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Diagnosis And Treatment Frequency for Overweight Children And Adolescents at Well Child Visits
Diagnosis And Treatment Frequency for Overweight Children And Adolescents at Well Child Visits -- Posted by Gumbo on 02-16-05 05:27
Diagnosis And Treatment Frequency for Overweight Children And Adolescents at
Well Child Visits
Originally Published:20050101.
Introduction
Much attention has been focused in both the medical literature and the
popular press on the current epidemic increase in overweight children. The
prevalence of overweight children has increased from 5% to more than 15% in
the past 25 years and shows no sign of abating.1 In the past, many of the
health consequences of obesity were found in adulthood.2 Unfortunately, we
are now seeing many comorbidities of obesity in the pediatric office,
including insulin resistance, hypertension, hyperlipidemia, growth changes,
social and psychological disorders, hepatic steatosis, sleep apnea, and
orthopedic complications.3 With this dramatic increase in disease, many are
asking about the role of pediatricians in the prevention, identification,
and treatment of overweight.
Recently published articles in the pediatric literature have highlighted
disparities in the diagnosis, evaluation, and treatment of overweight
children and adolescents.4-9 Medical evaluation surveys of pediatricians and
nurse practitioners demonstrated that the majority of self-reported
practices of diagnosing overweight children did not meet the recommended
evaluation practices.7 In 1998, the body mass index (BMI) percentile for
gender and age was established as the recommended method for office-based
assessment of overweight10 in children and adults, yet the same surveys
demonstrated that only 12.5% of pediatricians reported using this method.
The majority reported using clinical impression, weight-for-age percentile,
and weight-for-height percentile.
In our clinics, the BMI percentile for age and gender was not being used at
the time of our study. This gave us the opportunity to determine the
accuracy and frequency of diagnosis of children "at risk to be overweight"
or overweight at well child visits from use of clinical impression,
weight-for-age percentile, and weight-for-height percentile. Additionally,
we determined how often treatment was provided to those identified as at
risk or overweight.
Methods
During a 2-week period in July 2002, charts of children who attended well
child checkups at 3 general pediatric clinics affiliated with the University
of Louisville, Department of Pediatrics, were reviewed. Two clinics serve an
inner city Medicaid population while a third serves a low-income suburban
area. We identified all children aged 2 to 18 years presenting (or well
child visits from the clinic sign-in list and obtained demographic
variables, height, weight, diagnosis, and treatment information from their
charts. Ethnic group designation was obtained from the Medicaid information
sheet when available or from the notes by the nurse or physician. Using the
height and weight recorded for each child, we calculated the BMI
(weight/height2 × 703) and then determined the BMI percentile for age and
gender. The recommended classification from the Centers for Disease Control
was utilized to classify a child with BMI ? 85th to 95th percentile as "at
risk for overweight" and a child with BMI ? 95th percentile as overweight.
Each physician or nurse practitioner's record of the well child visit was
reviewed by 1 of 3 reviewers for evidence of the diagnosis of "at risk to be
overweight" or overweight. A child was considered "diagnosed" if the record
of the visit contained any of the following words in the assessment and
plan: obese, obesity, overweight, weight problem, weight >95th perccntile,
weight > 85th, or "at risk to be overweight." Each well child plan was
assessed for any indication of treatment provided for overweight.
Data were entered into SPSS, and simple percentages and frequency were
obtained. The variables influencing the risk of diagnosis were analyzed by
use of frequency tables and multiple logistic regression. The mean BMI of
the children diagnosed versus not diagnosed was compared by use of
independent samples t-test.
Results
During the 2-week study period (July 2002) 478 children aged 2 to 18 years
were seen for well child visits. The charts of 473 children were available
for review and comprised the study population. There were 257 (54%) males
and 216 (46%) females. Racial distribution reflected the clinics'
population: 72% (340 of 473) African-American, 24% (112 of 473) Caucasian,
and 1% (5 of 4-73) Hispanic. The majority of the subjects (93%) were
enrolled in a managed Medicaid program.
The 473 well child visits were staffed by 14 board-certified general
pediatricians. The majority (64%) of the physicians were trained at this
same institution, with the remainder trained at 5 different pediatric
institutions. The mean length of time in practice was 16 years (± 11.2) with
a range of 2 to 36 years. Each physician practiced at only 1 clinic, and
responsibilities for well child visits were evenly distributed among the
physicians at all 3 clinics. The frequency of identifying children as
overweight or "at risk for overweight" did not vary significantly among the
3 clinics (p=0.160, Table 1), although there was a wide range from 9 to 36%
(p=0.130, Table 1).
We identified 17% (82 of 473) of the subjects as "at risk to be overweight"
with BMI ? 85th and < 95th percentile and 20% (93 of 473) as overweight (BMI
? 95th percentile). The demographics of the overweight children again
reflected our general patient population with 68 (73%) under 12 years old,
54 (58%) male, and 65 (70%) African-American. A diagnosis of overweight was
made in only 29% (27 of 93) of overweight children, while only 1 of the 82
children "at risk to be overweight" was identified as such.
Race and gender did not have a significant influence on diagnosis, although
there was a trend for the diagnosed overweight child to be female (Table 2).
In addition, older children (7 ½ years old) were more likely to be diagnosed
(OR=3.26, p=0.015). The mean BMI for the diagnosed overweight children (30.5
±5.13) was significantly higher than that for the undiagnosed overweight
children (24.6 ± 6.80), with a mean difference of 5.891 (3.29-8.50,
p<0.001).
A treatment plan was given to 85% (23 of 27) of the children diagnosed as
overweight. The majority of the interventions for overweight children were
recommendations for increased exercise, improved nutrition, and changes in
eating patterns. In addition, 22% received a referral to a nutritionist.
Discussion
Our analysis of the 473 well child visits confirmed that the majority of
children who were "at risk to be overweight" and who were overweight were
not identified as such by the physician at the visit. At the time of this
study, our charts had weight-for-age and height-for-age percentiles
available for plotting but did not routinely contain a BMI chart. In fact,
none of the charts reviewed had a BMI calculated and recorded, but most of
the children did have the weight-for-age percentile plotted. Presumably,
diagnosis of obesity was made by using clinical impression, weight-for-age,
and weight-for-height percentile assessment. These diagnostic methods
resulted in only 29% of overweight children being correctly identified,
while 71% of overweight children were missed.
Previous articles have shown that most physicians report using the
above-cited clinical methods to diagnose children as overweight.9
Unfortunately, given our findings, this leads to gross underdiagnosis of
overweight children. The situation is even more serious when "at risk to be
overweight" children are considered. This category of children should be
identified for further health evaluation such as family history, blood
pressure, and more.11 Our results show that almost all (99%) of "at risk to
be overweight" children were unidentified for further evaluation.
Well child checkups are an important opportunity for prevention of many
diseases, including obesity. Expert committee recommendations in 1998 stated
that children in the at risk category (85th to 95th percentile) should
undergo evaluation and possible treatment, including family oriented
stepwise improvements in activity and nutrition.11 The well child visit is a
golden opportunity and accessible venue for these preventive pursuits.
Recently (August 2003), the American Academy of Pediatrics issued a policy
statement proposing strategies for early identification of excessive weight
gain.12 The statement concluded that early recognition depended on routine
BMI calculation and plotting of the BMI percentile periodically to assess
trends in the child's weight. Pediatricians have long used height and weight
trends to assess health risks such as failure to thrive, growth hormone
deficiency, familial short stature, and more. Our data provide evidence of
the importance of adding routine assessment of BMI percentile for age and
gender to the vital signs of the well child visit for early identification
of both at risk and overweight children.
In our data, children who were older and heavier were more likely to be
diagnosed than the younger more moderately overweight children. We agree
that the more severely overweight children are unlikely to be missed by any
method of detection of overweight. However, the children who are younger and
mildly overweight and who have more potential to have their disease process
successfully interrupted are the ones who were typically missed by the
non-BMI-based methods of identification. Although data on early recognition
and prevention of obesity are very limited, studies in the literature
suggest an early identification benefit. Treatment studies in preadolescent
children were more successful than in adults provided the same family-based
intervention.13 Also, children who are still growing in height can normalize
their BMI with weight maintenance, an easier feat than losing weight.14,15
Both of these factors suggest that early intervention and identification at
a younger age will be more successful in producing improvements in weight
through office-based education and treatment.
The majority (85%) of children in our study who were identified as either
"at risk to be overweight" or overweight were appropriately treated. The
treatments were typical of the office setting and included recommendations
for increased exercise, improved nutrition, decreased TV watching, changes
in eating patterns, and referrals to nutritionists. Results of these
treatment regimens were not analyzed for purposes of this study. At this
center, we do not have a specific fitness program for overweight children,
so this was not a treatment option.
All of the physicians who participated in this study were practicing in an
academic setting. While this may introduce a bias into this study, given the
high emphasis on continuing education in the academic setting, one would
assume that the bias would be in favor of increased diagnosis. This study
would be improved if additional types of practices could be included.
Since this study was performed, we have instituted the calculation and
plotting of the BMI percentile on every child at every sick and well visit
at these clinics. We feel that this is the first step to improving our
diagnosis and treatment frequency. Over time we expect this will also
improve our prevention of overweight, as we identify the children developing
an increasing BMI, but who are not yet above the 85th percentile. In the
future, we plan to reassess our diagnosis frequency and the success of our
interventions.
(C) 2005 Clinical Pediatrics. via ProQuest Information and Learning Company;
All Rights Reserved
Re: Diagnosis And Treatment Frequency for Overweight Children And Adolescents at Well Child Visits -- Posted by Larry on 02-21-05 09:12
Gumbo,
If you have time since it is so frozen up Canada these days, check our
www.hee-corp.com and tell me what you think
"Gumbo" wrote in message news:cuvhoa$cc1$0@pita.alt.net...
>
> Diagnosis And Treatment Frequency for Overweight Children And Adolescents
> at Well Child Visits
>
>
> Originally Published:20050101.
>
> Introduction
>
> Much attention has been focused in both the medical literature and the
> popular press on the current epidemic increase in overweight children. The
> prevalence of overweight children has increased from 5% to more than 15%
> in the past 25 years and shows no sign of abating.1 In the past, many of
> the health consequences of obesity were found in adulthood.2
> Unfortunately, we are now seeing many comorbidities of obesity in the
> pediatric office, including insulin resistance, hypertension,
> hyperlipidemia, growth changes, social and psychological disorders,
> hepatic steatosis, sleep apnea, and orthopedic complications.3 With this
> dramatic increase in disease, many are asking about the role of
> pediatricians in the prevention, identification, and treatment of
> overweight.
>
> Recently published articles in the pediatric literature have highlighted
> disparities in the diagnosis, evaluation, and treatment of overweight
> children and adolescents.4-9 Medical evaluation surveys of pediatricians
> and nurse practitioners demonstrated that the majority of self-reported
> practices of diagnosing overweight children did not meet the recommended
> evaluation practices.7 In 1998, the body mass index (BMI) percentile for
> gender and age was established as the recommended method for office-based
> assessment of overweight10 in children and adults, yet the same surveys
> demonstrated that only 12.5% of pediatricians reported using this method.
> The majority reported using clinical impression, weight-for-age
> percentile, and weight-for-height percentile.
>
> In our clinics, the BMI percentile for age and gender was not being used
> at the time of our study. This gave us the opportunity to determine the
> accuracy and frequency of diagnosis of children "at risk to be overweight"
> or overweight at well child visits from use of clinical impression,
> weight-for-age percentile, and weight-for-height percentile. Additionally,
> we determined how often treatment was provided to those identified as at
> risk or overweight.
>
> Methods
>
> During a 2-week period in July 2002, charts of children who attended well
> child checkups at 3 general pediatric clinics affiliated with the
> University of Louisville, Department of Pediatrics, were reviewed. Two
> clinics serve an inner city Medicaid population while a third serves a
> low-income suburban area. We identified all children aged 2 to 18 years
> presenting (or well child visits from the clinic sign-in list and obtained
> demographic variables, height, weight, diagnosis, and treatment
> information from their charts. Ethnic group designation was obtained from
> the Medicaid information sheet when available or from the notes by the
> nurse or physician. Using the height and weight recorded for each child,
> we calculated the BMI (weight/height2 × 703) and then determined the BMI
> percentile for age and gender. The recommended classification from the
> Centers for Disease Control was utilized to classify a child with BMI ?
> 85th to 95th percentile as "at risk for overweight" and a child with BMI ?
> 95th percentile as overweight.
>
> Each physician or nurse practitioner's record of the well child visit was
> reviewed by 1 of 3 reviewers for evidence of the diagnosis of "at risk to
> be overweight" or overweight. A child was considered "diagnosed" if the
> record of the visit contained any of the following words in the assessment
> and plan: obese, obesity, overweight, weight problem, weight >95th
> perccntile, weight > 85th, or "at risk to be overweight." Each well child
> plan was assessed for any indication of treatment provided for overweight.
>
> Data were entered into SPSS, and simple percentages and frequency were
> obtained. The variables influencing the risk of diagnosis were analyzed by
> use of frequency tables and multiple logistic regression. The mean BMI of
> the children diagnosed versus not diagnosed was compared by use of
> independent samples t-test.
>
> Results
>
> During the 2-week study period (July 2002) 478 children aged 2 to 18 years
> were seen for well child visits. The charts of 473 children were available
> for review and comprised the study population. There were 257 (54%) males
> and 216 (46%) females. Racial distribution reflected the clinics'
> population: 72% (340 of 473) African-American, 24% (112 of 473) Caucasian,
> and 1% (5 of 4-73) Hispanic. The majority of the subjects (93%) were
> enrolled in a managed Medicaid program.
>
> The 473 well child visits were staffed by 14 board-certified general
> pediatricians. The majority (64%) of the physicians were trained at this
> same institution, with the remainder trained at 5 different pediatric
> institutions. The mean length of time in practice was 16 years (± 11.2)
> with a range of 2 to 36 years. Each physician practiced at only 1 clinic,
> and responsibilities for well child visits were evenly distributed among
> the physicians at all 3 clinics. The frequency of identifying children as
> overweight or "at risk for overweight" did not vary significantly among
> the 3 clinics (p=0.160, Table 1), although there was a wide range from 9
> to 36% (p=0.130, Table 1).
>
> We identified 17% (82 of 473) of the subjects as "at risk to be
> overweight" with BMI ? 85th and < 95th percentile and 20% (93 of 473) as
> overweight (BMI ? 95th percentile). The demographics of the overweight
> children again reflected our general patient population with 68 (73%)
> under 12 years old, 54 (58%) male, and 65 (70%) African-American. A
> diagnosis of overweight was made in only 29% (27 of 93) of overweight
> children, while only 1 of the 82 children "at risk to be overweight" was
> identified as such.
>
> Race and gender did not have a significant influence on diagnosis,
> although there was a trend for the diagnosed overweight child to be female
> (Table 2). In addition, older children (7 ½ years old) were more likely to
> be diagnosed (OR=3.26, p=0.015). The mean BMI for the diagnosed overweight
> children (30.5 ±5.13) was significantly higher than that for the
> undiagnosed overweight children (24.6 ± 6.80), with a mean difference of
> 5.891 (3.29-8.50, p<0.001).
>
> A treatment plan was given to 85% (23 of 27) of the children diagnosed as
> overweight. The majority of the interventions for overweight children were
> recommendations for increased exercise, improved nutrition, and changes in
> eating patterns. In addition, 22% received a referral to a nutritionist.
>
> Discussion
>
> Our analysis of the 473 well child visits confirmed that the majority of
> children who were "at risk to be overweight" and who were overweight were
> not identified as such by the physician at the visit. At the time of this
> study, our charts had weight-for-age and height-for-age percentiles
> available for plotting but did not routinely contain a BMI chart. In fact,
> none of the charts reviewed had a BMI calculated and recorded, but most of
> the children did have the weight-for-age percentile plotted. Presumably,
> diagnosis of obesity was made by using clinical impression,
> weight-for-age, and weight-for-height percentile assessment. These
> diagnostic methods resulted in only 29% of overweight children being
> correctly identified, while 71% of overweight children were missed.
>
> Previous articles have shown that most physicians report using the
> above-cited clinical methods to diagnose children as overweight.9
> Unfortunately, given our findings, this leads to gross underdiagnosis of
> overweight children. The situation is even more serious when "at risk to
> be overweight" children are considered. This category of children should
> be identified for further health evaluation such as family history, blood
> pressure, and more.11 Our results show that almost all (99%) of "at risk
> to be overweight" children were unidentified for further evaluation.
>
> Well child checkups are an important opportunity for prevention of many
> diseases, including obesity. Expert committee recommendations in 1998
> stated that children in the at risk category (85th to 95th percentile)
> should undergo evaluation and possible treatment, including family
> oriented stepwise improvements in activity and nutrition.11 The well child
> visit is a golden opportunity and accessible venue for these preventive
> pursuits.
>
> Recently (August 2003), the American Academy of Pediatrics issued a policy
> statement proposing strategies for early identification of excessive
> weight gain.12 The statement concluded that early recognition depended on
> routine BMI calculation and plotting of the BMI percentile periodically to
> assess trends in the child's weight. Pediatricians have long used height
> and weight trends to assess health risks such as failure to thrive, growth
> hormone deficiency, familial short stature, and more. Our data provide
> evidence of the importance of adding routine assessment of BMI percentile
> for age and gender to the vital signs of the well child visit for early
> identification of both at risk and overweight children.
>
> In our data, children who were older and heavier were more likely to be
> diagnosed than the younger more moderately overweight children. We agree
> that the more severely overweight children are unlikely to be missed by
> any method of detection of overweight. However, the children who are
> younger and mildly overweight and who have more potential to have their
> disease process successfully interrupted are the ones who were typically
> missed by the non-BMI-based methods of identification. Although data on
> early recognition and prevention of obesity are very limited, studies in
> the literature suggest an early identification benefit. Treatment studies
> in preadolescent children were more successful than in adults provided the
> same family-based intervention.13 Also, children who are still growing in
> height can normalize their BMI with weight maintenance, an easier feat
> than losing weight.14,15 Both of these factors suggest that early
> intervention and identification at a younger age will be more successful
> in producing improvements in weight through office-based education and
> treatment.
>
> The majority (85%) of children in our study who were identified as either
> "at risk to be overweight" or overweight were appropriately treated. The
> treatments were typical of the office setting and included recommendations
> for increased exercise, improved nutrition, decreased TV watching, changes
> in eating patterns, and referrals to nutritionists. Results of these
> treatment regimens were not analyzed for purposes of this study. At this
> center, we do not have a specific fitness program for overweight children,
> so this was not a treatment option.
>
> All of the physicians who participated in this study were practicing in an
> academic setting. While this may introduce a bias into this study, given
> the high emphasis on continuing education in the academic setting, one
> would assume that the bias would be in favor of increased diagnosis. This
> study would be improved if additional types of practices could be
> included.
>
> Since this study was performed, we have instituted the calculation and
> plotting of the BMI percentile on every child at every sick and well visit
> at these clinics. We feel that this is the first step to improving our
> diagnosis and treatment frequency. Over time we expect this will also
> improve our prevention of overweight, as we identify the children
> developing an increasing BMI, but who are not yet above the 85th
> percentile. In the future, we plan to reassess our diagnosis frequency and
> the success of our interventions.
>
> (C) 2005 Clinical Pediatrics. via ProQuest Information and Learning
> Company; All Rights Reserved
>
>
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