584216
research-article2015
CPJXXX10.1177/0009922815584216Clinical PediatricsMoyce and Bell
Article
Receipt of Pediatric Weight-Related Counseling and Screening in a National Sample After the Expert Committee Recommendations
Clinical Pediatrics 2015, Vol. 54(14) 1366–1374 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815584216 cpj.sagepub.com
Sally C. Moyce, BSN, RN1, and Janice F. Bell, PhD, RN, MPH1
Abstract Objective. It is uncertain whether children of all weight classifications receive the recommended screening and counseling and if these affect weight status in the subsequent year. Methods. Data from the 2008-2011 Medical Expenditures Panel Survey were used to examine associations between weight classification and receipt of weightrelated screening and counseling from the pediatric provider (n = 9835). Body mass index (BMI) z-score in the subsequent year was modeled as a function of the BMI z-score in year 1. Results. Normal and overweight children have lower odds than obese children of receiving counseling regarding diet (adjusted odds ratio [AOR] = 0.58, 95% confidence interval [CI] = 0.50-0.68; AOR = 0.75, 95% CI = 0.63-0.89, respectively) and exercise (AOR = 0.56, 95% CI = 0.48-0.65; AOR = 0.75, 95% CI = 0.64-0.89, respectively). Counseling was associated with a small increase in BMI z-score in the subsequent year (β = 0.06, 95% CI = 0.01-0.11), as was maternal weight class. Conclusions. Recommendations to focus prevention on the family unit may reduce childhood overweight and obesity. Keywords primary care, counseling, screening, prevention
Introduction Childhood obesity is a major public health concern. In 2009-2010, over a third of US children were overweight or obese, reflecting a dramatic increase in prevalence over the past 3 decades.1,2 Obese children are likely to be obese as adults.3,4 Many obesity-related conditions— now diagnosed at younger ages—are associated with adverse health status and health care expenditures later in life.5-8 In response to the growing prevalence of overweight and obesity among youth, in 2007 an expert committee, representing the American Medical Association, Health Resources and Service Administration, and Centers for Disease Control and Prevention, convened to revise existing recommendations on childhood obesity. The committee established new guidelines for the prevention, assessment, and treatment of child overweight and obesity. Recognizing the difficulty in treating obesity and its long-term health impacts, the committee expanded recommendations to include universal assessment of body mass index (BMI), regardless of weight class, and the delivery of diet- and exercise-related counseling to all children. The guidelines advocate greater efforts to establish or improve
health behaviors in the presence of maternal obesity or diabetes mellitus, regardless of the child’s weight classification.9 Pediatric providers are often the first professionals to discuss weight status with patients and families by delivering prevention messages, and such counseling is shown to improve nutrition in young children10 and to increase exercise among adolescents.11 Prior to the updated childhood obesity recommendations, in a national sample of pediatric ambulatory visits, researchers found that visits associated with a diagnosis of obesity were more likely to include diet counseling (88.4% vs 35.7%) and exercise counseling (69.2% vs 18.6%) than those without.12 It is not clear if these differences in counseling rates persist since the expansion of the Expert Committee recommendations on childhood obesity. 1
University of California, Davis, Sacramento, CA, USA
Corresponding Author: Sally C. Moyce, Betty Irene Moore School of Nursing, University of California, Davis, 4610 X Street Ste 4202, Sacramento, CA 95817, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at UNIV OF LETHBRIDGE on November 14, 2015
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Moyce and Bell One study examining counseling rates after 2007 found that less than half of providers follow the Expert Committee recommendations on childhood obesity.13 Another study surveyed primary care providers and found that while 92% feel comfortable discussing weight management with children and families, only 56% reported familiarity with the Expert Committee recommendations.14 Analyses of the adherence to recommendations, based on patient perception or selfreported data, reveal that children classified as overweight or obese are more likely to receive prevention messages. In a study of adolescents, Klein et al15 found that adolescents perceived that their physicians were significantly more likely to discuss weight management with overweight teens than healthy weight teens. Finally, it is unclear if prevention counseling in the pediatric provider’s office has an effect on a child’s subsequent weight classification. Providers report doubt that prevention messages delivered in the primary care setting make a difference in a child’s weight status.13 Evidence exists for the efficacy of moderate- to high-intensity behavioral modification programs in the treatment of children and adolescents classified as overweight16 or obese.17 But an analysis of treatment interventions conducted by the US Preventive Services Task Force in 2009 revealed a need to evaluate interventions in the primary care provider’s office for children with BMI classifications of healthy weight or overweight.18 The current study was designed to determine if the recommendations of the Expert Committee for the delivery of weight-related prevention messages are occurring for children regardless of their weight classification. Specifically, we test whether those classified as healthy weight and those classified as overweight receive the same weight-related screening and counseling as those classified as obese. Additionally, we examine whether receipt of counseling is modified by the presence of maternal overweight or obesity and/or the presence of maternal diabetes. Finally, we test whether receipt of counseling is associated with the child’s weight status, measured in the subsequent year.
Data were pooled across years to assure sufficient observations for analysis of screening and counseling by clinical weight classification. MEPS employs an overlapping panel design with data collected in 5 survey rounds over 2 years, allowing for an analysis of the effect of an intervention in the subsequent year. Child data in MEPS are reported by a single member of each household, usually the child’s mother. Minority and low-income populations are oversampled. Children were linked by a unique person identifier to variables collected about their parents.
Methods
In the analysis of the effect of counseling on a child’s subsequent weight status, the dependent variable was the child’s sex- and age-specific BMI z-score (ie, the number of SD units that the child’s BMI deviates from the mean reference value for age and gender19) relative to US growth reference charts measured in Round 4 (MEPS Year 2). BMI z-scores were used rather than absolute BMI due to expected age-related increases in child height and weight as part of normal development.19
Data Source Data were examined from the 2008-2011 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the civilian, noninstitutionalized US population, with annual response rates ranging from 58.6% to 64.4%. These years were chosen because they were subsequent to the 2007 Expert Committee’s recommendations.
Sample Children under age 6 were excluded from the study because their BMI measures were inconsistently available in MEPS. Of the children and youth ages 6 to 17 years (n = 24 311), those with at least one office-based provider visit in the previous year were included to assure opportunity for receipt of counseling and screening (n = 16 190). Children were excluded if their BMI was missing (n = 5317) or they were classified as underweight (n = 1675). The analysis sample included 9835 observations.
Dependent Variables Three binary variables (coded yes = 1, no = reference) were developed to examine receipt of weight-related preventive recommendations in the year prior to the MEPS interview, each reported in the MEPS Child Preventive Health Supplement by a parent (>90%) or other caregiver: 1. BMI screening (ie, the child had both height and weight measured) 2. Child received counseling from a provider related to healthy eating (ie, obesity prevention messages related to diet) 3. Child received counseling from a provider related to exercise (ie, obesity prevention messages related to exercise)
Downloaded from cpj.sagepub.com at UNIV OF LETHBRIDGE on November 14, 2015
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Clinical Pediatrics 54(14)
Independent Variables In the analysis of receipt of recommendations, the primary independent variable was child and youth body mass index (BMI = kg/m2) classified using age- and sexspecific cutoff points as recommended by the Centers for Disease Control.20 BMI was categorized as normal weight (5th to 84th percentile), overweight (85th to 94th percentile), or obese (≥95th percentile). Two maternal risk factors were also included in the models: (a) maternal weight class, derived from height and weight reported by mother, categorized as normal weight (BMI = 18.5-24.9), overweight (BMI = 25-29.9), or obese (BMI ≥ 30); and (b) maternal diagnosis of diabetes (yes/no). In the analysis of child BMI z-scores in Year 2, the independent variable was an indicator of whether the child had received both diet and exercise counseling in the previous year, as reported by the mother.
Covariates Variables expected to influence receipt of counseling and screening were selected a priori based on the Anderson and Aday model of health care access and utilization.21 Predisposing variables (ie, demographic characteristics) included sex (male = reference, female), the child’s age in years (6-11 years, 12-17 years = reference), racial/ ethnic group (White non-Hispanic = reference, Black nonHispanic, Hispanic, and other), residence in a rural area (metropolitan = reference, nonmetropolitan), and year of the MEPS survey collection to account for any temporal variation in the provision of counseling and screening. Enabling factors (ie, health insurance and other resources) included family income as percentage of the federal poverty level (400%), medical insurance status (any private insurance = reference, at least some public insurance, uninsured), mother’s education level (12 years to
research-article2015
CPJXXX10.1177/0009922815584216Clinical PediatricsMoyce and Bell
Article
Receipt of Pediatric Weight-Related Counseling and Screening in a National Sample After the Expert Committee Recommendations
Clinical Pediatrics 2015, Vol. 54(14) 1366–1374 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815584216 cpj.sagepub.com
Sally C. Moyce, BSN, RN1, and Janice F. Bell, PhD, RN, MPH1
Abstract Objective. It is uncertain whether children of all weight classifications receive the recommended screening and counseling and if these affect weight status in the subsequent year. Methods. Data from the 2008-2011 Medical Expenditures Panel Survey were used to examine associations between weight classification and receipt of weightrelated screening and counseling from the pediatric provider (n = 9835). Body mass index (BMI) z-score in the subsequent year was modeled as a function of the BMI z-score in year 1. Results. Normal and overweight children have lower odds than obese children of receiving counseling regarding diet (adjusted odds ratio [AOR] = 0.58, 95% confidence interval [CI] = 0.50-0.68; AOR = 0.75, 95% CI = 0.63-0.89, respectively) and exercise (AOR = 0.56, 95% CI = 0.48-0.65; AOR = 0.75, 95% CI = 0.64-0.89, respectively). Counseling was associated with a small increase in BMI z-score in the subsequent year (β = 0.06, 95% CI = 0.01-0.11), as was maternal weight class. Conclusions. Recommendations to focus prevention on the family unit may reduce childhood overweight and obesity. Keywords primary care, counseling, screening, prevention
Introduction Childhood obesity is a major public health concern. In 2009-2010, over a third of US children were overweight or obese, reflecting a dramatic increase in prevalence over the past 3 decades.1,2 Obese children are likely to be obese as adults.3,4 Many obesity-related conditions— now diagnosed at younger ages—are associated with adverse health status and health care expenditures later in life.5-8 In response to the growing prevalence of overweight and obesity among youth, in 2007 an expert committee, representing the American Medical Association, Health Resources and Service Administration, and Centers for Disease Control and Prevention, convened to revise existing recommendations on childhood obesity. The committee established new guidelines for the prevention, assessment, and treatment of child overweight and obesity. Recognizing the difficulty in treating obesity and its long-term health impacts, the committee expanded recommendations to include universal assessment of body mass index (BMI), regardless of weight class, and the delivery of diet- and exercise-related counseling to all children. The guidelines advocate greater efforts to establish or improve
health behaviors in the presence of maternal obesity or diabetes mellitus, regardless of the child’s weight classification.9 Pediatric providers are often the first professionals to discuss weight status with patients and families by delivering prevention messages, and such counseling is shown to improve nutrition in young children10 and to increase exercise among adolescents.11 Prior to the updated childhood obesity recommendations, in a national sample of pediatric ambulatory visits, researchers found that visits associated with a diagnosis of obesity were more likely to include diet counseling (88.4% vs 35.7%) and exercise counseling (69.2% vs 18.6%) than those without.12 It is not clear if these differences in counseling rates persist since the expansion of the Expert Committee recommendations on childhood obesity. 1
University of California, Davis, Sacramento, CA, USA
Corresponding Author: Sally C. Moyce, Betty Irene Moore School of Nursing, University of California, Davis, 4610 X Street Ste 4202, Sacramento, CA 95817, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at UNIV OF LETHBRIDGE on November 14, 2015
1367
Moyce and Bell One study examining counseling rates after 2007 found that less than half of providers follow the Expert Committee recommendations on childhood obesity.13 Another study surveyed primary care providers and found that while 92% feel comfortable discussing weight management with children and families, only 56% reported familiarity with the Expert Committee recommendations.14 Analyses of the adherence to recommendations, based on patient perception or selfreported data, reveal that children classified as overweight or obese are more likely to receive prevention messages. In a study of adolescents, Klein et al15 found that adolescents perceived that their physicians were significantly more likely to discuss weight management with overweight teens than healthy weight teens. Finally, it is unclear if prevention counseling in the pediatric provider’s office has an effect on a child’s subsequent weight classification. Providers report doubt that prevention messages delivered in the primary care setting make a difference in a child’s weight status.13 Evidence exists for the efficacy of moderate- to high-intensity behavioral modification programs in the treatment of children and adolescents classified as overweight16 or obese.17 But an analysis of treatment interventions conducted by the US Preventive Services Task Force in 2009 revealed a need to evaluate interventions in the primary care provider’s office for children with BMI classifications of healthy weight or overweight.18 The current study was designed to determine if the recommendations of the Expert Committee for the delivery of weight-related prevention messages are occurring for children regardless of their weight classification. Specifically, we test whether those classified as healthy weight and those classified as overweight receive the same weight-related screening and counseling as those classified as obese. Additionally, we examine whether receipt of counseling is modified by the presence of maternal overweight or obesity and/or the presence of maternal diabetes. Finally, we test whether receipt of counseling is associated with the child’s weight status, measured in the subsequent year.
Data were pooled across years to assure sufficient observations for analysis of screening and counseling by clinical weight classification. MEPS employs an overlapping panel design with data collected in 5 survey rounds over 2 years, allowing for an analysis of the effect of an intervention in the subsequent year. Child data in MEPS are reported by a single member of each household, usually the child’s mother. Minority and low-income populations are oversampled. Children were linked by a unique person identifier to variables collected about their parents.
Methods
In the analysis of the effect of counseling on a child’s subsequent weight status, the dependent variable was the child’s sex- and age-specific BMI z-score (ie, the number of SD units that the child’s BMI deviates from the mean reference value for age and gender19) relative to US growth reference charts measured in Round 4 (MEPS Year 2). BMI z-scores were used rather than absolute BMI due to expected age-related increases in child height and weight as part of normal development.19
Data Source Data were examined from the 2008-2011 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the civilian, noninstitutionalized US population, with annual response rates ranging from 58.6% to 64.4%. These years were chosen because they were subsequent to the 2007 Expert Committee’s recommendations.
Sample Children under age 6 were excluded from the study because their BMI measures were inconsistently available in MEPS. Of the children and youth ages 6 to 17 years (n = 24 311), those with at least one office-based provider visit in the previous year were included to assure opportunity for receipt of counseling and screening (n = 16 190). Children were excluded if their BMI was missing (n = 5317) or they were classified as underweight (n = 1675). The analysis sample included 9835 observations.
Dependent Variables Three binary variables (coded yes = 1, no = reference) were developed to examine receipt of weight-related preventive recommendations in the year prior to the MEPS interview, each reported in the MEPS Child Preventive Health Supplement by a parent (>90%) or other caregiver: 1. BMI screening (ie, the child had both height and weight measured) 2. Child received counseling from a provider related to healthy eating (ie, obesity prevention messages related to diet) 3. Child received counseling from a provider related to exercise (ie, obesity prevention messages related to exercise)
Downloaded from cpj.sagepub.com at UNIV OF LETHBRIDGE on November 14, 2015
1368
Clinical Pediatrics 54(14)
Independent Variables In the analysis of receipt of recommendations, the primary independent variable was child and youth body mass index (BMI = kg/m2) classified using age- and sexspecific cutoff points as recommended by the Centers for Disease Control.20 BMI was categorized as normal weight (5th to 84th percentile), overweight (85th to 94th percentile), or obese (≥95th percentile). Two maternal risk factors were also included in the models: (a) maternal weight class, derived from height and weight reported by mother, categorized as normal weight (BMI = 18.5-24.9), overweight (BMI = 25-29.9), or obese (BMI ≥ 30); and (b) maternal diagnosis of diabetes (yes/no). In the analysis of child BMI z-scores in Year 2, the independent variable was an indicator of whether the child had received both diet and exercise counseling in the previous year, as reported by the mother.
Covariates Variables expected to influence receipt of counseling and screening were selected a priori based on the Anderson and Aday model of health care access and utilization.21 Predisposing variables (ie, demographic characteristics) included sex (male = reference, female), the child’s age in years (6-11 years, 12-17 years = reference), racial/ ethnic group (White non-Hispanic = reference, Black nonHispanic, Hispanic, and other), residence in a rural area (metropolitan = reference, nonmetropolitan), and year of the MEPS survey collection to account for any temporal variation in the provision of counseling and screening. Enabling factors (ie, health insurance and other resources) included family income as percentage of the federal poverty level (400%), medical insurance status (any private insurance = reference, at least some public insurance, uninsured), mother’s education level (12 years to
