Ambulatory Management of Childhood Obesity
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Objective: Childhood obesity is one of the most challenging issues facing healthcare providers today. The aims of this study were to describe the ambulatory management of childhood obesity by pediatricians (PDs) and family physicians (FPs) and to evaluate knowledge of and adherence to published recommendations.
Research Methods and Procedures: A 42-item, self-administered questionnaire was mailed to 1207 randomly selected primary care physicians (PDs = 700, FPs = 507) between September 2001 and January 2002.
Results: Of 339 (28%) responses, 287 were eligible (PDs = 213, FPs = 74). Most respondents were in group or solo practice (87%) in a suburban or urban, non-inner city location (67%). The average age was 48 years (range = 31 to 85 years), and the mean years in practice was 17 (range = 1 to 55 years). Nineteen percent of physicians were aware of national recommendations. Three percent of physicians reported adherence to all recommendations. Knowledge of recommendations was not associated with a greater likelihood of adherence. However, physicians who were aware of recommendations were more likely to have positive attitudes about personal counseling ability (odds ratio = 2.4, confidence interval = 1.3 to 4.4) and the overall efficacy of obesity counseling (odds ratio = 4.3, confidence interval = 1.7 to 10.8). Poor patient motivation, patient noncompliance, and treatment futility were perceived as the most frequently encountered barriers to obesity treatment.
Discussion: Most physicians are not aware of or adherent to national recommendations regarding childhood obesity. Awareness of recommendations was associated with more positive attitudes about personal counseling ability and the effectiveness of obesity counseling in general.
The prevalence of obesity in the U.S. has been increasing steadily over the past few decades. Currently, one of five U.S. children is overweight. Obese children are at increased risk for a number of comorbid conditions, including hypertension, dyslipidemia, impaired glucose tolerance, and obstructive sleep apnea. In addition, obese children and adolescents often become obese adults. Adults with obesity are at increased risk of coronary heart disease, diabetes, hypertension, dyslipidemia, gallbladder disease, osteoarthritis, and some cancers. The cost of the obesity epidemic has been estimated to account for up to 6% of U.S. healthcare spending.
Obesity in children is one of the most challenging issues facing healthcare providers today. In an effort to provide guidance for physicians and other personnel who care for obese children, the Maternal and Child Health Bureau convened a committee of experts in the field of pediatric obesity to create recommendations for the evaluation and management of childhood obesity. The expert committee recommendations were published in Pediatrics in 1998. Similar recommendations are available to family physicians through the American Academy of Family Physicians (AAFP).
The recommendations on the AAFP website (http://www.aafp.org) differ slightly from the expert committee recommendations. The authors offer five different measures that can be used to identify obesity, and whereas they describe BMI as being a good measure of body fat in children and adolescents, they do not specifically recommend it as the parameter of choice. In addition, these guidelines do not address evaluation of some obesity-related disorders such as sleep apnea, gall bladder disease, pseudotumor cerebri, and eating disorders. Finally, the AAFP recommendations suggest using a food diary for dietary assessment, whereas the expert committee recommendations suggest using a 24-hour dietary recall.
A series of articles were recently published that evaluated the ambulatory management of childhood obesity. However, these studies did not evaluate knowledge of guidelines and did not include family practice physicians (FPs). The purpose of this study was to describe current knowledge, attitudes, and practices of both primary care pediatricians (PDs) and FPs and to evaluate differences in practice patterns based on guideline knowledge.
Discussion
Few physicians in this study were aware of or adherent to published recommendations regarding the management of childhood obesity. Many physicians continued to use weight for height instead of BMI to diagnose children as overweight or obese. Physicians ranked patient-related barriers, such as noncompliance and poor motivation, and treatment-related barriers, such as treatment futility, as the most frequently encountered barriers. Awareness of recommendations was not associated with a greater likelihood of adherence. However, physicians who were aware of recommendations were more likely to have positive attitudes regarding their own ability to counsel obese children and the overall efficacy of obesity counseling, and those who reported global adherence to guidelines were more likely to practice according to the expert committee recommendations. We found only minor differences between PDs and FPs in the ambulatory management of childhood obesity.
Recently, a series of articles summarizing the results of a national survey of child health professionals regarding the management of childhood obesity was published. Our study is similar, but extends the findings in a number of areas. We have included FPs in our sample and have examined the association between knowledge of recommendations and current management of childhood obesity. We found that a slightly smaller percentage of our sample was adherent to the entire medical assessment, even when we examined adherence in PDs only (3% in our study compared with 7% in the previously published study), possibly because of different sampling frames. The lower adherence rate in our study may also be attributable to the inclusion of FPs. As mentioned in the Introduction, the AAFP guidelines do not address certain obesity-related disorders. Because we used the expert committee recommendations published in Pediatrics as the standard, a potential explanation may be that FPs who were aware only of the AAFP guidelines would be less likely to adhere to all aspects of the medical assessment. However, this explanation was not supported by the results of our study. We found no difference in the overall rates of adherence between FPs and PDs.
To our knowledge, this is the first study to examine the association between knowledge of recommendations and physician attitudes and practices regarding childhood obesity. As with previous studies on clinical guidelines and physician behavior, we found that guidelines do not necessarily change behavior. Fewer than one-half of physicians (46%) who were aware of guidelines reported adhering to them often or always. However, guidelines are likely the first step toward changing behaviors, in that they communicate knowledge and provide effective treatment strategies. Our finding that physicians who were aware of guidelines were more likely to have positive attitudes about obesity counseling and their own counseling proficiency supports this proposition. Changing physician attitudes has important implications, because a number of studies have documented that poor proficiency in counseling skills and treatment futility were significant barriers to care. Alternatively, physicians interested in treating obese children may be more likely to read about the subject and may be more likely to be aware of the guidelines. Regardless, making these guidelines more readily available to PDs and FPs is an important step toward improving obesity management.
We hypothesized that physician BMI may have had an impact on their attitudes and behaviors regarding obesity treatment, but we did not find any association between physician BMI and attitudes or behaviors regarding obesity treatment. Our ability to detect an association between BMI and physician behavior and attitudes may have been limited by the use of self-reported height and weight. Although self-report is more convenient than objective measurement, it may be inaccurate because individuals tend to under-report weight and over-report height.
We found little difference in overall rates of adherence to recommendations between PDs and FPs. FPs reported using BMI to diagnose obesity more frequently, at least in older children and adolescents, compared with PDs. This may result from their experience with adults, and they may be using adult BMI cut-offs as well. However, our finding that 50% of FPs and 38% of PDs who used BMI reported using the 95th percentile for sex and age to classify children as obese suggests that FPs are as likely to use the appropriate cut-off point as PDs.
PDs were more likely to report performing more thorough physical examinations and behavioral assessments of obese children. PDs were significantly more likely to ask about television viewing. The AAFP guidelines discuss the importance of reducing television viewing in addressing obesity, and, hence, a discrepancy in guidelines does not explain the disparity between FPs and PDs. Reduction of television viewing has been demonstrated to have a positive effect on children’s weight. Healthcare providers should actively screen for this behavior and encourage families to reduce television viewing.
The results from this study should be interpreted with caution because our response rate was low, although it was similar to other recently conducted obesity surveys. Nonresponders may have different views about childhood obesity and could be more or less adherent to national recommendations. However, our results likely overestimate adherence because physicians who take a greater interest in childhood obesity were probably more likely to take the time to respond to this survey. As with all surveys, subject responses may be influenced by factors such as social desirability and may not be a true reflection of physicians’ day-to-day management of childhood obesity. Further research using different study designs and data-collection methods (e.g., chart reviews) should be conducted to corroborate and extend the findings of this survey.
In conclusion, knowledge of guidelines was associated with more positive attitudes toward personal counseling proficiency and the overall effectiveness of obesity counseling. Furthermore, physicians who reported adhering to guidelines were more likely to practice according to the recommendations of the expert committee. Unfortunately, few physicians, overall, were adherent to national recommendations regarding the ambulatory management of childhood obesity. Both limited knowledge and limited acceptance of expert recommendations seem to play a role in poor adherence. Efforts should be taken to better understand the reasons for the limited awareness and acceptance of existing guidelines. Substantial improvements in obesity care could be expected by making the current guidelines more widely available.
Source: Lakshmi Kolagotla and William Adams
Division of General Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts.
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