JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
DISCUSSION
services to their patients through the age of 18 years, while 16% extended their care up to those aged 21 years.
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 five 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. Given88%of thesurveyedproviders reportedregularlyscreening 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 United States 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%
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. 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 health care 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.
8 J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017
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