- Adolescent Medicine
Clinical Professor, Pediatrics - Adolescent Medicine
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, Female Athlete Triad Coalition (2013 - Present)
Member, Epic Adolescent Medicine Steering Board (2018 - Present)
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.
Graham Middle School
Opportunities for Student Involvement
Current Research and Scholarly Interests
My research interests and scholarship fall into two major "buckets" of activity: 1) confidentiality and clinical informatics and 2) eating disorders, particularly the Female/Male Athlete Triad.
Independent Studies (7)
- Directed Reading in Pediatrics
PEDS 299 (Aut, Sum)
- Early Clinical Experience
PEDS 280 (Aut, Sum)
- Graduate Research
PEDS 399 (Aut, Sum)
HUMBIO 194 (Aut, Win, Spr)
- Medical Scholars Research
PEDS 370 (Aut, Sum)
- Research in Human Biology
HUMBIO 193 (Win, Spr)
- Undergraduate Directed Reading/Research
PEDS 199 (Aut, Sum)
- Directed Reading in Pediatrics
Graduate and Fellowship Programs
Adolescent Medicine (Fellowship Program)
Clinician confidence and practices for evaluating bone health in male and female adolescents and young adults with an eating disorder.
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
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
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.
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.
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
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
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
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
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)
To meat or not to meat: disordered eating and vegetarian status in university students.
Eating and weight disorders : EWD
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
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 2021; 34 (1): 3–5
- NASPAG/SAHM Statement: The 21st Century Cures Act and Adolescent Confidentiality. The Journal of adolescent health : official publication of the Society for Adolescent Medicine 2021; 68 (2): 426–28
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
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 2020
- Teenager, Parent, and Clinician Perspectives on the Electronic Health Record. Pediatrics 2020
Associations between ergogenic supplement use and eating behaviors among university students.
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
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 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 2019; 52 (5): 591–96
Eating behavior and reasons for exercise among competitive collegiate male athletes.
Eating and weight disorders : EWD
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 2018; 50 (12): 2536–43
Sport and Triad Risk Factors Influence Bone Mineral Density in Collegiate Athletes.
Medicine and science in sports and exercise
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.
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
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
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
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
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
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
- HEALTHY RELATIONSHIPS AND PHYSICAL ACTIVITY: A QUALITATIVE ANALYSIS OF MIDDLE SCHOOL GIRLS AND THEIR PARENTS ELSEVIER SCIENCE INC. 2016: S87
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
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
ELSEVIER SCIENCE INC. 2013: S37–S38
View details for Web of Science ID 000314104000076
- RUNNING CLUB PARTICIPATION AFFECTS WEIGHT CONCERNS AND BMI IN MIDDLE SCHOOL GIRLS ELSEVIER SCIENCE INC. 2013: S104
- The Female Athlete Triad The Female Patient 2012; 37 (6): 16-24
Obstacles in the Optimization of Bone Health Outcomes in the Female Athlete Triad
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 2009; 54 (2): 39-46
- The pathophysiology of amenorrhea in the adolescent. Ann N Y Acad Sci 2008; 1135: 163-178
Clinician practices for the management of amenorrhea in the adolescent and young adult athlete
JOURNAL OF ADOLESCENT HEALTH
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
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
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