Damian McNamara

FORT LAUDERDALE, FLA. – More children are achieving long-term survival following repair of a congenital diaphragmatic hernia, but "this new group of survivors does not appear to have much greater sequelae," Dr. Melinda Solomon said.

For example, despite early pulmonary hypertension and decreased pulmonary artery size, their cardiac function tends to be normal in adulthood. Exercise impairments tend to be mild as well, Dr. Solomon said at a seminar on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

"The issue used to be: Can we get these patients to survive and make it to adulthood?" Dr. Solomon said.

They are not entirely free of adverse sequelae, however; obstructive findings and the incidence of asthmalike symptoms can be significantly increased in this population, according to long-term follow-up studies. Recurrence of the hernia is also a lifelong concern, said Dr. Solomon of the division of respiratory medicine at the Hospital for Sick Children in Toronto.

In a long-term follow-up study done in the Netherlands, mean forced expiratory volume in 1 second (FEV₁) was significantly lower among 53 survivors at –1.63, compared with 0.08 among controls (Eur. J. Respir. 2009;34:1140-7). "Prebronchodilatation, the FEV₁ was below the lower limit of normal in 46% of patients but not in controls," Dr. Solomon said. The residual volume/total lung capacity (RV/TLC) ratio exceeded the upper limit of normal in 52% of affected children and in none of the controls, a significant difference.

The same study did not reveal a difference in exercise performance between groups. "This is good news" that children with congenital diaphragmatic hernia can have normal exercise capacity in adulthood, Dr. Solomon said.

All cardiac indexes from exercise testing were within the normal range in another follow-up study of 23 children and 23 case-matched controls at the Hospital for Sick Children (Pediatr. Pulmonol. 2006;41:522-9).

Echocardiography revealed that "they actually had very good myocardial function but, as expected, a smaller pulmonary artery on the affected side," Dr. Solomon said. Pulmonary function testing revealed abnormalities even 10-16 years after treatment, she added, but FEV₁ was in the normal range. For example, mean FEV₁ as percent predicted was 83% in patients versus 98% in controls; mean RV/TLC ratio was 31% in patients versus 22% in controls.

Some degree of obstructive disease is common among survivors. Airway hyperactivity with asthmalike symptoms, for example, can last well into adulthood, Dr. Solomon said. It is sometimes difficult to determine who should be prescribed bronchodilators, she added. The 2009 study in the Netherlands found that 28% of affected children responded to these agents, compared with 6% of controls.

Musculoskeletal abnormalities such as scoliosis, pectus excavatum, and chest wall asymmetry develop in almost one-third of patients, Dr. Solomon said. "This often bothers the family as the respiratory issues resolve. It’s important to warn them in advance."

Long-term neurocognitive function remains unclear, and sensorineural hearing loss and its association with congenital diaphragmatic hernia are controversial (Int. J. Pediatr. Otorhinolaryngol. 2010;74:1176-9). Because such hearing loss occurs both in those who undergo extracorporeal membrane oxygenation and in those who don’t, the underlying etiology remains unknown, she said.

Another unanswered question is whether patch repair or video-assisted thoracic surgery (VATS) yields better long-term outcomes, Dr. Solomon said. Although many studies in the literature point to a higher recurrence rate with patch repairs, at her institution, "VATS has a much higher incidence of recurrence."

Congenital diaphragmatic hernia occurs in about 1 in every 3,000 live births. About 85% are left sided, the classic posterolateral Bochdalek hernia. Comorbidities affect approximately 40%-50% of these children; congenital heart disease, in particular, is associated with an increased risk of mortality.

Dr. Solomon said she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – More children are achieving long-term survival following repair of a congenital diaphragmatic hernia, but "this new group of survivors does not appear to have much greater sequelae," Dr. Melinda Solomon said.

For example, despite early pulmonary hypertension and decreased pulmonary artery size, their cardiac function tends to be normal in adulthood. Exercise impairments tend to be mild as well, Dr. Solomon said at a seminar on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

"The issue used to be: Can we get these patients to survive and make it to adulthood?" Dr. Solomon said.

They are not entirely free of adverse sequelae, however; obstructive findings and the incidence of asthmalike symptoms can be significantly increased in this population, according to long-term follow-up studies. Recurrence of the hernia is also a lifelong concern, said Dr. Solomon of the division of respiratory medicine at the Hospital for Sick Children in Toronto.

In a long-term follow-up study done in the Netherlands, mean forced expiratory volume in 1 second (FEV₁) was significantly lower among 53 survivors at –1.63, compared with 0.08 among controls (Eur. J. Respir. 2009;34:1140-7). "Prebronchodilatation, the FEV₁ was below the lower limit of normal in 46% of patients but not in controls," Dr. Solomon said. The residual volume/total lung capacity (RV/TLC) ratio exceeded the upper limit of normal in 52% of affected children and in none of the controls, a significant difference.

The same study did not reveal a difference in exercise performance between groups. "This is good news" that children with congenital diaphragmatic hernia can have normal exercise capacity in adulthood, Dr. Solomon said.

All cardiac indexes from exercise testing were within the normal range in another follow-up study of 23 children and 23 case-matched controls at the Hospital for Sick Children (Pediatr. Pulmonol. 2006;41:522-9).

Echocardiography revealed that "they actually had very good myocardial function but, as expected, a smaller pulmonary artery on the affected side," Dr. Solomon said. Pulmonary function testing revealed abnormalities even 10-16 years after treatment, she added, but FEV₁ was in the normal range. For example, mean FEV₁ as percent predicted was 83% in patients versus 98% in controls; mean RV/TLC ratio was 31% in patients versus 22% in controls.

Some degree of obstructive disease is common among survivors. Airway hyperactivity with asthmalike symptoms, for example, can last well into adulthood, Dr. Solomon said. It is sometimes difficult to determine who should be prescribed bronchodilators, she added. The 2009 study in the Netherlands found that 28% of affected children responded to these agents, compared with 6% of controls.

Musculoskeletal abnormalities such as scoliosis, pectus excavatum, and chest wall asymmetry develop in almost one-third of patients, Dr. Solomon said. "This often bothers the family as the respiratory issues resolve. It’s important to warn them in advance."

Long-term neurocognitive function remains unclear, and sensorineural hearing loss and its association with congenital diaphragmatic hernia are controversial (Int. J. Pediatr. Otorhinolaryngol. 2010;74:1176-9). Because such hearing loss occurs both in those who undergo extracorporeal membrane oxygenation and in those who don’t, the underlying etiology remains unknown, she said.

Another unanswered question is whether patch repair or video-assisted thoracic surgery (VATS) yields better long-term outcomes, Dr. Solomon said. Although many studies in the literature point to a higher recurrence rate with patch repairs, at her institution, "VATS has a much higher incidence of recurrence."

Congenital diaphragmatic hernia occurs in about 1 in every 3,000 live births. About 85% are left sided, the classic posterolateral Bochdalek hernia. Comorbidities affect approximately 40%-50% of these children; congenital heart disease, in particular, is associated with an increased risk of mortality.

Dr. Solomon said she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – More children are achieving long-term survival following repair of a congenital diaphragmatic hernia, but "this new group of survivors does not appear to have much greater sequelae," Dr. Melinda Solomon said.

For example, despite early pulmonary hypertension and decreased pulmonary artery size, their cardiac function tends to be normal in adulthood. Exercise impairments tend to be mild as well, Dr. Solomon said at a seminar on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

"The issue used to be: Can we get these patients to survive and make it to adulthood?" Dr. Solomon said.

They are not entirely free of adverse sequelae, however; obstructive findings and the incidence of asthmalike symptoms can be significantly increased in this population, according to long-term follow-up studies. Recurrence of the hernia is also a lifelong concern, said Dr. Solomon of the division of respiratory medicine at the Hospital for Sick Children in Toronto.

In a long-term follow-up study done in the Netherlands, mean forced expiratory volume in 1 second (FEV₁) was significantly lower among 53 survivors at –1.63, compared with 0.08 among controls (Eur. J. Respir. 2009;34:1140-7). "Prebronchodilatation, the FEV₁ was below the lower limit of normal in 46% of patients but not in controls," Dr. Solomon said. The residual volume/total lung capacity (RV/TLC) ratio exceeded the upper limit of normal in 52% of affected children and in none of the controls, a significant difference.

The same study did not reveal a difference in exercise performance between groups. "This is good news" that children with congenital diaphragmatic hernia can have normal exercise capacity in adulthood, Dr. Solomon said.

All cardiac indexes from exercise testing were within the normal range in another follow-up study of 23 children and 23 case-matched controls at the Hospital for Sick Children (Pediatr. Pulmonol. 2006;41:522-9).

Echocardiography revealed that "they actually had very good myocardial function but, as expected, a smaller pulmonary artery on the affected side," Dr. Solomon said. Pulmonary function testing revealed abnormalities even 10-16 years after treatment, she added, but FEV₁ was in the normal range. For example, mean FEV₁ as percent predicted was 83% in patients versus 98% in controls; mean RV/TLC ratio was 31% in patients versus 22% in controls.

Some degree of obstructive disease is common among survivors. Airway hyperactivity with asthmalike symptoms, for example, can last well into adulthood, Dr. Solomon said. It is sometimes difficult to determine who should be prescribed bronchodilators, she added. The 2009 study in the Netherlands found that 28% of affected children responded to these agents, compared with 6% of controls.

Musculoskeletal abnormalities such as scoliosis, pectus excavatum, and chest wall asymmetry develop in almost one-third of patients, Dr. Solomon said. "This often bothers the family as the respiratory issues resolve. It’s important to warn them in advance."

Long-term neurocognitive function remains unclear, and sensorineural hearing loss and its association with congenital diaphragmatic hernia are controversial (Int. J. Pediatr. Otorhinolaryngol. 2010;74:1176-9). Because such hearing loss occurs both in those who undergo extracorporeal membrane oxygenation and in those who don’t, the underlying etiology remains unknown, she said.

Another unanswered question is whether patch repair or video-assisted thoracic surgery (VATS) yields better long-term outcomes, Dr. Solomon said. Although many studies in the literature point to a higher recurrence rate with patch repairs, at her institution, "VATS has a much higher incidence of recurrence."

Congenital diaphragmatic hernia occurs in about 1 in every 3,000 live births. About 85% are left sided, the classic posterolateral Bochdalek hernia. Comorbidities affect approximately 40%-50% of these children; congenital heart disease, in particular, is associated with an increased risk of mortality.

Dr. Solomon said she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – When it’s necessary to mechanically ventilate a child with acute asthma, first stabilize the patient and then set the ventilator optimally to avoid major complications, Dr. Veda L. Ackerman said.

Intubation and initial ventilator set-up are the most critical times and require a high level of clinical skill, Dr. Ackerman said at a symposium on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

Supplemental oxygen to maintain saturation above 92% and an inhaled, short-acting beta-2 agonist such as albuterol also are important to lessen an acute asthma exacerbation, Dr. Ackerman said. Administer systemic steroids for all moderate to severe episodes that do not respond completely to beta-2 agonists, she said. Also consider adding the anticholinergic ipratropium bromide to combat any moderate to severe asthma attack.

This is standard of care in most emergency departments, but some children need more, Dr. Ackerman said.

The next step is intubation. "I had not seen a child with asthma intubated for years until the economy sank a few years ago. Then I saw three or four kids who died because they had not been taking their meds" and had acute episodes, said Dr. Ackerman, a pediatric intensivist at Riley Hospital for Children, Indianapolis.

Your decision to intubate or not to intubate relies on your clinical judgment, not on any specific pH or partial pressure of carbon dioxide (PaCO₂), Dr. Ackerman said. Keep in mind that generally fewer than 10% of children admitted to a pediatric ICU for severe asthma require intubation. Absolute indications include cardiopulmonary arrest, obtundation, profound hypoxemia unresponsive to therapy, and mixed respiratory and metabolic acidosis.

Once you decide to intubate, there is only a minimal margin of error if the child is hypoxic, acidotic, and fatigued, Dr. Ackerman said. An effective rapid sequence intubation relies on preoxygenation with 100% oxygen using a facemask during spontaneous breathing and a combination of ketamine and a benzodiazepine for sedation and analgesia. "Avoid assisted breathing with an Ambu bag until the tube is placed, or you will have emesis or worsening of your air trapping." Also consider use of a cuffed endotracheal tube because some children require high ventilatory pressures in the ICU.

In the "next critical 5 minutes" after intubation, a natural tendency for many clinicians may be to hyperventilate the patient using a self-inflating bag valve mask resuscitator such as an Ambu bag. This is ill advised, Dr. Ackerman said. "In the asthmatic child, this will impede exhalation, leading to worsening hypercapnia and acidosis with potential cardiac collapse, as well as increased risk of barotrauma due to worsening hyperinflation," she said.

"Eventually, the best thing is to put them on a ventilator," Dr. Ackerman said. Reversal of hypoxemia, relief of respiratory muscle fatigue, and allowing enough time for inflammation and bronchospasm to respond to systemic steroids and bronchodilator therapy are among the goals of ventilation. "These kids are exhausted and need to rest."

Initial ventilator settings are based on physician choice. Most clinicians use volume control, although pressure control can be used instead to leak peak pressure, Dr. Ackerman said. Assist control or pressure-regulated volume control are other ventilator options. "There is no evidence to suggest one mode is superior, provided one understands the specific characteristics of each mode," she said.

"We start at 100% oxygen. There is no reason to worry about hyperoxygenation of a child with asthma," Dr. Ackerman said. Tidal volume is initially set between 8 and 12 mL/kg to achieve adequate chest movement with each ventilator breath and to keep peak pressures below 50. Set the rate below the physiologic breathing rate for the child to allow enough time for the exhalation phase, she advised. The inspiratory-expiratory ratio should be at least 1:4, but may need to go as high as 1:8. "You don’t want to stack the breaths," as barotrauma may result if a breath is not fully exhaled before the subsequent breath starts, she added.

Permissive hypercapnia is another strategy to minimize risk of barotrauma. "CO₂ is not going to hurt the child if the pH is at a normal level," Dr. Ackerman said. Limited duration, permissive hypercapnia is accomplished by reducing tidal volume to 7 mL/kg or less, keeping peak airway pressure a maximum of 40 cm H₂O, and allowing PaCO₂ to rise no more than 10 mm Hg per hour up to a maximum of 80-100 mm Hg. At the same time, maintain oxygen saturation above 90%, allow at least 4 seconds for expiration, and set low minute ventilation (10 L/min or less) and low respiratory rate (fewer than 10 breaths per minute) (Intensive Care Med. 2006;32:501-10).

In addition to barotrauma, monitor patients for any signs of ventilator-associated pneumonia, massive gastrointestinal bleeding, and hypotension and circulatory compromise from poor venous return, Dr. Ackerman said. "If there is an acute change, think pneumothorax unless proven otherwise."

Dr. Ackerman said that she had no relevant disclosures.

FORT LAUDERDALE, FLA. – When it’s necessary to mechanically ventilate a child with acute asthma, first stabilize the patient and then set the ventilator optimally to avoid major complications, Dr. Veda L. Ackerman said.

Intubation and initial ventilator set-up are the most critical times and require a high level of clinical skill, Dr. Ackerman said at a symposium on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

Supplemental oxygen to maintain saturation above 92% and an inhaled, short-acting beta-2 agonist such as albuterol also are important to lessen an acute asthma exacerbation, Dr. Ackerman said. Administer systemic steroids for all moderate to severe episodes that do not respond completely to beta-2 agonists, she said. Also consider adding the anticholinergic ipratropium bromide to combat any moderate to severe asthma attack.

This is standard of care in most emergency departments, but some children need more, Dr. Ackerman said.

The next step is intubation. "I had not seen a child with asthma intubated for years until the economy sank a few years ago. Then I saw three or four kids who died because they had not been taking their meds" and had acute episodes, said Dr. Ackerman, a pediatric intensivist at Riley Hospital for Children, Indianapolis.

Your decision to intubate or not to intubate relies on your clinical judgment, not on any specific pH or partial pressure of carbon dioxide (PaCO₂), Dr. Ackerman said. Keep in mind that generally fewer than 10% of children admitted to a pediatric ICU for severe asthma require intubation. Absolute indications include cardiopulmonary arrest, obtundation, profound hypoxemia unresponsive to therapy, and mixed respiratory and metabolic acidosis.

Once you decide to intubate, there is only a minimal margin of error if the child is hypoxic, acidotic, and fatigued, Dr. Ackerman said. An effective rapid sequence intubation relies on preoxygenation with 100% oxygen using a facemask during spontaneous breathing and a combination of ketamine and a benzodiazepine for sedation and analgesia. "Avoid assisted breathing with an Ambu bag until the tube is placed, or you will have emesis or worsening of your air trapping." Also consider use of a cuffed endotracheal tube because some children require high ventilatory pressures in the ICU.

In the "next critical 5 minutes" after intubation, a natural tendency for many clinicians may be to hyperventilate the patient using a self-inflating bag valve mask resuscitator such as an Ambu bag. This is ill advised, Dr. Ackerman said. "In the asthmatic child, this will impede exhalation, leading to worsening hypercapnia and acidosis with potential cardiac collapse, as well as increased risk of barotrauma due to worsening hyperinflation," she said.

"Eventually, the best thing is to put them on a ventilator," Dr. Ackerman said. Reversal of hypoxemia, relief of respiratory muscle fatigue, and allowing enough time for inflammation and bronchospasm to respond to systemic steroids and bronchodilator therapy are among the goals of ventilation. "These kids are exhausted and need to rest."

Initial ventilator settings are based on physician choice. Most clinicians use volume control, although pressure control can be used instead to leak peak pressure, Dr. Ackerman said. Assist control or pressure-regulated volume control are other ventilator options. "There is no evidence to suggest one mode is superior, provided one understands the specific characteristics of each mode," she said.

"We start at 100% oxygen. There is no reason to worry about hyperoxygenation of a child with asthma," Dr. Ackerman said. Tidal volume is initially set between 8 and 12 mL/kg to achieve adequate chest movement with each ventilator breath and to keep peak pressures below 50. Set the rate below the physiologic breathing rate for the child to allow enough time for the exhalation phase, she advised. The inspiratory-expiratory ratio should be at least 1:4, but may need to go as high as 1:8. "You don’t want to stack the breaths," as barotrauma may result if a breath is not fully exhaled before the subsequent breath starts, she added.

Permissive hypercapnia is another strategy to minimize risk of barotrauma. "CO₂ is not going to hurt the child if the pH is at a normal level," Dr. Ackerman said. Limited duration, permissive hypercapnia is accomplished by reducing tidal volume to 7 mL/kg or less, keeping peak airway pressure a maximum of 40 cm H₂O, and allowing PaCO₂ to rise no more than 10 mm Hg per hour up to a maximum of 80-100 mm Hg. At the same time, maintain oxygen saturation above 90%, allow at least 4 seconds for expiration, and set low minute ventilation (10 L/min or less) and low respiratory rate (fewer than 10 breaths per minute) (Intensive Care Med. 2006;32:501-10).

In addition to barotrauma, monitor patients for any signs of ventilator-associated pneumonia, massive gastrointestinal bleeding, and hypotension and circulatory compromise from poor venous return, Dr. Ackerman said. "If there is an acute change, think pneumothorax unless proven otherwise."

Dr. Ackerman said that she had no relevant disclosures.

FORT LAUDERDALE, FLA. – When it’s necessary to mechanically ventilate a child with acute asthma, first stabilize the patient and then set the ventilator optimally to avoid major complications, Dr. Veda L. Ackerman said.

Intubation and initial ventilator set-up are the most critical times and require a high level of clinical skill, Dr. Ackerman said at a symposium on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

Supplemental oxygen to maintain saturation above 92% and an inhaled, short-acting beta-2 agonist such as albuterol also are important to lessen an acute asthma exacerbation, Dr. Ackerman said. Administer systemic steroids for all moderate to severe episodes that do not respond completely to beta-2 agonists, she said. Also consider adding the anticholinergic ipratropium bromide to combat any moderate to severe asthma attack.

This is standard of care in most emergency departments, but some children need more, Dr. Ackerman said.

The next step is intubation. "I had not seen a child with asthma intubated for years until the economy sank a few years ago. Then I saw three or four kids who died because they had not been taking their meds" and had acute episodes, said Dr. Ackerman, a pediatric intensivist at Riley Hospital for Children, Indianapolis.

Your decision to intubate or not to intubate relies on your clinical judgment, not on any specific pH or partial pressure of carbon dioxide (PaCO₂), Dr. Ackerman said. Keep in mind that generally fewer than 10% of children admitted to a pediatric ICU for severe asthma require intubation. Absolute indications include cardiopulmonary arrest, obtundation, profound hypoxemia unresponsive to therapy, and mixed respiratory and metabolic acidosis.

Once you decide to intubate, there is only a minimal margin of error if the child is hypoxic, acidotic, and fatigued, Dr. Ackerman said. An effective rapid sequence intubation relies on preoxygenation with 100% oxygen using a facemask during spontaneous breathing and a combination of ketamine and a benzodiazepine for sedation and analgesia. "Avoid assisted breathing with an Ambu bag until the tube is placed, or you will have emesis or worsening of your air trapping." Also consider use of a cuffed endotracheal tube because some children require high ventilatory pressures in the ICU.

In the "next critical 5 minutes" after intubation, a natural tendency for many clinicians may be to hyperventilate the patient using a self-inflating bag valve mask resuscitator such as an Ambu bag. This is ill advised, Dr. Ackerman said. "In the asthmatic child, this will impede exhalation, leading to worsening hypercapnia and acidosis with potential cardiac collapse, as well as increased risk of barotrauma due to worsening hyperinflation," she said.

"Eventually, the best thing is to put them on a ventilator," Dr. Ackerman said. Reversal of hypoxemia, relief of respiratory muscle fatigue, and allowing enough time for inflammation and bronchospasm to respond to systemic steroids and bronchodilator therapy are among the goals of ventilation. "These kids are exhausted and need to rest."

Initial ventilator settings are based on physician choice. Most clinicians use volume control, although pressure control can be used instead to leak peak pressure, Dr. Ackerman said. Assist control or pressure-regulated volume control are other ventilator options. "There is no evidence to suggest one mode is superior, provided one understands the specific characteristics of each mode," she said.

"We start at 100% oxygen. There is no reason to worry about hyperoxygenation of a child with asthma," Dr. Ackerman said. Tidal volume is initially set between 8 and 12 mL/kg to achieve adequate chest movement with each ventilator breath and to keep peak pressures below 50. Set the rate below the physiologic breathing rate for the child to allow enough time for the exhalation phase, she advised. The inspiratory-expiratory ratio should be at least 1:4, but may need to go as high as 1:8. "You don’t want to stack the breaths," as barotrauma may result if a breath is not fully exhaled before the subsequent breath starts, she added.

Permissive hypercapnia is another strategy to minimize risk of barotrauma. "CO₂ is not going to hurt the child if the pH is at a normal level," Dr. Ackerman said. Limited duration, permissive hypercapnia is accomplished by reducing tidal volume to 7 mL/kg or less, keeping peak airway pressure a maximum of 40 cm H₂O, and allowing PaCO₂ to rise no more than 10 mm Hg per hour up to a maximum of 80-100 mm Hg. At the same time, maintain oxygen saturation above 90%, allow at least 4 seconds for expiration, and set low minute ventilation (10 L/min or less) and low respiratory rate (fewer than 10 breaths per minute) (Intensive Care Med. 2006;32:501-10).

In addition to barotrauma, monitor patients for any signs of ventilator-associated pneumonia, massive gastrointestinal bleeding, and hypotension and circulatory compromise from poor venous return, Dr. Ackerman said. "If there is an acute change, think pneumothorax unless proven otherwise."

Dr. Ackerman said that she had no relevant disclosures.

DENVER – Bariatric surgery results in significant weight loss at 1 year for morbidly-obese adolescents who have a procedure at a designated center of excellence, according to a study of 890 teenagers.

"This is one of the first reports of a national scope ... revealing the prevalence estimates of weight loss among adolescent patients," Dr. Nestor de la Cruz-Munoz said at the annual meeting of the Pediatric Academic Societies. "Bariatric surgery has the potential to be a safe and effective treatment option for significant weight loss in U.S. adolescents, irrespective of gender."

Fewer than 1% of bariatric surgery cases in the country are being done on adolescents, and "very little is know about the short-term and long-term outcomes in terms of weight and associated health consequences in these patients," said Dr. de la Cruz-Munoz, a bariatric surgeon at the University of Miami.

To find out more, Dr. de la Cruz-Munoz and his coworkers evaluated all patients aged 11-19 years old who had bariatric surgery from June 2007 through October 2010 in the prospective BOLD (Bariatric Outcomes Longitudinal Database) registry.

Weight decreased from a mean 138 kg at baseline to 110 kg at 1 year in these 890 patients. Baseline mean z score changed from 2.86 to 2.31, and the weight percentile of these adolescents (compared with the general population) decreased from 99.6% to 97.1%. In addition, the body mass index z score decreased from 2.6 to 2.11 during this time. Assessments were also done at 6 months post surgery in all patients. "All of those [changes] were statistically significant," Dr. de la Cruz-Munoz said.

"Bariatric surgery results in significant weight loss among morbidly obese multiethnic adolescents at 1 year post surgery, for both boys and girls," Dr. de la Cruz-Munoz said.

Broken down by sex, the mean baseline weight was 162 kg for boys and 129 for girls. The mean z score decreased from 3.52 to 2.77 for boys and from 2.64 to 2.12 for girls. "The weight percentages for boys started at about as high as you can get (99.95%) and ended up at 98.7%," Dr. de la Cruz-Munoz said. At the same time, weight percentages for girls decreased from 99.46% to 95.97%. The BMI z score decreased from a baseline 3.15 in boys to 2.57 at 1 year. For girls, this measure decreased from 2.42 to 1.92. Again, all these changes were statistically significant.

"The most rapid weight loss was in the first 6 months," Dr. de la Cruz-Munoz said.

One patient died from cardiac failure 5 months after surgery, resulting in a mortality rate of 0.11% in the cohort. In all, 141 postoperative adverse events were reported. Nausea and vomiting were the most common (13%), followed by vitamin D deficiency (8%).

Gastric bypass was the most common type of bariatric surgery in these adolescents, performed in 454 patients (51%). Gastric banding was a close second and was performed in 436 patients (49%). No gastric sleeve procedures were done in this age group during this time.

Consistent with adult data, about 80% were females; mean age was 18 years, and 69% were white, 15% Hispanic, 11% black, and 5% other.

There are now more than 375,000 patients in the BOLD registry, so adolescents represent only 0.7%. The independent, nonprofit Surgical Review Corporation (SRC) administers the American Society for Metabolic and Bariatric Surgery Center of Excellence (BSCOE) program. The SRC developed BOLD in 2007 to help ensure compliance with the BSCOE program.

There are 440 facilities currently designated as centers of excellence, with 758 surgeons; approximately 100 additional facilities have provisional status, Dr. de la Cruz-Munoz said.

A meeting attendee said that they had a lot of issues getting insurance coverage for bariatric surgery. "Insurance is huge issue for both the kids and the adults, and maybe even larger for the kids," Dr. de la Cruz-Munoz said. "Most of the data we’re seeing are [from] adult surgeons that also do kids. There are some pediatric surgeons who do kids as well, but most of those programs are just growing. A lot of times they don’t qualify yet for the centers of excellence designation."

Dr. de la Cruz-Munoz disclosed that he is a member of the SRC’s surgical review committee and a consultant for Ethicon Endo-Surgery Inc.

DENVER – Bariatric surgery results in significant weight loss at 1 year for morbidly-obese adolescents who have a procedure at a designated center of excellence, according to a study of 890 teenagers.

"This is one of the first reports of a national scope ... revealing the prevalence estimates of weight loss among adolescent patients," Dr. Nestor de la Cruz-Munoz said at the annual meeting of the Pediatric Academic Societies. "Bariatric surgery has the potential to be a safe and effective treatment option for significant weight loss in U.S. adolescents, irrespective of gender."

Fewer than 1% of bariatric surgery cases in the country are being done on adolescents, and "very little is know about the short-term and long-term outcomes in terms of weight and associated health consequences in these patients," said Dr. de la Cruz-Munoz, a bariatric surgeon at the University of Miami.

To find out more, Dr. de la Cruz-Munoz and his coworkers evaluated all patients aged 11-19 years old who had bariatric surgery from June 2007 through October 2010 in the prospective BOLD (Bariatric Outcomes Longitudinal Database) registry.

Weight decreased from a mean 138 kg at baseline to 110 kg at 1 year in these 890 patients. Baseline mean z score changed from 2.86 to 2.31, and the weight percentile of these adolescents (compared with the general population) decreased from 99.6% to 97.1%. In addition, the body mass index z score decreased from 2.6 to 2.11 during this time. Assessments were also done at 6 months post surgery in all patients. "All of those [changes] were statistically significant," Dr. de la Cruz-Munoz said.

"Bariatric surgery results in significant weight loss among morbidly obese multiethnic adolescents at 1 year post surgery, for both boys and girls," Dr. de la Cruz-Munoz said.

Broken down by sex, the mean baseline weight was 162 kg for boys and 129 for girls. The mean z score decreased from 3.52 to 2.77 for boys and from 2.64 to 2.12 for girls. "The weight percentages for boys started at about as high as you can get (99.95%) and ended up at 98.7%," Dr. de la Cruz-Munoz said. At the same time, weight percentages for girls decreased from 99.46% to 95.97%. The BMI z score decreased from a baseline 3.15 in boys to 2.57 at 1 year. For girls, this measure decreased from 2.42 to 1.92. Again, all these changes were statistically significant.

"The most rapid weight loss was in the first 6 months," Dr. de la Cruz-Munoz said.

One patient died from cardiac failure 5 months after surgery, resulting in a mortality rate of 0.11% in the cohort. In all, 141 postoperative adverse events were reported. Nausea and vomiting were the most common (13%), followed by vitamin D deficiency (8%).

Gastric bypass was the most common type of bariatric surgery in these adolescents, performed in 454 patients (51%). Gastric banding was a close second and was performed in 436 patients (49%). No gastric sleeve procedures were done in this age group during this time.

Consistent with adult data, about 80% were females; mean age was 18 years, and 69% were white, 15% Hispanic, 11% black, and 5% other.

There are now more than 375,000 patients in the BOLD registry, so adolescents represent only 0.7%. The independent, nonprofit Surgical Review Corporation (SRC) administers the American Society for Metabolic and Bariatric Surgery Center of Excellence (BSCOE) program. The SRC developed BOLD in 2007 to help ensure compliance with the BSCOE program.

There are 440 facilities currently designated as centers of excellence, with 758 surgeons; approximately 100 additional facilities have provisional status, Dr. de la Cruz-Munoz said.

A meeting attendee said that they had a lot of issues getting insurance coverage for bariatric surgery. "Insurance is huge issue for both the kids and the adults, and maybe even larger for the kids," Dr. de la Cruz-Munoz said. "Most of the data we’re seeing are [from] adult surgeons that also do kids. There are some pediatric surgeons who do kids as well, but most of those programs are just growing. A lot of times they don’t qualify yet for the centers of excellence designation."

Dr. de la Cruz-Munoz disclosed that he is a member of the SRC’s surgical review committee and a consultant for Ethicon Endo-Surgery Inc.

DENVER – Bariatric surgery results in significant weight loss at 1 year for morbidly-obese adolescents who have a procedure at a designated center of excellence, according to a study of 890 teenagers.

"This is one of the first reports of a national scope ... revealing the prevalence estimates of weight loss among adolescent patients," Dr. Nestor de la Cruz-Munoz said at the annual meeting of the Pediatric Academic Societies. "Bariatric surgery has the potential to be a safe and effective treatment option for significant weight loss in U.S. adolescents, irrespective of gender."

Fewer than 1% of bariatric surgery cases in the country are being done on adolescents, and "very little is know about the short-term and long-term outcomes in terms of weight and associated health consequences in these patients," said Dr. de la Cruz-Munoz, a bariatric surgeon at the University of Miami.

To find out more, Dr. de la Cruz-Munoz and his coworkers evaluated all patients aged 11-19 years old who had bariatric surgery from June 2007 through October 2010 in the prospective BOLD (Bariatric Outcomes Longitudinal Database) registry.

Weight decreased from a mean 138 kg at baseline to 110 kg at 1 year in these 890 patients. Baseline mean z score changed from 2.86 to 2.31, and the weight percentile of these adolescents (compared with the general population) decreased from 99.6% to 97.1%. In addition, the body mass index z score decreased from 2.6 to 2.11 during this time. Assessments were also done at 6 months post surgery in all patients. "All of those [changes] were statistically significant," Dr. de la Cruz-Munoz said.

"Bariatric surgery results in significant weight loss among morbidly obese multiethnic adolescents at 1 year post surgery, for both boys and girls," Dr. de la Cruz-Munoz said.

Broken down by sex, the mean baseline weight was 162 kg for boys and 129 for girls. The mean z score decreased from 3.52 to 2.77 for boys and from 2.64 to 2.12 for girls. "The weight percentages for boys started at about as high as you can get (99.95%) and ended up at 98.7%," Dr. de la Cruz-Munoz said. At the same time, weight percentages for girls decreased from 99.46% to 95.97%. The BMI z score decreased from a baseline 3.15 in boys to 2.57 at 1 year. For girls, this measure decreased from 2.42 to 1.92. Again, all these changes were statistically significant.

"The most rapid weight loss was in the first 6 months," Dr. de la Cruz-Munoz said.

One patient died from cardiac failure 5 months after surgery, resulting in a mortality rate of 0.11% in the cohort. In all, 141 postoperative adverse events were reported. Nausea and vomiting were the most common (13%), followed by vitamin D deficiency (8%).

Gastric bypass was the most common type of bariatric surgery in these adolescents, performed in 454 patients (51%). Gastric banding was a close second and was performed in 436 patients (49%). No gastric sleeve procedures were done in this age group during this time.

Consistent with adult data, about 80% were females; mean age was 18 years, and 69% were white, 15% Hispanic, 11% black, and 5% other.

There are now more than 375,000 patients in the BOLD registry, so adolescents represent only 0.7%. The independent, nonprofit Surgical Review Corporation (SRC) administers the American Society for Metabolic and Bariatric Surgery Center of Excellence (BSCOE) program. The SRC developed BOLD in 2007 to help ensure compliance with the BSCOE program.

There are 440 facilities currently designated as centers of excellence, with 758 surgeons; approximately 100 additional facilities have provisional status, Dr. de la Cruz-Munoz said.

A meeting attendee said that they had a lot of issues getting insurance coverage for bariatric surgery. "Insurance is huge issue for both the kids and the adults, and maybe even larger for the kids," Dr. de la Cruz-Munoz said. "Most of the data we’re seeing are [from] adult surgeons that also do kids. There are some pediatric surgeons who do kids as well, but most of those programs are just growing. A lot of times they don’t qualify yet for the centers of excellence designation."

Dr. de la Cruz-Munoz disclosed that he is a member of the SRC’s surgical review committee and a consultant for Ethicon Endo-Surgery Inc.

DENVER – Bariatric surgery results in significant weight loss at 1 year for morbidly-obese adolescents who have a procedure at a designated center of excellence, according to a study of 890 teenagers.

"This is one of the first reports of a national scope ... revealing the prevalence estimates of weight loss among adolescent patients," Dr. Nestor de la Cruz-Munoz said at the annual meeting of the Pediatric Academic Societies. "Bariatric surgery has the potential to be a safe and effective treatment option for significant weight loss in U.S. adolescents, irrespective of gender."

Fewer than 1% of bariatric surgery cases in the country are being done on adolescents, and "very little is know about the short-term and long-term outcomes in terms of weight and associated health consequences in these patients," said Dr. de la Cruz-Munoz, a bariatric surgeon at the University of Miami.

To find out more, Dr. de la Cruz-Munoz and his coworkers evaluated all patients aged 11-19 years old who had bariatric surgery from June 2007 through October 2010 in the prospective BOLD (Bariatric Outcomes Longitudinal Database) registry.

Weight decreased from a mean 138 kg at baseline to 110 kg at 1 year in these 890 patients. Baseline mean z score changed from 2.86 to 2.31, and the weight percentile of these adolescents (compared with the general population) decreased from 99.6% to 97.1%. In addition, the body mass index z score decreased from 2.6 to 2.11 during this time. Assessments were also done at 6 months post surgery in all patients. "All of those [changes] were statistically significant," Dr. de la Cruz-Munoz said.

"Bariatric surgery results in significant weight loss among morbidly obese multiethnic adolescents at 1 year post surgery, for both boys and girls," Dr. de la Cruz-Munoz said.

Broken down by sex, the mean baseline weight was 162 kg for boys and 129 for girls. The mean z score decreased from 3.52 to 2.77 for boys and from 2.64 to 2.12 for girls. "The weight percentages for boys started at about as high as you can get (99.95%) and ended up at 98.7%," Dr. de la Cruz-Munoz said. At the same time, weight percentages for girls decreased from 99.46% to 95.97%. The BMI z score decreased from a baseline 3.15 in boys to 2.57 at 1 year. For girls, this measure decreased from 2.42 to 1.92. Again, all these changes were statistically significant.

"The most rapid weight loss was in the first 6 months," Dr. de la Cruz-Munoz said.

One patient died from cardiac failure 5 months after surgery, resulting in a mortality rate of 0.11% in the cohort. In all, 141 postoperative adverse events were reported. Nausea and vomiting were the most common (13%), followed by vitamin D deficiency (8%).

Gastric bypass was the most common type of bariatric surgery in these adolescents, performed in 454 patients (51%). Gastric banding was a close second and was performed in 436 patients (49%). No gastric sleeve procedures were done in this age group during this time.

Consistent with adult data, about 80% were females; mean age was 18 years, and 69% were white, 15% Hispanic, 11% black, and 5% other.

There are now more than 375,000 patients in the BOLD registry, so adolescents represent only 0.7%. The independent, nonprofit Surgical Review Corporation (SRC) administers the American Society for Metabolic and Bariatric Surgery Center of Excellence (BSCOE) program. The SRC developed BOLD in 2007 to help ensure compliance with the BSCOE program.

There are 440 facilities currently designated as centers of excellence, with 758 surgeons; approximately 100 additional facilities have provisional status, Dr. de la Cruz-Munoz said.

A meeting attendee said that they had a lot of issues getting insurance coverage for bariatric surgery. "Insurance is huge issue for both the kids and the adults, and maybe even larger for the kids," Dr. de la Cruz-Munoz said. "Most of the data we’re seeing are [from] adult surgeons that also do kids. There are some pediatric surgeons who do kids as well, but most of those programs are just growing. A lot of times they don’t qualify yet for the centers of excellence designation."

Dr. de la Cruz-Munoz disclosed that he is a member of the SRC’s surgical review committee and a consultant for Ethicon Endo-Surgery Inc.

DENVER – Bariatric surgery results in significant weight loss at 1 year for morbidly-obese adolescents who have a procedure at a designated center of excellence, according to a study of 890 teenagers.

"This is one of the first reports of a national scope ... revealing the prevalence estimates of weight loss among adolescent patients," Dr. Nestor de la Cruz-Munoz said at the annual meeting of the Pediatric Academic Societies. "Bariatric surgery has the potential to be a safe and effective treatment option for significant weight loss in U.S. adolescents, irrespective of gender."

Fewer than 1% of bariatric surgery cases in the country are being done on adolescents, and "very little is know about the short-term and long-term outcomes in terms of weight and associated health consequences in these patients," said Dr. de la Cruz-Munoz, a bariatric surgeon at the University of Miami.

To find out more, Dr. de la Cruz-Munoz and his coworkers evaluated all patients aged 11-19 years old who had bariatric surgery from June 2007 through October 2010 in the prospective BOLD (Bariatric Outcomes Longitudinal Database) registry.

Weight decreased from a mean 138 kg at baseline to 110 kg at 1 year in these 890 patients. Baseline mean z score changed from 2.86 to 2.31, and the weight percentile of these adolescents (compared with the general population) decreased from 99.6% to 97.1%. In addition, the body mass index z score decreased from 2.6 to 2.11 during this time. Assessments were also done at 6 months post surgery in all patients. "All of those [changes] were statistically significant," Dr. de la Cruz-Munoz said.

"Bariatric surgery results in significant weight loss among morbidly obese multiethnic adolescents at 1 year post surgery, for both boys and girls," Dr. de la Cruz-Munoz said.

Broken down by sex, the mean baseline weight was 162 kg for boys and 129 for girls. The mean z score decreased from 3.52 to 2.77 for boys and from 2.64 to 2.12 for girls. "The weight percentages for boys started at about as high as you can get (99.95%) and ended up at 98.7%," Dr. de la Cruz-Munoz said. At the same time, weight percentages for girls decreased from 99.46% to 95.97%. The BMI z score decreased from a baseline 3.15 in boys to 2.57 at 1 year. For girls, this measure decreased from 2.42 to 1.92. Again, all these changes were statistically significant.

"The most rapid weight loss was in the first 6 months," Dr. de la Cruz-Munoz said.

One patient died from cardiac failure 5 months after surgery, resulting in a mortality rate of 0.11% in the cohort. In all, 141 postoperative adverse events were reported. Nausea and vomiting were the most common (13%), followed by vitamin D deficiency (8%).

Gastric bypass was the most common type of bariatric surgery in these adolescents, performed in 454 patients (51%). Gastric banding was a close second and was performed in 436 patients (49%). No gastric sleeve procedures were done in this age group during this time.

Consistent with adult data, about 80% were females; mean age was 18 years, and 69% were white, 15% Hispanic, 11% black, and 5% other.

There are now more than 375,000 patients in the BOLD registry, so adolescents represent only 0.7%. The independent, nonprofit Surgical Review Corporation (SRC) administers the American Society for Metabolic and Bariatric Surgery Center of Excellence (BSCOE) program. The SRC developed BOLD in 2007 to help ensure compliance with the BSCOE program.

There are 440 facilities currently designated as centers of excellence, with 758 surgeons; approximately 100 additional facilities have provisional status, Dr. de la Cruz-Munoz said.

A meeting attendee said that they had a lot of issues getting insurance coverage for bariatric surgery. "Insurance is huge issue for both the kids and the adults, and maybe even larger for the kids," Dr. de la Cruz-Munoz said. "Most of the data we’re seeing are [from] adult surgeons that also do kids. There are some pediatric surgeons who do kids as well, but most of those programs are just growing. A lot of times they don’t qualify yet for the centers of excellence designation."

Dr. de la Cruz-Munoz disclosed that he is a member of the SRC’s surgical review committee and a consultant for Ethicon Endo-Surgery Inc.

DENVER – Bariatric surgery results in significant weight loss at 1 year for morbidly-obese adolescents who have a procedure at a designated center of excellence, according to a study of 890 teenagers.

"This is one of the first reports of a national scope ... revealing the prevalence estimates of weight loss among adolescent patients," Dr. Nestor de la Cruz-Munoz said at the annual meeting of the Pediatric Academic Societies. "Bariatric surgery has the potential to be a safe and effective treatment option for significant weight loss in U.S. adolescents, irrespective of gender."

Fewer than 1% of bariatric surgery cases in the country are being done on adolescents, and "very little is know about the short-term and long-term outcomes in terms of weight and associated health consequences in these patients," said Dr. de la Cruz-Munoz, a bariatric surgeon at the University of Miami.

To find out more, Dr. de la Cruz-Munoz and his coworkers evaluated all patients aged 11-19 years old who had bariatric surgery from June 2007 through October 2010 in the prospective BOLD (Bariatric Outcomes Longitudinal Database) registry.

Weight decreased from a mean 138 kg at baseline to 110 kg at 1 year in these 890 patients. Baseline mean z score changed from 2.86 to 2.31, and the weight percentile of these adolescents (compared with the general population) decreased from 99.6% to 97.1%. In addition, the body mass index z score decreased from 2.6 to 2.11 during this time. Assessments were also done at 6 months post surgery in all patients. "All of those [changes] were statistically significant," Dr. de la Cruz-Munoz said.

"Bariatric surgery results in significant weight loss among morbidly obese multiethnic adolescents at 1 year post surgery, for both boys and girls," Dr. de la Cruz-Munoz said.

Broken down by sex, the mean baseline weight was 162 kg for boys and 129 for girls. The mean z score decreased from 3.52 to 2.77 for boys and from 2.64 to 2.12 for girls. "The weight percentages for boys started at about as high as you can get (99.95%) and ended up at 98.7%," Dr. de la Cruz-Munoz said. At the same time, weight percentages for girls decreased from 99.46% to 95.97%. The BMI z score decreased from a baseline 3.15 in boys to 2.57 at 1 year. For girls, this measure decreased from 2.42 to 1.92. Again, all these changes were statistically significant.

"The most rapid weight loss was in the first 6 months," Dr. de la Cruz-Munoz said.

One patient died from cardiac failure 5 months after surgery, resulting in a mortality rate of 0.11% in the cohort. In all, 141 postoperative adverse events were reported. Nausea and vomiting were the most common (13%), followed by vitamin D deficiency (8%).

Gastric bypass was the most common type of bariatric surgery in these adolescents, performed in 454 patients (51%). Gastric banding was a close second and was performed in 436 patients (49%). No gastric sleeve procedures were done in this age group during this time.

Consistent with adult data, about 80% were females; mean age was 18 years, and 69% were white, 15% Hispanic, 11% black, and 5% other.

There are now more than 375,000 patients in the BOLD registry, so adolescents represent only 0.7%. The independent, nonprofit Surgical Review Corporation (SRC) administers the American Society for Metabolic and Bariatric Surgery Center of Excellence (BSCOE) program. The SRC developed BOLD in 2007 to help ensure compliance with the BSCOE program.

There are 440 facilities currently designated as centers of excellence, with 758 surgeons; approximately 100 additional facilities have provisional status, Dr. de la Cruz-Munoz said.

A meeting attendee said that they had a lot of issues getting insurance coverage for bariatric surgery. "Insurance is huge issue for both the kids and the adults, and maybe even larger for the kids," Dr. de la Cruz-Munoz said. "Most of the data we’re seeing are [from] adult surgeons that also do kids. There are some pediatric surgeons who do kids as well, but most of those programs are just growing. A lot of times they don’t qualify yet for the centers of excellence designation."

Dr. de la Cruz-Munoz disclosed that he is a member of the SRC’s surgical review committee and a consultant for Ethicon Endo-Surgery Inc.

DENVER – Drinking sugar-sweetened beverages, not eating breakfast, and eating too many low-nutrient, high-fat snacks were among the modifiable risk factors for obesity found in a cross-sectional survey of obese, low-income children.

Remind parents and guardians of the importance of eating breakfast every day, particularly if they have an older, obese child, Patricia Cluss, Ph.D., said at the at the annual meeting of the Pediatric Academic Societies.

Photo credit: Courtesy National Cancer Institute

In addition, younger children were significantly less likely to eat enough vegetables, according to the survey of 136 parents or guardians of children aged 2-11 years with a body mass index at the 95th percentile or greater for age and sex.

"I’m not sure we would have predicted this: As children got older, they ate more vegetables," Dr. Cluss said.

Most children – 89% – drank sugar-sweetened beverages. "This is probably not a surprise to this audience," Dr. Cluss said.

Counsel all your families with obese children to eliminate or significantly reduce their consumption of sugar-sweetened beverages, Dr. Cluss said.

The total number of meals and snacks eaten per day was another modifiable factor identified in the study. A total of 28% of parents reported their obese child ate five or more meals and snacks per day.

Intake of low-nutrient, high-fat snacks was another modifiable risk factor, according to the study. Half the children snacked "often" or "very often" on chips, cheese puffs, and similar items. "It’s horrifying to see how much of their daily calorie consumption – these are kids in the 99th percentile for BMI – can come from high-calorie snacks with almost no nutrition," said Dr. Cluss, a psychiatrist at the University of Pittsburgh.

Dr. Cluss, lead researcher Linda J. Ewing, Ph.D., and their associates assessed this population because, although approximately 30% of children and adolescents are overweight or obese, minorities and low-income groups are at higher risk.

The cohort of children skewed older (half were aged 9-11 years). In addition, 39% had a BMI in the 99th or greater percentile, "so this is a very obese sample." The majority of caregivers were women (96%) and parents (94%); most of the 6% who were guardians were close relatives. The mean age of the adults was 35 years (range, 22-71 years). A majority were black (75%), 20% were white, and 5% were other race/ethnicities. About 93% of adults had at least a high school diploma.

More than two-thirds (71%) of parents and guardians were obese themselves, "but that was not a requirement for participation," Dr. Cluss said. However, having an obese caregiver significantly increased the chances the child was eating five or more meals/snacks per day.

A meeting attendee asked Dr. Cluss if she recommends no snacks or healthy snacks. "On the surface, eating three meals and two snacks may not be all that bad, depending on how healthy the snack is," she replied.

All families in the study were insured by Medicaid. The majority (79%) lived in households with annual incomes of $25,000 or less, which included 49% with household incomes of $15,000 or less. The relatively lower-income caregivers were significantly more likely to shop for food at a convenience store versus a supermarket, Dr. Cluss said. "This could reflect their preference, but the lower-income sample may be living in areas where a convenience store is the only place they can buy food if they don’t have transportation."

The majority of surveys were completed in a pediatric primary care clinic setting, but a few were done in the child’s home when transportation was an issue, she said.

Overall, 37% of adults in the study said they "almost never" ate together with the child without the television on. However, caregivers and children from households with annual incomes of $15,000 or less were more likely to eat without the television on, which Dr. Cluss called an intriguing finding that warrants further research.

Dr. Cluss said they plan to validate these initial results using food recall data. She said, "I think future food recall data will give us a better picture versus the initial survey data."

Dr. Cluss said she had no relevant financial disclosures.

DENVER – Drinking sugar-sweetened beverages, not eating breakfast, and eating too many low-nutrient, high-fat snacks were among the modifiable risk factors for obesity found in a cross-sectional survey of obese, low-income children.

Remind parents and guardians of the importance of eating breakfast every day, particularly if they have an older, obese child, Patricia Cluss, Ph.D., said at the at the annual meeting of the Pediatric Academic Societies.

Photo credit: Courtesy National Cancer Institute

In addition, younger children were significantly less likely to eat enough vegetables, according to the survey of 136 parents or guardians of children aged 2-11 years with a body mass index at the 95th percentile or greater for age and sex.

"I’m not sure we would have predicted this: As children got older, they ate more vegetables," Dr. Cluss said.

Most children – 89% – drank sugar-sweetened beverages. "This is probably not a surprise to this audience," Dr. Cluss said.

Counsel all your families with obese children to eliminate or significantly reduce their consumption of sugar-sweetened beverages, Dr. Cluss said.

The total number of meals and snacks eaten per day was another modifiable factor identified in the study. A total of 28% of parents reported their obese child ate five or more meals and snacks per day.

Intake of low-nutrient, high-fat snacks was another modifiable risk factor, according to the study. Half the children snacked "often" or "very often" on chips, cheese puffs, and similar items. "It’s horrifying to see how much of their daily calorie consumption – these are kids in the 99th percentile for BMI – can come from high-calorie snacks with almost no nutrition," said Dr. Cluss, a psychiatrist at the University of Pittsburgh.

Dr. Cluss, lead researcher Linda J. Ewing, Ph.D., and their associates assessed this population because, although approximately 30% of children and adolescents are overweight or obese, minorities and low-income groups are at higher risk.

The cohort of children skewed older (half were aged 9-11 years). In addition, 39% had a BMI in the 99th or greater percentile, "so this is a very obese sample." The majority of caregivers were women (96%) and parents (94%); most of the 6% who were guardians were close relatives. The mean age of the adults was 35 years (range, 22-71 years). A majority were black (75%), 20% were white, and 5% were other race/ethnicities. About 93% of adults had at least a high school diploma.

More than two-thirds (71%) of parents and guardians were obese themselves, "but that was not a requirement for participation," Dr. Cluss said. However, having an obese caregiver significantly increased the chances the child was eating five or more meals/snacks per day.

A meeting attendee asked Dr. Cluss if she recommends no snacks or healthy snacks. "On the surface, eating three meals and two snacks may not be all that bad, depending on how healthy the snack is," she replied.

All families in the study were insured by Medicaid. The majority (79%) lived in households with annual incomes of $25,000 or less, which included 49% with household incomes of $15,000 or less. The relatively lower-income caregivers were significantly more likely to shop for food at a convenience store versus a supermarket, Dr. Cluss said. "This could reflect their preference, but the lower-income sample may be living in areas where a convenience store is the only place they can buy food if they don’t have transportation."

The majority of surveys were completed in a pediatric primary care clinic setting, but a few were done in the child’s home when transportation was an issue, she said.

Overall, 37% of adults in the study said they "almost never" ate together with the child without the television on. However, caregivers and children from households with annual incomes of $15,000 or less were more likely to eat without the television on, which Dr. Cluss called an intriguing finding that warrants further research.

Dr. Cluss said they plan to validate these initial results using food recall data. She said, "I think future food recall data will give us a better picture versus the initial survey data."

Dr. Cluss said she had no relevant financial disclosures.

DENVER – Drinking sugar-sweetened beverages, not eating breakfast, and eating too many low-nutrient, high-fat snacks were among the modifiable risk factors for obesity found in a cross-sectional survey of obese, low-income children.

Remind parents and guardians of the importance of eating breakfast every day, particularly if they have an older, obese child, Patricia Cluss, Ph.D., said at the at the annual meeting of the Pediatric Academic Societies.

Photo credit: Courtesy National Cancer Institute

In addition, younger children were significantly less likely to eat enough vegetables, according to the survey of 136 parents or guardians of children aged 2-11 years with a body mass index at the 95th percentile or greater for age and sex.

"I’m not sure we would have predicted this: As children got older, they ate more vegetables," Dr. Cluss said.

Most children – 89% – drank sugar-sweetened beverages. "This is probably not a surprise to this audience," Dr. Cluss said.

Counsel all your families with obese children to eliminate or significantly reduce their consumption of sugar-sweetened beverages, Dr. Cluss said.

The total number of meals and snacks eaten per day was another modifiable factor identified in the study. A total of 28% of parents reported their obese child ate five or more meals and snacks per day.

Intake of low-nutrient, high-fat snacks was another modifiable risk factor, according to the study. Half the children snacked "often" or "very often" on chips, cheese puffs, and similar items. "It’s horrifying to see how much of their daily calorie consumption – these are kids in the 99th percentile for BMI – can come from high-calorie snacks with almost no nutrition," said Dr. Cluss, a psychiatrist at the University of Pittsburgh.

Dr. Cluss, lead researcher Linda J. Ewing, Ph.D., and their associates assessed this population because, although approximately 30% of children and adolescents are overweight or obese, minorities and low-income groups are at higher risk.

The cohort of children skewed older (half were aged 9-11 years). In addition, 39% had a BMI in the 99th or greater percentile, "so this is a very obese sample." The majority of caregivers were women (96%) and parents (94%); most of the 6% who were guardians were close relatives. The mean age of the adults was 35 years (range, 22-71 years). A majority were black (75%), 20% were white, and 5% were other race/ethnicities. About 93% of adults had at least a high school diploma.

More than two-thirds (71%) of parents and guardians were obese themselves, "but that was not a requirement for participation," Dr. Cluss said. However, having an obese caregiver significantly increased the chances the child was eating five or more meals/snacks per day.

A meeting attendee asked Dr. Cluss if she recommends no snacks or healthy snacks. "On the surface, eating three meals and two snacks may not be all that bad, depending on how healthy the snack is," she replied.

All families in the study were insured by Medicaid. The majority (79%) lived in households with annual incomes of $25,000 or less, which included 49% with household incomes of $15,000 or less. The relatively lower-income caregivers were significantly more likely to shop for food at a convenience store versus a supermarket, Dr. Cluss said. "This could reflect their preference, but the lower-income sample may be living in areas where a convenience store is the only place they can buy food if they don’t have transportation."

The majority of surveys were completed in a pediatric primary care clinic setting, but a few were done in the child’s home when transportation was an issue, she said.

Overall, 37% of adults in the study said they "almost never" ate together with the child without the television on. However, caregivers and children from households with annual incomes of $15,000 or less were more likely to eat without the television on, which Dr. Cluss called an intriguing finding that warrants further research.

Dr. Cluss said they plan to validate these initial results using food recall data. She said, "I think future food recall data will give us a better picture versus the initial survey data."

Dr. Cluss said she had no relevant financial disclosures.

HONOLULU – About 8% of U.S. veterans are problem gamblers who report between one and four gambling-related problems, and an additional 2% are pathological gamblers with five or more such problems, a study of 2,185 veterans in Department of Veterans Affairs care reveals.

Age, education level, and ethnicity were not big predictors of pathological gambling risk. "The one that does show a lot of difference is unemployment [odds ratio, 1.85], which is not necessarily what you expect. People need money to gamble, and they need a lot of money," Dr. Joseph J. Westermeyer IV said at the annual meeting of the American Psychiatric Association. The unemployed in the study, however, included part-time and seasonal workers who had some access to money, he said, and others were "homebodies" (typically unemployed men who were married to women with jobs).

(c) Tom Lozano/Creative Commons License

Marital status emerged as an important variable in a binary analysis, with unemployment remaining significant (OR, 1.41). "The folks who were divorced, separated, widowed, or single were underrepresented [OR, 0.69], so folks who were married were more likely to be in the problem and pathological gambling group. Again, this is not necessarily what you would expect," said Dr. Westermeyer, who is director of the mental health service at the Minneapolis VA Medical Center and professor of psychiatry at the University of Minnesota.

"Interestingly, male veterans and female veterans had almost identical rates of both problem gambling and pathological gambling, which is not – so far – what you see in the general population." Men usually outnumber women by a factor of two to three or more, Dr. Westermeyer said. It might be that the military exposes more women to gambling. "Some of the women we talked to say, ‘We hang around with the guys when we have time off. We don’t go to different places. We go to the same bars, and if they go gambling, we go gambling with them.’ "

The study included only veterans who were treated at least once in the previous 2 years at a VA facility. This design was intentional, so that any demographic or other risk factor that was identified would be relevant when incorporated into a future screening instrument.

Another aim was to identify comorbid symptoms "so primary care, as well as psychiatry, can begin to be alert to what might be associated with pathological gambling," Dr. Westermeyer said.

The veterans completed the SCL-90 (the 90-item Symptom Checklist instrument) and the PCL (PTSD [Posttraumatic Stress Disorder] Checklist). Their responses were directly and highly correlated with DSM-IV criteria and the South Oaks Gambling Screen. "In other words, people who have more posttraumatic symptoms, anxiety, and depression tend to have more gambling problems," Dr. Westermeyer said.

Participants also completed the AUDIT (Alcohol Use Disorders Identification Test) and the MAST (Michigan Alcohol Screening Test). The AUDIT addresses recent alcohol use and the MAST is a lifetime alcohol use measure, which was adapted to include drug use. Again, correlations were high. But in this study, people with more alcohol and drug problems tended to have fewer gambling problems, according to Dr. Westermeyer, which is contrary to other research that shows more substance problems associated with more gambling problems.

"All these findings tend to be a tad atypical," Dr. Westermeyer said.

The data were assessed in two different ways to reflect the current prevalence and to predict the future prevalence of problem and pathological gambling. For example, data were weighted to reflect the typical older male population that is seen at most VA centers today. Raw data included an oversampling of women (to bring the 7% in weighted data up to 35%) as well as younger veterans from the Iraq and Afghanistan conflicts (to reflect the way the VA population is likely to appear in a decade or two).

The weighted data show that veterans have about twice the rate of problem gambling as does the general population. The raw data suggest a greater disparity in the future, with a rate 2.7 times that of the general population.

The other worrisome thing about the future is the ratio of problem gamblers to pathological gamblers, Dr. Westermeyer said. General population surveys show a 1:1 ratio of problem gambling to pathological gambling among people who are exposed to gambling for a decade or more, and up to 2:1 with more recent exposure. "It’s worrisome with the veterans. The ratio is ... like four or five problem gamblers to one pathological gambler. The problem gamblers are the people at risk to become pathological gamblers ... which does not bode well for the future."

"Veterans in VA care have a high rate" of pathological gambling, he added.

All 10 DSM-IV gambling symptoms were assessed in the study. The sixth criteria (characterized in the DSM-IV as "chasing one’s losses") was the most common symptom, endorsed by 6.3% of participants with problem or pathological gambling. Tolerance was next at 5.1%, followed by escape gambling at 5.1%. The eighth criteria, which refers to committing illegal acts such as writing bad checks and committing property crimes, was the least commonly reported symptom, at just over 1%.

Another unexpected finding was a propensity for younger veterans to have higher scores on the South Oaks Gambling Screen for pathological gambling. "Most surveys that include people in their 20s rarely find a high prevalence [of pathological gambling], so ours was not a typical finding," said Dr. Westermeyer. Those who show up on the survey data tend to be people aged 35 years and older, he noted.

Participants were paid $20 to complete 2 hours of computer-based data collection; a research assistant was on hand to answer any questions. Participants were recruited at two VA medical centers and 14 rural community-based outpatient clinics.

This was a clinical epidemiologic study and not community-based research, a potential limitation.

Unanswered questions remain, Dr. Westermeyer said. Do these high rates among veterans in VA care reflect rates among all veterans? Also, would it be possible to identify earlier cases through screening?

The study was funded by VA Health Services Research & Development. Dr. Westermeyer said he had no relevant disclosures.

HONOLULU – About 8% of U.S. veterans are problem gamblers who report between one and four gambling-related problems, and an additional 2% are pathological gamblers with five or more such problems, a study of 2,185 veterans in Department of Veterans Affairs care reveals.

Age, education level, and ethnicity were not big predictors of pathological gambling risk. "The one that does show a lot of difference is unemployment [odds ratio, 1.85], which is not necessarily what you expect. People need money to gamble, and they need a lot of money," Dr. Joseph J. Westermeyer IV said at the annual meeting of the American Psychiatric Association. The unemployed in the study, however, included part-time and seasonal workers who had some access to money, he said, and others were "homebodies" (typically unemployed men who were married to women with jobs).

(c) Tom Lozano/Creative Commons License

Marital status emerged as an important variable in a binary analysis, with unemployment remaining significant (OR, 1.41). "The folks who were divorced, separated, widowed, or single were underrepresented [OR, 0.69], so folks who were married were more likely to be in the problem and pathological gambling group. Again, this is not necessarily what you would expect," said Dr. Westermeyer, who is director of the mental health service at the Minneapolis VA Medical Center and professor of psychiatry at the University of Minnesota.

"Interestingly, male veterans and female veterans had almost identical rates of both problem gambling and pathological gambling, which is not – so far – what you see in the general population." Men usually outnumber women by a factor of two to three or more, Dr. Westermeyer said. It might be that the military exposes more women to gambling. "Some of the women we talked to say, ‘We hang around with the guys when we have time off. We don’t go to different places. We go to the same bars, and if they go gambling, we go gambling with them.’ "

The study included only veterans who were treated at least once in the previous 2 years at a VA facility. This design was intentional, so that any demographic or other risk factor that was identified would be relevant when incorporated into a future screening instrument.

Another aim was to identify comorbid symptoms "so primary care, as well as psychiatry, can begin to be alert to what might be associated with pathological gambling," Dr. Westermeyer said.

The veterans completed the SCL-90 (the 90-item Symptom Checklist instrument) and the PCL (PTSD [Posttraumatic Stress Disorder] Checklist). Their responses were directly and highly correlated with DSM-IV criteria and the South Oaks Gambling Screen. "In other words, people who have more posttraumatic symptoms, anxiety, and depression tend to have more gambling problems," Dr. Westermeyer said.

Participants also completed the AUDIT (Alcohol Use Disorders Identification Test) and the MAST (Michigan Alcohol Screening Test). The AUDIT addresses recent alcohol use and the MAST is a lifetime alcohol use measure, which was adapted to include drug use. Again, correlations were high. But in this study, people with more alcohol and drug problems tended to have fewer gambling problems, according to Dr. Westermeyer, which is contrary to other research that shows more substance problems associated with more gambling problems.

"All these findings tend to be a tad atypical," Dr. Westermeyer said.

The data were assessed in two different ways to reflect the current prevalence and to predict the future prevalence of problem and pathological gambling. For example, data were weighted to reflect the typical older male population that is seen at most VA centers today. Raw data included an oversampling of women (to bring the 7% in weighted data up to 35%) as well as younger veterans from the Iraq and Afghanistan conflicts (to reflect the way the VA population is likely to appear in a decade or two).

The weighted data show that veterans have about twice the rate of problem gambling as does the general population. The raw data suggest a greater disparity in the future, with a rate 2.7 times that of the general population.

The other worrisome thing about the future is the ratio of problem gamblers to pathological gamblers, Dr. Westermeyer said. General population surveys show a 1:1 ratio of problem gambling to pathological gambling among people who are exposed to gambling for a decade or more, and up to 2:1 with more recent exposure. "It’s worrisome with the veterans. The ratio is ... like four or five problem gamblers to one pathological gambler. The problem gamblers are the people at risk to become pathological gamblers ... which does not bode well for the future."

"Veterans in VA care have a high rate" of pathological gambling, he added.

All 10 DSM-IV gambling symptoms were assessed in the study. The sixth criteria (characterized in the DSM-IV as "chasing one’s losses") was the most common symptom, endorsed by 6.3% of participants with problem or pathological gambling. Tolerance was next at 5.1%, followed by escape gambling at 5.1%. The eighth criteria, which refers to committing illegal acts such as writing bad checks and committing property crimes, was the least commonly reported symptom, at just over 1%.

Another unexpected finding was a propensity for younger veterans to have higher scores on the South Oaks Gambling Screen for pathological gambling. "Most surveys that include people in their 20s rarely find a high prevalence [of pathological gambling], so ours was not a typical finding," said Dr. Westermeyer. Those who show up on the survey data tend to be people aged 35 years and older, he noted.

Participants were paid $20 to complete 2 hours of computer-based data collection; a research assistant was on hand to answer any questions. Participants were recruited at two VA medical centers and 14 rural community-based outpatient clinics.

This was a clinical epidemiologic study and not community-based research, a potential limitation.

Unanswered questions remain, Dr. Westermeyer said. Do these high rates among veterans in VA care reflect rates among all veterans? Also, would it be possible to identify earlier cases through screening?

The study was funded by VA Health Services Research & Development. Dr. Westermeyer said he had no relevant disclosures.

HONOLULU – About 8% of U.S. veterans are problem gamblers who report between one and four gambling-related problems, and an additional 2% are pathological gamblers with five or more such problems, a study of 2,185 veterans in Department of Veterans Affairs care reveals.

Age, education level, and ethnicity were not big predictors of pathological gambling risk. "The one that does show a lot of difference is unemployment [odds ratio, 1.85], which is not necessarily what you expect. People need money to gamble, and they need a lot of money," Dr. Joseph J. Westermeyer IV said at the annual meeting of the American Psychiatric Association. The unemployed in the study, however, included part-time and seasonal workers who had some access to money, he said, and others were "homebodies" (typically unemployed men who were married to women with jobs).

(c) Tom Lozano/Creative Commons License

Marital status emerged as an important variable in a binary analysis, with unemployment remaining significant (OR, 1.41). "The folks who were divorced, separated, widowed, or single were underrepresented [OR, 0.69], so folks who were married were more likely to be in the problem and pathological gambling group. Again, this is not necessarily what you would expect," said Dr. Westermeyer, who is director of the mental health service at the Minneapolis VA Medical Center and professor of psychiatry at the University of Minnesota.

"Interestingly, male veterans and female veterans had almost identical rates of both problem gambling and pathological gambling, which is not – so far – what you see in the general population." Men usually outnumber women by a factor of two to three or more, Dr. Westermeyer said. It might be that the military exposes more women to gambling. "Some of the women we talked to say, ‘We hang around with the guys when we have time off. We don’t go to different places. We go to the same bars, and if they go gambling, we go gambling with them.’ "

The study included only veterans who were treated at least once in the previous 2 years at a VA facility. This design was intentional, so that any demographic or other risk factor that was identified would be relevant when incorporated into a future screening instrument.

Another aim was to identify comorbid symptoms "so primary care, as well as psychiatry, can begin to be alert to what might be associated with pathological gambling," Dr. Westermeyer said.

The veterans completed the SCL-90 (the 90-item Symptom Checklist instrument) and the PCL (PTSD [Posttraumatic Stress Disorder] Checklist). Their responses were directly and highly correlated with DSM-IV criteria and the South Oaks Gambling Screen. "In other words, people who have more posttraumatic symptoms, anxiety, and depression tend to have more gambling problems," Dr. Westermeyer said.

Participants also completed the AUDIT (Alcohol Use Disorders Identification Test) and the MAST (Michigan Alcohol Screening Test). The AUDIT addresses recent alcohol use and the MAST is a lifetime alcohol use measure, which was adapted to include drug use. Again, correlations were high. But in this study, people with more alcohol and drug problems tended to have fewer gambling problems, according to Dr. Westermeyer, which is contrary to other research that shows more substance problems associated with more gambling problems.

"All these findings tend to be a tad atypical," Dr. Westermeyer said.

The data were assessed in two different ways to reflect the current prevalence and to predict the future prevalence of problem and pathological gambling. For example, data were weighted to reflect the typical older male population that is seen at most VA centers today. Raw data included an oversampling of women (to bring the 7% in weighted data up to 35%) as well as younger veterans from the Iraq and Afghanistan conflicts (to reflect the way the VA population is likely to appear in a decade or two).

The weighted data show that veterans have about twice the rate of problem gambling as does the general population. The raw data suggest a greater disparity in the future, with a rate 2.7 times that of the general population.

The other worrisome thing about the future is the ratio of problem gamblers to pathological gamblers, Dr. Westermeyer said. General population surveys show a 1:1 ratio of problem gambling to pathological gambling among people who are exposed to gambling for a decade or more, and up to 2:1 with more recent exposure. "It’s worrisome with the veterans. The ratio is ... like four or five problem gamblers to one pathological gambler. The problem gamblers are the people at risk to become pathological gamblers ... which does not bode well for the future."

"Veterans in VA care have a high rate" of pathological gambling, he added.

All 10 DSM-IV gambling symptoms were assessed in the study. The sixth criteria (characterized in the DSM-IV as "chasing one’s losses") was the most common symptom, endorsed by 6.3% of participants with problem or pathological gambling. Tolerance was next at 5.1%, followed by escape gambling at 5.1%. The eighth criteria, which refers to committing illegal acts such as writing bad checks and committing property crimes, was the least commonly reported symptom, at just over 1%.

Another unexpected finding was a propensity for younger veterans to have higher scores on the South Oaks Gambling Screen for pathological gambling. "Most surveys that include people in their 20s rarely find a high prevalence [of pathological gambling], so ours was not a typical finding," said Dr. Westermeyer. Those who show up on the survey data tend to be people aged 35 years and older, he noted.

Participants were paid $20 to complete 2 hours of computer-based data collection; a research assistant was on hand to answer any questions. Participants were recruited at two VA medical centers and 14 rural community-based outpatient clinics.

This was a clinical epidemiologic study and not community-based research, a potential limitation.

Unanswered questions remain, Dr. Westermeyer said. Do these high rates among veterans in VA care reflect rates among all veterans? Also, would it be possible to identify earlier cases through screening?

The study was funded by VA Health Services Research & Development. Dr. Westermeyer said he had no relevant disclosures.

HONOLULU – About 8% of U.S. veterans are problem gamblers who report between one and four gambling-related problems, and an additional 2% are pathological gamblers with five or more such problems, a study of 2,185 veterans in Department of Veterans Affairs care reveals.

Age, education level, and ethnicity were not big predictors of pathological gambling risk. "The one that does show a lot of difference is unemployment [odds ratio, 1.85], which is not necessarily what you expect. People need money to gamble, and they need a lot of money," Dr. Joseph J. Westermeyer IV said at the annual meeting of the American Psychiatric Association. The unemployed in the study, however, included part-time and seasonal workers who had some access to money, he said, and others were "homebodies" (typically unemployed men who were married to women with jobs).

(c) Tom Lozano/Creative Commons License

Marital status emerged as an important variable in a binary analysis, with unemployment remaining significant (OR, 1.41). "The folks who were divorced, separated, widowed, or single were underrepresented [OR, 0.69], so folks who were married were more likely to be in the problem and pathological gambling group. Again, this is not necessarily what you would expect," said Dr. Westermeyer, who is director of the mental health service at the Minneapolis VA Medical Center and professor of psychiatry at the University of Minnesota.

"Interestingly, male veterans and female veterans had almost identical rates of both problem gambling and pathological gambling, which is not – so far – what you see in the general population." Men usually outnumber women by a factor of two to three or more, Dr. Westermeyer said. It might be that the military exposes more women to gambling. "Some of the women we talked to say, ‘We hang around with the guys when we have time off. We don’t go to different places. We go to the same bars, and if they go gambling, we go gambling with them.’ "

The study included only veterans who were treated at least once in the previous 2 years at a VA facility. This design was intentional, so that any demographic or other risk factor that was identified would be relevant when incorporated into a future screening instrument.

Another aim was to identify comorbid symptoms "so primary care, as well as psychiatry, can begin to be alert to what might be associated with pathological gambling," Dr. Westermeyer said.

The veterans completed the SCL-90 (the 90-item Symptom Checklist instrument) and the PCL (PTSD [Posttraumatic Stress Disorder] Checklist). Their responses were directly and highly correlated with DSM-IV criteria and the South Oaks Gambling Screen. "In other words, people who have more posttraumatic symptoms, anxiety, and depression tend to have more gambling problems," Dr. Westermeyer said.

Participants also completed the AUDIT (Alcohol Use Disorders Identification Test) and the MAST (Michigan Alcohol Screening Test). The AUDIT addresses recent alcohol use and the MAST is a lifetime alcohol use measure, which was adapted to include drug use. Again, correlations were high. But in this study, people with more alcohol and drug problems tended to have fewer gambling problems, according to Dr. Westermeyer, which is contrary to other research that shows more substance problems associated with more gambling problems.

"All these findings tend to be a tad atypical," Dr. Westermeyer said.

The data were assessed in two different ways to reflect the current prevalence and to predict the future prevalence of problem and pathological gambling. For example, data were weighted to reflect the typical older male population that is seen at most VA centers today. Raw data included an oversampling of women (to bring the 7% in weighted data up to 35%) as well as younger veterans from the Iraq and Afghanistan conflicts (to reflect the way the VA population is likely to appear in a decade or two).

The weighted data show that veterans have about twice the rate of problem gambling as does the general population. The raw data suggest a greater disparity in the future, with a rate 2.7 times that of the general population.

The other worrisome thing about the future is the ratio of problem gamblers to pathological gamblers, Dr. Westermeyer said. General population surveys show a 1:1 ratio of problem gambling to pathological gambling among people who are exposed to gambling for a decade or more, and up to 2:1 with more recent exposure. "It’s worrisome with the veterans. The ratio is ... like four or five problem gamblers to one pathological gambler. The problem gamblers are the people at risk to become pathological gamblers ... which does not bode well for the future."

"Veterans in VA care have a high rate" of pathological gambling, he added.

All 10 DSM-IV gambling symptoms were assessed in the study. The sixth criteria (characterized in the DSM-IV as "chasing one’s losses") was the most common symptom, endorsed by 6.3% of participants with problem or pathological gambling. Tolerance was next at 5.1%, followed by escape gambling at 5.1%. The eighth criteria, which refers to committing illegal acts such as writing bad checks and committing property crimes, was the least commonly reported symptom, at just over 1%.

Another unexpected finding was a propensity for younger veterans to have higher scores on the South Oaks Gambling Screen for pathological gambling. "Most surveys that include people in their 20s rarely find a high prevalence [of pathological gambling], so ours was not a typical finding," said Dr. Westermeyer. Those who show up on the survey data tend to be people aged 35 years and older, he noted.

Participants were paid $20 to complete 2 hours of computer-based data collection; a research assistant was on hand to answer any questions. Participants were recruited at two VA medical centers and 14 rural community-based outpatient clinics.

This was a clinical epidemiologic study and not community-based research, a potential limitation.

Unanswered questions remain, Dr. Westermeyer said. Do these high rates among veterans in VA care reflect rates among all veterans? Also, would it be possible to identify earlier cases through screening?

The study was funded by VA Health Services Research & Development. Dr. Westermeyer said he had no relevant disclosures.

HONOLULU – About 8% of U.S. veterans are problem gamblers who report between one and four gambling-related problems, and an additional 2% are pathological gamblers with five or more such problems, a study of 2,185 veterans in Department of Veterans Affairs care reveals.

Age, education level, and ethnicity were not big predictors of pathological gambling risk. "The one that does show a lot of difference is unemployment [odds ratio, 1.85], which is not necessarily what you expect. People need money to gamble, and they need a lot of money," Dr. Joseph J. Westermeyer IV said at the annual meeting of the American Psychiatric Association. The unemployed in the study, however, included part-time and seasonal workers who had some access to money, he said, and others were "homebodies" (typically unemployed men who were married to women with jobs).

(c) Tom Lozano/Creative Commons License

Marital status emerged as an important variable in a binary analysis, with unemployment remaining significant (OR, 1.41). "The folks who were divorced, separated, widowed, or single were underrepresented [OR, 0.69], so folks who were married were more likely to be in the problem and pathological gambling group. Again, this is not necessarily what you would expect," said Dr. Westermeyer, who is director of the mental health service at the Minneapolis VA Medical Center and professor of psychiatry at the University of Minnesota.

"Interestingly, male veterans and female veterans had almost identical rates of both problem gambling and pathological gambling, which is not – so far – what you see in the general population." Men usually outnumber women by a factor of two to three or more, Dr. Westermeyer said. It might be that the military exposes more women to gambling. "Some of the women we talked to say, ‘We hang around with the guys when we have time off. We don’t go to different places. We go to the same bars, and if they go gambling, we go gambling with them.’ "

The study included only veterans who were treated at least once in the previous 2 years at a VA facility. This design was intentional, so that any demographic or other risk factor that was identified would be relevant when incorporated into a future screening instrument.

Another aim was to identify comorbid symptoms "so primary care, as well as psychiatry, can begin to be alert to what might be associated with pathological gambling," Dr. Westermeyer said.

The veterans completed the SCL-90 (the 90-item Symptom Checklist instrument) and the PCL (PTSD [Posttraumatic Stress Disorder] Checklist). Their responses were directly and highly correlated with DSM-IV criteria and the South Oaks Gambling Screen. "In other words, people who have more posttraumatic symptoms, anxiety, and depression tend to have more gambling problems," Dr. Westermeyer said.

Participants also completed the AUDIT (Alcohol Use Disorders Identification Test) and the MAST (Michigan Alcohol Screening Test). The AUDIT addresses recent alcohol use and the MAST is a lifetime alcohol use measure, which was adapted to include drug use. Again, correlations were high. But in this study, people with more alcohol and drug problems tended to have fewer gambling problems, according to Dr. Westermeyer, which is contrary to other research that shows more substance problems associated with more gambling problems.

"All these findings tend to be a tad atypical," Dr. Westermeyer said.

The data were assessed in two different ways to reflect the current prevalence and to predict the future prevalence of problem and pathological gambling. For example, data were weighted to reflect the typical older male population that is seen at most VA centers today. Raw data included an oversampling of women (to bring the 7% in weighted data up to 35%) as well as younger veterans from the Iraq and Afghanistan conflicts (to reflect the way the VA population is likely to appear in a decade or two).

The weighted data show that veterans have about twice the rate of problem gambling as does the general population. The raw data suggest a greater disparity in the future, with a rate 2.7 times that of the general population.

The other worrisome thing about the future is the ratio of problem gamblers to pathological gamblers, Dr. Westermeyer said. General population surveys show a 1:1 ratio of problem gambling to pathological gambling among people who are exposed to gambling for a decade or more, and up to 2:1 with more recent exposure. "It’s worrisome with the veterans. The ratio is ... like four or five problem gamblers to one pathological gambler. The problem gamblers are the people at risk to become pathological gamblers ... which does not bode well for the future."

"Veterans in VA care have a high rate" of pathological gambling, he added.

All 10 DSM-IV gambling symptoms were assessed in the study. The sixth criteria (characterized in the DSM-IV as "chasing one’s losses") was the most common symptom, endorsed by 6.3% of participants with problem or pathological gambling. Tolerance was next at 5.1%, followed by escape gambling at 5.1%. The eighth criteria, which refers to committing illegal acts such as writing bad checks and committing property crimes, was the least commonly reported symptom, at just over 1%.

Another unexpected finding was a propensity for younger veterans to have higher scores on the South Oaks Gambling Screen for pathological gambling. "Most surveys that include people in their 20s rarely find a high prevalence [of pathological gambling], so ours was not a typical finding," said Dr. Westermeyer. Those who show up on the survey data tend to be people aged 35 years and older, he noted.

Participants were paid $20 to complete 2 hours of computer-based data collection; a research assistant was on hand to answer any questions. Participants were recruited at two VA medical centers and 14 rural community-based outpatient clinics.

This was a clinical epidemiologic study and not community-based research, a potential limitation.

Unanswered questions remain, Dr. Westermeyer said. Do these high rates among veterans in VA care reflect rates among all veterans? Also, would it be possible to identify earlier cases through screening?

The study was funded by VA Health Services Research & Development. Dr. Westermeyer said he had no relevant disclosures.

HONOLULU – About 8% of U.S. veterans are problem gamblers who report between one and four gambling-related problems, and an additional 2% are pathological gamblers with five or more such problems, a study of 2,185 veterans in Department of Veterans Affairs care reveals.

Age, education level, and ethnicity were not big predictors of pathological gambling risk. "The one that does show a lot of difference is unemployment [odds ratio, 1.85], which is not necessarily what you expect. People need money to gamble, and they need a lot of money," Dr. Joseph J. Westermeyer IV said at the annual meeting of the American Psychiatric Association. The unemployed in the study, however, included part-time and seasonal workers who had some access to money, he said, and others were "homebodies" (typically unemployed men who were married to women with jobs).

(c) Tom Lozano/Creative Commons License

Marital status emerged as an important variable in a binary analysis, with unemployment remaining significant (OR, 1.41). "The folks who were divorced, separated, widowed, or single were underrepresented [OR, 0.69], so folks who were married were more likely to be in the problem and pathological gambling group. Again, this is not necessarily what you would expect," said Dr. Westermeyer, who is director of the mental health service at the Minneapolis VA Medical Center and professor of psychiatry at the University of Minnesota.

"Interestingly, male veterans and female veterans had almost identical rates of both problem gambling and pathological gambling, which is not – so far – what you see in the general population." Men usually outnumber women by a factor of two to three or more, Dr. Westermeyer said. It might be that the military exposes more women to gambling. "Some of the women we talked to say, ‘We hang around with the guys when we have time off. We don’t go to different places. We go to the same bars, and if they go gambling, we go gambling with them.’ "

The study included only veterans who were treated at least once in the previous 2 years at a VA facility. This design was intentional, so that any demographic or other risk factor that was identified would be relevant when incorporated into a future screening instrument.

Another aim was to identify comorbid symptoms "so primary care, as well as psychiatry, can begin to be alert to what might be associated with pathological gambling," Dr. Westermeyer said.

The veterans completed the SCL-90 (the 90-item Symptom Checklist instrument) and the PCL (PTSD [Posttraumatic Stress Disorder] Checklist). Their responses were directly and highly correlated with DSM-IV criteria and the South Oaks Gambling Screen. "In other words, people who have more posttraumatic symptoms, anxiety, and depression tend to have more gambling problems," Dr. Westermeyer said.

Participants also completed the AUDIT (Alcohol Use Disorders Identification Test) and the MAST (Michigan Alcohol Screening Test). The AUDIT addresses recent alcohol use and the MAST is a lifetime alcohol use measure, which was adapted to include drug use. Again, correlations were high. But in this study, people with more alcohol and drug problems tended to have fewer gambling problems, according to Dr. Westermeyer, which is contrary to other research that shows more substance problems associated with more gambling problems.

"All these findings tend to be a tad atypical," Dr. Westermeyer said.

The data were assessed in two different ways to reflect the current prevalence and to predict the future prevalence of problem and pathological gambling. For example, data were weighted to reflect the typical older male population that is seen at most VA centers today. Raw data included an oversampling of women (to bring the 7% in weighted data up to 35%) as well as younger veterans from the Iraq and Afghanistan conflicts (to reflect the way the VA population is likely to appear in a decade or two).

The weighted data show that veterans have about twice the rate of problem gambling as does the general population. The raw data suggest a greater disparity in the future, with a rate 2.7 times that of the general population.

The other worrisome thing about the future is the ratio of problem gamblers to pathological gamblers, Dr. Westermeyer said. General population surveys show a 1:1 ratio of problem gambling to pathological gambling among people who are exposed to gambling for a decade or more, and up to 2:1 with more recent exposure. "It’s worrisome with the veterans. The ratio is ... like four or five problem gamblers to one pathological gambler. The problem gamblers are the people at risk to become pathological gamblers ... which does not bode well for the future."

"Veterans in VA care have a high rate" of pathological gambling, he added.

All 10 DSM-IV gambling symptoms were assessed in the study. The sixth criteria (characterized in the DSM-IV as "chasing one’s losses") was the most common symptom, endorsed by 6.3% of participants with problem or pathological gambling. Tolerance was next at 5.1%, followed by escape gambling at 5.1%. The eighth criteria, which refers to committing illegal acts such as writing bad checks and committing property crimes, was the least commonly reported symptom, at just over 1%.

Another unexpected finding was a propensity for younger veterans to have higher scores on the South Oaks Gambling Screen for pathological gambling. "Most surveys that include people in their 20s rarely find a high prevalence [of pathological gambling], so ours was not a typical finding," said Dr. Westermeyer. Those who show up on the survey data tend to be people aged 35 years and older, he noted.

Participants were paid $20 to complete 2 hours of computer-based data collection; a research assistant was on hand to answer any questions. Participants were recruited at two VA medical centers and 14 rural community-based outpatient clinics.

This was a clinical epidemiologic study and not community-based research, a potential limitation.

Unanswered questions remain, Dr. Westermeyer said. Do these high rates among veterans in VA care reflect rates among all veterans? Also, would it be possible to identify earlier cases through screening?

The study was funded by VA Health Services Research & Development. Dr. Westermeyer said he had no relevant disclosures.

HONOLULU – About 8% of U.S. veterans are problem gamblers who report between one and four gambling-related problems, and an additional 2% are pathological gamblers with five or more such problems, a study of 2,185 veterans in Department of Veterans Affairs care reveals.

Age, education level, and ethnicity were not big predictors of pathological gambling risk. "The one that does show a lot of difference is unemployment [odds ratio, 1.85], which is not necessarily what you expect. People need money to gamble, and they need a lot of money," Dr. Joseph J. Westermeyer IV said at the annual meeting of the American Psychiatric Association. The unemployed in the study, however, included part-time and seasonal workers who had some access to money, he said, and others were "homebodies" (typically unemployed men who were married to women with jobs).

(c) Tom Lozano/Creative Commons License

Marital status emerged as an important variable in a binary analysis, with unemployment remaining significant (OR, 1.41). "The folks who were divorced, separated, widowed, or single were underrepresented [OR, 0.69], so folks who were married were more likely to be in the problem and pathological gambling group. Again, this is not necessarily what you would expect," said Dr. Westermeyer, who is director of the mental health service at the Minneapolis VA Medical Center and professor of psychiatry at the University of Minnesota.

"Interestingly, male veterans and female veterans had almost identical rates of both problem gambling and pathological gambling, which is not – so far – what you see in the general population." Men usually outnumber women by a factor of two to three or more, Dr. Westermeyer said. It might be that the military exposes more women to gambling. "Some of the women we talked to say, ‘We hang around with the guys when we have time off. We don’t go to different places. We go to the same bars, and if they go gambling, we go gambling with them.’ "

The study included only veterans who were treated at least once in the previous 2 years at a VA facility. This design was intentional, so that any demographic or other risk factor that was identified would be relevant when incorporated into a future screening instrument.

Another aim was to identify comorbid symptoms "so primary care, as well as psychiatry, can begin to be alert to what might be associated with pathological gambling," Dr. Westermeyer said.

The veterans completed the SCL-90 (the 90-item Symptom Checklist instrument) and the PCL (PTSD [Posttraumatic Stress Disorder] Checklist). Their responses were directly and highly correlated with DSM-IV criteria and the South Oaks Gambling Screen. "In other words, people who have more posttraumatic symptoms, anxiety, and depression tend to have more gambling problems," Dr. Westermeyer said.

Participants also completed the AUDIT (Alcohol Use Disorders Identification Test) and the MAST (Michigan Alcohol Screening Test). The AUDIT addresses recent alcohol use and the MAST is a lifetime alcohol use measure, which was adapted to include drug use. Again, correlations were high. But in this study, people with more alcohol and drug problems tended to have fewer gambling problems, according to Dr. Westermeyer, which is contrary to other research that shows more substance problems associated with more gambling problems.

"All these findings tend to be a tad atypical," Dr. Westermeyer said.

The data were assessed in two different ways to reflect the current prevalence and to predict the future prevalence of problem and pathological gambling. For example, data were weighted to reflect the typical older male population that is seen at most VA centers today. Raw data included an oversampling of women (to bring the 7% in weighted data up to 35%) as well as younger veterans from the Iraq and Afghanistan conflicts (to reflect the way the VA population is likely to appear in a decade or two).

The weighted data show that veterans have about twice the rate of problem gambling as does the general population. The raw data suggest a greater disparity in the future, with a rate 2.7 times that of the general population.

The other worrisome thing about the future is the ratio of problem gamblers to pathological gamblers, Dr. Westermeyer said. General population surveys show a 1:1 ratio of problem gambling to pathological gambling among people who are exposed to gambling for a decade or more, and up to 2:1 with more recent exposure. "It’s worrisome with the veterans. The ratio is ... like four or five problem gamblers to one pathological gambler. The problem gamblers are the people at risk to become pathological gamblers ... which does not bode well for the future."

"Veterans in VA care have a high rate" of pathological gambling, he added.

All 10 DSM-IV gambling symptoms were assessed in the study. The sixth criteria (characterized in the DSM-IV as "chasing one’s losses") was the most common symptom, endorsed by 6.3% of participants with problem or pathological gambling. Tolerance was next at 5.1%, followed by escape gambling at 5.1%. The eighth criteria, which refers to committing illegal acts such as writing bad checks and committing property crimes, was the least commonly reported symptom, at just over 1%.

Another unexpected finding was a propensity for younger veterans to have higher scores on the South Oaks Gambling Screen for pathological gambling. "Most surveys that include people in their 20s rarely find a high prevalence [of pathological gambling], so ours was not a typical finding," said Dr. Westermeyer. Those who show up on the survey data tend to be people aged 35 years and older, he noted.

Participants were paid $20 to complete 2 hours of computer-based data collection; a research assistant was on hand to answer any questions. Participants were recruited at two VA medical centers and 14 rural community-based outpatient clinics.

This was a clinical epidemiologic study and not community-based research, a potential limitation.

Unanswered questions remain, Dr. Westermeyer said. Do these high rates among veterans in VA care reflect rates among all veterans? Also, would it be possible to identify earlier cases through screening?

The study was funded by VA Health Services Research & Development. Dr. Westermeyer said he had no relevant disclosures.

To listen to an HHS Healthbeat broadcast about gambling, press play here.

HONOLULU – About 8% of U.S. veterans are problem gamblers who report between one and four gambling-related problems, and an additional 2% are pathological gamblers with five or more such problems, a study of 2,185 veterans in Department of Veterans Affairs care reveals.

Age, education level, and ethnicity were not big predictors of pathological gambling risk. "The one that does show a lot of difference is unemployment [odds ratio, 1.85], which is not necessarily what you expect. People need money to gamble, and they need a lot of money," Dr. Joseph J. Westermeyer IV said at the annual meeting of the American Psychiatric Association. The unemployed in the study, however, included part-time and seasonal workers who had some access to money, he said, and others were "homebodies" (typically unemployed men who were married to women with jobs).

(c) Tom Lozano/Creative Commons License

Marital status emerged as an important variable in a binary analysis, with unemployment remaining significant (OR, 1.41). "The folks who were divorced, separated, widowed, or single were underrepresented [OR, 0.69], so folks who were married were more likely to be in the problem and pathological gambling group. Again, this is not necessarily what you would expect," said Dr. Westermeyer, who is director of the mental health service at the Minneapolis VA Medical Center and professor of psychiatry at the University of Minnesota.

"Interestingly, male veterans and female veterans had almost identical rates of both problem gambling and pathological gambling, which is not – so far – what you see in the general population." Men usually outnumber women by a factor of two to three or more, Dr. Westermeyer said. It might be that the military exposes more women to gambling. "Some of the women we talked to say, ‘We hang around with the guys when we have time off. We don’t go to different places. We go to the same bars, and if they go gambling, we go gambling with them.’ "

The study included only veterans who were treated at least once in the previous 2 years at a VA facility. This design was intentional, so that any demographic or other risk factor that was identified would be relevant when incorporated into a future screening instrument.

Another aim was to identify comorbid symptoms "so primary care, as well as psychiatry, can begin to be alert to what might be associated with pathological gambling," Dr. Westermeyer said.

The veterans completed the SCL-90 (the 90-item Symptom Checklist instrument) and the PCL (PTSD [Posttraumatic Stress Disorder] Checklist). Their responses were directly and highly correlated with DSM-IV criteria and the South Oaks Gambling Screen. "In other words, people who have more posttraumatic symptoms, anxiety, and depression tend to have more gambling problems," Dr. Westermeyer said.

Participants also completed the AUDIT (Alcohol Use Disorders Identification Test) and the MAST (Michigan Alcohol Screening Test). The AUDIT addresses recent alcohol use and the MAST is a lifetime alcohol use measure, which was adapted to include drug use. Again, correlations were high. But in this study, people with more alcohol and drug problems tended to have fewer gambling problems, according to Dr. Westermeyer, which is contrary to other research that shows more substance problems associated with more gambling problems.

"All these findings tend to be a tad atypical," Dr. Westermeyer said.

The data were assessed in two different ways to reflect the current prevalence and to predict the future prevalence of problem and pathological gambling. For example, data were weighted to reflect the typical older male population that is seen at most VA centers today. Raw data included an oversampling of women (to bring the 7% in weighted data up to 35%) as well as younger veterans from the Iraq and Afghanistan conflicts (to reflect the way the VA population is likely to appear in a decade or two).

The weighted data show that veterans have about twice the rate of problem gambling as does the general population. The raw data suggest a greater disparity in the future, with a rate 2.7 times that of the general population.

The other worrisome thing about the future is the ratio of problem gamblers to pathological gamblers, Dr. Westermeyer said. General population surveys show a 1:1 ratio of problem gambling to pathological gambling among people who are exposed to gambling for a decade or more, and up to 2:1 with more recent exposure. "It’s worrisome with the veterans. The ratio is ... like four or five problem gamblers to one pathological gambler. The problem gamblers are the people at risk to become pathological gamblers ... which does not bode well for the future."

"Veterans in VA care have a high rate" of pathological gambling, he added.

All 10 DSM-IV gambling symptoms were assessed in the study. The sixth criteria (characterized in the DSM-IV as "chasing one’s losses") was the most common symptom, endorsed by 6.3% of participants with problem or pathological gambling. Tolerance was next at 5.1%, followed by escape gambling at 5.1%. The eighth criteria, which refers to committing illegal acts such as writing bad checks and committing property crimes, was the least commonly reported symptom, at just over 1%.

Another unexpected finding was a propensity for younger veterans to have higher scores on the South Oaks Gambling Screen for pathological gambling. "Most surveys that include people in their 20s rarely find a high prevalence [of pathological gambling], so ours was not a typical finding," said Dr. Westermeyer. Those who show up on the survey data tend to be people aged 35 years and older, he noted.

Participants were paid $20 to complete 2 hours of computer-based data collection; a research assistant was on hand to answer any questions. Participants were recruited at two VA medical centers and 14 rural community-based outpatient clinics.

This was a clinical epidemiologic study and not community-based research, a potential limitation.

Unanswered questions remain, Dr. Westermeyer said. Do these high rates among veterans in VA care reflect rates among all veterans? Also, would it be possible to identify earlier cases through screening?

The study was funded by VA Health Services Research & Development. Dr. Westermeyer said he had no relevant disclosures.

To listen to an HHS Healthbeat broadcast about gambling, press play here.

HONOLULU – About 8% of U.S. veterans are problem gamblers who report between one and four gambling-related problems, and an additional 2% are pathological gamblers with five or more such problems, a study of 2,185 veterans in Department of Veterans Affairs care reveals.

Age, education level, and ethnicity were not big predictors of pathological gambling risk. "The one that does show a lot of difference is unemployment [odds ratio, 1.85], which is not necessarily what you expect. People need money to gamble, and they need a lot of money," Dr. Joseph J. Westermeyer IV said at the annual meeting of the American Psychiatric Association. The unemployed in the study, however, included part-time and seasonal workers who had some access to money, he said, and others were "homebodies" (typically unemployed men who were married to women with jobs).

(c) Tom Lozano/Creative Commons License

Marital status emerged as an important variable in a binary analysis, with unemployment remaining significant (OR, 1.41). "The folks who were divorced, separated, widowed, or single were underrepresented [OR, 0.69], so folks who were married were more likely to be in the problem and pathological gambling group. Again, this is not necessarily what you would expect," said Dr. Westermeyer, who is director of the mental health service at the Minneapolis VA Medical Center and professor of psychiatry at the University of Minnesota.

"Interestingly, male veterans and female veterans had almost identical rates of both problem gambling and pathological gambling, which is not – so far – what you see in the general population." Men usually outnumber women by a factor of two to three or more, Dr. Westermeyer said. It might be that the military exposes more women to gambling. "Some of the women we talked to say, ‘We hang around with the guys when we have time off. We don’t go to different places. We go to the same bars, and if they go gambling, we go gambling with them.’ "

The study included only veterans who were treated at least once in the previous 2 years at a VA facility. This design was intentional, so that any demographic or other risk factor that was identified would be relevant when incorporated into a future screening instrument.

Another aim was to identify comorbid symptoms "so primary care, as well as psychiatry, can begin to be alert to what might be associated with pathological gambling," Dr. Westermeyer said.

The veterans completed the SCL-90 (the 90-item Symptom Checklist instrument) and the PCL (PTSD [Posttraumatic Stress Disorder] Checklist). Their responses were directly and highly correlated with DSM-IV criteria and the South Oaks Gambling Screen. "In other words, people who have more posttraumatic symptoms, anxiety, and depression tend to have more gambling problems," Dr. Westermeyer said.

Participants also completed the AUDIT (Alcohol Use Disorders Identification Test) and the MAST (Michigan Alcohol Screening Test). The AUDIT addresses recent alcohol use and the MAST is a lifetime alcohol use measure, which was adapted to include drug use. Again, correlations were high. But in this study, people with more alcohol and drug problems tended to have fewer gambling problems, according to Dr. Westermeyer, which is contrary to other research that shows more substance problems associated with more gambling problems.

"All these findings tend to be a tad atypical," Dr. Westermeyer said.

The data were assessed in two different ways to reflect the current prevalence and to predict the future prevalence of problem and pathological gambling. For example, data were weighted to reflect the typical older male population that is seen at most VA centers today. Raw data included an oversampling of women (to bring the 7% in weighted data up to 35%) as well as younger veterans from the Iraq and Afghanistan conflicts (to reflect the way the VA population is likely to appear in a decade or two).

The weighted data show that veterans have about twice the rate of problem gambling as does the general population. The raw data suggest a greater disparity in the future, with a rate 2.7 times that of the general population.

The other worrisome thing about the future is the ratio of problem gamblers to pathological gamblers, Dr. Westermeyer said. General population surveys show a 1:1 ratio of problem gambling to pathological gambling among people who are exposed to gambling for a decade or more, and up to 2:1 with more recent exposure. "It’s worrisome with the veterans. The ratio is ... like four or five problem gamblers to one pathological gambler. The problem gamblers are the people at risk to become pathological gamblers ... which does not bode well for the future."

"Veterans in VA care have a high rate" of pathological gambling, he added.

All 10 DSM-IV gambling symptoms were assessed in the study. The sixth criteria (characterized in the DSM-IV as "chasing one’s losses") was the most common symptom, endorsed by 6.3% of participants with problem or pathological gambling. Tolerance was next at 5.1%, followed by escape gambling at 5.1%. The eighth criteria, which refers to committing illegal acts such as writing bad checks and committing property crimes, was the least commonly reported symptom, at just over 1%.

Another unexpected finding was a propensity for younger veterans to have higher scores on the South Oaks Gambling Screen for pathological gambling. "Most surveys that include people in their 20s rarely find a high prevalence [of pathological gambling], so ours was not a typical finding," said Dr. Westermeyer. Those who show up on the survey data tend to be people aged 35 years and older, he noted.

Participants were paid $20 to complete 2 hours of computer-based data collection; a research assistant was on hand to answer any questions. Participants were recruited at two VA medical centers and 14 rural community-based outpatient clinics.

This was a clinical epidemiologic study and not community-based research, a potential limitation.

Unanswered questions remain, Dr. Westermeyer said. Do these high rates among veterans in VA care reflect rates among all veterans? Also, would it be possible to identify earlier cases through screening?

The study was funded by VA Health Services Research & Development. Dr. Westermeyer said he had no relevant disclosures.

To listen to an HHS Healthbeat broadcast about gambling, press play here.

HONOLULU  – Diabetes can be a challenge to control, depression can be difficult to treat and keep in remission, and growing evidence suggests the combination can be especially problematic for patients. And as if this adverse synergy were not bad enough, having these two conditions more than doubles the likelihood that a patient will develop dementia, Dr. Wayne J. Katon said.

Screening all patients with type 2 diabetes for depression, therefore, could have a big impact, he said at the annual meeting of the American Psychiatric Association. The American Diabetes Association has endorsed such screening since 2005.

Given the bidirectional relationship between these conditions, physicians treating patients with depression also should assess, counsel, and monitor them for the development of diabetes. "Some of our psychiatric education will be pushing residents to keep up their medical skills to do monitoring. If we only train psychiatrists to do blood pressure monitoring alone, it would make a big difference," said Dr. Katon, professor of psychiatry and behavioral sciences at the University of Washington in Seattle.

This dual comorbidity puts patients at increased risk for earlier mortality.

Major depression predicts an increased likelihood of cigarette smoking during adolescence (and more difficulty quitting), a sedentary lifestyle, and obesity. Patients with major depression also can feature decreased insulin sensitivity, increased inflammatory markers, and high cortisol levels, which all become risk factors for diabetes and heart disease.

"You can see why you would be at higher risk of earlier mortality," Dr. Katon said.

Diabetes and depression are independent risk factors for dementia, based on the findings in a prospective study of 3,837 primary care patients (J. Gen. Intern. Med. 2010;25:423-9). "It looks like these are particularly bad conditions to have together in terms of risk of dementia," he said.

Dr. Katon and his colleagues found that 7.9% of patients with diabetes and major depression developed dementia over a 5-year period (based on ICD-9 codes) compared with 4.8% of those with diabetes alone (fully adjusted hazard ratio, 2.69). "This was not explained by depression being a prodrome for dementia," he said.

A more than twofold increased risk for dementia is "especially frightening," Dr. Katon added. "It speaks to the importance of more aggressively screening diabetics for depression and more effectively treating them."

Beyond having an increased risk of mortality and dementia, people with diabetes and depression also have lower levels of self-care, do not exercise as much, and are not as adherent to medications, compared with nondepressed diabetics (Diabetes Care 2004;27:2154-60). In this study, those with diabetes and major depression had significantly more nonadherent medication days over time, compared with nondepressed diabetics. "This does not portend well for increased risk of morbidity and mortality," Dr. Katon said.

Session moderator Dr. Herbert Pardes commented, "This is a big deal. The comorbidity of depression with a major medical condition ... people have got to pay attention to the medical health as part of the comorbidities." Dr. Pardes is president and CEO of the New York Presbyterian Hospital in New York City.

The baseline severity of diabetes (higher number of symptoms) was a strong predictor of a patient having major depression in a 5-year follow-up study (Psychosomatics 2009;50:570-9). Dr. Katon and his coauthors also found having one or more coronary procedures during the 5 years predicted major depression in this prospective study of 2,759 primary care patients with diabetes.

The study also revealed a higher likelihood for all-cause mortality associated with depression (hazard ratio, 1.53, vs. 1.23 for those without depression). "Diabetics with major depression were about 50% more likely to die than nondepressed diabetics over 5 years," Dr. Katon said.

After confounders, including cigarette smoking and a sedentary lifestyle were controlled for, major depression was associated with more microvascular complications (HR, 1.33 vs. 1.05); more macrovascular complications (1.38 vs. 1.32), and a higher prevalence of foot ulcers (1.99 vs. 1.22).

Diabetes, depression, and coronary artery disease appear to be one of the "natural clusters of illnesses that doctors see," Dr. Katon said. These illnesses each have a high prevalence, high comorbidity, and bidirectional adverse interactions. Depression, chronic pain, and substance abuse comprise another natural cluster, he added "but that is a whole other lecture for another day."

Dr. Katon said he has received honoraria from Forest Laboratories, Lilly, Pfizer, and Wyeth.

HONOLULU  – Diabetes can be a challenge to control, depression can be difficult to treat and keep in remission, and growing evidence suggests the combination can be especially problematic for patients. And as if this adverse synergy were not bad enough, having these two conditions more than doubles the likelihood that a patient will develop dementia, Dr. Wayne J. Katon said.

Screening all patients with type 2 diabetes for depression, therefore, could have a big impact, he said at the annual meeting of the American Psychiatric Association. The American Diabetes Association has endorsed such screening since 2005.

Given the bidirectional relationship between these conditions, physicians treating patients with depression also should assess, counsel, and monitor them for the development of diabetes. "Some of our psychiatric education will be pushing residents to keep up their medical skills to do monitoring. If we only train psychiatrists to do blood pressure monitoring alone, it would make a big difference," said Dr. Katon, professor of psychiatry and behavioral sciences at the University of Washington in Seattle.

This dual comorbidity puts patients at increased risk for earlier mortality.

Major depression predicts an increased likelihood of cigarette smoking during adolescence (and more difficulty quitting), a sedentary lifestyle, and obesity. Patients with major depression also can feature decreased insulin sensitivity, increased inflammatory markers, and high cortisol levels, which all become risk factors for diabetes and heart disease.

"You can see why you would be at higher risk of earlier mortality," Dr. Katon said.

Diabetes and depression are independent risk factors for dementia, based on the findings in a prospective study of 3,837 primary care patients (J. Gen. Intern. Med. 2010;25:423-9). "It looks like these are particularly bad conditions to have together in terms of risk of dementia," he said.

Dr. Katon and his colleagues found that 7.9% of patients with diabetes and major depression developed dementia over a 5-year period (based on ICD-9 codes) compared with 4.8% of those with diabetes alone (fully adjusted hazard ratio, 2.69). "This was not explained by depression being a prodrome for dementia," he said.

A more than twofold increased risk for dementia is "especially frightening," Dr. Katon added. "It speaks to the importance of more aggressively screening diabetics for depression and more effectively treating them."

Beyond having an increased risk of mortality and dementia, people with diabetes and depression also have lower levels of self-care, do not exercise as much, and are not as adherent to medications, compared with nondepressed diabetics (Diabetes Care 2004;27:2154-60). In this study, those with diabetes and major depression had significantly more nonadherent medication days over time, compared with nondepressed diabetics. "This does not portend well for increased risk of morbidity and mortality," Dr. Katon said.

Session moderator Dr. Herbert Pardes commented, "This is a big deal. The comorbidity of depression with a major medical condition ... people have got to pay attention to the medical health as part of the comorbidities." Dr. Pardes is president and CEO of the New York Presbyterian Hospital in New York City.

The baseline severity of diabetes (higher number of symptoms) was a strong predictor of a patient having major depression in a 5-year follow-up study (Psychosomatics 2009;50:570-9). Dr. Katon and his coauthors also found having one or more coronary procedures during the 5 years predicted major depression in this prospective study of 2,759 primary care patients with diabetes.

The study also revealed a higher likelihood for all-cause mortality associated with depression (hazard ratio, 1.53, vs. 1.23 for those without depression). "Diabetics with major depression were about 50% more likely to die than nondepressed diabetics over 5 years," Dr. Katon said.

After confounders, including cigarette smoking and a sedentary lifestyle were controlled for, major depression was associated with more microvascular complications (HR, 1.33 vs. 1.05); more macrovascular complications (1.38 vs. 1.32), and a higher prevalence of foot ulcers (1.99 vs. 1.22).

Diabetes, depression, and coronary artery disease appear to be one of the "natural clusters of illnesses that doctors see," Dr. Katon said. These illnesses each have a high prevalence, high comorbidity, and bidirectional adverse interactions. Depression, chronic pain, and substance abuse comprise another natural cluster, he added "but that is a whole other lecture for another day."

Dr. Katon said he has received honoraria from Forest Laboratories, Lilly, Pfizer, and Wyeth.

HONOLULU  – Diabetes can be a challenge to control, depression can be difficult to treat and keep in remission, and growing evidence suggests the combination can be especially problematic for patients. And as if this adverse synergy were not bad enough, having these two conditions more than doubles the likelihood that a patient will develop dementia, Dr. Wayne J. Katon said.

Screening all patients with type 2 diabetes for depression, therefore, could have a big impact, he said at the annual meeting of the American Psychiatric Association. The American Diabetes Association has endorsed such screening since 2005.

Given the bidirectional relationship between these conditions, physicians treating patients with depression also should assess, counsel, and monitor them for the development of diabetes. "Some of our psychiatric education will be pushing residents to keep up their medical skills to do monitoring. If we only train psychiatrists to do blood pressure monitoring alone, it would make a big difference," said Dr. Katon, professor of psychiatry and behavioral sciences at the University of Washington in Seattle.

This dual comorbidity puts patients at increased risk for earlier mortality.

Major depression predicts an increased likelihood of cigarette smoking during adolescence (and more difficulty quitting), a sedentary lifestyle, and obesity. Patients with major depression also can feature decreased insulin sensitivity, increased inflammatory markers, and high cortisol levels, which all become risk factors for diabetes and heart disease.

"You can see why you would be at higher risk of earlier mortality," Dr. Katon said.

Diabetes and depression are independent risk factors for dementia, based on the findings in a prospective study of 3,837 primary care patients (J. Gen. Intern. Med. 2010;25:423-9). "It looks like these are particularly bad conditions to have together in terms of risk of dementia," he said.

Dr. Katon and his colleagues found that 7.9% of patients with diabetes and major depression developed dementia over a 5-year period (based on ICD-9 codes) compared with 4.8% of those with diabetes alone (fully adjusted hazard ratio, 2.69). "This was not explained by depression being a prodrome for dementia," he said.

A more than twofold increased risk for dementia is "especially frightening," Dr. Katon added. "It speaks to the importance of more aggressively screening diabetics for depression and more effectively treating them."

Beyond having an increased risk of mortality and dementia, people with diabetes and depression also have lower levels of self-care, do not exercise as much, and are not as adherent to medications, compared with nondepressed diabetics (Diabetes Care 2004;27:2154-60). In this study, those with diabetes and major depression had significantly more nonadherent medication days over time, compared with nondepressed diabetics. "This does not portend well for increased risk of morbidity and mortality," Dr. Katon said.

Session moderator Dr. Herbert Pardes commented, "This is a big deal. The comorbidity of depression with a major medical condition ... people have got to pay attention to the medical health as part of the comorbidities." Dr. Pardes is president and CEO of the New York Presbyterian Hospital in New York City.

The baseline severity of diabetes (higher number of symptoms) was a strong predictor of a patient having major depression in a 5-year follow-up study (Psychosomatics 2009;50:570-9). Dr. Katon and his coauthors also found having one or more coronary procedures during the 5 years predicted major depression in this prospective study of 2,759 primary care patients with diabetes.

The study also revealed a higher likelihood for all-cause mortality associated with depression (hazard ratio, 1.53, vs. 1.23 for those without depression). "Diabetics with major depression were about 50% more likely to die than nondepressed diabetics over 5 years," Dr. Katon said.

After confounders, including cigarette smoking and a sedentary lifestyle were controlled for, major depression was associated with more microvascular complications (HR, 1.33 vs. 1.05); more macrovascular complications (1.38 vs. 1.32), and a higher prevalence of foot ulcers (1.99 vs. 1.22).

Diabetes, depression, and coronary artery disease appear to be one of the "natural clusters of illnesses that doctors see," Dr. Katon said. These illnesses each have a high prevalence, high comorbidity, and bidirectional adverse interactions. Depression, chronic pain, and substance abuse comprise another natural cluster, he added "but that is a whole other lecture for another day."

Dr. Katon said he has received honoraria from Forest Laboratories, Lilly, Pfizer, and Wyeth.

HONOLULU  – Diabetes can be a challenge to control, depression can be difficult to treat and keep in remission, and growing evidence suggests the combination can be especially problematic for patients. And as if this adverse synergy were not bad enough, having these two conditions more than doubles the likelihood that a patient will develop dementia, Dr. Wayne J. Katon said.

Screening all patients with type 2 diabetes for depression, therefore, could have a big impact, he said at the annual meeting of the American Psychiatric Association. The American Diabetes Association has endorsed such screening since 2005.

Given the bidirectional relationship between these conditions, physicians treating patients with depression also should assess, counsel, and monitor them for the development of diabetes. "Some of our psychiatric education will be pushing residents to keep up their medical skills to do monitoring. If we only train psychiatrists to do blood pressure monitoring alone, it would make a big difference," said Dr. Katon, professor of psychiatry and behavioral sciences at the University of Washington in Seattle.

This dual comorbidity puts patients at increased risk for earlier mortality.

Major depression predicts an increased likelihood of cigarette smoking during adolescence (and more difficulty quitting), a sedentary lifestyle, and obesity. Patients with major depression also can feature decreased insulin sensitivity, increased inflammatory markers, and high cortisol levels, which all become risk factors for diabetes and heart disease.

"You can see why you would be at higher risk of earlier mortality," Dr. Katon said.

Diabetes and depression are independent risk factors for dementia, based on the findings in a prospective study of 3,837 primary care patients (J. Gen. Intern. Med. 2010;25:423-9). "It looks like these are particularly bad conditions to have together in terms of risk of dementia," he said.

Dr. Katon and his colleagues found that 7.9% of patients with diabetes and major depression developed dementia over a 5-year period (based on ICD-9 codes) compared with 4.8% of those with diabetes alone (fully adjusted hazard ratio, 2.69). "This was not explained by depression being a prodrome for dementia," he said.

A more than twofold increased risk for dementia is "especially frightening," Dr. Katon added. "It speaks to the importance of more aggressively screening diabetics for depression and more effectively treating them."

Beyond having an increased risk of mortality and dementia, people with diabetes and depression also have lower levels of self-care, do not exercise as much, and are not as adherent to medications, compared with nondepressed diabetics (Diabetes Care 2004;27:2154-60). In this study, those with diabetes and major depression had significantly more nonadherent medication days over time, compared with nondepressed diabetics. "This does not portend well for increased risk of morbidity and mortality," Dr. Katon said.

Session moderator Dr. Herbert Pardes commented, "This is a big deal. The comorbidity of depression with a major medical condition ... people have got to pay attention to the medical health as part of the comorbidities." Dr. Pardes is president and CEO of the New York Presbyterian Hospital in New York City.

The baseline severity of diabetes (higher number of symptoms) was a strong predictor of a patient having major depression in a 5-year follow-up study (Psychosomatics 2009;50:570-9). Dr. Katon and his coauthors also found having one or more coronary procedures during the 5 years predicted major depression in this prospective study of 2,759 primary care patients with diabetes.

The study also revealed a higher likelihood for all-cause mortality associated with depression (hazard ratio, 1.53, vs. 1.23 for those without depression). "Diabetics with major depression were about 50% more likely to die than nondepressed diabetics over 5 years," Dr. Katon said.

After confounders, including cigarette smoking and a sedentary lifestyle were controlled for, major depression was associated with more microvascular complications (HR, 1.33 vs. 1.05); more macrovascular complications (1.38 vs. 1.32), and a higher prevalence of foot ulcers (1.99 vs. 1.22).

Diabetes, depression, and coronary artery disease appear to be one of the "natural clusters of illnesses that doctors see," Dr. Katon said. These illnesses each have a high prevalence, high comorbidity, and bidirectional adverse interactions. Depression, chronic pain, and substance abuse comprise another natural cluster, he added "but that is a whole other lecture for another day."

Dr. Katon said he has received honoraria from Forest Laboratories, Lilly, Pfizer, and Wyeth.

HONOLULU  – Diabetes can be a challenge to control, depression can be difficult to treat and keep in remission, and growing evidence suggests the combination can be especially problematic for patients. And as if this adverse synergy were not bad enough, having these two conditions more than doubles the likelihood that a patient will develop dementia, Dr. Wayne J. Katon said.

Screening all patients with type 2 diabetes for depression, therefore, could have a big impact, he said at the annual meeting of the American Psychiatric Association. The American Diabetes Association has endorsed such screening since 2005.

Given the bidirectional relationship between these conditions, physicians treating patients with depression also should assess, counsel, and monitor them for the development of diabetes. "Some of our psychiatric education will be pushing residents to keep up their medical skills to do monitoring. If we only train psychiatrists to do blood pressure monitoring alone, it would make a big difference," said Dr. Katon, professor of psychiatry and behavioral sciences at the University of Washington in Seattle.

This dual comorbidity puts patients at increased risk for earlier mortality.

Major depression predicts an increased likelihood of cigarette smoking during adolescence (and more difficulty quitting), a sedentary lifestyle, and obesity. Patients with major depression also can feature decreased insulin sensitivity, increased inflammatory markers, and high cortisol levels, which all become risk factors for diabetes and heart disease.

"You can see why you would be at higher risk of earlier mortality," Dr. Katon said.

Diabetes and depression are independent risk factors for dementia, based on the findings in a prospective study of 3,837 primary care patients (J. Gen. Intern. Med. 2010;25:423-9). "It looks like these are particularly bad conditions to have together in terms of risk of dementia," he said.

Dr. Katon and his colleagues found that 7.9% of patients with diabetes and major depression developed dementia over a 5-year period (based on ICD-9 codes) compared with 4.8% of those with diabetes alone (fully adjusted hazard ratio, 2.69). "This was not explained by depression being a prodrome for dementia," he said.

A more than twofold increased risk for dementia is "especially frightening," Dr. Katon added. "It speaks to the importance of more aggressively screening diabetics for depression and more effectively treating them."

Beyond having an increased risk of mortality and dementia, people with diabetes and depression also have lower levels of self-care, do not exercise as much, and are not as adherent to medications, compared with nondepressed diabetics (Diabetes Care 2004;27:2154-60). In this study, those with diabetes and major depression had significantly more nonadherent medication days over time, compared with nondepressed diabetics. "This does not portend well for increased risk of morbidity and mortality," Dr. Katon said.

Session moderator Dr. Herbert Pardes commented, "This is a big deal. The comorbidity of depression with a major medical condition ... people have got to pay attention to the medical health as part of the comorbidities." Dr. Pardes is president and CEO of the New York Presbyterian Hospital in New York City.

The baseline severity of diabetes (higher number of symptoms) was a strong predictor of a patient having major depression in a 5-year follow-up study (Psychosomatics 2009;50:570-9). Dr. Katon and his coauthors also found having one or more coronary procedures during the 5 years predicted major depression in this prospective study of 2,759 primary care patients with diabetes.

The study also revealed a higher likelihood for all-cause mortality associated with depression (hazard ratio, 1.53, vs. 1.23 for those without depression). "Diabetics with major depression were about 50% more likely to die than nondepressed diabetics over 5 years," Dr. Katon said.

After confounders, including cigarette smoking and a sedentary lifestyle were controlled for, major depression was associated with more microvascular complications (HR, 1.33 vs. 1.05); more macrovascular complications (1.38 vs. 1.32), and a higher prevalence of foot ulcers (1.99 vs. 1.22).

Diabetes, depression, and coronary artery disease appear to be one of the "natural clusters of illnesses that doctors see," Dr. Katon said. These illnesses each have a high prevalence, high comorbidity, and bidirectional adverse interactions. Depression, chronic pain, and substance abuse comprise another natural cluster, he added "but that is a whole other lecture for another day."

Dr. Katon said he has received honoraria from Forest Laboratories, Lilly, Pfizer, and Wyeth.

HONOLULU  – Diabetes can be a challenge to control, depression can be difficult to treat and keep in remission, and growing evidence suggests the combination can be especially problematic for patients. And as if this adverse synergy were not bad enough, having these two conditions more than doubles the likelihood that a patient will develop dementia, Dr. Wayne J. Katon said.

Screening all patients with type 2 diabetes for depression, therefore, could have a big impact, he said at the annual meeting of the American Psychiatric Association. The American Diabetes Association has endorsed such screening since 2005.

Given the bidirectional relationship between these conditions, physicians treating patients with depression also should assess, counsel, and monitor them for the development of diabetes. "Some of our psychiatric education will be pushing residents to keep up their medical skills to do monitoring. If we only train psychiatrists to do blood pressure monitoring alone, it would make a big difference," said Dr. Katon, professor of psychiatry and behavioral sciences at the University of Washington in Seattle.

This dual comorbidity puts patients at increased risk for earlier mortality.

Major depression predicts an increased likelihood of cigarette smoking during adolescence (and more difficulty quitting), a sedentary lifestyle, and obesity. Patients with major depression also can feature decreased insulin sensitivity, increased inflammatory markers, and high cortisol levels, which all become risk factors for diabetes and heart disease.

"You can see why you would be at higher risk of earlier mortality," Dr. Katon said.

Diabetes and depression are independent risk factors for dementia, based on the findings in a prospective study of 3,837 primary care patients (J. Gen. Intern. Med. 2010;25:423-9). "It looks like these are particularly bad conditions to have together in terms of risk of dementia," he said.

Dr. Katon and his colleagues found that 7.9% of patients with diabetes and major depression developed dementia over a 5-year period (based on ICD-9 codes) compared with 4.8% of those with diabetes alone (fully adjusted hazard ratio, 2.69). "This was not explained by depression being a prodrome for dementia," he said.

A more than twofold increased risk for dementia is "especially frightening," Dr. Katon added. "It speaks to the importance of more aggressively screening diabetics for depression and more effectively treating them."

Beyond having an increased risk of mortality and dementia, people with diabetes and depression also have lower levels of self-care, do not exercise as much, and are not as adherent to medications, compared with nondepressed diabetics (Diabetes Care 2004;27:2154-60). In this study, those with diabetes and major depression had significantly more nonadherent medication days over time, compared with nondepressed diabetics. "This does not portend well for increased risk of morbidity and mortality," Dr. Katon said.

Session moderator Dr. Herbert Pardes commented, "This is a big deal. The comorbidity of depression with a major medical condition ... people have got to pay attention to the medical health as part of the comorbidities." Dr. Pardes is president and CEO of the New York Presbyterian Hospital in New York City.

The baseline severity of diabetes (higher number of symptoms) was a strong predictor of a patient having major depression in a 5-year follow-up study (Psychosomatics 2009;50:570-9). Dr. Katon and his coauthors also found having one or more coronary procedures during the 5 years predicted major depression in this prospective study of 2,759 primary care patients with diabetes.

The study also revealed a higher likelihood for all-cause mortality associated with depression (hazard ratio, 1.53, vs. 1.23 for those without depression). "Diabetics with major depression were about 50% more likely to die than nondepressed diabetics over 5 years," Dr. Katon said.

After confounders, including cigarette smoking and a sedentary lifestyle were controlled for, major depression was associated with more microvascular complications (HR, 1.33 vs. 1.05); more macrovascular complications (1.38 vs. 1.32), and a higher prevalence of foot ulcers (1.99 vs. 1.22).

Diabetes, depression, and coronary artery disease appear to be one of the "natural clusters of illnesses that doctors see," Dr. Katon said. These illnesses each have a high prevalence, high comorbidity, and bidirectional adverse interactions. Depression, chronic pain, and substance abuse comprise another natural cluster, he added "but that is a whole other lecture for another day."

Dr. Katon said he has received honoraria from Forest Laboratories, Lilly, Pfizer, and Wyeth.