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Am Fam Physician. 2006;73(3):528-532

Fifteen percent of patients six to 19 years of age are considered to be overweight or obese as defined by percentile growth charts. Although guidelines and surveys have suggested that physicians discuss weight control with overweight patients at most visits, the rate of treatment has been low. Cook and associates conducted a study of a nationally representative sample of well-child visits to determine the frequency and quality of obesity evaluation and counseling.

Coding, demographic, and office visit data were collected from the National Ambulatory Care Survey and the National Hospital Ambulatory Care Survey. Of the 32,930 office visits evaluated, 281 (0.78 percent) were coded with a diagnosis of obesity, morbid obesity, or excess weight gain. Pediatricians were more likely to code for obesity than other clinicians. Children six to 11 years of age were more likely to be diagnosed as obese. Although blood pressure screening was slightly more common in children with identified obesity compared with children without diagnosed obesity, the difference was not statistically significant.

Diet counseling occurred in 88.4 percent of obesity-coded visits compared with 35.7 percent of visits without an obesity code. Exercise counseling was provided in 69.2 percent of visits when obesity was diagnosed and 18.6 percent of visits when obesity was not diagnosed. Diet and exercise counseling was more likely to be provided by pediatricians than by general practitioners and other physicians and was more likely to be given if private insurance covered the visit than if the visit was being paid for out of pocket. Younger children also were more likely to receive diet counseling, and white children were more likely than black children to receive exercise counseling.

Even though 15 percent of children are estimated to be obese, less than 1 percent visiting their primary care physician received an obesity diagnosis. This study also showed that insurance status and race influenced counseling rates.

The authors conclude that because increased screening for obesity is associated with increased diagnosis and counseling rates, programs should target methods that will increase screening rates. They also suggest that insurance and race discrepancies should be corroborated by other studies and actively addressed. Because the actual charts were not reviewed in the study, the reasoning behind the coding or its absence was not apparent. For example, physicians may have discussed obesity without coding for it. The authors speculate that lack of time and inadequate reimbursement also may be barriers to obesity counseling.

editor’s note: This study, which documents the underdiagnosis of childhood obesity at office visits, does not acknowledge the problem of treatment. Does office-based, primary care intervention for obesity reduce obesity in children? According to the U.S. Preventive Services Task Force, the evidence is insufficient to recommend for or against routine screening for overweight children.1 First, physicians must demonstrate that their time counseling families of obese children is well spent. If so, then they will want to make sure that, in terms of diagnosis, no child is left behind.—c.w.

REFERENCEU.S. Preventive Services Task Force. Screening and interventions for overweight in children and adolescents: recommendation statement.Pediatrics2005;116:205–9.

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