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Objective To explore outcomes and measures of success that matter most to 'positive outlier' children who improved their body mass index (BMI) despite living in obesogenic neighborhoods. Methods We collected residential address and longitudinal height/weight data from electronic health records of 22,657 children ages 6–12 years in Massachusetts. We defined obesity “hotspots” as zip codes where >15% of children had a BMI ≥95th percentile. Using linear mixed effects models, we generated a BMI z-score slope for each child with a history of obesity. We recruited 10–12 year-olds with negative slopes living in hotspots for focus groups. We analyzed group transcripts and discussed emerging themes in iterative meetings using an immersion/crystallization approach. Results We reached thematic saturation after 4 focus groups with 21 children. Children identified bullying and negative peer comparisons related to physical appearance, clothing size, and athletic ability as motivating them to achieve a healthier weight, and they measured success as improvement in these domains. Positive relationships with friends and family facilitated both behavior change initiation and maintenance. Conclusions The perspectives of positive outlier children can provide insight into children’s motivations leading to successful obesity management. Practice implications: Child/family engagement should guide the development of patient-centered obesity interventions.

Objectives This study sought to determine feasibility and prognostic performance of stress cardiac magnetic resonance (CMR) in obese patients (body mass index [BMI] ≥30 kg/m2). Background Current stress imaging methods remain limited in obese patients. Given the impact of the obesity epidemic on cardiovascular disease, alternative methods to effectively risk stratify obese patients are needed. Methods Consecutive patients with a BMI ≥30 kg/m2 referred for vasodilating stress CMR were followed for major adverse cardiovascular events (MACE), defined as cardiac death or nonfatal myocardial infarction. Univariable and multivariable Cox regressions for MACE were performed to determine the prognostic association of inducible ischemia or late gadolinium enhancement (LGE) by CMR beyond traditional clinical risk indexes. Results Of 285 obese patients, 272 (95%) completed the CMR protocol, and among these, 255 (94%) achieved diagnostic imaging quality. Mean BMI was 35.4 ± 4.8 kg/m2, with a maximum weight of 200 kg. Reasons for failure to complete CMR included claustrophobia (n = 4), intolerance to stress agent (n = 4), poor gating (n = 4), and declining participation (n = 1). Sedation was required in 19 patients (7%; 2 patients with intravenous sedation). Sixteen patients required scanning by a 70-cm-bore system (6%). Patients without inducible ischemia or LGE experienced a substantially lower annual rate of MACE (0.3% vs. 6.3% for those with ischemia and 6.7% for those with ischemia and LGE). Median follow-up of the cohort was 2.1 years. In a multivariable stepwise Cox regression including clinical characteristics and CMR indexes, inducible ischemia (hazard ratio 7.5; 95% confidence interval: 2.0 to 28.0; p = 0.002) remained independently associated with MACE. When patients with early coronary revascularization (within 90 days of CMR) were censored on the day of revascularization, both presence of inducible ischemia and ischemia extent per segment maintained a strong association with MACE. Conclusions Stress CMR is feasible and effective in prognosticating obese patients, with a very low negative event rate in patients without ischemia or infarction.

Objective New approaches for obesity prevention and management can be gleaned from 'positive outliers', i.e., individuals who have succeeded in changing health behaviors and reducing their body mass index (BMI) in the context of adverse built and social environments. We explored perspectives and strategies of parents of positive outlier children living in high risk neighborhoods. Methods We collected up to five years of height/weight data from the electronic health records of 22,443 Massachusetts children, ages 6-12 years, seen for well-child care. We identified children with any history of BMI ≥95th percentile (n=4007) and generated a BMI z-score slope for each child using a linear mixed effects model. We recruited parents for focus groups from the sub-sample of children with negative slopes who also lived in zip codes where >15% of children were obese. We analyzed focus group transcripts using an immersion/crystallization approach. Results We reached thematic saturation after 5 focus groups with 41 parents. Commonly cited outcomes that mattered most to parents and motivated change were child inactivity, above-average clothing sizes, exercise intolerance, and negative peer interactions; few reported BMI as a motivator. Convergent strategies among positive outlier families were family-level changes, parent modeling, consistency, household rules/limits, and creativity in overcoming resistance. Parents voiced preferences for obesity interventions that include tailored education and support that extend outside clinical settings and are delivered by both health care professionals and successful peers. Conclusions Successful strategies learned from positive outlier families can be generalized and tested to accelerate progress in reducing childhood obesity.

BACKGROUND: Obese patients may face higher complication rates during surgical treatment of colon cancer. The aim of this study was to measure this effect at a high-volume tertiary care center. METHODS: All patients with colon cancer treated surgically at a single center from 2004 through 2011 were reviewed. Multivariate regression assessed relationships of complications and stay outcomes with body mass index (BMI) controlling for age, gender, comorbidity score, surgical approach, and history of smoking. RESULTS: In 1,048 included patients, BMI was a predictor of several complications in both laparoscopic and open procedures. For every increase of BMI by one World Health Organization category, the odds ratios were 1.61 (P < .001) for wound infection and 1.54 (P < .001) for slow healing. Additionally, right colectomies had an odds ratio of 3.23 (P = .017) for wound dehiscence. No further associations with BMI were found. CONCLUSIONS: BMI was incrementally associated with wound-related complications, illustrating how the proliferation of obesity relates to a growing risk for surgical complications. As the surgical community strives to improve the quality of care, patient-controllable factors will play an increasingly important role in cost containment and quality improvement.

Background: When activated by the sympathetic nervous system, brown adipose tissue (BAT) increases energy expenditure to produce heat. Augmenting BAT mass or increasing BAT activation could potentially be used to decrease obesity. Noninvasive methods to detect and monitor BAT mass are needed. Contrast ultrasound can estimate BAT blood flow and is able to measure the perfused volume of an organ and thus its mass. The objective of this study was to evaluate whether contrast ultrasound could characterize BAT mass in two mouse models of obesity: wild-type mice fed a high-fat diet and mutant db/db mice. Methods: Contrast ultrasound of BAT (Definity 2 μL/min; 14-MHz linear probe) was performed before and after stimulation of BAT with norepinephrine (NE). BAT replenishment curves were obtained, and blood flow was estimated by the product of the curve’s plateau and slope. Additionally, consecutive two-dimensional images of perfused BAT were acquired at 1-mm intervals after stimulation with NE and used to assess BAT volume and mass. Results: BAT blood flow increased after NE infusion in all mice studied. Blood flow response to NE was similar in wild-type mice fed either a low-fat diet or a high-fat diet. BAT blood flow was lower in db/db mice than in wild-type mice (P = .02). Contrast ultrasound–derived BAT mass was correlated with BAT mass obtained at necropsy (R2 = 0.83, P < .001). BAT mass was higher in mice fed a high-fat diet than in those fed a low-fat diet. Conclusions: Contrast ultrasound can be used to estimate BAT mass in mice when BAT vascularization is not significantly impaired. This noninvasive technique may potentially allow the serial evaluation of therapies designed to augment BAT mass.

Purpose This study examined how college students choose beverages and whether behavioral interventions might reduce their heavy consumption of sugar-sweetened beverages. Methods From April to June 2010, 90 students participated in 12 focus groups at 6 colleges in Massachusetts and Louisiana. The study team undertook a group content analysis of the verbatim focus group transcripts using the immersion-crystallization method. Results The mean age of participants was 19 years. 50% were white, and 47% were black. Several themes emerged in focus groups: taste is paramount; price is important but secondary; health and nutritional content of beverages are of limited interest; juice has a “health halo”; and water is consumed primarily for hydration. Students were often highly fixated on favorite sugar-sweetened beverages. Price was uniquely important for good-tasting beverages costing less than one dollar. Some students reported calorie content as important for food choices, but most had no awareness of beverage calorie content. Students’ negative perceptions of sugar-sweetened beverages focused largely on the “dangers” of sugar and chemicals in sodas. They expressed particular concern about soda’s corrosive chemical properties or diet soda causing cancer. The health halo for juice persisted even with some recognition of high sugar content. Students thought shocking educational messages would be necessary to get them to reduce consumption of sugar-sweetened beverages. Conclusions Among college students, taste and price were the most important factors in choosing beverages. Interventions using shocking visual images or providing low-cost or free water may conquer taste and brand preference to reduce sugar-sweetened beverage intake.

To date, only a small number of commercial chemicals have been tested and documented as developmental neurotoxicants. Moreover, an increasing number of epidemiological, clinical and experimental studies suggest an association between toxicant or drug exposure during the perinatal period and the development of metabolic-related diseases and neurotoxicity later in life. The four speakers in this symposium presented their research results on different neurotoxic chemicals as they relate to the developmental origins of health and adult disease (DOHaD). Philippe Grandjean presented epidemiological data on children exposed to methylmercury and discussed the behavioral outcome measures as they relate to age and stage of brain development. Donald A. Fox presented data that low-to-moderate dose human equivalent gestational lead exposure produced late-onset obesity, and motor and coordination dysfunction only in male mice. Didima de Groot discussed the role of caloric restriction and/or high fat diets during gestation and/or postnatal development in mediating the metabolic and neurotoxic effects of developmental methylmercury exposure in rats. Merle G. Paule addressed the long-term changes in learning, motivation and short-term memory in aged Rhesus monkeys following 24 hour exposure to ketamine during early development. Overall, these presentations addressed fundamental issues in the emerging areas of lifetime neurotoxicity testing, differential vulnerable periods of exposure, nonmonotonic dose-response effects and neurotoxic risk assessment.