Childhood Obesity Screening and Treatment Practices of Pediatric Healthcare Providers

Abstract

This study evaluated physicians’ childhood obesity screening and treatment practices. A 26-question survey was delivered to pediatric providers in-person or via mail, e-mail, or fax throughout Louisiana. Fifty-seven providers completed the survey, the majority in primary care clinics. Five providers met at least four of seven clinical guidelines, but no provider met all of the guidelines. Whereas 88% of providers screened for obesity, 7% met guidelines for referring patients with obesity to weight management services. Six providers offered interventions that included all recommended components (i.e. dietary, physical activity, and behavioral counseling). One intervention met intensity guidelines (i.e. >25 hours delivered over at least six months). Barriers to offering services included lack of reimbursement and poor compliance by families. Solutions to overcome treatment barriers should be identified to increase the provision of healthcare services for children with obesity.

Obesity is characterized by a body mass index (BMI) ≥ 95^th percentile and affects 17% of youth in the U.S.¹ Family-based, intensive, multidisciplinary behavioral intervention has been proven efficacious to treat childhood obesity,² including sustained weight loss up to ten years after the program.³ The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all children ages 6 years and older for obesity, then offer or refer them to an intensive and comprehensive behavioral intervention for obesity treatment if necessary.⁴ The interventions should include dietary, physical activity, and behavioral counseling; be moderate (>25 to 75 contact hours) to high (> 75 contact hours) intensity; and delivered over six months.^4,5 This recommendation aligns with the stage 3 comprehensive multidisciplinary intervention of the four-stage treatment approach recommended by the Expert Committee convened by the American Medical Association, Centers for Disease Control and Prevention, and American Academy of Pediatrics.⁶ While one survey evaluating clinicians’ screening practices for obesity was recently conducted among tertiary care hospitals,⁷ this study sought to document how pediatric primary care providers and allied health professionals manage their patients’ weight and whether these primary care providers follow clinic practice guidelines. Most pediatric medical visits occur in primary care settings,⁸ and the primary care setting offers an opportunity for early detection and intervention to achieve a healthy weight.

Further, the extent to which healthcare providers screen for obesity-related comorbidities such as type 2 diabetes mellitus (T2DM) in youth is not known, despite an escalation in cases of pediatric T2DM in recent years.⁹ The American Diabetes Association¹⁰ and American Academy of Pediatrics¹¹ recommend screening children who are overweight (BMI ≥ 85th percentile) and have any two additional risk factors for diabetes every three years upon reaching age 10 or puberty. Recommended screening tools are based on hemoglobin A1c criteria or plasma glucose criteria. The objective of this study was to identify pediatric healthcare providers’ current obesity and T2DM screening practices and the referral or provision of behavioral interventions for the treatment of childhood obesity.

Methods

Participants

A survey was directly distributed to 677 healthcare providers located in 164 clinics in 28 cities in the U.S. state of Louisiana. The survey was distributed to an additional 675 stakeholders including representatives from the Louisiana chapter of the American Academy of Pediatrics, insurance groups, advocacy groups, and academia throughout the state, with a letter requesting that the stakeholder forward the survey to primary care providers. In total, 70 providers started and 57 completed the survey (26 online and 31 completed by hand), for a response rate of 10% (among providers directly solicited) and a completion rate of 81%.

Pennington Biomedical Research Center’s Institutional Review Board approved the protocol and survey. No formal written consent was administered, but the following was included on the survey to notify participants that responses were collected for research purposes: “Your participation in this survey is voluntary and you do not have to participate if you do not want to. By submitting this survey, you provide your consent for our research team to review and use the information you share with us. Your responses will be kept confidential.”

Description of Survey and Procedures

The survey consisted of 26 multiple-choice and open-ended questions pertaining to the provider’s current practices in childhood obesity and T2DM screening and the pediatric weight management services offered at the provider’s facility. The USPSTF guidelines included: 1) screen for obesity if age ≥ 6 y; 2) if obese, refer to intervention; 3) offer obesity intervention with diet, physical activity, and behavioral counseling; 4) offer intervention lasting ≥ 6 months; and 5) offer intervention consisting of > 25 contact hours). The guidelines for T2D screening included: 1) screen for T2DM and 2) T2DM screening includes hemoglobin A1c or glucose.^10,11 The survey also queried the provider’s medical specialty and clinic location.

Surveys were hand delivered, emailed, mailed, and/or faxed to recipients over a 6-month period (i.e. January to June 2015). An open-access link to the survey was listed on a website that targeted primary care providers. The online version of the survey was deployed by the Research Electronic Data Capture (REDCap) website hosted at Pennington Biomedical Research Center. Designed by Vanderbilt University, REDCap uses a secure, web-based application to collect and store data for research purposes.¹² Alternatively, providers could complete a hard copy and return the survey via fax, mail, or email. Hard-copy surveys that were mailed or hand-delivered were entered into REDCap by a research assistant.

Participants were informed that their responses would be used for research purposes. Providers could choose to provide personal contact information or complete the survey anonymously. Study procedures and materials were approved by the Pennington Biomedical Research Center Institutional Review Board.

Data Analysis

Of the 70 providers, 13 were excluded from the analysis due to answering only one question. Fifty-seven surveys were included in the analysis. The primary endpoints were summary data of the screening and treatment practices currently offered by providers. The secondary endpoints were proportion of providers who provided screening and treatment services that met each of seven identified clinical guidelines.

Results

Survey Participants

The 57 providers were located in 17 cities across Louisiana. The majority practiced in primary care (56%) or specialty (18%) clinics. Others worked in hospitals, school health centers, a federally qualified health center, or a mobile medical unit. Most of the providers identified as physicians (75%), though nurses/nurse practitioners (9%), dietitians (5%), exercise physiologists (4%), and a clinical psychologist also provided information. The types of physicians represented included pediatricians, pediatric subspecialists (endocrinologists and a gastroenterologist), combined internists/pediatricians, and family practitioners.

Providers’ Screening and Treatment Practices

The providers’ screening and obesity treatment practices are displayed in Table 1. The majority (88%) of providers reported screening for obesity via calculating body mass index (BMI) as a part of a regular child visit, and 61% used electronic medical records (EMRs) to automatically calculate BMI. Most providers (67%) indicated using multiple ICD-9 codes to bill for childhood obesity screening and treatment services. Sixty-three percent of providers reported screening for T2DM, and the most commonly used tools were hemoglobin A1c, fasting plasma glucose, and overweight/obesity.

Table 1.

Pediatric weight management practices among 57 clinicians.

	Number of Providers
Is body mass index (BMI) calculated as part of your regular visits with children?
Yes	50
No	6
Did not answer	1
What code(s) do you use to bill for childhood obesity screening/treatment?*
278.00: Obesity, unspecified	33
278.02: Overweight	26
783.1: Abnormal weight gain	22
V85.54: Obesity, pediatric BMI ≥ 95th percentile for age	21
278.01: Morbid obesity	15
272.4: Hyperlipidemia	13
272.1: Hypertriglyceridemia	9
277.7: Insulin resistance	8
780.57: Sleep apnea, unspecified	6
790.5: Elevated liver enzymes	6
790.99: Elevated hemoglobin A1C	6
571.8: Nonalcoholic steatohepatitis (NASH)	5
250.00, 250.02, v58.67, 272.2, acanthosis, PCOS	2
278.03: Obesity hypoventilation syndrome	1
278.1: Localized adiposity	1
Weight gain	1
277.7 & 278 - Metabolic Syndrome	1
Don’t know	2
Not applicable/did not answer	6
Do you screen for type 2 diabetes mellitus in children and adolescents?
Yes	16
No	20
Not applicable/did not answer	21
If yes, what is your primary screening tool for type 2 diabetes in children and adolescents?*
Hemoglobin A1c	28
Fasting Plasma Glucose	22
Overweight/Obesity	11
Oral Glucose Tolerance Test (OGTT)	6
American Diabetes Association criteria	3
Fasting Insulin	1
Urinalysis	1
Acanthosis Nigricans presence	1
Do not do labs on every child	1
Which department in your hospital/clinic provides pediatric obesity treatment?*
General Pediatrics	21
Nutrition	15
Gastroenterology	8
Endocrinology	7
Adolescent Medicine	4
Outpatient Services	3
Community Outreach and Education	2
Psychiatry	2
Referred	2
Cardiology	1
Sports Medicine	1
Surgery	1
Orthopedic	1
Exercise through wellness	1
None of the above	18
Not applicable/did not answer	7
What stages of obesity treatment does your hospital/clinic offer?*
Stage 1: Prevention Plus	26
Stage 2: Structured Weight Management	14
Stage 3: Comprehensive Multidisciplinary Intervention	8
Stage 4: Tertiary Care Intervention	1
Don’t know	5
Not applicable/did not answer	21
What weight management services do you (or your clinic) provide for obese children?*
Nutrition Therapy	34
Medical Monitoring	21
Exercise	19
Medical Assessment	19
Behavior Therapy	8
Physical Therapy	2
Education, Overweight Handout, Follow-up Visits	2
OLOL Program	1
Provide referral	1
Orthopedic diagnosis	1
None	8
Unspecified other	5
Don’t know	1
Not applicable/did not answer	2
What outcome(s) do you use to measure change in weight management programs?*
BMI and BMI percentile	37
Blood pressure	22
Nutrition/Diet	21
Physical activity	19
Labs (blood work)	16
BMI trajectory	11
Psychosocial outcomes (e.g. confidence, self-esteem)	10
BMI z-score	3
Weight	2
Waist circumference	1
Body fat percentage	1
Fitness tests	1
Don’t know	2
Not applicable/did not answer	17
Does your weight management program offer a maintenance phase after intensive treatment?
Yes	6
Yes, follow up with provider	1
No	13
Don’t know	8
Not applicable/did not answer	29
How long do your weight management services last?
1 Week	2
6 Weeks	1
8 Weeks	2
10 Weeks	5
12 Weeks	5
18 Weeks	1
Don’t know/referred to another program	4
Not applicable/no services offered	37
How many hours of service are provided in this time?
0.5 hour	1
1 hour	7
1.5 hours	2
2 hours	1
3 hours	1
10 hours	1
Varies	1
Other	1
Don’t know	4
Not applicable/did not answer	38
What is the frequency of visits during weight management services (e.g. once a week, once a month)?
Once a week	10
Once a month	6
Twice a month	2
Every other month	1
Other	1
Don’t know	4
Not applicable/did not answer	33
What are the cut-offs you use for inclusion of children into weight management/treatment programs?
Overweight (≥85th percentile BMI)	12
Overweight with at least 1 comorbidity	4
Overweight with at least 1 obese parent	0
Obese (≥95th percentile BMI)	12
Don’t know	1
Not applicable/did not answer	28

^*indicates that the provider was allowed to select multiple responses.

Weight Management Services

Referral to services

Though most providers estimated that between 20 and 39% of their pediatric patients were overweight/obese (see Figure 1a), few referred children who were overweight or obese to a weight management service (see Figure 1b). The majority (59%) of the providers indicated an increase in number of pediatric patients with overweight/obesity in the last 5 years, while 30% reported the number had not changed.

Figure 1.

a. Providers’ estimates of the proportion of pediatric patients under their care who are obese or overweight. Note. The remaining 5% of providers did not provide an estimate.

b. Providers’ reports of proportion of patients with overweight/obesity who are referred to weight management services. Note. The remaining 23% of providers did not provide an estimate.

Provision of services

Weight management services were provided by various departments within the providers’ facilities, including general pediatrics, nutrition, gastroenterology, and endocrinology. Fifty-five percent reported treatment delivered by multiple departments within the same facility. Out of the 31 providers who offered obesity treatment, most offered Stage 1 or 2 but few offered Stage 3 or 4 (see Table 1). Among the healthcare providers and/or facilities who directly provided any weight intervention component, 64% provided multiple types of services, most commonly nutrition therapy, medical monitoring or assessment, and exercise services.

Of six who prescribed medication as an additional treatment for pediatric obesity, three offered Metformin. Other prescriptions included appetite stimulants/depressants, Adderall, and Xenical/Orlistat. Two providers reported prescribing multiple medications. Thirty-three percent of the responding providers’ facilities offered multiple stages of treatment.

Eligibility for services

To determine inclusion of children into the weight management programs, most providers used the 85^th percentile (overweight) or 95^th percentile (obesity) as the threshold. Twenty-four percent of the providers offered their weight management services to children as young as 5 years, and 8% to infants (0–1 years) if needed. Fifty-six percent of the providers provided these services to their patients through the age of 18 years, while 16% extended their care up to those aged 21 years.

Outcome measures

The most frequently used outcomes to measure patient’s change in the weight management program were BMI or BMI percentile, blood pressure, nutrition/diet, physical activity, or labs (non-specified). Sixty-seven percent of the providers used multiple outcome measures.

Duration and frequency of services

The weight management programs ranged between periods of 1 and 18 weeks. Seven of the weight management programs included a maintenance phase after intensive treatment.

Provider training

Forty percent of the facilities provided support and/or education about childhood obesity for providers. The offered resources included in-person continuing education (80%), lists of available resources (47%), toolkits (47%), web-based continuing education (40%), electronic health records with tools to prevent/treat obesity (40%), quality improvement collaboratives (27%), and seminars (7%).

Identified barriers and needs

In an open-ended question (“Is there anything further you’d like to share related to childhood obesity management, prevention, and treatment?”), several of the providers identified a need for more supportive services including “programs [for] pediatricians [to] make quick and simple referrals without hassle.” The scarcity of insurance plans that provide for nutritional counseling was another reported obstacle. Other barriers included poor compliance by patients and their families to prescribed treatments and following through with referrals.

Comparison of Reported Practices to National Guidelines

Five of the 57 providers met at least half of the seven national recommendations examined in this study for screening and referring/providing behavioral intervention for obesity treatment (Table 2). Though one provider met six of the seven guidelines, none met all.

Table 2.

Comparison of current screening and treatment practices to the national guidelines among 57 clinicians.

	National Guidelines
	If age ≥ 6 y, screen for obesity	If obese, refer to intervention	Screen for T2DM	T2DM screen includes HbA1c or glucose	Offers obesity intervention with diet, physical activity, and behavioral counseling	Offers intervention lasting ≥ 6 months	Offers intervention consisting of ≥ 26 contact hours
Met Guideline	50	4	36	36	6	3	1
Met Guideline, %	88 %	7 %	63 %	63 %	11 %	5 %	2 %
Provider Type
Physician	40	3	32	32	5	2	1
Registered Nurse or Pediatric Nurse Practitioner	4	–	2	2	–	–	–
Registered Dietitian	3	1	1	1	–	–	–
Exercise Physiologist or Fitness Trainer	2	–	1	1	1	1	–
Clinical Psychologist	1	–	–	–	–	–	–
Facility Type
Primary Care Clinica	32	3	23	23	1	1	–
Specialty Clinicb	9	1	8	8	2	1	1
Hospital	4	–	3	3	1	–	–
Mobile Medical Unit	1	–	1	1	1	1	–
Other	4	–	1	1	1	–	–

Note. Values represent number of respondents unless otherwise noted.

^aincludes outpatient clinic, student health center, federally qualified health center;

^bincludes adolescent medicine

The responses revealed that while the USPSTF guideline for screening children for obesity was commonly practiced, the recommendation to refer or offer an intervention was rarely met. Six healthcare providers offered an intervention that incorporated all three recommended components (i.e. dietary, physical activity, and behavioral counseling). Only one of the six programs met both USPSTF guidelines of more than 25 hours of contact time and delivery over at least six months.

Discussion

Similar to national trends showing an increase in childhood obesity prevalence,¹³ the majority of providers reported seeing an increase in number of overweight or obese pediatric patients over the past 5 years. The majority of providers screened for both obesity and T2DM. Yet the survey responses indicate that these patients are not receiving recommended weight management services. Most providers did not meet clinical guidelines to refer or offer weight management services, and only one of the 57 providers offered a multi-component obesity intervention that met the recommended duration and contact hours. Furthermore, few providers followed the Expert Committee recommended four-staged approach to childhood obesity treatment.⁶ Importantly, providers noted barriers to provision of services including lack of resources to provide an intervention, lack of reimbursement for nutritional counseling services, and poor compliance by patients and families.

Given 88% of the surveyed providers reported regularly screening children for obesity, there is evidence that screening practices have improved since the USPSTF recommendations were released in 2010. Based on retrospective data from the U.S. National Health and Nutrition Examination Survey (1999–2008),¹⁴ only 22% of parents of children who were overweight or obese were informed by their doctor that the child was overweight or obese. Though there was a slight increase over time in physicians notifying parents, from 19.4% in 1999–2004 to 29.1% in 2007–2008,¹⁴ the majority of physicians either were not screening children for overweight/obesity or were not informing parents of the child’s weight status. A survey conducted in 2006 of family physicians similarly found that only 45% of physicians calculated BMI percentile at most or every well-child visit.¹⁵ Similarly, a chart review of 255 children 2, 6, and 10 years of age identified that only 34% of those who were overweight or obese were properly documented as such.¹⁶ The present data indicate that most providers surveyed now do regularly monitor child’s BMI, but it is not known whether these providers communicated the child’s obesity status to the parents. Many physicians were not utilizing EMRs as a tool to automatically calculate and plot BMI to facilitate obesity screening.

The provision of weight management services among these predominantly primary care providers was lower than what has been previously demonstrated for tertiary care centers. In 2013, the national Children’s Hospital Association surveyed 118 children’s hospitals and identified 85 that offered comprehensive weight management services,⁷ a higher proportion than the 11% who offered multi-component interventions in the present study. Nearly all of the tertiary care centers provided nutrition therapy (99% vs. 60% in the present study), behavioral counseling (86% vs. 14% in the present study), and exercise or physical therapy (80% vs. 37% in the present study). Though two-thirds of tertiary care providers stated that their programs met the USPSTF guidelines, only 40% offered programs for 6 months or longer, indicating wide variability in meeting the intensity and duration recommendations. Data from national surveys of ambulatory medical care determined that only 33% and 18% of patients aged 2 to 18 years received diet/nutrition and exercise counseling, respectively, and this counseling was less frequent among socioeconomically disadvantaged children.¹⁷ The present study found even fewer physicians in Louisiana are providing behavioral counseling, with only one program that met USPSTF intensity guidelines (i.e. > 25 hours contact time delivered over at least six months).

In a 2006 survey of family practitioners, 86% said families could not afford services not covered by insurance and 55% lacked referral services for weight management programs.¹⁵ Since then, the USPSTF recommendation for obesity screening and comprehensive, intensive behavioral intervention was rated as Grade B, indicating that the task force recommends that practitioners offer or provide this service due to the high certainty that a net benefit is moderate, or moderate certainty that the net benefit is moderate to substantial.⁵ The USPSTF recommendation applies to all practitioners, not just tertiary care providers. Under the Patient Protection and Affordable Care Act of 2010, private insurance plans are mandated to cover preventive services with a USPSTF Grade A or B rating without patient cost-sharing. In spite of these recommendations and insurance mandates, providers still reported reimbursement for services as a barrier, are not providing or referring weight management services, and reported using numerous billing codes for obesity screening and treatment.

Strengths of this study included responses from 17 areas that covered the major populated regions of the state of Louisiana and from a range of healthcare providers. Focusing on Louisiana providers may pose a challenge for generalizability to other geographic regions. Yet Louisiana and the lower Mississippi delta region is one of the most medically underserved, at-risk populations living in the U.S, characterized by high levels of poverty, food insecurity, obesity, and related diseases. Therefore, the state of Louisiana represents a prime opportunity to establish baseline values of childhood obesity screening and management in order to monitor changes with the enactment of policy and programmatic interventions.

This study included several limitations. Despite outreach to over 1300 providers and affiliated stakeholders and a high number of website visits to the survey, only 10% of the contacted providers participated in the survey. The sample may have been biased towards providers more interested or more active in obesity screening and treatment. Despite including “not applicable” or “do not know” as response items, some questions were skipped by providers, making it difficult to determine practices for the entire sample.

In conclusion, obesity and T2DM screening practices were common but the referral and provision of weight management services for children with obesity remained rare among these pediatric healthcare providers. When offered, the interventions did not meet the recommended contact time. Despite clinical guidelines, coupled with legal requirements for insurance coverage, there is a continued lack of behavioral treatment for the most common medical disease among the nation’s youth. To address this deficit in healthcare access, weight management programs should be developed and disseminated and include reimbursement for services, ongoing provider training, and family input to assure patient commitment.