TY - JOUR
T1 - Temporal trends in the diagnosis and management of childhood obesity/overweight in primary care
AU - Nader, Nicole
AU - Singhal, Vibha
AU - Javed, Asma
AU - Weaver, Amy
AU - Kumar, Seema
N1 - Funding Information:
This study examines temporal trends in obesity diagnosis and management by primary care providers at a single medical center. We found a significant increase in the rates of diagnosis of overweight and obesity in the past decade. Our results are in agreement to those of Sharifi et al 19 who also reported higher rates of diagnosis coding for overweight and obese children in 2008 than in 2006. In contrast, Benson et al 2 using the International Classification of Diseases–Ninth Revision (ICD-9) codes reported increase in rates of obesity diagnosis until 2005 but year to year plateauing between 2005 and 2007. These contrasting results may be related to several factors such as the method of determining diagnosis of obesity (ICD-9 code vs search of the medical records for appropriate terms), geographic differences (subjects in the Benson study were from Northeast Ohio whereas our population was mainly from a Midwestern town) and ethnicity (majority of the subjects in the Benson study were Blacks and Hispanics and only a third were Whites unlike our subjects majority of whom were White. Therefore, further research is needed to determine the role of ethnicity and geographic location on diagnosis of childhood obesity. Guidelines pertaining to diagnosis and management of childhood obesity recommend that BMI should be calculated and plotted at least annually by primary care providers. 15 Children who are found to be “overweight” or “obese” based on BMI criteria should receive counseling aimed at improving eating habits, increasing physical activity and decreasing sedentary activities such as television. 15 For children with BMI at or higher than the 95th percentile, measurement of fasting lipid panel, fasting glucose, ALT and AST levels is recommended every 2 years starting at 10 years of age. 15 It is also recommended that children with BMI between 85th and 94th percentile undergo lipid panel testing and, if risk factors such as family history of obesity-related diseases, elevated blood pressure, elevated lipid levels, or tobacco use are present, then fasting glucose, ALT, and AST levels should be measured every 2 years for children aged 10 years and older. We noted significant increase in screening for nonalcoholic fatty liver disease in 2009 compared with 2006. Other investigators have not reported any differences in laboratory test ordering between 2008 and 2006. 19 As clinical guidelines relating to laboratory screening for fatty liver disease were published in December 2007, it is likely that greater awareness among the care providers in the year 2009 than in 2008 may have contributed to these differences. We also found a significant increase in counseling pertaining to screen time. This may be secondary to the heightened attention increased screen time has received relative to its roles not only in promoting obesity but also in delaying language development and increasing aggression in young children. 20 , 21 Despite increasing diagnosis of childhood obesity, almost half of the obese children in 2009 were not diagnosed as obese and only 1 in 6 overweight children were identified as being overweight. Similar to other reports, we found that the diagnosis of obesity was the strongest predictor for receiving weight-related management. 2 , 3 , 6 Therefore, measures aimed at improving the diagnosis of obesity are warranted. Guideline adherence is often promoted in health care centers by incorporation of the recommendations in various continuing medical education activities for care providers. In addition, these recommendations are often incorporated in flow charts/standard practice guidelines for general medical examinations. These activities may be particularly helpful for those providers/groups that are least adherent. Follow-up evaluation is recommended to determine if interventions aimed at improving adherence of the primary care providers to the guidelines have been effective. Only about a third of obese children older than 10 years in 2009 underwent recommended screening for type 2 diabetes, nonalcoholic fatty liver disease, and lipid disorders. The higher rates of screening for type 2 diabetes mellitus and lipid disorders in our population compared with another report from an academic center serving predominantly minority subjects during the years 2001-2002 may be related both to the demographics of the population served and to the later timing of our study. 7 Our study has several limitations. First, our study results may not be representative of the ethnically diverse population in the United States as our study subjects were primarily white and our data was derived from a single medical center with majority of the study population living within the same town. Second, we evaluated whether physicians diagnosed or managed obesity by reviewing documentation in the medical records. Physicians may have discussed obesity as a health problem and discussed appropriate counseling but not documented it. We did, however, use a search for an exhaustive list of terms in the medical records to decrease that possibility instead of relying on ICD-9 codes. We did not collect information on the demographic attributes of the providers and these may be an important determinant of physician practices regarding obesity diagnosis and management. We determined whether laboratory studies had been performed in obese children older than 10 years of age. Many children or their families may have elected to not get these tests drawn despite recommendations from their health care provider. The effect of socioeconomic and demographic characteristics of the parents such as ethnicity, income, and education on rates of laboratory screening was also not examined. Although we noted improvement in obesity diagnosis and obesity-related counseling and laboratory screening by primary care providers, continued efforts to increase awareness of these issues are needed as nearly half of obese children remained undiagnosed and recommended laboratory screening for obesity-related comorbidities was performed in only a third of obese children. We would like to thank Pauline Funk for data retrieval. Authors’ Note Drs Nader and Singhal contributed equally to the manuscript. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the T. Denny Sanford Endowed Pediatric Collaborative Research Fund.
PY - 2014/1
Y1 - 2014/1
N2 - Objective: To determine the temporal trends in diagnosis and management of pediatric overweight/obesity by primary care providers at a single medical center. Patients: Children 2 to 18 years old undergoing a general medical examination during 3 calendar years (2003, 2006, and 2009). The number of visits for general medical examination were 6390 in 2003, 6646 in 2006, and 7408 in 2009. Methods: We performed a retrospective review of the electronic medical records for weight related diagnostic and/or management terms and laboratory screening in children with body mass index at or greater than the 85th percentile (n = 1630 in 2003, 1495 in 2006, and 1730 in 2009). Results: There was a significant increase in the diagnosis of obesity among obese children seen in 2009 (53.3%) compared with 2006 (36%, P <.001) and 2003 (24.3%, P <.001). Weight-related counseling was documented in a higher proportion of obese children in 2009 (49.4%) compared with 2006 (34.8%) and 2003 (26.6%). There was a significant increase in counseling regarding screen time in 2009 compared with 2006. A significant increase in screening for nonalcoholic fatty liver disease was also noted (30.5% in 2009 vs 21.9% in 2006, P =.018). Conclusions: There has been steady improvement in the rates of obesity diagnosis and obesity-related counseling by primary care providers. However, continued efforts to increase awareness of these issues are needed as nearly half of obese children remained undiagnosed and recommended laboratory screening for obesity-related comorbidities was performed in only a third of obese children.
AB - Objective: To determine the temporal trends in diagnosis and management of pediatric overweight/obesity by primary care providers at a single medical center. Patients: Children 2 to 18 years old undergoing a general medical examination during 3 calendar years (2003, 2006, and 2009). The number of visits for general medical examination were 6390 in 2003, 6646 in 2006, and 7408 in 2009. Methods: We performed a retrospective review of the electronic medical records for weight related diagnostic and/or management terms and laboratory screening in children with body mass index at or greater than the 85th percentile (n = 1630 in 2003, 1495 in 2006, and 1730 in 2009). Results: There was a significant increase in the diagnosis of obesity among obese children seen in 2009 (53.3%) compared with 2006 (36%, P <.001) and 2003 (24.3%, P <.001). Weight-related counseling was documented in a higher proportion of obese children in 2009 (49.4%) compared with 2006 (34.8%) and 2003 (26.6%). There was a significant increase in counseling regarding screen time in 2009 compared with 2006. A significant increase in screening for nonalcoholic fatty liver disease was also noted (30.5% in 2009 vs 21.9% in 2006, P =.018). Conclusions: There has been steady improvement in the rates of obesity diagnosis and obesity-related counseling by primary care providers. However, continued efforts to increase awareness of these issues are needed as nearly half of obese children remained undiagnosed and recommended laboratory screening for obesity-related comorbidities was performed in only a third of obese children.
KW - Guidelines
KW - Laboratory screening
KW - Obesity
KW - Overweight
KW - Pediatric
UR - http://www.scopus.com/inward/record.url?scp=84904106917&partnerID=8YFLogxK
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U2 - 10.1177/2150131913495739
DO - 10.1177/2150131913495739
M3 - Article
C2 - 24327587
AN - SCOPUS:84904106917
SN - 2150-1319
VL - 5
SP - 44
EP - 49
JO - Journal of primary care & community health
JF - Journal of primary care & community health
IS - 1
ER -