National Survey Shows Childhood Obesity Under-diagnosed

July 06, 2005

Pediatricians often miss opportunities to diagnose obesity and offer diet and exercise counseling to children and their parents during regular office visits, according to a University of Rochester Medical Center study published in the July issue of Pediatrics.

Research data from 1997 to 2000 shows that physicians diagnosed obesity less than 1 percent of the time during 33,000 office visits (representing 131.2 million visits when weighted national estimates are applied) for 2- to 18-year-olds.

In 2001, it was estimated that 15 percent of children ages 6 to 19 in the United States were overweight or obese, indicating a marked discrepancy between diagnosis and reality. The study authors believe physicians may overlook obesity as a diagnosis due to a number of factors: a perceived lack of patient motivation; lack of time available for counseling; lack of effective treatment; and lack of insurance reimbursement for a focused discussion of the condition.

This is the first study to use a nationally representative sample of outpatient visits to investigate the rates of obesity diagnoses, and also the rates of screening for hypertension, nutrition and exercise counseling, researchers said. However, they caution that variation in the way doctors use the term “obesity” may limit the study findings. For example, diagnostic codes use the phrases “obesity” and “morbid obesity,” but recent guidelines issued by the Centers for Disease Control use the term “overweight.”  It is also possible that doctors talk about excess weight during the well-child visit but do not make note of it in the medical chart.

“The rates of diagnosis were much lower than what we expected, and that’s disappointing considering that obesity is growing quite rapidly as a serious chronic medical threat to children,” said lead author Stephen Cook, M.D., from the university’s Golisano Children’s Hospital at Strong, the Strong Children’s Research Center, and the American Academy of Pediatrics Center for Child Health Research.

Among the 32,930 regular office visits, the study showed that only 281 (or 0.78 percent) carried a charted diagnosis of excess weight gain, obesity or morbid obesity. In the case of well-child visits – which are specifically designed to discuss and screen for chronic conditions – the frequency of obesity diagnosis was 0.9 percent over the four-year study period.

What is encouraging, though, is that once obesity was identified, physicians were more likely to screen for complications of obesity, the study said. Blood pressure screenings, for example, occurred more often at well-child visits with obesity identified (61 percent) as opposed to well-child visits without obesity identified (43 percent.) Counseling rates for nutrition and exercise increased 10-fold when obesity was identified.

Controlling obesity is important because it may lead to other serious medical conditions such as type 2 diabetes, metabolic syndrome, and heart disease. In the same issue of Pediatrics, the U.S. Preventive Services Task Force, a group of national experts, issued a “call to action” to the pediatric scientific community to address obesity.

The task force reports that most obesity interventions have not been tested in rigorous, randomized clinical trials. At this point, for example, it is unknown whether screening for obesity does any good, or if it results in potential harm such as labeling, reduced self-esteem, or eating disorders. Researchers also don’t know whether screening correctly identifies children at risk for future health problems linked to obesity.

Still, with obesity rates tripling during the past 20 years, “we can’t afford to wait for a perfect experiment to find out what we should do to help people stay healthy,” advises Jonathan Klein, M.D., MPH, associate professor of Pediatrics and of Community and Preventive Medicine at the University of Rochester Medical Center, and a co-author of the commentary. Pediatricians must use the best tools available to help children and families address obesity, even as additional studies move forward to identify the most effective treatments, he said.

Data for Cook’s study came from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey, which collects information about patients visits to hospitals and non-hospital sites such as private offices, clinics and HMOs. The study was funded by grants from Faculty Development in Primary Care, Health Resources and Service Administration; and the Agency for Healthcare Research and Quality. The research team includes Michael Weitzman, M.D., of the University of Rochester, and Sarah Barlow, M.D., from St. Louis University in Missouri.

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