This study documented that only 50% of PEDs and 22% of GPs who treated pediatric patients reported routinely using BMI-for-age to screen for weight status in all patients at each well child visit as recommended by the AAP [3
]. While the authors' hypothesis that PEDs would use BMI-for-age more than GPs was supported, these findings suggest that increased efforts are needed to attain the AAP goal among both specialties.
The literature documents fairly similar levels of use of BMI by PEDs compared to GPs. This study's finding that 50% PEDs reported using BMI-for-age at every well child visit is slightly higher than previous findings, which ranged from 11% to 35% for reporting always or generally using BMI [6
]. However, these results are very similar to a 2010 AAP study that found 52% of PEDs compute or plot BMI at most or every well child visit [25
]. This study's finding of 22% of GPs reporting use of BMI-for-age to screen for obesity at every well child visit, although disconcerting, is consistent with previous studies. Woolford and colleagues (2008) reported 17% of family physicians' used BMI charts [21
] and Kolagotla and Adams' (2004) found that 22% of family physicians routinely used BMI on pre-adolescents [22
]. Interestingly, Kolagotla and Adams, who reported results by patient age, found that 5% of family practitioners routinely used BMI for children ages 3-7 years, and 49% routinely used BMI for adolescents. The authors were unable to examine whether GPs had different levels of BMI-for-age usage for different age groups. This is an area in need of further investigation.
Both PEDs and GPs reported high levels of confidence in explaining BMI-for-age results, although a significantly higher proportion of PEDs reported a high level of confidence. For both specialties, these findings suggest that factors other than lack of confidence may be responsible for the low levels of using BMI-for-age, such as time [26
A significantly lower proportion of GPs with pediatric patients reported access to a pediatric obesity specialty clinic than PEDs. This highlights a potential disparity for GPs with pediatric patients and could be one explanation as to why a smaller proportion of GPs screen with BMI-for-age at every visit compared to PEDs: GPs do not have a sufficient protocol for their obese pediatric patients. GPs should be encouraged to access AAP resources in their states and communities to help them find referral clinics for their obese patients. Further, organizations such as AAP could include outreach efforts to GPs with pediatric patients.
The five counseling topics were examined separately because they are five of the six priority target behaviors to prevent and control obesity for the Division of Nutrition, Physical Activity, and Obesity at the Centers for Disease Control and Prevention (http://www.cdc.gov/nccdphp/DNPAO/aboutus/index.html
). The counseling topics were also included in the recommendations for healthcare providers' counseling for pediatric patients and their families by the Expert Committee on Childhood Obesity [4
This study assessed if PEDs and GPs were counseling on a topic area in general, not if PEDs' and GPs' were educating patients and their parents on specific recommendations. Recommendations exist for children on three of the five counseling topics: physical activity, TV viewing time, and fruit and vegetable consumption. Regarding physical activity, the 2008 Physical Activity Guidelines for Americans recommend children and adolescents (ages 6-17 years) engage in 60 minutes or more of physical activity daily, where most of the 60 minutes or more per day be either moderate- or vigorous-intensity and include vigorous-intensity physical activity at least three days per week [28
]. Furthermore, children and adolescents should engage in muscle-strengthening and bone-strengthening exercises as part of daily physical activity, or at least three days of the week [28
]. Regarding TV viewing, the AAP currently recommends youth ages two years and over engage in no more than two hours of television viewing, or screen time (television plus other forms of media for entertainment purposes) per day [29
]. Lastly, recommendations for fruit and vegetable exist, yet recommended consumption amounts vary depending on a child's age, sex, and activity level, where for example children aged 2 years require daily about 1 cup each of vegetables and fruit and 18 year olds require daily about 3 cups of vegetables and 2 cups of fruit [30
Interestingly, this study found among PEDs that the three topic areas with recommendations have the highest prevalence of counseling: physical activity (83%), TV time (79%), and fruit and vegetable consumption (87%) compared to energy dense foods (59%) and sugar-sweetened beverages (65%). These findings are very similar to an AAP study that found 86% of PEDs reported counseling all patients on physical activity, 76% counseled on TV viewing time, 89% on fruits and vegetables, 44% on energy dense foods, and 65% on sugar-sweetened beverages [25
]. The lower counseling prevalence of energy density and sugar-sweetened beverages suggests that if there were recommendations for these topic areas, physicians might counsel their patients in these areas more frequently. Consumption of energy dense foods was the least counseled topic by both PEDs and GPs. This is an important issue because of the frequent consumption of high energy dense foods, such as fast food [32
]. Somewhat similar to PEDs, GPs with pediatric patients reported a higher prevalence of counseling all patients on physical activity and fruit and vegetable consumption compared to the other three topics examined.
It is unknown why PEDs and GPs with pediatric patients do not report higher rates of using BMI-for-age and counseling, and why a discrepancy exists between the two specialties. One barrier may be the lack of time because evidence shows that the time needed for recommended screening and counseling exceeds the available time for primary care visits [26
]. Future research could discover other barriers that PEDs and GPs with pediatric patients confront and determine if different steps are necessary to overcome such barriers for the two different specialties.
The analyses to identify predictors associated with use of BMI-for-age and counseling habits documented that race/ethnicity of PEDs and gender of physician among GPs as significant predictors. Interestingly, "Other" PEDs were more likely to counsel all patients on energy dense foods compared to non-Hispanic white PEDs. GPs with a patient population that is mostly non-white were also more likely to use BMI-for-age. To the best of the authors' knowledge, these findings have not been previously reported. Additionally, among GPs, females were more likely to use BMI-for-age, counsel all patients on TV viewing time, and counsel all patients on fruit and vegetable consumption compared to male GPs. This is consistent with previous research showing female physicians were more likely to offer preventive services and counseling compared to male physicians [22
]. These findings need to be further explored so that education and training can be targeted to those most in need of changing their screening and counseling practices.
There were two strengths to this study. First is the attempt to match the convenience sample of physicians included in the Epocrates Honors Panel to the AMA master file for age, gender, and region, for each specialty area to make the findings more generalizable. A second strength is the inquiry about a quality of care issue, the use of BMI-for-age to screen for childhood obesity, given this is the AAP recommended method for screening. Previous research has shown that substantial proportions of PEDs and family practitioners reported not using the recommended BMI-for-age to screen for obesity, but they relied on height and weight growth charts, visual assessment, evaluating trends overtime, or only calculating BMI if concerned [22
]. With increased attention on obesity, it is important to demonstrate whether screening practices, based on the recommended tool are improving.
This study has limitations. First, there may be sampling bias. While attempts were made to match the sample to the AMA master file for age, gender, and region, there were differences in the sample for gender compared to the AMA master file. This sample included a higher percentage of male physician respondents for both PEDs and GPs compared to the AMA master file. Additionally, the sample may not be representative of all PEDs and GPs because of potential for volunteer bias due to quota sampling and the original database being an opt-in database. Generalizing results to all PEDs and GPs is not possible because of the low response rates for PEDs and GPs. A second limitation is a possible reporting bias from physicians' self-reported use of BMI-for-age to screen for obesity resulting in an overestimated BMI-for-age use. A third limitation is that the authors were not able to assess methods other than BMI-for-age for obesity screening. It is possible practitioners in this sample are using other methods to assess weight status although not the recommended protocol. Using methods other than BMI-for-age has different implications than not screening at all. For example, obese children who are not screened at all may be less likely to receive appropriate referral compared to obese children who receive appropriate referral after being diagnosed using a different method. Unfortunately, the data did not allow for more exploration for use of other methods. A fourth limitation is the authors did not specify which type of specialty clinic when asking about referral to a pediatric obesity specialty clinic. Physician respondents may have interpreted this question differently (e.g., bariatric surgery clinic, endocrinologist, lipidologist). However, those who responded affirmatively have a system in place to refer obese patients regardless of clinic type. A fifth limitation, the responses to the question about counseling activities could have been biased or incomplete because the physician respondent might not know whether or not his/her staff is counseling on overweight prevention topics that were listed in the question. Finally, the number of calculations necessary to examine counseling habits by six physician characteristics (i.e., gender of physician, years practiced, race of physician, type of practice, SES of patients, and race of patient population), five counseling topic (physical activity, TV viewing, energy dense food consumption, fruit and vegetable consumption, and sugar-sweetened beverage consumption), and two physician types (PEDs and GPs) resulted in 60 odds ratios (6*5*2). With a significance level of 0.05, this increased the possibility of a type I error.
These findings suggest a great need for some important next steps to increase adherence to the AAP and Institute of Medicine (IOM) obesity screening recommendations [2
], counseling recommendations on nutrition and age-appropriate physical activity, as well as establish a system for referral to a pediatric obesity specialty clinic. Strategies for improving screening include changes in the protocol for staff to screen for obesity [35
] and having a nurse or assistant calculate BMI for the physician have been identified as facilitators to use of BMI [27
]. Another strategy is the use of electronic medical record systems that automatically calculate BMI-for-age once height and weight data are entered [37
]. This would allow the graphs to be readily available to the physician to review and draw attention to necessary counseling. Another strategy is continuing medical education (CME) for PEDs and GPs with pediatric patients which may increase self-efficacy and knowledge of obesity screening and counseling, which may in turn increase the level of confidence when discussing the topic with parents [25
]. There are existing resources to increase physician screening and counseling expertise. The Maine Youth Overweight Collaborative (MYOC) and the Washington state model provide examples for improving physicians' ability to screen for obesity and offer appropriate management of obesity [38
]. The MYOC intervention provides tools for clinical decision support and counseling and self-management support for families and patients, [38
] while the Washington state model integrates obesity prevention and management into the clinic setting that emphasizes small, consistent behavior changes, and self-regulation of eating/feeding practices with children, teenagers, and families; building local community partnerships; and encouraging broader advocacy and policy change [39
In addition, as of January 2010, the American Board of Pediatrics requires ongoing practice improvements for maintenance of certification [40
]. These ongoing practice improvements ensure that board certified PEDs understand the importance of BMI-for-age to identify obesity and provide obese patients with appropriate medical assessment. In the future, the 2009 Healthcare Effectiveness Data and Information Set (HEDIS) measure, "Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents," will provide useful information on whether or not healthcare providers are screening for obesity with BMI and offering appropriate counseling for children and adolescents and their parents [41