Journal of Primaryhttp://jpc.sagepub.com/ Care & Community Health
Temporal Trends in the Diagnosis and Management of Childhood Obesity/Overweight in Primary Care Nicole Nader, Vibha Singhal, Asma Javed, Amy Weaver and Seema Kumar Journal of Primary Care & Community Health published online 14 July 2013 DOI: 10.1177/2150131913495739 The online version of this article can be found at: http://jpc.sagepub.com/content/early/2013/07/14/2150131913495739 A more recent version of this article was published on - Jan 2, 2014
Published by: http://www.sagepublications.com
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495739
research-article2013
JPCXXX10.1177/2150131913495739Journal of Primary Care & Community HealthNader et al
Article
Temporal Trends in the Diagnosis and Management of Childhood Obesity/Overweight in Primary Care
Journal of Primary Care & Community Health XX(X) 1–6 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131913495739 jpc.sagepub.com
Nicole Nader1, Vibha Singhal2, Asma Javed3, Amy Weaver3 and Seema Kumar3
Abstract 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. Keywords pediatric, overweight, obesity, guidelines, laboratory screening
Introduction The prevalence of childhood obesity has reached epidemic proportions. 16.9% of children and adolescents aged 2 through 19 years have a body mass index (BMI) ≥the 95th percentile for their age and gender and 31.8% have a BMI at or higher than the 85th percentile.1 Nevertheless, studies have indicated that a large percentage of overweight and obese patients remain undiagnosed.2-8 Previous studies have reported rates of diagnosis ranging from 18% to 54%.1 Nevertheless, studies have indicated that a large percentage of overweight and obese patients remain undiagnosed.2-8 Higher rates of diagnosis of obesity have been noted in those with severe obesity, females and those older than 6 years.2,4,9 Factors responsible for low rates of obesity diagnosis may include a lack of familiarity with the revised definitions of childhood overweight and obesity, insufficient time available for appropriate counseling and the contention that counseling may have modest impact as suggested
by recent nationally representative surveys of the American Academy of Pediatrics and American Academy of Family Physicians.10-14 In 2007, recommendations were made to classify children with BMI ≥95th percentile for their age and gender as “obese” rather than “overweight” and those with a BMI between the 85th and 94th percentile as “overweight” rather than “at risk for overweight.”15 Specific recommendations were also made regarding lifestyle counseling and laboratory screening for obesity-related comorbidities.15 The objective of this study was to examine temporal trends in the 1
Park Nicollet Clinic, St Louis Park, MN, USA Massachusetts General Hospital, Boston, MA, USA 3 Mayo Clinic, Rochester, MN, USA 2
Corresponding Author: Seema Kumar, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Email: [email protected]
Downloaded from jpc.sagepub.com at GEORGIAN COURT UNIV on October 14, 2014
2
Journal of Primary Care & Community Health XX(X)
rates of diagnosis and management of obesity and overweight by primary care providers at a single medical center.
Methods The study cohort consisted of children 2 to 18 years old who underwent an outpatient general medical examination, in primary care (pediatrics and family medicine) at a single medical center during 2003, 2006, or 2009. In all, 70% of the study subjects/patients live within the same town and non-Hispanic whites constitute majority (84%) of the study local population.16,17 The study was approved by the institutional review board. The BMI recorded in the electronic medical record was obtained. For patients with more than one medical examination visit in the calendar year of interest, the visit with the highest documented BMI in that calendar year was defined as the index visit. Age- and sex-specific BMI percentiles were calculated using the 2000 Centers for Disease Control and Prevention growth charts.18 The patients were then classified into 3 groups: obese (BMI ≥95th percentile for age and gender), overweight (BMI between the 85th and 94th percentile), and others. Severe obesity was defined as BMI at or greater than the 99th percentile. For the overweight or obese children, the text in the diagnosis, impression, report, and plan sections of the record was electronically searched by personnel unaware of study hypothesis for weight related diagnostic and management terms (supplemental table for terms available on request). Examples of searched terms for diagnosis were BMI, overweight, weight concerns, obesity, weight gain or weight increase and for weight management or counseling were weight, exercise, diet, television, screen time, portion control, healthy eating, diet modification, and physical activity. The medical records of patients identified during the electronic search as having one or more of the weightrelated diagnostic and management terms were also reviewed manually and the type of management plan was categorized into: dietary changes, increased activity, decreased screen time, and follow-up. For the obese patients older than 10 years, laboratory tests were queried electronically to determine whether any of the laboratory studies recommended for overweight or obese children older than 10 years (lipid panel, aspartate aminotransferase [AST], alanine aminotransferase [ALT], fasting plasma glucose) had been performed within 2 years before or after the index visit.
Analysis The binary outcomes were compared between specific calendar years of interest (2003 vs 2006 or 2006 vs 2009) using the χ2 test, or across all 3 calendar years using the
Cochran–Armitage test for trend. Associations of patient and provider factors with each of the outcomes, documentation of a weight-related diagnostic term, and documentation of a weight management term, respectively, were assessed by fitting univariable and multivariable logistic regression models. The strength of the associations was assessed by calculating odds ratios (ORs) and corresponding 95% percent confidence intervals (95% CIs). All calculated P values were 2-sided and P values
Temporal Trends in the Diagnosis and Management of Childhood Obesity/Overweight in Primary Care Nicole Nader, Vibha Singhal, Asma Javed, Amy Weaver and Seema Kumar Journal of Primary Care & Community Health published online 14 July 2013 DOI: 10.1177/2150131913495739 The online version of this article can be found at: http://jpc.sagepub.com/content/early/2013/07/14/2150131913495739 A more recent version of this article was published on - Jan 2, 2014
Published by: http://www.sagepublications.com
Additional services and information for Journal of Primary Care & Community Health can be found at: Email Alerts: http://jpc.sagepub.com/cgi/alerts Subscriptions: http://jpc.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
Version of Record - Jan 2, 2014 >> OnlineFirst Version of Record - Jul 14, 2013 What is This?
Downloaded from jpc.sagepub.com at GEORGIAN COURT UNIV on October 14, 2014
495739
research-article2013
JPCXXX10.1177/2150131913495739Journal of Primary Care & Community HealthNader et al
Article
Temporal Trends in the Diagnosis and Management of Childhood Obesity/Overweight in Primary Care
Journal of Primary Care & Community Health XX(X) 1–6 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131913495739 jpc.sagepub.com
Nicole Nader1, Vibha Singhal2, Asma Javed3, Amy Weaver3 and Seema Kumar3
Abstract 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. Keywords pediatric, overweight, obesity, guidelines, laboratory screening
Introduction The prevalence of childhood obesity has reached epidemic proportions. 16.9% of children and adolescents aged 2 through 19 years have a body mass index (BMI) ≥the 95th percentile for their age and gender and 31.8% have a BMI at or higher than the 85th percentile.1 Nevertheless, studies have indicated that a large percentage of overweight and obese patients remain undiagnosed.2-8 Previous studies have reported rates of diagnosis ranging from 18% to 54%.1 Nevertheless, studies have indicated that a large percentage of overweight and obese patients remain undiagnosed.2-8 Higher rates of diagnosis of obesity have been noted in those with severe obesity, females and those older than 6 years.2,4,9 Factors responsible for low rates of obesity diagnosis may include a lack of familiarity with the revised definitions of childhood overweight and obesity, insufficient time available for appropriate counseling and the contention that counseling may have modest impact as suggested
by recent nationally representative surveys of the American Academy of Pediatrics and American Academy of Family Physicians.10-14 In 2007, recommendations were made to classify children with BMI ≥95th percentile for their age and gender as “obese” rather than “overweight” and those with a BMI between the 85th and 94th percentile as “overweight” rather than “at risk for overweight.”15 Specific recommendations were also made regarding lifestyle counseling and laboratory screening for obesity-related comorbidities.15 The objective of this study was to examine temporal trends in the 1
Park Nicollet Clinic, St Louis Park, MN, USA Massachusetts General Hospital, Boston, MA, USA 3 Mayo Clinic, Rochester, MN, USA 2
Corresponding Author: Seema Kumar, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Email: [email protected]
Downloaded from jpc.sagepub.com at GEORGIAN COURT UNIV on October 14, 2014
2
Journal of Primary Care & Community Health XX(X)
rates of diagnosis and management of obesity and overweight by primary care providers at a single medical center.
Methods The study cohort consisted of children 2 to 18 years old who underwent an outpatient general medical examination, in primary care (pediatrics and family medicine) at a single medical center during 2003, 2006, or 2009. In all, 70% of the study subjects/patients live within the same town and non-Hispanic whites constitute majority (84%) of the study local population.16,17 The study was approved by the institutional review board. The BMI recorded in the electronic medical record was obtained. For patients with more than one medical examination visit in the calendar year of interest, the visit with the highest documented BMI in that calendar year was defined as the index visit. Age- and sex-specific BMI percentiles were calculated using the 2000 Centers for Disease Control and Prevention growth charts.18 The patients were then classified into 3 groups: obese (BMI ≥95th percentile for age and gender), overweight (BMI between the 85th and 94th percentile), and others. Severe obesity was defined as BMI at or greater than the 99th percentile. For the overweight or obese children, the text in the diagnosis, impression, report, and plan sections of the record was electronically searched by personnel unaware of study hypothesis for weight related diagnostic and management terms (supplemental table for terms available on request). Examples of searched terms for diagnosis were BMI, overweight, weight concerns, obesity, weight gain or weight increase and for weight management or counseling were weight, exercise, diet, television, screen time, portion control, healthy eating, diet modification, and physical activity. The medical records of patients identified during the electronic search as having one or more of the weightrelated diagnostic and management terms were also reviewed manually and the type of management plan was categorized into: dietary changes, increased activity, decreased screen time, and follow-up. For the obese patients older than 10 years, laboratory tests were queried electronically to determine whether any of the laboratory studies recommended for overweight or obese children older than 10 years (lipid panel, aspartate aminotransferase [AST], alanine aminotransferase [ALT], fasting plasma glucose) had been performed within 2 years before or after the index visit.
Analysis The binary outcomes were compared between specific calendar years of interest (2003 vs 2006 or 2006 vs 2009) using the χ2 test, or across all 3 calendar years using the
Cochran–Armitage test for trend. Associations of patient and provider factors with each of the outcomes, documentation of a weight-related diagnostic term, and documentation of a weight management term, respectively, were assessed by fitting univariable and multivariable logistic regression models. The strength of the associations was assessed by calculating odds ratios (ORs) and corresponding 95% percent confidence intervals (95% CIs). All calculated P values were 2-sided and P values
