About

Sarah Armstrong is an Associate Professor of Pediatrics at Duke University. Her clinical and research interests focus on the prevention and treatment of childhood and adolescent obesity. She serves as the director of the Duke Children's Healthy Lifestyles Program, overseeing a cohort of over 3,000 overweight children and teenagers. Her work includes addressing issues such as sustaining effective outpatient management of overweight and obese children in primary care settings and understanding factors that influence reimbursement levels. Dr. Armstrong's contributions extend to improving overall health outcomes in pediatric patients through initiatives like the Parks Partnership and efforts to address food insecurity at a local scale.

Research topics

• Medicine
• Internal medicine
• Pediatrics
• Family medicine
• Biology
• Geography
• Intensive care medicine
• Biochemistry
• Biomedical engineering
• Endocrinology
• Nanotechnology
• Pathology
• Microbiology
• Genetics
• Immunology
• Food science
• Materials science
• Nursing
• Chemistry
• Emergency medicine
• Virology

Selected publications

• Children With Obesity Are Not Little Adults With Obesity

  PEDIATRICS · 2025-07-23

  articleSenior author

  Few diagnoses in medicine are as controversial as obesity. In an attempt to provide some clarity, The Lancet Diabetes & Endocrinology recently commissioned an expert committee to arrive at a consensus on the “Definition and Diagnostic Criteria of Obesity.”1 The objective of this Commission’s new framework for obesity, which is inclusive of the pediatric population, is to “establish objective criteria for disease diagnosis, aiding clinical decision making and prioritization of therapeutic interventions and public health strategies.” As experts in the field of pediatric obesity, we recognize the importance of this goal and also have significant concerns about applying this adult-focused new definition to children and adolescents.Recognizing the limitations of body mass index (BMI), the Commission recommends that clinicians should use additional measures of body composition or body fat distribution (eg, waist circumference, dual-energy x-ray absorptiometry [DXA], and bioelectrical impedance) to confirm excess adiposity before making a diagnosis of obesity, except for a BMI 40 kg/m2 or greater for which “excess adiposity may be assumed.” Several problems exist when applying this definition to pediatric populations. First, the use of raw BMI values (ie, “≥40 kg/m2”) ignores the normal BMI changes across a child’s growth and development. The American Academy of Pediatrics (AAP) recommends that clinicians use Centers for Disease Control growth curves that are normed by age- and sex-specific BMI percentiles. Second, the “additional” measures that the Commission recommends, such as waist circumference and bioelectrical impedance, are currently not standardized or validated across pediatric age groups. Additionally, although BMI is somewhat less reliable in certain conditions (adolescence, high lean mass, certain racial/ethnic groups), broadly it has a high specificity (93%) for detecting excess adiposity (very few false positives). By contrast, BMI has a moderate sensitivity (73%) for detecting excess adiposity.2 Thus, confirmatory measures, if used, should have a high sensitivity to complement the BMI measure. Currently, waist circumference, waist-to height/hip ratio, and bioelectrical impedance all have lower sensitivity than BMI to detect excess adiposity. Only DXA has a higher sensitivity and specificity; however, it is resource-intensive, and if used for routine diagnosis and longitudinal tracking, it exposes children to unnecessary radiation risk. Until further research identifies an accurate, age-normed, and nonstigmatizing measure of body composition, clinicians should continue to use BMI percentiles for children and adolescents to guide further risk assessment.The Commission distinguishes between “clinical obesity” and “preclinical obesity,” with the former defined as a systemic disease characterized by dysfunction of tissues, organs, or individuals due to excess adiposity and the latter as excess adiposity without associated dysfunction. Intervention is recommended for individuals with “clinical obesity,” whereas those with “preclinical obesity” warrant only “science-based lifestyle counseling” without intensive lifestyle therapy, obesity medication, or other treatment.Obesity in childhood, even in the absence of measurable complications, is a strong risk factor for current and future diseases of multiple organ systems. For children, these conditions may emerge below the limits of detection of existing screening tools and only present when the disease is established and causing harm. For example, a child with obesity has a 4 times higher risk of developing type 2 diabetes3 even if their hemoglobin A1c is normal. Children with these subclinical harbingers of future disease, under the Commission’s report, would be classified as having “preclinical” obesity. Accordingly, the recommendation would be to only provide “science-based counseling” and wait until more entrenched disease is apparent before providing comprehensive, evidence-based treatment, including intensive lifestyle therapy, pharmacotherapy, and/or metabolic and bariatric surgery, as outlined in the 2023 AAP Clinical Practice Guideline on obesity.4 The Commission’s watchful waiting approach defaults to the natural history of childhood obesity, which is well-documented worsening of disease, development of complications, and risk for early mortality. In contrast, implementation of evidence-based treatments for obesity in childhood has been shown to delay and lower future morbidity and mortality.5The goal of the Commission is laudable in that we need a nonbiased and accurate description of the disease of obesity. However, the unintended consequences of broad adoption of this new definition of obesity for children and adolescents may cause harm. Payers may use this definition to deny coverage of treatment of children with obesity whose complications are not yet detectable. Parents may interpret “preclinical” obesity as inconsequential and avoid or decline treatment. Finally, pediatric health care providers may delay offering evidenced based interventions to children and adolescents with obesity.Although we do not recommend adoption of the Commission’s definition of obesity for children and adolescents, we recognize the need to fully understand the long-term health implications of the amount and distribution of excess adiposity in a growing and developing child or adolescent. On a population level, high BMI predicts future morbidity and mortality, yet on an individual level, the degree of risk is varied. Identification of clusters of risk factors, such as visceral adiposity and family history of diabetes or cardiovascular disease, as a way of predicting which children are most likely to experience adverse consequences of high BMI will help clinicians and patients determine the optimal intervention for a given patient, whether it is intensive lifestyle therapy, pharmacotherapy, and/or metabolic and bariatric surgery.The AAP Clinical Practice Guideline for obesity provides comprehensive guidance for screening, evaluation, and treatment of obesity, based on a scientific review of over 16 000 peer-reviewed publications. This guideline aligns with the Commission’s acknowledgment of the complexity of obesity and the importance of access to time-sensitive care, free from bias and stigma, for people experiencing ill-health related to obesity. We hope that the Commission’s work will be the beginning of our work together to improve the care for all children and teens with obesity.

  PublisherDOI

• Branched chain amino acid metabolism and microbiome in adolescents with obesity during weight loss therapy

  medRxiv · 2025-02-04 · 2 citations

  preprintOpen access

  BACKGROUND: Obesity and weight loss in adults have been associated with distinct metabolome and gut microbiome features, but the extent to which those associations apply to adolescent stages remain unclear. METHODS: The Pediatric Obesity Microbiome and Metabolism Study (POMMS) enrolled 220 adolescents aged 10-18 with severe obesity (OB) and 67 healthy weight controls (HWC). Blood, stool, and clinical measures were collected at baseline and after a 6-month obesity intervention for the OB group. Metabolomic profiling in serum using targeted quantitative mass spectrometry and microbiome profiling in stool were performed, and those features were assessed for associations with BMI, insulin resistance, and inflammation. Fecal microbiome transplants were performed on germ-free mice using samples from both groups to assess effects on weight gain and metabolic pathways. RESULTS: Adolescents with OB exhibited higher serum branched-chain amino acid (BCAA) but lower ketoacid metabolite (BCKA) levels compared with HWC. This pattern was sex- and age-dependent, unlike adults with OB, who show elevated levels of both. Longitudinal analysis identified metabolic and microbial features correlated with changes in health measures during the intervention. The fecal microbiomes of adolescents with OB and HWC had similar diversity but differed in membership and functional potential. FMT from both OB and HWC donors had similar effects on mouse body weight, but specific taxa were linked to weight gain in FMT recipients. CONCLUSION: Adolescents with OB have unique metabolomic adaptations and microbiome signatures compared to their HWC counterparts and adults with OB. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03139877 (Observational Study) and NCT02959034 (Repository). FUNDING SOURCES: American Heart Association Grants: 17SFRN33670990, 20PRE35180195National Institute of Diabetes and Digestive and Kidney Diseases Grant: R24-DK110492.

  PublisherOA PDFDOI

• Building a National Framework to Pair Scientists and Schools During a Global Pandemic

  UNC Libraries · 2025-04-29

  articleOpen access

  The coronavirus disease 2019 (COVID-19) pandemic forced the suspension of in-person education in schools serving students in kindergarten through 12th grade (K-12) across the United States. As time passed, teachers, students, and parents struggled with remote education. With limited guidance at the federal level, physicians and school leaders across the country collaborated to develop local solutions for schools. This article describes the lessons learned from the development of 4 academic-community partnerships and collaboration among these partnerships to provide national leadership on managing COVID-19 mitigation in the K-12 environment. In addition, we describe a pathway forward for using academic-community partnerships to improve child health.

  PublisherDOI

• Using Parks and Recreation Providers to Enhance Obesity Treatment: A Randomized Controlled Trial

  PEDIATRICS · 2025-02-10 · 4 citations

  articleOpen access1st authorCorresponding

  OBJECTIVE: Intensive health behavior and lifestyle treatment (IHBLT) is recommended for children aged 6-18 years with obesity. The objective was to evaluate the effectiveness of Fit Together, a health care and parks and recreation partnership to deliver IHBLT. METHODS: A randomized controlled trial was conducted from 2018 to 2021. Youths (aged 5-17 years) with obesity were recruited from primary care clinics and randomized to a waitlist control or Fit Together (ie, clinical obesity care plus group-based lifestyle sessions at a local recreation center). Primary outcomes, child body mass index relative to the 95th percentile (BMIp95) and submaximal heart rate, were collected at baseline and 6 months. Generalized estimating equation models were used to assess changes in primary outcomes for those affected and not affected by COVID-19 study disruptions. RESULTS: Participants (n = 255) had a mean (SD) age of 10.0 (3.0) years, were 39% Hispanic, and were 38% non-Hispanic Black. Intervention youths not affected by COVID-19 disruptions experienced a significant decrease in BMIp95 (β = -3.05; 95% confidence interval [CI], -5.08 to -1.01) compared with controls. There was no difference in BMIp95 between intervention and control youths affected by COVID-19 disruptions (β = -3.25; 95% CI, -7.98 to 1.48). For the entire cohort, intervention youths had a significant decrease in BMIp95 compared with control youths (β = -3.32; 95% CI, -5.69 to -0.96). Submaximal heart rate was only available for the nondisrupted group, but there was no difference between intervention and control youths (β = -7.18; 95% CI, -16.12 to 1.76). CONCLUSION: Effective child obesity treatment can be implemented in local communities through a partnership between clinical practices and parks and recreation providers. Future research will explore this model in combination with newer, more effective obesity treatments.

  PublisherOA PDFDOI

• The influence of acculturation and stress on obesity in US latino dyads using systems science

  Ethnicity and Health · 2025-08-18

  article

  OBJECTIVE: Pediatric obesity continues to grow in the US Latino population despite public health efforts. Little work has explored the link between acculturation and stress across caregiver-child dyads using systems science. METHODS: Semi-structured interviews were completed with US Latino dyads made up of foreign-born caregivers and US-born children (8-13 years). Participants were recruited from a pediatric weight management clinic in Durham, NC. Interviews were guided by system support mapping to illustrate interconnected components of the child's weight management journey. Maps were thematically coded by responsibilities, needs, resources, wishes. Codes were aggregated across caregivers and children, respectively, and frequency of themes were calculated. RESULTS: 14 dyads completed interviews. Children reported 17 aspects of health within their responsibility, with a focus on physical activity. Children were unaware of available resources beyond their caregivers. Caregivers reported 26 unique responsibilities, with overlap between basic needs and living in low-resource environments. Immigration and acculturation status were major barriers and sources of stress relevant to aspects of the system support map. CONCLUSIONS: Immigration and acculturation status impede pediatric weight management and increase stress in US Latino caregiver-child dyads. Future studies should consider immigration and acculturation status in caregivers and children as a mediator of treatment outcomes.

  PublisherDOI

• Effects of caregiver‐child acculturation on child obesity among US Latino individuals

  UNC Libraries · 2025-03-22

  articleOpen accessSenior author

  OBJECTIVE: The goal of this study was to assess the association of Latino caregiver-child nativity status (US- and foreign-born) with child obesity using a nationally representative sample. METHODS: Using data from the National Health and Nutrition Examination Survey (NHANES 1999-2018), this study used generalized linear models to identify associations between caregiver-child nativity status (as a proxy for acculturation) and children's BMI. RESULTS: Compared with foreign-born caregiver-child dyads, US-born caregiver-child dyads had 2.35 times the risk of class 2 obesity (95% CI: 1.59-3.47) and 3.60 times the risk of class 3 obesity (95% CI: 1.86-6.96). Foreign-born caregiver and US-born child dyads had 2.01 times the risk of class 2 obesity (95% CI: 1.42-2.84) and 2.47 times the risk of class 3 obesity (95% CI: 1.38-4.44; p < 0.05 for class 2 and class 3). CONCLUSIONS: Compared with foreign-born Latino caregiver-child dyads, dyads with US-born caregivers and children and dyads with foreign-born caregivers and US-born children had significantly increased risk across the severe classes of obesity. Examining the influence and relationship of varying acculturation levels in an immigrant household will help guide more effective clinical and policy guidelines surrounding obesity and weight management in both pediatric and adult US Latino populations.

  PublisherDOI

• Parent Perspectives on the 2023 Clinical Practice Guideline for Pediatric Obesity: A Mixed‐Methods Study of Acceptance and Concerns

  Pediatric Obesity · 2025-10-26 · 2 citations

  article

  BACKGROUND: The 2023 Clinical Practice Guideline for pediatric obesity recommends immediate, intensive treatment, including behavioral therapy, medications, and surgery when indicated. Understanding parental agreement with the guideline is critical for successful implementation. OBJECTIVE: To evaluate parental awareness of and agreement with the guideline. METHODS: = 37.6 ± 7.4 years) completed an online survey assessing guideline awareness and agreement. K-means cluster analysis identified parent subgroups based on agreement patterns. Linear regression examined predictors of agreement (e.g., parent age, BMI). Inductive content analysis explored underlying perspectives. RESULTS: Few parents (5.3%) were aware of the guideline before the survey. Cluster analysis identified three subgroups: Guideline Skeptics (34%; broadly disagreed), Selective Supporters (28%; mostly agreed but opposed medications and surgery), and Guideline Supporters (38%; broadly agreed). Higher parental BMI predicted lower agreement (β = -0.20, p = 0.018). Qualitative findings added nuance to parents' preference for lifestyle changes, highlighted concerns about mental health and eating disorders, and emphasized parental responsibility in the development and treatment of obesity. CONCLUSIONS: Parental agreement with the guideline varies widely. While most support behavioral treatment, many express concerns about medications and surgery, and a subset of "Guideline Skeptics" reject core principles such as the use of BMI. Tailored implementation strategies are needed to address these diverse views.

  PublisherDOI

• Grocery intervention and <scp>DNA</scp>‐based assessment to improve diet quality in pediatric obesity: a pilot randomized controlled study

  Obesity · 2025-01-22 · 8 citations

  articleOpen accessCorresponding

  Abstract Objective We assessed the impact of a food‐provisioning intervention on diet quality in children with obesity. Methods Participants ( n = 33, aged 6–11 years) were randomly assigned to either usual care (intensive health behavior and lifestyle treatment) or intervention (usual care + food provisioning; high‐fiber, low‐dairy diet) for 4 weeks. The primary outcome was a change in child diet quality at Week 4. Secondary outcomes were changes in weight, food insecurity, gut microbiome composition (16S ribosomal RNA), and dietary intake, measured via an objective DNA‐based biomarker (i.e., FoodSeq). Genomic dietary data were analyzed against a larger pediatric adolescent obesity cohort ( n = 195, aged 10–18 years) from similar households. Results Intervention demonstrated changes across all assessed diet components and was more effective than usual care in increasing whole grain (β = 0.20, 95% CI: 0.05 to 0.34; p = 0.013) and fiber (β = 2.52, 95% CI: 1.28 to 3.76; p &lt; 0.001) and decreasing dairy (β = −1.31, 95% CI: −2.02 to −0.60; p = 0.001). FoodSeq results, highly concordant with grocery orders (adjusted R 2 = 0.65; p &lt; 0.001), indicated a dietary shift toward low‐energy‐density plant taxa in the intervention relative to a prior survey of diet in a related cohort (β = 8.64, 95% CI: 5.18 to 12.14; p &lt; 0.001). No significant changes were observed in microbiome, weight, or food insecurity. Conclusions Our study supports the potential of dietitian‐guided food provisioning for improving diet quality in children with obesity and demonstrates an objective genomic approach for evaluating dietary shifts.

  PublisherOA PDFDOI

• Weight-related quality of life and temperament as predictors and moderators of outcomes among treatment-seeking, low-income, ethnically diverse children with obesity

  UNC Libraries · 2025-08-22

  articleOpen accessSenior author

  Within any childhood obesity treatment program, some children have better outcomes than others. Little is known about predictors or moderators of more positive outcomes. We aimed to identify whether child temperament and weight-related quality of life predict or moderate childhood obesity treatment outcomes at 6 months. From 2015 to 2016, children (n = 97) ages 5-11 years old with obesity were randomized to a clinic-community (Bull City Fit) or a clinic-only treatment program. Linear regression was used to explore whether dimensions of child temperament and weight-related quality of life predicted or moderated 6-month anthropometric and physical activity outcomes. Children who had more social avoidance due to their weight at baseline had significantly better improvements in body fat percent in the clinic-community model compared with the clinic-only model at 6 months. Across programs, better baseline social quality of life predicted greater increases in waist circumference; conversely, better physical quality of life predicted a decrease in percent of the 95th percentile. Also, children with longer attention spans had greater increases in physical activity. Our findings suggest that children who have social avoidance due to their weight may benefit most from comprehensive clinic-community treatment. Weight-related quality of life may influence outcomes across all treatments, and practitioners need to carefully counsel children experiencing weight negatively.

  PublisherDOI

• Immunomodulatory therapy in children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS, MIS-C; RECOVERY): a randomised, controlled, open-label, platform trial

  The Lancet Child & Adolescent Health · 2024 · 34 citations

  • Medicine
  • Internal medicine
  • Virology

  BACKGROUND: Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PIMS-TS), also known as multisystem inflammatory syndrome in children (MIS-C) emerged in April, 2020. The paediatric comparisons within the RECOVERY trial aimed to assess the effect of intravenous immunoglobulin or corticosteroids compared with usual care on duration of hospital stay for children with PIMS-TS and to compare tocilizumab (anti-IL-6 receptor monoclonal antibody) or anakinra (anti-IL-1 receptor antagonist) with usual care for those with inflammation refractory to initial treatment. METHODS: We did this randomised, controlled, open-label, platform trial in 51 hospitals in the UK. Eligible patients were younger than 18 years and had been admitted to hospital for PIMS-TS. In the first randomisation, patients were randomly assigned (1:1:1) to usual care (no additional treatments), usual care plus methylprednisolone (10mg/kg per day for 3 consecutive days), or usual care plus intravenous immunoglobulin (a single dose of 2 g/kg). If further anti-inflammatory treatment was considered necessary, children aged at least 1 year could be considered for a second randomisation, in which patients were randomly assigned (1:2:2) to usual care, intravenous tocilizumab (12 mg/kg in patients <30 kg; 8mg/kg in patients ≥30 kg, up to a maximum dose of 800 mg), or subcutaneous anakinra (2 mg/kg once per day in patients ≥10 kg). Randomisation was by use of a web-based simple (unstratified) randomisation with allocation concealment. The primary outcome was duration of hospital stay. Analysis was by intention to treat. For treatments assessed in each randomisation, a single Bayesian framework assuming uninformative priors for treatment was used to jointly assess the efficacy of each intervention compared with usual care. The trial was registered with ISRCTN (50189673) and ClinicalTrials.gov (NCT04381936). FINDINGS: Between May 18, 2020, and Jan 20, 2022, 237 children with PIMS-TS were enrolled and included in the intention-to-treat analysis. Of the 214 patients who entered the first randomisation, 73 were assigned to receive intravenous immunoglobulin, 61 methylprednisolone, and 80 usual care. Of the 70 children who entered the second randomisation (including 23 who did not enter the first randomisation), 28 were assigned to receive tocilizumab, 14 anakinra, and 28 usual care. Mean age was 9·5 years (SD 3·8) in the randomisation and 9·6 years (3·6) in the second randomisation. 118 (55%) of 214 patients in the first randomisation and 39 (56%) of 70 patients in the second randomisation were male. 130 (55%) of 237 patients were Black, Asian, or minority ethnic, and 105 (44%) were White. Mean duration of hospital stay was 7·4 days (SD 0·4) in children assigned to intravenous immunoglobulin and 7·6 days (0·4) in children assigned to usual care (difference -0·1 days, 95% credible interval [CrI] -1·3 to 1·0; posterior probability 59%). Mean duration of hospital stay was 6·9 days (SD 0·5) in children assigned to methylprednisolone (difference from usual care -0·7 days, 95% CrI -1·9 to 0·6; posterior probability 87%). Mean duration of hospital stay was 6·6 days (SD 0·7) in children assigned to second-line tocilizumab and 9·9 days (0·9) in children assigned to usual care (difference -3·3 days, 95% CrI -5·6 to -1·0; posterior probability >99%). Mean duration of hospital stay was 8·5 days (SD 1·2) in children assigned to anakinra (difference from usual care -1·4 days, 95% CrI -4·3 to 1·8; posterior probability 84%). Two persistent coronary artery aneurysms were reported among patients assigned to usual care in the first randomisation. There were few cardiac arrythmias, bleeding, or thrombotic events in any group. Two children died; neither was considered related to study treatment. INTERPRETATION: Moderate evidence suggests that, compared with usual care, first-line intravenous methylprednisolone reduces duration of hospital stay for children with PIMS-TS. Good evidence suggests that second-line tocilizumab reduces duration of hospital stay for children with inflammation refractory to initial treatment. Neither intravenous immunoglobulin nor anakinra had any effect on duration of hospital stay compared with usual care. FUNDING: Medical Research Council and National Institute of Health Research.

  DOI

Frequent coauthors

• K. Robinson

  University of Nottingham

  972 shared

• Christopher J. Gordon

  Woolcock Institute of Medical Research

  972 shared

• James Lee

  650 shared

• Kristin Baird

  648 shared

• Shamala Thilarajah

  648 shared

• Matthew Boyd

  University of Nottingham

  648 shared

• Gerald Choon‐Huat Koh

  Ministry of Health

  648 shared

• Melanie A. Vile

  West Chester University

  648 shared