analysis and were connected to quantitative analysis elements using the merge approach.RESULTS: Of the 73 invited providers, 43 had available outcome data and were included in the analysis. Prior to using the CDSS, 86% of participants had never prescribed PrEP. Compared to before CDSS exposure, there were significant increases in the proportion of providers who were knowledgeable about PrEP (p=0.0001), likely to prescribe PrEP (p<0.0001), and likely to refer their patient for PrEP (p<0.0001). Suggestions for improving the CDSS included alternative "triggers" for the CDSS earlier in visit workflows, having a non-interruptive CDSS, additional provider educational materials, access to patient-facing PrEP materials, and additional CDSS support for adolescent confidentiality and navigating financial implications of PrEP.CONCLUSIONS: Our findings suggest that an interruptive PrEP CDSS attached to HIV test orders can be an effective tool to increase knowledge and likelihood to initiate PrEP among pediatric providers. Continual improvement of the PrEP CDSS based on provider feedback is required to optimize usability, effectiveness, and adoption. A highly usable PrEP CDSS may be a powerful tool to close the gap in youth PrEP access and uptake.

    View details for DOI 10.1055/a-1975-4277

    View details for PubMedID 36351546

  • Female Athlete Triad Risk Factors Are More Strongly Associated With Trabecular-Rich Versus Cortical-Rich Bone Stress Injuries in Collegiate Athletes. Orthopaedic journal of sports medicine Tenforde, A. S., Katz, N. B., Sainani, K. L., Carlson, J. L., Golden, N. H., Fredericson, M. 2022; 10 (9): 23259671221123588


    Background: Bone stress injuries (BSIs) are common in athletes. Risk factors for BSI may differ by skeletal anatomy and relative contribution of trabecular-rich and cortical-rich bone.Hypothesis: We hypothesized that Female Athlete Triad (Triad) risk factors would be more strongly associated with BSIs sustained at trabecular-rich versus cortical-rich skeletal sites.Study Design: Cohort study; Level of evidence, 2.Methods: The study population comprised 321 female National Collegiate Athletic Association Division I athletes participating in 16 sports from 2008 to 2014. Triad risk factors and a Triad cumulative risk score were assessed using responses to preparticipation examination and dual energy x-ray absorptiometry to measure lumbar spine and whole-body bone mineral density (BMD). Sports-related BSIs were diagnosed by a physician and confirmed radiologically. Athletes were grouped into those sustaining a subsequent trabecular-rich BSI, a subsequent cortical-rich BSI, and those without a BSI. Data were analyzed with multinomial logistic regression adjusted for participation in cross-country running versus other sports.Results: A total of 19 participants sustained a cortical-rich BSI (6%) and 10 sustained a trabecular-rich BSI (3%) over the course of collegiate sports participation. The Triad cumulative risk score was significantly related to both trabecular-rich and cortical-rich BSI. However, lower BMD and weight were associated with significantly greater risk for trabecular-rich than cortical-rich BSIs. For every value lower than 1 SD, the odds ratios (95% CIs) for trabecular-rich versus cortical-rich BSI were 3.08 (1.25-7.56) for spine BMD; 2.38 (1.22-4.64) for whole-body BMD; and 5.26 (1.48-18.70) for weight. Taller height was a significantly better predictor of cortical-rich than trabecular-rich BSI.Conclusion: The Triad cumulative risk score was significantly associated with both trabecular-rich and cortical-rich BSI, but Triad-related risk factors appeared more strongly related to trabecular-rich BSI. In particular, low BMD and low weight were associated with significantly higher increases in the risk of trabecular-rich BSI than cortical-rich BSI. These findings suggest Triad risk factors are more common in athletes sustaining BSI in trabecular-rich than cortical-rich locations.

    View details for DOI 10.1177/23259671221123588

    View details for PubMedID 36157087

  • Dobbs v. Jackson Decision: It's Time to Get Uncomfortable. Hospital pediatrics Goldstein, R. L., Carlson, J. L., Tyson, N. A. 2022


    The recently announced decision of the Supreme Court in the Dobbs v. Jackson case has left health care providers, researchers, and administrators struggling to defend reproductive health care against legal restrictions. Although some hospital-based providers may not consider reproductive health care as part of their "wheelhouse," anyone who cares for adolescents and young adults must see this as a call to action. Reproductive health screening is often missed in the primary care setting1 which has led to recommendations to provide this care wherever adolescents and young adults present for care.2 As adolescents are under the legal age of majority and typically have less experience, education, and resources to help them access reproductive health care when needed, these new abortion laws will create disproportionate burdens on the adolescent population. For low-income youth and adolescent and young adults of color, this will likely worsen the disparities that already exist with regard to access to reproductive health care.3 Adolescents have the highest rates of unintended pregnancy4 and these pregnancies are more likely to end in abortion than adult pregnancies.5,6 Adolescents younger than age 20 make up 12% of individuals who have abortions in the US; minors who are 17 years or younger account for about 4% of all abortions in the US.7.

    View details for DOI 10.1542/hpeds.2022-006829

    View details for PubMedID 35799327

  • Implementation of an Inpatient Reproductive Health Screening Consult Service. Hospital pediatrics Goldstein, R. L., Keppler, H., Pineda, N., Weng, Y., Carlson, J. L. 2022


    OBJECTIVES: Reproductive health is an important issue in the care of adolescents and young adults (AYA). Unfortunately, many AYAs, particularly those with chronic medical conditions, may not regularly access primary care to address these issues. This study evaluates the impact of an inpatient reproductive health consult service on reproductive health care.METHODS: A reproductive health-focused screening consult service was initiated in June 2017 at an academic teaching hospital. Patients aged 15 to 26 admitted to pediatric ward teams were eligible for screening. A retrospective chart review was conducted from December 2016 to June 2019 to determine the effect of the consult service on the primary outcome, documentation of a psychosocial assessment, and reproductive health concerns.RESULTS: Nine hundred twenty-nine encounters were analyzed (345 preintervention and 584 during intervention), representing 675 patients. The proportion of encounters with a documented psychosocial assessment increased from 14.8% to 41.3% during the intervention (P < .001); a reproductive health screening consult was responsible for 37.3% (109 of 292) of the documented assessments. There were high self-reported rates of sexual activity (38%), substance use (47%), and mood concerns (48%) among hospitalized AYA; all behaviors were documented at statistically significant increased frequencies (P < .001) during the intervention compared with preintervention.CONCLUSIONS: Initiation of an inpatient reproductive health screening consult service led to increased documentation of psychosocial assessments, including increased documentation of sexual health history and other risk factors. With improved screening of reproductive and psychosocial needs, targeted interventions can meet underrecognized needs among hospitalized AYA.

    View details for DOI 10.1542/hpeds.2021-006178

    View details for PubMedID 35165737

  • Pediatric Provider Utilization of a Clinical Decision Support Alert and Association with HIV Pre-exposure Prophylaxis Prescription Rates. Applied clinical informatics Chan, C. T., Vo, M., Carlson, J., Lee, T., Chang, M., Hart-Cooper, G. 2022; 13 (1): 30-36


     An electronic clinical decision support (CDS) alert can provide real-time provider support to offer pre-exposure prophylaxis (PrEP) to youth at risk for human immunodeficiency virus (HIV). The purpose of this study was to evaluate provider utilization of a PrEP CDS alert in a large academic-community pediatric network and assess the association of the alert with PrEP prescribing rates. HIV test orders were altered for patients 13 years and older to include a hard-stop prompt asking if the patient would benefit from PrEP. If providers answered "Yes" or "Not Sure," the CDS alert launched with options to open a standardized order set, refer to an internal PrEP specialist, and/or receive an education module. We analyzed provider utilization using a frequency analysis. The rate of new PrEP prescriptions for 1 year after CDS alert implementation was compared with the year prior using Fisher's exact test. Of the 56 providers exposed to the CDS alert, 70% (n = 39) responded "Not sure" to the alert prompt asking if their patient would benefit from PrEP, and 54% (n = 30) chose at least one clinical support tool. The PrEP prescribing rate increased from 2.3 prescriptions per 10,000 patients to 6.6 prescriptions per 10,000 patients in the year post-intervention (p = 0.02). Our findings suggest a knowledge gap among pediatric providers in identifying patients who would benefit from PrEP. A hard-stop prompt within an HIV test order that offers CDS and provider education might be an effective tool to increase PrEP prescribing among pediatric providers.

    View details for DOI 10.1055/s-0041-1740484

    View details for PubMedID 35021253

  • Ensuring Adolescent Patient Portal Confidentiality in the Age of the Cures Act Final Rule. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Xie, J., McPherson, T., Powell, A., Fong, P., Hogan, A., Ip, W., Morse, K., Carlson, J. L., Lee, T., Pageler, N. 2021


    PURPOSE: Managing confidential adolescent health information in patient portals presents unique challenges. Adolescent patients and guardians electronically access medical records and communicate with providers via portals. In confidential matters like sexual health, ensuring confidentiality is crucial. A key aspect of confidential portals is ensuring that the account is registered to and utilized by the intended user. Inappropriately registered or guardian-accessed adolescent portal accounts may lead to confidentiality breaches.METHODS: We used a quality improvement framework to develop screening methodologies to flag guardian-accessible accounts. Accounts of patients aged 12-17 were flagged via manual review of account emails and natural language processing of portal messages. We implemented a reconciliation program to correct affected accounts' registered email. Clinics were notified about sign-up errors and educated on sign-up workflow. An electronic alert was created to check the adolescent's email prior to account activation.RESULTS: After initial screening, 2,307 of 3,701 (62%) adolescent accounts were flagged as registered with a guardian's email. Those accounts were notified to resolve their logins. After five notifications over 8 weeks, 266 of 2,307 accounts (12%) were corrected; the remaining 2,041 (88%) were deactivated.CONCLUSIONS: The finding that 62% of adolescent portal accounts were used/accessed by guardians has significant confidentiality implications. In the context of the Cures Act Final Rule and increased information sharing, our institution's experience with ensuring appropriate access to adolescent portal accounts is necessary, timely, and relevant. This study highlights ways to improve patient portal confidentiality and prompts institutions caring for adolescents to review their systems and processes.

    View details for DOI 10.1016/j.jadohealth.2021.09.009

    View details for PubMedID 34666956

  • Clinician practices assessing hypothalamic-pituitary-gonadal axis suppression in adolescents with an eating disorder. The International journal of eating disorders Nelson, L. R., Halpern-Felsher, B. L., Nagata, J. M., Carlson, J. L. 2021


    OBJECTIVE: Although extensive literature exists on hypothalamic-pituitary-gonadal (HPG) axis suppression in females with an eating disorder, there are few studies in males. Our study aimed to determine clinician practices for the assessment of HPG axis suppression and to identify differences in practice based on the sex of the patient.METHOD: Our 31-item survey queried clinicians about confidence level and practices for assessing HPG suppression in male compared to female patients.RESULTS: Findings showed that clinicians (n=104) were less likely to evaluate HPG suppression in males compared to females, including assessment of sexual maturity rating (p<.050), screening of decreased libido compared to amenorrhea (p<.001) and lab assessment (luteinizing hormone and follicular-stimulating hormone: p<.001; estradiol/testosterone: p<.010; TSH: p<.050). Participants also felt less confident evaluating male patients (p<.001) and requested better screening tools for males (p<.001).DISCUSSION: Our data suggest that clinician practices differ based on patient sex and that clinicians request tools for HPG suppression assessment in males. This is the first study examining specific practices and comfort levels of clinicians when assessing HPG axis suppression. Findings suggest that more guidance on the management of male patients may be needed to standardize care and to prevent short and long-term sequela of malnutrition.

    View details for DOI 10.1002/eat.23625

    View details for PubMedID 34611918

  • Low-Energy Availability and the Electronic Preparticipation Examination in College Athletes: Is There a Better Way to Screen? Current sports medicine reports Goldstein, R., Carlson, J., Tenforde, A., Golden, N., Fredericson, M. 2021; 20 (9): 489-493


    ABSTRACT: The electronic preparticipation physical examination (ePPE) is commonly used to identify health conditions that would affect participation in sports for athletes, including disordered eating and/or low energy availability (EA). A secondary analysis was performed using a cohort study of female college athletes attending a Division 1 university between 2008 and 2014. Descriptive statistics and logistic regression analyses were used to explore the association between responses to questions on the ePPE related to eating behaviors and Female Athlete Triad (Triad). Risk categories (low, moderate, or high) were assigned to 239 athletes participating in 16 sports. The majority of responses on the ePPE did not identify athletes associated with moderate-/high-risk categories. Our findings suggest that ePPE may not sufficiently identify athletes at elevated risk for health concerns of the Triad. Our findings suggest that future ePPE may consider validated screening tools for disordered eating to help identify athletes at risk of low EA.

    View details for DOI 10.1249/JSR.0000000000000880

    View details for PubMedID 34524193

  • The 21st Century Cures Act & Adolescent Confidentiality. Pediatrics 2021; 147 (6)

    View details for DOI 10.1542/peds.2021-051487

    View details for PubMedID 34031235

  • To meat or not to meat: disordered eating and vegetarian status in university students. Eating and weight disorders : EWD Sieke, E. H., Carlson, J. L., Lock, J., Timko, C. A., Neumark-Sztainer, D., Peebles, R. 2021


    PURPOSE: This study sought to examine associations between meat-restricted diets and disordered eating cognitions and behaviors in a large sample of university students and assess the relationships between motivations for choosing a vegetarian or semi-vegetarian diet and eating patterns.METHODS: University students (n=1585; 60%F, 40%M, mean age 20.9) completed an online survey; students were categorized into vegetarians, semi-vegetarians, and non-vegetarians. Vegetarians and semi-vegetarians were sub-categorized into groups: those who cited weight or health among their reasons for adopting the diet and those who reported other reasons (e.g., religion). Outcomes were Eating Disorder Examination Questionnaire (EDE-Q) scores and rates of disordered eating behaviors.RESULTS: Vegetarians comprised 8.6% (32M, 104F) and semi-vegetarians comprised 3.2% (6M, 45F) of the sample; 25% of vegetarians (n=34) and 65% of semi-vegetarians (n=33) chose the diet for weight or health-related reasons. Semi-vegetarians scored the highest on measures of eating disorder cognitions and were the most likely to report engaging in disordered eating behaviors, with vegetarians at intermediate risk and non-vegetarians the least likely to report disordered cognitions or behaviors. Semi-vegetarians adopting the diet for reasons of weight or health were at especially high risk compared to other semi-vegetarians, while no associations were found between motivations for adopting a vegetarian diet and disordered eating patterns.CONCLUSION: Semi-vegetarians, especially those adopting the diet for reasons of weight or health, are more likely to exhibit disordered eating cognitions and behaviors compared to vegetarians and non-vegetarians.LEVEL OF EVIDENCE: Level III, cohort study.

    View details for DOI 10.1007/s40519-021-01202-8

    View details for PubMedID 34021903

  • Markers of Low Iron Status Are Associated with Female Athlete Triad Risk Factors. Medicine and science in sports and exercise Finn, E. E., Tenforde, A. S., Fredericson, M., Golden, N. H., Carson, T. L., Karvonen-Gutierrez, C. A., Carlson, J. L. 2021


    PURPOSE: The Female Athlete Triad (Triad) is common in female athletes. The Triad is caused by low energy availability (EA), which is often difficult to measure and has been postulated to be associated with low iron status. Here, we explore whether markers of low iron status may be associated with indicators of low EA including Triad risk factors.METHODS: 239 female NCAA Division I athletes completed pre-participation examinations that included Triad risk factors, medication/supplement use, diagnosis of anemia, and elected to complete dual-energy x-ray absorptiometry scan to measure bone mineral density (BMD). Association of markers of low iron (defined as self-report of iron supplementation and/or history of anemia) with each component of the Triad risk assessment score were assessed by stratifying low iron status across different levels of Triad risk category. Differences across iron status groups were assessed using Fisher exact testing.RESULTS: Every component of the Triad risk assessment score excluding delayed menarche was associated with low iron status. 11.5% of women reported low iron in the low-risk EA group, compared to 50% in the moderate-risk and 66.7% in the high-risk EA groups (P=0.02); respectively, these numbers were 11.6%, 25.0%, and 66.7% (P=0.02) for body mass index, 9.7%, 16.7%, and 25.0% (P<0.05) for oligomenorrhea, 10.3%, 45.5%, and 50.0% (P<0.01) for BMD, and 10.4%, 20.8%, and 30.8% (P=0.03) for history of stress reaction or fracture. Lean/endurance athletes were more likely to have low iron status than other athletes (15.5% vs. 3.4%, P=0.02).CONCLUSION: Markers for low iron status were associated with Triad risk factors. Our study suggests that female athletes with history of anemia or iron supplementation may require further screening for low EA.

    View details for DOI 10.1249/MSS.0000000000002660

    View details for PubMedID 33731653

  • NASPAG/SAHM Statement: The 21st Century Cures Act and Adolescent Confidentiality. Journal of pediatric and adolescent gynecology Carlson, J., Goldstein, R., Hoover, K., Tyson, N. 2021; 34 (1): 3–5

    View details for DOI 10.1016/j.jpag.2020.12.015

    View details for PubMedID 33485521

  • NASPAG/SAHM Statement: The 21st Century Cures Act and Adolescent Confidentiality. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Carlson, J., Goldstein, R., Hoover, K., Tyson, N. 2021; 68 (2): 426–28

    View details for DOI 10.1016/j.jadohealth.2020.10.020

    View details for PubMedID 33541602

  • Lower Trabecular Bone Score and Spine Bone Mineral Density Are Associated with Bone Stress Injuries and Triad Risk Factors in Collegiate Athletes. PM & R : the journal of injury, function, and rehabilitation Tenforde, A. S., Carlson, J. L., Sainani, K. L., Chang, A. O., Kim, J. H., Diaz, R., Golden, N. H., Fredericson, M. 2020


    INTRODUCTION: Determinants of bone health and injury are important to identify in athletes. Bone mineral density (BMD) is commonly measured in athletes with Female Athlete Triad (Triad) risk factors; Trabecular Bone Score (TBS) has been proposed to predict fracture risk independent of BMD. Evaluation of TBS and spine BMD to bone stress injury (BSI) risk has not been studied in female collegiate athletes.OBJECTIVE: We hypothesized that spine BMD and TBS would each independently predict BSI and the combined measures would improve injury prediction in female collegiate athletes. We also hypothesized each measure would be correlated with Triad risk factors.DESIGN: Retrospective cohort SETTING: Academic Institution METHODS: Dual energy x-ray absorptiometry (DXA) of lumbar spine was used to calculate BMD and TBS values. Chart review was used to identify BSI that occurred after the DXA measurement and to obtain Triad risk factors. We used logistic regression to examine the ability of TBS and BMD alone or in combination to predict prospective BSI.RESULTS: Within 321 athletes, 29 (9.0%) sustained a BSI after DXA. BMD and TBS were highly correlated (Pearson's correlation r=0.62, P<0.0001). Spine BMD and TBS had similar ability to predict BSI; the C-statistic and 95% confidence intervals were: 0.69 (0.58, 0.81) for spine BMD versus 0.68 (0.57, 0.79) for TBS. No improvement in discrimination was observed with combined BMD+TBS (C-statistic 0.70 [0.59, 0.81]). Both TBS and BMD predicted trabecular-rich BSI (defined as pelvis, femoral neck and calcaneus) better than cortical-rich BSI. Both measures had similar correlations with Triad risk factors.CONCLUSION: Lower BMD and TBS values are associated with elevated risk for BSI and similar correlation to Triad risk factors. TBS does not improve prediction of BSI. Collectively, our findings suggest BMD may be a sufficient measure of skeletal integrity from DXA in female collegiate athletes. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/pmrj.12510

    View details for PubMedID 33037847

  • Using the Electronic Health Record to Conduct Adolescent Telehealth Visits in the Time of COVID-19. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Carlson, J. L., Goldstein, R. 2020

    View details for DOI 10.1016/j.jadohealth.2020.05.022

    View details for PubMedID 32517972

  • Teenager, Parent, and Clinician Perspectives on the Electronic Health Record. Pediatrics Carlson, J. L., Goldstein, R. n., Buhr, T. n., Buhr, N. n. 2020

    View details for DOI 10.1542/peds.2019-0193

    View details for PubMedID 32024749

  • Associations between ergogenic supplement use and eating behaviors among university students. Eating disorders Nagata, J. M., Peebles, R. n., Hill, K. B., Gorrell, S. n., Carlson, J. L. 2020: 1–17


    Ergogenic supplements to improve athletic performance are commonly used among college athletes, but little is known about their association with eating disorder symptoms. The objective of this study was to examine associations between ergogenic supplement use and disordered eating attitudes and behaviors among university students, and to compare differences by sex. Undergraduate students from 10 top-ranked National College Athletics Association (NCAA) Division I colleges completed an online survey on supplement use, athletic activities, and eating attitudes and behaviors. Among 1633 university students, males (38.9%) reported higher rates of current supplement use than females (15.2%) (p < .001). In linear regression models adjusting for athletic status and body mass index, current supplement use was associated with higher Eating Disorders Examination-Questionnaire (EDE-Q) Global, Shape Concern, and Restraint scores in both males and females. Supplement use was associated with driven/compelled exercise (OR 2.00, 95% CI 1.33-2.99) in males and diuretic (OR 6.39, 95% CI 2.02-20.22) and diet pill use (OR 3.07, 95% CI 1.79-5.27) in females. Results suggest ergogenic supplement use is common in undergraduates and associated with disordered eating attitudes and behaviors. Clinicians should screen for disordered eating behaviors particularly in young adults who use ergogenic supplements.

    View details for DOI 10.1080/10640266.2020.1712637

    View details for PubMedID 32129729

  • Providers' Perspectives on Adolescent Confidentiality and the Electronic Health Record: A State of Transition. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Goldstein, R. L., Anoshiravani, A., Svetaz, M. V., Carlson, J. L. 2019


    PURPOSE: Electronic health records (EHRs) have led to more transparency and improvements in patient safety, yet electronic access to personal health information can pose significant threats to maintaining confidentiality for adolescents. To date, no studies have explored clinicians' perspectives on EHR functionality and institutional policies related to confidentiality and health information sharing for adolescents aged <18years.METHODS: A Web-based survey was sent out via the national listserv of the Society for Adolescent Health and Medicine. All English-speaking members practicing in the U.S. were eligible to participate. The survey included questions about demographics, EHR functionality, information sharing, and attitudes about confidentiality within the EHR.RESULTS: Participants included 212 clinicians who consented to the survey and used an EHR to document clinical visits with minors. Most participants were physicians and nurse practitioners (96.5%), and 60.0% had been on their institution's EHR for >5years. Positive findings included high levels of experience and comfort using the EHR and awareness of confidential features within their EHR. However, providers reported lack of training related to confidentiality within the EHR, low confidence in their EHR's ability to maintain confidentiality, and variation in approaches to portal access for adolescents and their adult proxies.CONCLUSIONS: Despite high comfort levels and robust EHR functionality at many institutions, significant concerns about adolescent confidentiality remain. Varying institutional approaches to protecting confidentiality underscores the need for a standardized and comprehensive framework to enable providers and institutions to take better care of adolescents in the age of EHRs.

    View details for DOI 10.1016/j.jadohealth.2019.09.020

    View details for PubMedID 31831320

  • Associations between exercise, bone mineral density, and body composition in adolescents with anorexia nervosa EATING AND WEIGHT DISORDERS-STUDIES ON ANOREXIA BULIMIA AND OBESITY Nagata, J. M., Carlson, J. L., Golden, N. H., Murray, S. B., Long, J., Leonard, M. B., Peebles, R. 2019; 24 (5): 939–45
  • Comparisons of bone density and body composition among adolescents with anorexia nervosa and atypical anorexia nervosa INTERNATIONAL JOURNAL OF EATING DISORDERS Nagata, J. M., Carlson, J. L., Golden, N. H., Long, J., Murray, S. B., Peebles, R. 2019; 52 (5): 591–96

    View details for DOI 10.1002/eat.23048

    View details for Web of Science ID 000466815200013

  • Eating behavior and reasons for exercise among competitive collegiate male athletes. Eating and weight disorders : EWD Gorrell, S. n., Nagata, J. M., Hill, K. B., Carlson, J. L., Shain, A. F., Wilson, J. n., Alix Timko, C. n., Hardy, K. K., Lock, J. n., Peebles, R. n. 2019


    Research concerning eating disorders among adolescent and young adult male athletes is limited compared with female counterparts, but increasing evidence indicates that they may be at unique risk for unhealthy exercise and eating behavior. The current study aimed to characterize unhealthy exercise and eating behavior according to competitive athlete status, as well as per sport type.Collegiate male athletes (N = 611), each affiliated with one of the 10 National College Athletics Association (NCAA) Division I schools in the United States, completed an online survey, reporting on eating and extreme weight control behaviors, and reasons for exercise.Competitive athletes endorsed increased driven exercise and exercising when sick. Baseball players, cyclists, and wrestlers emerged as the sports with the most players reporting elevated Eating Disorder Examination-Questionnaire scores in a clinical range, and basketball players reported the highest rates of binge eating. overall, baseball players, cyclists, rowers, and wrestlers appeared to demonstrate the greatest vulnerability for unhealthy eating and exercise behavior.Findings revealed differences between competitive and non-competitive male athletes. Among competitive athletes, results identified unique risk for unhealthy eating and exercise behavior across a variety of sport categories and support continued examination of these attitudes and behaviors in a nuanced manner.Evidence obtained from well-designed controlled trials without randomization.

    View details for DOI 10.1007/s40519-019-00819-0

    View details for PubMedID 31782028

  • Sport and Triad Risk Factors Influence Bone Mineral Density in Collegiate Athletes MEDICINE AND SCIENCE IN SPORTS AND EXERCISE Tenforde, A. S., Carlson, J. L., Sainani, K. L., Chang, A. O., Kim, J., Golden, N. H., Fredericson, M. 2018; 50 (12): 2536–43
  • Sport and Triad Risk Factors Influence Bone Mineral Density in Collegiate Athletes. Medicine and science in sports and exercise Tenforde, A. S., Carlson, J. L., Sainani, K. L., Chang, A. O., Kim, J. H., Golden, N. H., Fredericson, M. 2018


    PURPOSE: Athletes in weight bearing sports may benefit from higher bone mineral density (BMD). However, some athletes are at risk for impaired BMD with Female Athlete Triad (Triad). The purpose of this study is to understand the influence of sports participation and Triad on BMD. We hypothesize that athletes in high-impact and multi-directional loading sports will have highest BMD, whereas non-impact and low-impact sports will have lowest BMD. Triad risk factors are expected to reduce BMD values independent of sports participation.METHODS: 239 female athletes participating in 16 collegiate sports completed dual energy x-ray absorptiometry (DXA) scans to measure BMD Z-scores of the lumbar spine(LS) and total body(TB). Height and weight were measured to calculate body mass index (BMI). Triad risk assessment variables were obtained from preparticipation examination. Mean BMD Z-scores were compared between sports and by sport category (high-impact, multi-directional, low-impact, and non-impact). Multivariable regression analyses were performed to identify differences of BMD Z-scores accounting for Triad and body size/composition.RESULTS: Athlete populations with lowest average BMD Z-scores included synchronized swimming (LS:-0.34,TB:0.21) swimming/diving (LS:0.34,TB:-0.06), crew/rowing (LS:0.27,TB:0.62), and cross-country (LS:0.29,TB:0.91). Highest values were in gymnastics (LS:1.96,TB:1.37), volleyball (LS:1.90,TB:1.74), basketball (LS:1.73,TB:1.99), and softball (LS:1.68,TB:1.78). All Triad risk factors were associated with lower BMD Z-scores in univariable analyses; only low BMI and oligomenorrhea/amenorrhea were associated in multivariable analyses (all P<0.05). Accounting for Triad risk factors and body size/composition, high-impact sports were associated with higher LS and TB BMD Z-scores and non-impact sports with lower LS and TB BMD Z-scores compared to low-impact sport (all P<0.05).CONCLUSION: Both sport type and Triad risk factors influence BMD. Athletes in low-impact and non-impact sports and athletes with low BMI and oligomenorrhea/amenorrhea are at highest risk for reduced BMD.

    View details for PubMedID 29975299

  • Contraception for Adolescents and Young Adults in the Inpatient Setting: The Providers' Perspective. Hospital pediatrics Goldstein, R. L., Carlson, J. L., Halpern-Felsher, B. n. 2018


    To assess pediatric providers' attitudes and barriers to initiating a contraceptive method in the inpatient setting.Pediatric attending physicians and trainees from 5 academic institutions were surveyed about contraceptive prescribing practices, attitudes, and potential barriers to initiating contraception in the inpatient setting.In 2016, 271 pediatric providers (34.0% were attending physicians, 18.1% fellows, and 47.9% residents) completed the survey; the response rate was 19.2%. Most participants practiced in both inpatient and outpatient settings (95.7% and 85.0%, respectively). More providers felt confident screening for sexual activity among young adults as compared with adolescents (71.9% vs 65.6%). The same was true for discussing contraceptive options (44.0% vs 38.8%, respectively). Inpatient providers reported seeing adolescents and young adults privately, discussing confidentiality, and asking about sex less than half of the time. More than 80% of providers agreed that it would be appropriate to initiate a contraceptive method for inpatients; 35.8% had done so, and 85.2% indicated that having additional consultation would increase initiation of a contraceptive method in the hospital (88.1% felt similarly for long-active reversible contraception methods). General barriers to initiating contraception included insufficient training, insufficient exposure to adolescents and young adults to maintain skills, and lack of time. Barriers specific to the inpatient setting included concerns about follow-up, confidentiality, and interference with the treatment plan.Initiation of a contraceptive method in the inpatient setting is acceptable to providers. In our findings, it is suggested that strategies are needed to enhance provision of these services by addressing confidentiality concerns and educating providers.

    View details for PubMedID 29496729

  • Characterization and correlates of exercise among adolescents with anorexia nervosa and bulimia nervosa INTERNATIONAL JOURNAL OF EATING DISORDERS Nagata, J. M., Carlson, J. L., Kao, J. M., Golden, N. H., Murray, S. B., Peebles, R. 2017; 50 (12): 1394–1403


    To characterize exercise behaviors among adolescents with anorexia nervosa (AN), atypical AN, or bulimia nervosa (BN), and determine associations between exercise and medical risk.Cross-sectional electronic medical records of all patients evaluated by the Eating Disorder Program at Stanford between January 1997 and February 2011 were retrospectively reviewed.1,083 subjects (961 females, 122 males; mean age 15.6) met eligibility criteria. Most patients (89.7%) reported exercise (mean 7.0 h per week over mean 5.4 days per week) prior to presentation. Running (49.9%), calisthenics (40.7%), walking (23.4%), soccer (20.9%), and swimming (18.2%) were the most common exercises; a majority (60.6%) reported team sport participation. Males were less likely to report team exercise (p = .005). Bradycardia (heart rate <50) at presentation was associated with team sport participation (adjusted odds ratio [AOR] 1.66, 95% confidence interval [CI] 1.02-2.72) and hours of exercise per week (AOR 1.05, 95% CI 1.02-1.09), controlling for diagnosis, sex, age, duration of illness, rate of weight loss, and percent median body mass index (%mBMI).Adolescents with AN, atypical AN, and BN reported high levels of exercise. Females reported more team sport participation. Greater exercise frequency and team sport participation were associated with bradycardia. Further studies assessing the relationship between exercise and bradycardia may help inform the medical management of adolescents with these eating disorders who are more physically active.

    View details for PubMedID 29112280

  • Effect of a Prior History of Overweight on Return of Menses in Adolescents With Eating Disorders JOURNAL OF ADOLESCENT HEALTH Seetharaman, S., Golden, N. H., Halpern-Felsher, B., Peebles, R., Payne, A., Carlson, J. L. 2017; 60 (4): 469-471


    The purpose of this study was to determine whether a history of overweight, weight suppression, and weight gain during treatment have an effect on return of menses (ROM) in adolescents with eating disorders (EDs).Retrospective chart review of female adolescents presenting to an ED program from January 2007 to June 2009.One hundred sixty-three participants (mean age, 16.6 ± 2.1 years) met eligibility criteria. The mean median body mass index percent at ROM for those previously overweight was 106.1 ± 11.7 versus 94.2 ± 8.9 for those not previously overweight (p < .001). Both groups needed to gain weight for ROM. Greater weight suppression (odds ratio, 0.90; 95% confidence interval, 0.84-0.98; p = .013) was associated with lower likelihood of ROM, and greater weight gain during treatment (odds ratio, 1.20; 95% confidence interval, 1.07-1.36; p = .002) was associated with higher likelihood of ROM in those not previously overweight.Previously overweight amenorrheic patients with EDs needed to be at a higher median body mass index percent for ROM compared to those who were not previously overweight.

    View details for DOI 10.1016/j.jadohealth.2016.10.019

    View details for Web of Science ID 000401108300017

  • Assessment of sex differences in bone deficits among adolescents with anorexia nervosa INTERNATIONAL JOURNAL OF EATING DISORDERS Nagata, J. M., Golden, N. H., Peebles, R., Long, J., Leonard, M. B., Chang, A. O., Carlson, J. L. 2017; 50 (4): 352-358


    The objective of this study was to compare sex differences in bone deficits among adolescents with anorexia nervosa (AN) and to identify other correlates of bone health.Electronic medical records of all patients 9-20 years of age with a DSM-5 diagnosis of AN who were evaluated by the eating disorders program at Stanford with dual-energy X-ray absorptiometry (DXA) between March 1997 and February 2011 were retrospectively reviewed. Whole body bone mineral content Z-scores and bone mineral density (BMD) Z-scores at multiple sites were recorded using the Bone Mineral Density in Childhood Study (BMDCS) reference data.A total of 25 males and 253 females with AN were included, with median age 15 years (interquartile range [IQR] 14-17) and median duration of illness 9 months (IQR 5-13). Using linear regression analyses, no significant sex differences in bone deficits were found at the lumbar spine, total hip, femoral neck, or whole body when controlling for age, %mBMI, and duration of illness. Lower %mBMI was significantly associated with bone deficits at all sites in adjusted models.This is the first study to evaluate sex differences in bone health among adolescents with AN, using novel DSM-5 criteria for AN and robust BMDCS reference data. We find no significant sex differences in bone deficits among adolescents with AN except for a higher proportion of females with femoral neck BMD Z-scores <-1. Degree of malnutrition was correlated with bone deficits at all sites. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016).

    View details for DOI 10.1002/eat.22626

    View details for Web of Science ID 000398841500004

  • Association of the Female Athlete Triad Risk Assessment Stratification to the Development of Bone Stress Injuries in Collegiate Athletes. American journal of sports medicine Tenforde, A. S., Carlson, J. L., Chang, A., Sainani, K. L., Shultz, R., Kim, J. H., Cutti, P., Golden, N. H., Fredericson, M. 2017; 45 (2): 302-310


    The female athlete triad (referred to as the triad) contributes to adverse health outcomes, including bone stress injuries (BSIs), in female athletes. Guidelines were published in 2014 for clinical management of athletes affected by the triad.This study aimed to (1) classify athletes from a collegiate population of 16 sports into low-, moderate-, and high-risk categories using the Female Athlete Triad Cumulative Risk Assessment score and (2) evaluate the predictive value of the risk categories for subsequent BSIs.Cohort study; Level of evidence, 3.A total of 323 athletes completed both electronic preparticipation physical examination and dual-energy x-ray absorptiometry scans. Of these, 239 athletes with known oligomenorrhea/amenorrhea status were assigned to a low-, moderate-, or high-risk category. Chart review was used to identify athletes who sustained a subsequent BSI during collegiate sports participation; the injury required a physician diagnosis and imaging confirmation.Of 239 athletes, 61 (25.5%) were classified into moderate-risk and 9 (3.8%) into high-risk categories. Sports with the highest proportion of athletes assigned to the moderate- and high-risk categories included gymnastics (56.3%), lacrosse (50%), cross-country (48.9%), swimming/diving (42.9%), sailing (33%), and volleyball (33%). Twenty-five athletes (10.5%) assigned to risk categories sustained ≥1 BSI. Cross-country runners contributed the majority of BSIs (16; 64%). After adjusting for age and participation in cross-country, we found that moderate-risk athletes were twice as likely as low-risk athletes to sustain a BSI (risk ratio [RR], 2.6; 95% confidence interval [95% CI], 1.3-5.5) and high-risk athletes were nearly 4 times as likely (RR, 3.8; 95% CI, 1.8-8.0). When examining the 6 individual components of the triad risk assessment score, both the oligomenorrhea/amenorrhea score ( P = .0069) and the prior stress fracture/reaction score ( P = .0315) were identified as independent predictors for subsequent BSIs (after adjusting for cross-country participation and age).Using published guidelines, 29% of female collegiate athletes in this study were classified into moderate- or high-risk categories using the Female Athlete Triad Cumulative Risk Assessment Score. Moderate- and high-risk athletes were more likely to subsequently sustain a BSI; most BSIs were sustained by cross-country runners.

    View details for DOI 10.1177/0363546516676262

    View details for PubMedID 28038316

  • Assessment of Sex Differences in Body Composition Among Adolescents With Anorexia Nervosa. journal of adolescent health Nagata, J. M., Golden, N. H., Peebles, R., Long, J., Murray, S. B., Leonard, M. B., Carlson, J. L. 2017


    To compare deficits in fat mass (FM) and lean body mass (LM) among male and female adolescents with anorexia nervosa (AN) and to identify other covariates associated with body composition.We retrospectively reviewed electronic medical records of all subjects aged 9-20 years with a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis of AN and dual-energy x-ray absorptiometry scans after initial evaluation at Stanford between March 1997 and February 2011. From the dual-energy x-ray absorptiometry scans, LM and FM results were converted to age-, height-, sex-, and race-specific Z-scores for age using the National Health and Nutrition Examination Survey reference data.A total of 16 boys and 119 girls with AN met eligibility criteria. The FM Z-score in girls with AN (-3.24 ± 1.50) was significantly lower than that in boys with AN (-2.41 ± .96) in unadjusted models (p = .007). LM was reduced in both girls and boys with AN, but there was no significant sex difference in LM Z-scores. In multivariate models, lower percentage median body mass index was significantly associated with lower FM Z-scores (β = .08, p < .0001) and lower LM Z-score (β = .03, p = .0002), whereas lower whole body bone mineral content Z-score was significantly associated with lower LM Z-score (β = .21, p = .0006).FM deficits in girls were significantly greater than those in boys with AN in unadjusted models; however, the degree of malnutrition appeared to be the primary factor accounting for this difference. There were no significant sex differences in FM or LM in adjusted models.

    View details for DOI 10.1016/j.jadohealth.2016.11.005

    View details for PubMedID 28087266

  • Use of Psychopharmacologic Medications in Adolescents With Restrictive Eating Disorders: Analysis of Data From the National Eating Disorder Quality Improvement Collaborative. journal of adolescent health Monge, M. C., Forman, S. F., McKenzie, N. M., Rosen, D. S., Mammel, K. A., Callahan, S. T., Hehn, R., Rome, E. S., Kapphahn, C. J., Carlson, J. L., Romano, M. E., Malizio, J. B., Bravender, T. D., Sigel, E. J., Rouse, M. R., Graham, D. A., Jay, M. S., Hergenroeder, A. C., Fisher, M. M., Golden, N. H., Woods, E. R. 2015; 57 (1): 66-72


    Psychopharmacologic medications are often prescribed to patients with restrictive eating disorders (EDs), and little is known about the frequency of use in adolescents. We examined the use of psychopharmacologic medications in adolescents referred for treatment of restrictive ED, potential factors associated with their use, and reported psychiatric comorbidities.Retrospective data from the initial and 1-year visits were collected for patients referred for evaluation of restrictive ED at 12 adolescent-based ED programs during 2010 (Group 1), including diagnosis, demographic information, body mass index, prior treatment modalities, and psychopharmacologic medications. Additional data regarding patients' comorbid psychiatric conditions and classes of psychopharmacologic medications were obtained from six sites (Group 2).Overall, 635 patients met inclusion criteria and 359 had 1-year follow-up (Group 1). At intake, 20.4% of Group 1 was taking psychopharmacologic medication and 58.7% at 1 year (p ≤ .0001). White, non-Hispanic race (p = .020), and prior higher level of care (p < .0001) were positively associated with medication use at 1 year. Among Group 2 (n = 256), serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors use was most common, and 62.6% had a reported psychiatric comorbidity. Presence of any psychiatric comorbidity was highly associated with medication use; odds ratio, 10.0 (5.6, 18.0).Adolescents with restrictive ED treated at referral centers have high rates of reported psychopharmacologic medication use and psychiatric comorbidity. As more than half of this referral population were reported to be taking medication, continued investigation is warranted to ensure the desired outcomes of the medications are being met.

    View details for DOI 10.1016/j.jadohealth.2015.03.021

    View details for PubMedID 26095410

  • REPORT FROM THE NATIONAL EATING DISORDER QUALITY IMPROVEMENT COLLABORATIVE OF TEN ADOLESCENT MEDICINE-BASED EATING DISORDER PROGRAMS: POPULATION DESCRIPTION AND PREDICTORS OF WEIGHT OUTCOME AT ONE YEAR Forman, S. F., McKenzie, N. M., Monge, M. C., Mammel, K. A., Kapphahn, C. J., Callahan, S. T., Rome, E. S., Rosen, D. S., Hehn, R. S., Carlson, J. L., Romano, M. E., Malizio, J. B., Rouse, M. R., Graham, D. A., Jay, M. S., Hergenroeder, A. C., Fisher, M. M., Golden, N. H., Woods, E. R. ELSEVIER SCIENCE INC. 2013: S37–S38
  • The Female Athlete Triad The Female Patient Carlson JL, Golden NH 2012; 37 (6): 16-24
  • Obstacles in the Optimization of Bone Health Outcomes in the Female Athlete Triad SPORTS MEDICINE Ducher, G., Turner, A. I., Kukuljan, S., Pantano, K. J., Carlson, J. L., Williams, N. L., De Souza, M. J. 2011; 41 (7): 587-607


    Maintaining low body weight for the sake of performance and aesthetic purposes is a common feature among young girls and women who exercise on a regular basis, including elite, college and high-school athletes, members of fitness centres, and recreational exercisers. High energy expenditure without adequate compensation in energy intake leads to an energy deficiency, which may ultimately affect reproductive function and bone health. The combination of low energy availability, menstrual disturbances and low bone mineral density is referred to as the 'female athlete triad'. Not all athletes seek medical assistance in response to the absence of menstruation for 3 or more months as some believe that long-term amenorrhoea is not harmful. Indeed, many women may not seek medical attention until they sustain a stress fracture. This review investigates current issues, controversies and strategies in the clinical management of bone health concerns related to the female athlete triad. Current recommendations focus on either increasing energy intake or decreasing energy expenditure, as this approach remains the most efficient strategy to prevent further bone health complications. However, convincing the athlete to increase energy availability can be extremely challenging. Oral contraceptive therapy seems to be a common strategy chosen by many physicians to address bone health issues in young women with amenorrhoea, although there is little evidence that this strategy improves bone mineral density in this population. Assessment of bone health itself is difficult due to the limitations of dual-energy X-ray absorptiometry (DXA) to estimate bone strength. Understanding how bone strength is affected by low energy availability, weight gain and resumption of menses requires further investigations using 3-dimensional bone imaging techniques in order to improve the clinical management of the female athlete triad.

    View details for Web of Science ID 000292941700004

    View details for PubMedID 21688870

  • Using OCs in teen eating disorders: What are we treating? Contemporary OB/Gyn Carlson, J., Golden, NH 2009; 54 (2): 39-46
  • The pathophysiology of amenorrhea in the adolescent. Ann N Y Acad Sci Golden, N., Carlson, JL 2008; 1135: 163-178
  • Clinician practices for the management of amenorrhea in the adolescent and young adult athlete JOURNAL OF ADOLESCENT HEALTH Carlson, J. L., Curtis, M., Halpern-Felsher, B. 2007; 40 (4): 362-365


    This study sought to describe clinician practices for the management of amenorrhea in the adolescent and young adult athlete. Clinicians adhered to certain guidelines but did not have a uniform "standard of care" for amenorrheic athletes. Almost 80% of clinicians reported insufficient guidelines for the management of this population.

    View details for DOI 10.1016/j.jadohealth.2006.10.017

    View details for Web of Science ID 000245567900011

    View details for PubMedID 17367734

  • Service utilization and the life cycle of youth homelessness JOURNAL OF ADOLESCENT HEALTH Carlson, J. L., Sugano, E., MILLSTEIN, S. G., Auerswald, C. L. 2006; 38 (5): 624-627


    The study sought to describe service utilization patterns of homeless youth based on their life cycle stage. Ninety-nine percent of participants accessed services. Medical service utilization was highest among youth who were attempting to leave the street. Drug-related service utilization was lowest among youth most entrenched in street life.

    View details for DOI 10.1016/j.jadohealth.2005.10.009

    View details for Web of Science ID 000237215500024

    View details for PubMedID 16635781

  • Childhood and adolescent sexuality PEDIATRIC CLINICS OF NORTH AMERICA Duncan, P., Dixon, R. R., Carlson, J. 2003; 50 (4): 765-?


    Sexuality is an important aspect of the lives of all human beings, including children and adolescents. The clinician can provide important guidance to pediatric patients and their parents regarding the healthy development of sexuality. Counseling techniques are important, including the "helping skill" model, in which the clinician can state the problem, identify options for the patient, identify consequences of each option, help the patient make a plan, and develop a plan for check back and follow-up.

    View details for DOI 10.1016/S0031-3955(03)00068-3

    View details for Web of Science ID 000185077000003

    View details for PubMedID 12964693