It should be noted that BMI screening is only one part of identifying overweight or obesity in children. Further testing and evaluation for risk factors, including genetics, family history, fitness level, and fat distribution, are essential to formulate a diagnosis. The CDC and AAP emphasize this point and stress that the primary goal of consistent, yearly BMI screening is to identify trends and subsequent changes in trends.5,16 Ultimately, the goal is to identify BMI changes early because intervention efforts in the early stages have been shown to be more successful.14
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Current research: Are we assessing BMI at each visit?
Despite the consensus of the CDC, American Medical Association (AMA), USPSTF, and AAP regarding annual BMI assessments, practitioners do not consistently follow the recommendations.10,12,20-22,24-28 Reported ranges on the use of BMI percentile assessments show widespread variation of 5% to 66.8%.26,27 In 2006, a survey of 99 family nurse practitioners showed that although 73% were aware of the ECRs, more than half reported that they never or rarely recorded a BMI annually or used a change in BMI to identify excess weight gain.24 This study was done before the updated ECRs were released in 2007.
Despite clear recommendations, studies continue to show poor use of the BMI percentile as a primary assessment strategy.25,28 Sharifi and colleagues, in a retrospective analysis of 126,000 well-child visits, investigated whether release of the 2007 ECRs had had an effect on practitioners’ assessment habits for childhood overweight and obesity by comparing a group from 2006 with a group from 2008.10 Even after the release of the 2007 ECRs, a large majority of children in this study aged 2 to 17 years with a BMI in the 85th percentile or higher lacked diagnostic codes for overweight or obesity and did not have the recommended laboratory orders for an assessment of obesity-related comorbidities. Of interest, the number of diagnostic codes for children aged 2 to 5 years was significantly lower than the number for older children, suggesting that providers have less concern for weight-related issues in the preschool population. This finding is worrisome because obesity in these young children is associated with an increased incidence of obesity in adulthood as well as the development of comorbid conditions.3,5
One notable repercussion of inconsistent BMI assessment is the inability to translate potential overweight and obesity in children into diagnostic categories. The International Classification of Diseases, Ninth Revision (ICD-9) codes are not reflective of the actual prevalence of overweight and obesity.13-15,29 In a nationally representative sample of outpatient preventive visits from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 2005 to 2007, only 18% of patients in a BMI percentile of 95% or higher had a documented diagnosis of obesity.13 Using the same national surveys, Walsh and colleagues looked at 48,145 office visits for children aged 2 to 18 years from 2005 to 2009.30 Among the 19.5% of children who were obese by BMI standards, only 7% had the appropriate ICD-9 diagnostic code. Providers are not adequately diagnosing overweight and obesity, which hinders management and the initiation of appropriate treatment and interventions.13-15 An appropriate first step in tackling childhood overweight and obesity is to obtain an enhanced, timely diagnosis in the primary care clinic.
Barriers to implementation of recommendations
Aside from the evidence demonstrating underuse of the recommended BMI assessment, researchers have explored barriers to implementation of the 2007 ECRs. Frequently cited barriers include time constraints, futility of treatment efforts, lack of knowledge regarding current recommendations, reluctance to discuss weight-related issues, lack of patient and parental motivation, and lack of access to BMI charts.12,27,31,32 Interestingly, a survey showed that time constraints did not affect a provider’s ability to compute or document BMI; rather, providers were concerned about their ability to counsel patients identified as overweight or obese.32 Setting and environmental factors, such as training, office staff support, and access to professional journals and continuing medical education, could improve the implementation of and adherence to practice recommendations.12 Knowledge of the expert recommendations did correlate with a higher incidence of BMI screening, and therefore, efforts to increase practitioners’ awareness of the recommendations appear promising.5,11,12,21,27,33-37
Weight can be a very difficult subject for clinicians to address with children or adolescents and their parents. A qualitative survey of communication barriers between maternal child health nurses and parents of overweight children revealed several themes: (1) It was difficult to initiate a discussion of weight issues; (2) growth charts were an essential tool to start conversations about overweight or obesity; (3) denial, defensiveness, and excuses were common reactions among parents; and (4) weight-related conversations were especially difficult if the parents were also overweight.38 Although this study involved maternal and child health nurses, it is likely that these barriers would also apply to other practitioners (ie, primary care providers) treating pediatric patients. Of particular interest was that the use of growth charts was helpful when a crucial conversation with patients and parents was initiated, which indicates that BMI charts can be valuable as a conversation starter.
Other studies have looked more specifically at these communication barriers and found that the technique of motivational interviewing may be an effective counseling strategy for overweight and obese children and their parents.39-41 Motivational interviewing is a patient-focused, and in this case parent-focused, method of communication that has shown promise as a counseling technique for a broad range of behavioral issues, including overweight and obesity.42 The goal of motivational interviewing is to focus on helping the patient develop internal motivation to change rather than on providing information and factual data. The role of the provider is to encourage and support the patient’s and/or parent’s commitment to change unhealthful behaviors while remaining empathetic and nonjudgmental. Specific patient-centered communication recommendations are included in the ECRs and underscore this important component of addressing the childhood obesity epidemic.
Awareness of these barriers will be helpful to primary care providers addressing the issue of overweight and obesity with children and adolescents. In an effort to focus on the interventions that can be made in the primary care setting, knowledge of the ECRs is a pivotal first step in addressing the epidemic. It is imperative to focus on the tangible recommendations provided in the ECRs and the toolkit/resources included here. With the elimination of several noted barriers, the essential first step of diagnosis is facilitated.
The Expert Committee recommendations
In 2005, the AMA, along with the Health Resources & Service Administration and CDC, convened an expert committee to revise outdated recommendations based on the latest available evidence-based findings and expert opinion.2 This committee comprised 15 professional organizations, scientists, and clinical experts, and their report is referred to as the Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.5
