Hospital physicians rarely identify or address overweight/obesity in children

Saint Louis UniversityAug 6 2015

Physicians and physician trainees fail to identify or address overweight/obesity in over 90 percent of hospitalized children, according to new research from a Saint Louis University pediatric hospitalist.

"Physicians and Physician Trainees Rarely Identify or Address Overweight/Obesity in Hospitalized Children" was published online Aug. 5 in The Journal of Pediatrics.

Study author Marta King, M.D M.Ed., assistant professor of pediatrics at Saint Louis University School of Medicine, says this represents a missed opportunity for both patient care and physician trainee education.

"Overweight/obesity is the most common chronic pediatric disease in the United States," said King, who is also a SLUCare Physician Group pediatrician. "Physicians who recognize overweight/obesity can provide healthy weight counseling, inpatient consultations and outpatient referrals and thereby have the opportunity to improve outcomes for children with this severe and potentially life-threatening disease."

According to the Centers for Disease Control and Prevention, overweight is defined as a BMI at or above the 85th percentile and below the 95th percentile for children and teens of the same age and sex. Obesity is defined as a BMI at or above the 95th percentile.

King and her fellow authors conducted the study at Primary Children's Hospital, a pediatric facility associated with the University of Utah School of Medicine.

Using an administrative database, the CDC BMI calculator and a random sampling technique, King and her co-authors identified a population of 300 hospitalized children ages 2-18 with overweight or obesity. They then reviewed admission, progress and discharge notes written by medical students, interns, senior residents and attending physicians for this group of patients.

"The children were hospitalized on the general medical service for a variety of reasons," King said. "Common diagnoses included asthma, pneumonia and cellulitis."

The study found physicians and physician trainees identified overweight/obesity in 8.3 percent of the overweight patients and addressed it in 4 percent. Attending physicians were most likely to document weight issues in physical exam or assessment, while medical students were least likely to document such issues.

"We were very liberal in our definition of identifying and addressing overweight/obesity," King said. "Physicians received credit for identifying overweight/obesity risk factors if they documented any questions about a child's diet, physical activity, screen time or family history of overweight/obesity. That meant if a single member of the physician team asked a single question about the number of soft drinks a child drinks, frequency of eating meals out or any sports the child might be involved in, it would be counted as identifying overweight/obesity risk factors."

The American Academy of Pediatrics has recommended body mass index (BMI) calculations and universal overweight/obesity screening during preventive visits for patients over the age of two since 2003. In 2007, an expert committee made further recommendations regarding comorbid condition testing and interventions in outpatient situations. There are no similar recommendations for pediatric overweight/obesity screening or management in the inpatient setting.

Authors note previous studies have reported that BMI calculations are seldom performed during hospitalizations and that weight issues are rarely included among discharge diagnoses. An acute hospital admission presents an opportunity to identify and address weight issues.

Chart Review

A random number sampling technique selected the study population from patients with a BMI at or above the 85th percentile hospitalized on the general pediatric service.

The study reviewed documentation of weight issues in the following areas:

• History (diet, physical activity, screen time, family history of overweight/obesity)
• Physical exam (BMI, BMI percentile for age/sex, physical exam findings)
• Assessment
• Plan (inpatient nutrition consultation, diet counseling by physician team, lab studies discussed or ordered, activity counseling by physician team, referral to primary care physician or referral to weight management program)

Sixteen percent of children ages 2-18 hospitalized on the general pediatric service at Primary Children's Hospital during the time of the study had overweight or obesity. Physicians and physician trainees identified overweight/obesity in only 25 children (8.3 percent) of 300 hospitalized children with overweight/obesity. They addressed overweight/obesity for 12 (4 percent) of the patients.

"At least a third of parents do not acknowledge their child is overweight or obese, making recognition by health providers essential," King said.

"Like most patients admitted to a teaching hospital, patients in our study were cared for by numerous physicians and physician trainees," King said. "The fact that none of them identified or addressed weight as a problem might easily provide false reassurance to patients and family. 'Since none of a crowd of doctors caring for my child during the hospitalization mentioned weight, it must mean it is not a problem.'"

Despite the universal availability of BMI information, physicians and physician trainees documented weight issues in less than 10 percent of children with overweight/obesity and addressed it for less than 5 percent.

Likely barriers cited by outpatient pediatricians, such as perceived lack of patient and family interest, sense of treatment futility and lack of clinician time, apply to the hospital setting. Barriers unique to the inpatient setting likely include lack of guidelines specific for the hospital setting, lack of continuity with patients and families, perception that the responsibility lies with the child's primary care provider and lack of knowledge regarding outpatient resources.

Physicians might also believe patients and families would not wish to address chronic health concerns during an acute illness hospitalization, King noted.

"Although we currently have limited information about patient and family wishes, the assumption patients and families are not interested is likely false. Prior studies show parents of hospitalized children wish to be told if their child is found to have overweight or obesity, that they believe action should be taken, and that the majority identify the inpatient physician as the person who should address weight concerns."

A set of guidelines for pediatric hospitals, including follow-up directives with a child's primary care physician, is one way to address the issue.

"While best practice guidelines for identifying and addressing pediatric overweight/obesity in the ambulatory setting have been around for more than a decade, there are no similar hospital guidelines for pediatric overweight/obesity," King said.

For young patients, a restrictive diet to lose weight is usually not the answer. Parents should instead focus on helping children make healthier food choices, increase activity levels and keep weight steady as the child grows so that their height catches up to their weight.