Childhood Obesity Preventive Care in Primary Care Settings
Childhood Obesity Preventive Care in Primary Care Settings
Objectives: In this study we examined the impact of the Expert Committee Recommendations (ECRs) on childhood obesity preventive care during well-child visits in the United States.
Methods: Data from the 2006–2009 National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey–outpatient department were used to examine frequencies of diet/nutrition and exercise counseling during well-child visits by children aged 2 to 18 years. Differences in rates of the counseling before and after the ECRs were made were compared.
Results: Only 37% and 22% of all patients in 2006–2007 and 33% and 18% of all patients in 2008–2009 were provided with diet/nutrition and exercise counseling, respectively. The frequencies of counseling for patients with a diagnosis of obesity showed no change. Socioeconomically disadvantaged children received counseling less frequently after the ECRs were made.
Conclusion: Overall, rates of obesity preventive care were low in all years, with no evidence of improvement after the ECRs were made. Systematic approaches are needed to improve delivery of obesity preventive care irrespective of the socioeconomic backgrounds of children.
In the hope of slowing down the obesity epidemic and reducing obesity-related health consequences, the Expert Committee, consisting of representatives from 15 health organizations and steered by members of the American Medical Association, the Health Resources and Service Administration, and the Center for Disease Control and Prevention, announced its recommendations on the assessment, prevention, and treatment of child and adolescent overweight and obesity in 2007. Based on best available evidence and clinical judgment, the Expert Committee presented a chronic care model approach that emphasized the importance of healthy dietary habits and physical activity from early childhood and a graded treatment approach based on child and family risk factors (Barlow, 2007).
The Expert Committee Recommendations (ECRs) for childhood obesity prevention strategies include provision of diet/nutrition and exercise consultations at every well-child visit regardless of child's weight status. In addition, based on assessment of body mass index (BMI) and obesity-related child and family risk factors, practitioners are encouraged to make decisions for further, more intensive interventions. Evidence from a recent study suggests that normalization of weight status through family-based behavior interventions is more easily achieved when children are aged 8 to 10 years than in later years (Goldschmidt, Wilfley, Paluch, Roemmich, & Epstein, 2012). Similarly, a longitudinal study for behavioral treatment of obese children and adolescent aged 6 to 16 years has shown age at start of treatment as the single most significant factor for successful weight reduction after 3 years (Danielsson, Kowalski, Ekblom, & Marcus, 2012). This growing body of evidence suggests that preventive measures and monitoring of child's weight status must start at a young age.
The ECRs also called for collaborations among communities, schools, families, and health care providers to create an environment to support healthy food choices and physical activities. As partners of the collaborative team, the role of primary care providers was to continually evaluate child's health status, educate families and children about importance of healthy diets and physical activity during every routine well-child care visit, and make necessary referrals for further interventions (Barlow, 2007, Davis et al., 2007).
Past research has found that documentation of obesity preventive care provisions at primary care provider offices in the United States has been traditionally low (Demerath, Muratova, Spangler, Minor, & Neal, 2003). For example, Ma and Xiao (2009), using the 2005–2006 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Care Survey (NHAMCS), reported that an estimated 34% and 23% of adolescents aged 13 to 18 years received diet/nutrition and exercise counseling, respectively, at preventive care visits. Similarly, using the same surveys from 1997 to 2000,Cook, Weitzman, Auinger, and Barlow (2005) documented that the frequencies of diet/nutrition and exercise counseling among children aged 2 to 18 years during preventive care visits were 36.2% and 18.5%, respectively, with higher frequencies of receiving diet/nutrition (88.4%) and exercise (69.2%) counseling for all children who had a diagnosis of obesity. On the other hand,Dilley, Martin, Sullivan, Seshadri, and Binns (2007) documented that 78% and 36% of children received dietary and physical activity counseling, respectively, during visits made to pediatric primary care providers in the inner-city Chicago area. The study investigators did not find differential frequencies in the service provisions across patients' weight status categories. These discrepancies suggest that significant variations exist in obesity preventive practices at the primary care practitioner level.
No study has been conducted to determine how well the ECRs on obesity prevention have permeated into primary care practice. A few studies indicated that primary care providers were aware of the ECRs shortly after they were announced but that these providers were encountered obstacles to implementing the recommended actions, such as time constraints, lack of resources, and lack of confidence in teaching (Klein et al., 2010). The same authors noted that some physicians believed that children's behavior would not change if they provided counseling. Other physicians believed that BMI screening and obesity preventive education should be performed at schools and communities instead of at busy physician office settings, with an emphasis on community–school–healthcare provider collaborations (Demerath et al., 2003).
The current study was aimed at investigating the impact of the ECRs on childhood obesity preventive care provisions at the primary care practice level using a representative sample of preventive care visits in the United States. The objectives of this study were to (1) compare frequencies of diet/nutrition and exercise counseling given during preventive care visits 2 years before and 2 years after the ECRs were made, (2) assess whether the ECRs changed the frequency of service provision among high-risk populations (e.g., minority race/ethnicity, low income, and low education), (3) assess the impact of the ECRs on visits with children who had a diagnosis of obesity, and (4) examine year trends of the obesity preventive care.
Abstract and Introduction
Abstract
Objectives: In this study we examined the impact of the Expert Committee Recommendations (ECRs) on childhood obesity preventive care during well-child visits in the United States.
Methods: Data from the 2006–2009 National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey–outpatient department were used to examine frequencies of diet/nutrition and exercise counseling during well-child visits by children aged 2 to 18 years. Differences in rates of the counseling before and after the ECRs were made were compared.
Results: Only 37% and 22% of all patients in 2006–2007 and 33% and 18% of all patients in 2008–2009 were provided with diet/nutrition and exercise counseling, respectively. The frequencies of counseling for patients with a diagnosis of obesity showed no change. Socioeconomically disadvantaged children received counseling less frequently after the ECRs were made.
Conclusion: Overall, rates of obesity preventive care were low in all years, with no evidence of improvement after the ECRs were made. Systematic approaches are needed to improve delivery of obesity preventive care irrespective of the socioeconomic backgrounds of children.
Introduction
In the hope of slowing down the obesity epidemic and reducing obesity-related health consequences, the Expert Committee, consisting of representatives from 15 health organizations and steered by members of the American Medical Association, the Health Resources and Service Administration, and the Center for Disease Control and Prevention, announced its recommendations on the assessment, prevention, and treatment of child and adolescent overweight and obesity in 2007. Based on best available evidence and clinical judgment, the Expert Committee presented a chronic care model approach that emphasized the importance of healthy dietary habits and physical activity from early childhood and a graded treatment approach based on child and family risk factors (Barlow, 2007).
The Expert Committee Recommendations (ECRs) for childhood obesity prevention strategies include provision of diet/nutrition and exercise consultations at every well-child visit regardless of child's weight status. In addition, based on assessment of body mass index (BMI) and obesity-related child and family risk factors, practitioners are encouraged to make decisions for further, more intensive interventions. Evidence from a recent study suggests that normalization of weight status through family-based behavior interventions is more easily achieved when children are aged 8 to 10 years than in later years (Goldschmidt, Wilfley, Paluch, Roemmich, & Epstein, 2012). Similarly, a longitudinal study for behavioral treatment of obese children and adolescent aged 6 to 16 years has shown age at start of treatment as the single most significant factor for successful weight reduction after 3 years (Danielsson, Kowalski, Ekblom, & Marcus, 2012). This growing body of evidence suggests that preventive measures and monitoring of child's weight status must start at a young age.
The ECRs also called for collaborations among communities, schools, families, and health care providers to create an environment to support healthy food choices and physical activities. As partners of the collaborative team, the role of primary care providers was to continually evaluate child's health status, educate families and children about importance of healthy diets and physical activity during every routine well-child care visit, and make necessary referrals for further interventions (Barlow, 2007, Davis et al., 2007).
Past research has found that documentation of obesity preventive care provisions at primary care provider offices in the United States has been traditionally low (Demerath, Muratova, Spangler, Minor, & Neal, 2003). For example, Ma and Xiao (2009), using the 2005–2006 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Care Survey (NHAMCS), reported that an estimated 34% and 23% of adolescents aged 13 to 18 years received diet/nutrition and exercise counseling, respectively, at preventive care visits. Similarly, using the same surveys from 1997 to 2000,Cook, Weitzman, Auinger, and Barlow (2005) documented that the frequencies of diet/nutrition and exercise counseling among children aged 2 to 18 years during preventive care visits were 36.2% and 18.5%, respectively, with higher frequencies of receiving diet/nutrition (88.4%) and exercise (69.2%) counseling for all children who had a diagnosis of obesity. On the other hand,Dilley, Martin, Sullivan, Seshadri, and Binns (2007) documented that 78% and 36% of children received dietary and physical activity counseling, respectively, during visits made to pediatric primary care providers in the inner-city Chicago area. The study investigators did not find differential frequencies in the service provisions across patients' weight status categories. These discrepancies suggest that significant variations exist in obesity preventive practices at the primary care practitioner level.
No study has been conducted to determine how well the ECRs on obesity prevention have permeated into primary care practice. A few studies indicated that primary care providers were aware of the ECRs shortly after they were announced but that these providers were encountered obstacles to implementing the recommended actions, such as time constraints, lack of resources, and lack of confidence in teaching (Klein et al., 2010). The same authors noted that some physicians believed that children's behavior would not change if they provided counseling. Other physicians believed that BMI screening and obesity preventive education should be performed at schools and communities instead of at busy physician office settings, with an emphasis on community–school–healthcare provider collaborations (Demerath et al., 2003).
The current study was aimed at investigating the impact of the ECRs on childhood obesity preventive care provisions at the primary care practice level using a representative sample of preventive care visits in the United States. The objectives of this study were to (1) compare frequencies of diet/nutrition and exercise counseling given during preventive care visits 2 years before and 2 years after the ECRs were made, (2) assess whether the ECRs changed the frequency of service provision among high-risk populations (e.g., minority race/ethnicity, low income, and low education), (3) assess the impact of the ECRs on visits with children who had a diagnosis of obesity, and (4) examine year trends of the obesity preventive care.
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