PEDIATRICIAN Spring 2003 - AAP-CA

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SED — California Region Leonard Kutnik, M.D. California Surgeon General Needed to Protect Californians The Surgeon General’s Office reports that one in ten children and adolescents suffer from a mental health illness (1), but only one in five of these children receive specialty mental health services. Unfortunately, this rate of treatment is not being achieved in the State’s health insurance program for children, the Healthy Families Program. Only one-half of one percent of enrolled children were referred to a county mental health department for evaluation and treatment of a Serious Emotional Disturbance (SED). Primary care providers (including pediatricians) are ideally positioned at the frontline to identify HFP children with mental health problems. Therefore, greater assistance is needed from primary care providers (PCPs) to refer children who present signs and symptoms of SED to county mental health programs for evaluation and treatment. The Healthy Families Program is a state and federally funded insurance program that provides health care to low-income children up to age 19 who do not qualify for Medi-Cal and do not have private health insurance. The HFP provides comprehensive mental health services through participating health plans and local county mental health departments. Basic mental health services are provided by the participating health plans. Evaluation and treatment of SED are provided by county mental health departments. Serious emotional disturbance of a child is defined in the California Welfare and Institutions Code, Section 5600.3(a)(2) as a mental disorder as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (other than a primary substance use disorder or developmental disorder) which results in behavior inappropriate to the child’s age according to expected developmental norms. SED treatment services provided by county mental health departments include outpatient services, inpatient services and prescription drugs. Most children enrolled in the HFP are members of health plans that require a primary care provider (PCP). Because of the large number of children who are affiliated with a PCP, the PCP plays a crucial role in the early detection of mental health problems and in improving HFP children’s access to SED services. HFP data indicate that in 2000, approximately 57% of children enrolled in the program for 12 consecutive months saw a PCP. Reports show that most families, and to a higher degree, ethnic minority families, are more likely to seek help from primary care providers as opposed to specialty care providers. (2) Given the large number (80%) of HFP subscribers who belong to an ethnic minority group, these reports further validate the importance of the PCP in detecting mental health problems. PCPs can receive assistance from participating health plans in referring children to county mental health departments for SED The Healthy Families Program provides comprehensive mental health services through participating health plans and local county mental health departments. treatment. The health plans use a variety of methods to assist physicians in serving HFP subscribers and to communicate information about the HFP benefits. Examples of these methods include periodic newsletters and bulletins, quick reference guides, periodic luncheon meetings, electronic mail and website access. The methods used are specific to individual health plans. Physicians should call the health plans they are affiliated with for more information. In addition to the assistance the health plans provide, the California Institute of Mental Health (CIMH), with funding from the David and Lucile Packard Foundation, has developed a provider manual. This manual, Healthy Families Resources Binder, was developed through collaboration among counties, health plans, State staff and CIMH. The binder provides information about the HFP and the SED referral process that is practical and easily accessible. Specific information provided includes health plan and county mental health liaison phone numbers, flow charts for CONTINUED ON PAGE 31 On April 10, 2003, the Little Hoover Commission urged policy-makers to fortify California’s public health system so it can better detect and respond to a wide range of threats, from emerging diseases and hospital-acquired infections to bioterrorism. The Commission recommended the State develop expert leadership, establish standards, increase training, improve communications, and strengthen laboratory and other capacities essential to the public health infrastructure. The report — To Protect and Prevent: Rebuilding California’s Public Health System — was issued after 10 months of public meetings, interviews, and deliberations, during which an array of experts identified specific weaknesses and practical improvements to a system that has gradually eroded over the last three decades. The Commission initiated the project after the terrorist attacks of 2001 revealed that the traditional capacities of the public health system to detect and respond to epidemics and other disasters had been neglected as a public attention focused on individual health care. The Commission concluded that the improvements are needed to protect all California from a range of health risks. The Commission recommended that the core public health functions be consolidated into a single state department and that the State re-establish a volunteer public health board to provide expert involvement and public accountability to the government’s efforts. The State needs to strategically develop and employ technologies and trained professionals to make sure the system detects and assesses health threats, develops the most effective responses, and communicates with health care providers and the public. Together, the reforms would redefine public health as the third component of California’s public safety triad — police, fire, and public health. A fortified public health system would reduce the risk to all Californians, ensuring capacities in times of emergency, and reducing demands on the overall health system. While the federal and state government have taken steps since September 11, 2001 to repair the system, the fundamental and structural problems have not been adequately addressed in California. The Little Hoover Commission is a bipartisan and independent state agency charged with advising the Governor and Legislature on ways to improve the efficiency and effectiveness of state programs. The full Commission report is available on www.lhc.ca.gov. CALIFORNIA PEDIATRICIAN — SPRING 2003/ 29
A LOW-GLYCEMIC INDEX DIET IN THE TREATMENT OF PEDIATRIC OBESITY CONTINUED FROM PAGE 11 ing in treatment programs. Much of this weight is regained within 12 months, with a virtually complete relapse after five years. Clinical studies of obesity treatment in children have yielded mixed results. This situation has prompted calls from experts and official agencies for the development of innovative treatment strategies. 33 The results of this study suggest that a low-GI diet may be one such approach. Children receiving the standard reducedfat diet showed no change in adjusted BMI during the course of the study, representing a modest improvement over the increase in BMI that would be expected with increasing age. By contrast, children receiving the low-GI diet showed an adjusted decrease in BMI of 1.15 kg/m 2 . This result is especially interesting in that the low-GI diet involved no restriction of total energy or specific macronutrient consumption. Instead, patients in this treatment group were encouraged to eat to satiety and snack when hungry. Furthermore, the magnitude of the effect seen here may have been limited by factors inherent to an urban pediatric obesity clinic, including a heterogeneous patient population, inadequate insurance coverage for obesity management, and poverty. To our knowledge, the vast majority of pediatric obesity studies to date have tested different behavioral modification techniques or multimodality programs (behavioral therapy, diet, and physical activity together). Surprisingly few studies involving children have examined the effects of dietary composition on weight loss per se, while controlling for other interventions. In our study, by contrast, specific dietary prescriptions differed between groups, whereas dietary counseling methods (parent and child), behavioral modification techniques, ancillary recommendations (to increase physical activity and decrease inactivity), and treatment intensity did not. Regarding possible underlying mechanisms, a low-GI diet may facilitate weight loss by lowering insulin levels. High-GI diets stimulate more insulin secretion than isoenergetic, low-GI diets, as evidenced by higher postprandial insulin levels and greater c-peptide secretion. Acutely high insulin levels would tend to promote uptake of nutrients into liver, muscle, and adipose tissue; inhibit hepatic release of glucose; and suppress lipolysis. After the nutrients of a high-GI meal have been absorbed from the digestive tract, the body may have difficulty accessing stored metabolic fuels, leading to excessive hunger and overeating. Chronically, hyperinsulinemia would tend to direct nutrients from oxidation to storage. Several, though not all, epidemiological studies have shown that individuals with the highest fasting or stimulated insulin levels at baseline gain the most weight prospectively. Moreover, insulin treatment of type 2 diabetes, and intensive insulin treatment of type 1 diabetes predictably results in weight gain. In animal studies, a high-GI diet was found to increase fatty acid synthetase activity, adipocyte size, glucose incorporation into total lipids, and insulin resistance compared with a low-GI diet. Several issues relating to study design and interpretation should be addressed. First, participants were not formally randomized to treatment group. Thus, the presence of confounding influences, such as selection bias and provider effects, cannot be excluded. Second, dietary change was not monitored following intervention (as, for example, with diet records). Therefore, the degree to which noncompliance affected outcome is not known. Third, mean follow-up time was relatively short (4.3 months); long-term evaluation of the dietary treatments is beyond the scope of this study. Fourth, the target macronutrient composition of the low-GI diet differed from that of the reduced-fat diet, in an attempt to obtain the After the nutrients of a high-GI meal have been absorbed from the digestive tract, the body may have difficulty accessing stored metabolic fuels. . . lowest possible glycemic response. Therefore, the effects of this diet cannot be attributed solely to GI. In light of these qualifications, our findings should be viewed as preliminary. Nevertheless, we believe that these findings are relevant because the magnitude of the observed effect is large and remained significant after adjustment for a variety of potentially confounding factors; the low-GI diet was tested against the current standard of care; and the data are consistent with a plausible physiologic mechanism. Moreover, the study reflects experience of a major, clinical pediatric obesity program, not a specialized research protocol employing carefully selected subjects and costly interventions. Rather, our study confronted a variety of problems inherent to the outpatient treatment of childhood obesity today, including variable motivation and compliance (eg, some patients enrolled in our program at the insistence of a parent or physician, and have little interest in losing weight), limited resources (ie, inadequate insurance reimbursement), and a lengthy waiting period for clinic appointments. Thus, the findings speak to the clinical effectiveness of this dietary approach. Finally, this study underscores the need for a prospective, controlled clinical trial of a low-GI diet in the treatment of obesity. Corresponding author: David S. Ludwig, MD, PhD, Department of Medicine, Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 (e-mail: ludwigd@tch.harvard.edu). For references, see the original article in JAMA Archives of Pediatric and Adolescent Medicine, 2000. WHY CALIFORNIA’S MICRA IS GOOD FOR THE NATION CONTINUED FORM PAGE 12 1976 to $254.22 in 2000 (an increase of 2073% when adjusted for inflation). National MICRA Mindful of the national problem, Senator Dianne Feinstein (D-California) has courageously proposed a law modeled on California’s 27-year experience of dealing fairly with injured patients and protecting access to health care. Here it is in dollars and cents: In California two years ago, an OB/GYN paid on average $47,500 for malpractice insurance. In Florida, she paid $173,000. Neurosurgeons paid $68,436 in Los Angeles County in 2002, but $278,829 in Dade County, Fla., and $163,000 in suburban Detroit and New York. In California in 2002, an orthopedic surgeon paid $22,730, but in Pennsylvania $90,297. Why should patients care? It’s difficult to put a value on having doctors there when you need them. But patients in Nevada drive hundreds of miles to find obstetricians who still deliver babies. And for accident and cardiac victims, it is a matter of life and death if there is no neurosurgeon or ER doc at the local hospital. California has health care problems, but this insurance crisis isn’t one of them. That’s why the rest of the nation needs to take California’s lead and adopt medical malpractice reform. 30 / CALIFORNIA PEDIATRICIAN — SPRING 2003
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Page 5 and 6: in and of itself, but I think you t
Page 7 and 8: CMA House of Delegates Report Paul
Page 9 and 10: Adolescent Idiopathic Scoliosis Whi
Page 11 and 12: A Low-Glycemic Index Diet in the Tr
Page 13 and 14: Why California’s MICRA Is Good fo
Page 15 and 16: The Tao of Pediatrics and Chinese M
Page 17 and 18: Chronic Pain in Children: A Multidi
Page 19 and 20: LUNG TRANSPLANTATION CONTINUED FROM
Page 21 and 22: Childcare Health Linkages Program:
Page 23 and 24: Annual Las Vegas Seminars — 25 Ye
Page 25 and 26: Early Hearing Detection and Interve
Page 27: THE TAO OF PEDIATRICS AND CHINESE M
Page 31 and 32: I write in late March, as American
Page 33 and 34: Nikta Forghani, M.D. Weighing the R
Page 35 and 36: COUNCIL ON CHILD HEALTH CHAPTER 1 B
Page 37: CALENDAR May 14, 2003 Los Angeles P

PEDIATRICIAN Spring 2003 - AAP-CA

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