Despite the severity of the obesity epidemic in the U.S., only 68% of pediatricians and 38.5% of family physicians regularly assessed obesity status by BMI percentile in their pediatric patient population even though most measured patients’ weight and height regularly. Overall, pediatricians were more likely than family physicians to provide obesity-related behavioral counseling or guidance for their patients. The great majority of physicians reported not referring patients for further evaluation/management or systematically tracking patients on their diet, physical activity or weight.
These data suggest that physicians have substantial room for improvement in assessing weight status in the primary care setting. Higher prevalence of routine measurement by PCPs and communicating this information to patients and their families, as well as an integrated team approach to care, may be a small but important step that PCPs can take toward a comprehensive approach to obesity prevention and control.5,6
There is evidence that computer-assisted counseling in the primary care setting can be integrated into routine care to affect dietary and physical activity outcomes in children.24
General assessment of food intake and amount of physical and sedentary activities was generally high in this study which encompassed patients of all weight categories, compared to findings reported by Jelalian et al.15
, suggesting that over the last 7 years, there may have been greater awareness among PCPs of childhood obesity and the need to monitor and intervene in the primary care setting. However, the current study shows that PCPs remain reluctant or constrained in probing specifics about diet and physical activity among their patients.
Consistent differences are notable between pediatricians and family physicians with regard to the prevalence of delivering obesity-related counseling, guidance, or assessment. These may be due to the strong emphasis in most pediatric training programs on anticipatory guidance regarding developmental issues such as nutrient intake.4, 16
In addition, the American Academy of Pediatrics has been playing an active role in recent years in providing clinical pediatric obesity guidelines.5
The number of pediatricians also has increased dramatically over the past 3 decades.25
It is estimated that family physicians see only 16%–26% of pediatric visits in the U.S. depending on the age of the patients.26
This may have contributed to increasing levels of weight-related counseling over the years. Prevalence estimates related to assessment, counseling, follow-up and referral by family physicians were quite similar to family physicians who treat adults (see Smith et al.).
It is unclear whether patient characteristics differ among those who present to pediatricians versus family physicians for primary care. It is possible that patient characteristics may contribute to differences between the two specialties, and this warrants further study. Nevertheless, because family physicians remain an essential provider of primary care in children in general, and in particular in rural parts of the U.S. and among adolescents,26
greater engagement in obesity assessment, prevention, treatment among family physicians is likely to have a positive impact on children’s health nationally.
There are interesting gender, race/ethnicity, and regional differences in terms of the prevalence of obesity-related preventive care among PCPs treating children independent of specialty. Regional differences may in part result from the higher concentration of pediatricians in the Northeast due to the higher relative pediatric population density in this region, although controlling for practice urbanicity might have partly adjusted for this issue. Female and Asian-American PCPs, regardless of specialty, were more likely to provide behavioral counseling than men and PCPs in other racial/ethnic groups, although the reasons for this require further study.12
The Women Physicians’ Health Study reported that approximately half of female PCPs nationally thought nutrition and weight were important issues and one in five had received extensive related training. Female pediatricians were particularly likely to provide nutrition and weight counseling to patients.27
The relatively higher prevalence of assessment of waist circumference or waist-to-hip ratio, as proxy measures of central adiposity, among family physicians relative to pediatricians may be because these measures have greater standardization in the adult population. Family physicians, on average, treat older children than do pediatricians,26
and family physicians tend to practice similarly with their adult and pediatric patients (see Smith et al.) Measurement of waist circumference, and risk thresholds for its interpretation, are not standardized for children and no clinical guidelines currently exist for its measurement in routine practice.
The results of this study are relevant to clinical care policy. First, the level of assessment of pediatric weight status and obesity-related preventive care, referrals, and follow-ups in the primary care setting is low relative to the frequency of the problems in children. Much evidence from other chronic disease areas indicates that altering clinical practice will require more than the provision of clinical guidelines and physician education.28-29
Determining barriers to providing such assessment and management will be important for designing appropriate strategies to change physician behaviors. Lack of training, discomfort about weight-related issues and stigma, time constraints, reimbursement concerns have been cited previously as potential barriers.15
Second, use of standardized diet and physical activity assessment tools is limited. Enhanced assessment tools can better equip PCPs to increase their counseling and assessment. For example, one study suggested that color-coded charts could potentially increase physicians’ assessment of BMI.30
The movement toward wider use of electronic medical records will also increase the availability of BMI information to patients and PCPs as the computer can automatically generate such information from measured weight and height, reducing a commonly cited barrier among PCPs.31
More efficient dietary and physical activity tools, such as computer-assisted technologies, also may be particularly useful in the primary care setting to increase behavioral assessment and counseling. That PCPs were more likely to provide counseling on physical activity than either diet or weight status, also shown by Jelalian et al.,15
might be due to differences in the perceived level of ease by PCPs.
The message about physical activity may be less complex than that of diet. Published guidance on physical activity has focused on fewer key messages while that for diet is commonly framed as multicomponent and more complex. Therefore, providing PCPs with better management tools and patient communication strategies may be helpful.30
Finally, the demands of the current clinical practice in the U.S. preclude the investment of large amounts of time by PCPs in each patient visit. Therefore, greater linkage between PCPs and providers of ancillary medical services, such as nurses, registered dietitians, behavioral or exercise specialists, may be necessary to increase the level of obesity prevention and treatment services available to children and their families.6
This study was limited by self-reported data from physicians. Social desirability might have inflated the respondents’ response, indicating better care practices than in reality. However, a major strength of the study is that this was the first nationally representative survey among pediatricians and family physicians in terms of their care of children relating to diet, physical activity, and weight, and a substantial percentage of PCPs responded to the survey. Other strengths include the relatively large sample size, as well as the response rate, which is high in comparison to other physician surveys.
In sum, assessment of BMI percentile among children remains lower than optimal in U.S. primary care settings, especially among family practice physicians. Interventions are needed to increase the proportion of physicians who routinely assess BMI percentile and weight-for-length, as well as who routinely provide appropriate weight-related behavioral counseling. Efforts to increase physician training and the development of tools and technologies to enhance the delivery of obesity-related assessment and preventive counseling is an important part of a comprehensive public health approach to obesity prevention and control among U.S. youth.