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Original Research |
Department of Public Health, University of Toledo, Toledo, OH (DB)
Flower Hospital Family Medicine Residency Program, Sylvania, OH (CS)
University of Toledo, Toledo, OH (LA)
Toledo Hospital Family Practice Residency, Toledo, OH (JL)
Correspondence: Corresponding author: Debra Boardley, PhD, Department of Public Health, Mail Stop 119, 2801 West Bancroft, University of Toledo, Toledo, OH 43623 (E-mail: debra.boardley{at}utoledo.edu)
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Abstract |
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Methods: This was a cross-sectional study of 553 consecutive patients who presented for family medicine well visits. Patient charts were reviewed for documentation of body mass index (BMI) and patient education regarding weight, exercise, and diet.
Results: BMI was calculated for 63.5% of adults at the well visit. For patients who were overweight or obese (BMI greater than 25), 48.9% received education on weight, 50.2% on diet, and 41% on exercise. Adults who had BMI calculated were also more likely to receive weight-related education (P < .001). Although height and weight were measured for most of the children and adolescents, their BMI-for-age was not calculated and they were unlikely to receive weight-related education.
Conclusions: Training staff to measure and record BMI is a useful prompt for the physician to discuss overweight. To address weight during critical periods of development, children and adolescents need to have growth monitored with standardized tools.
The current obesity epidemic has significant future implications to our health care system. It is estimated that health care expenditures related to obesity and overweight in adults are approximately $117 billion each year.4,5 Given the number of patients affected, the comorbid health implications, and the economic impact, primary care providers have been urged to place significant emphasis on the diagnosis and treatment of obesity during preventive health physical examinations.6,7 It is estimated that every month, primary care physicians see 11.3% of the US population.8 This provides an opportunity for intervention. Orzano and Scott9 reviewed recommendations from many scientific bodies addressing obesity in adults. They concluded that clinicians should manage obesity as a chronic relapsing condition and recommended patient education strategies to manage overweight and obese adult patients. The Institute of Medicine report, Preventing Childhood Obesity: Health in the Balance10, recommends health professionals to routinely track BMI and to offer patients evidence-based guidance on weight control.
Measuring BMI is an effective measure for overweight and obesity; it is considered to be reliable, inexpensive, and quick.11 Even with the recommendations to identify and treat overweight and obesity, the prevalence of undiagnosed obesity in currently obese US adults is 22.9%.12 The high rate of undiagnosed obesity may be explained by the fact that, despite the availability and ease of measuring BMI, research has shown that it is frequently not used.13 Even when a formal diagnosis of obesity is made, clinicians may not provide patients with advice regarding weight loss. One study of obese patients seeking medical help for comorbid conditions found that only 27% to 42% were advised by their primary care physician to lose weight.13 In a national study of 12,835 adults classified as obese, only 42% reported that their health care provider advised them to lose weight.14
The purpose of this study was to determine the extent that primary care providers assess overweight and obesity and document treatment strategies in a family medicine setting during well visits. Review of medical records provided data to assess the use of BMI for adults and BMI-for-age for children and allowed examination of the documentation of patient education concerning body weight, diet, and exercise.
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Methods |
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Measures
To ensure consistency, the same 2 researchers worked together to review all charts. The variables collected included: practice location, physician name, patient age, patient sex, and BMI at last visit. If BMI was not recorded for the well visit, BMI for any visit was noted. In cases where there was not a BMI recorded at well visit, but height and weight were recorded, the researchers recorded these measures and BMI was calculated using the formula for BMI: weight in kilograms divided by height in meters squared. The children's charts were reviewed for the previously identified variables. In addition, the use of BMI-for-age or any other growth charts was noted.
To determine the level of instruction the patient received regarding weight, diet, and exercise, the chart note for the well visit was reviewed and coded using a 3-point scale; "none," "minimal," and "detailed." A score of "none" was recorded when the physician note did not indicate any discussion of, or plan to address weight, diet, or exercise. If the chart note included some mention of weight, diet, or exercise, "minimal" was recorded. For example, "minimal" was used if the chart note included general comments such as "patient was encouraged to lose weight," "discussed diet," and "encouraged exercise." To receive "detailed," there was documentation of specific goals or educational plan. Examples of "detailed" included referrals for further education, scheduled follow-up to assess progress ("come back in 6 months for weight and cholesterol check"), noting the educational materials used ("gave patient handouts and discussed portion sizes"), and specific goals ("walk 3 times a week").
Data Analysis
Descriptive statistics were used to describe the sample, the measurement of BMI and the amount and level of patient education. The 
2 statistic was used to test the association of level of education with patient weight category (overweight BMI, 25 or greater; obese, 30 or greater, and morbid obese, 40 or greater). In adults, the levels of education were then collapsed to a binary variable (no documented education, any documented education), and another 2 analysis compared education with the number of adults who had BMI measured in their well visit. In children, the analysis of education to weight category included normal, at risk of overweight, and overweight. The 2 statistic was also used to assess the association between a child's age and use of growth charts. Associations were considered significant if P < .05.
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Results |
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2 analysis showed that patients who had their BMI measured and recorded in the chart were more likely to have documented education, compared with those who did not have BMI measured (P < .001). Very few at-risk-for-overweight and overweight children in this sample had documented evidence of education about weight, diet, and exercise (Table 3). Although BMI-for-age is the recommended standard for evaluating weight in children, none of the charts indicated that this tool was being used. Standard growth charts were in many of the charts, and physicians often noted weight percentiles, but the use of growth charts decreased with the increased age of the child (Table 4).
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Discussion |
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To help reverse the current trend of obesity in the United States, primary care providers must not only recognize and document obesity, but also treat it as a chronic disease by providing patient education concerning weight, diet, and exercise. In the current study, 56.4% of the obese patients received documented information on weight, 55.3% were given diet advice, and only 45% were instructed to exercise.
These findings are similar to those of a national study of weight management practices,15 which found that for obese patients, 35.5% received weight loss advice, 32.8% received exercise advice, and 41.5% received diet advice from their physician. Another more recent investigation16 observed the amount of advice that primary care providers gave obese patients and reported that 65.1% of patients received information about the benefits of weight loss, whereas only 36.6% were given specific weight-control advice and 28.2% were instructed to increase physical activity. Similar to previous research,15,16 this study found that physicians are more likely to offer education on diet than on exercise.
It seems that primary care providers are missing opportunities during preventive visits to help their patients. In fact, patients report that they want more help with weight management from their primary care physician.17 Recently, Bish et al18 reported that adults who had a routine physician checkup in the previous year and also reported that they had received medical advice to lose weight were much more likely to try to lose weight, compared with adults who had a checkup but did not receive medical advice to lose weight.
Another important finding of this study was that children did not have BMI-for-age measured, and were not likely to receive education about weight, diet, or exercise. Although BMI-for-age was never noted, growth charts were often used and provided a method to monitor growth for children up to 10 years of age. Unfortunately, after age 10, there was a significant decline in the use of growth charts. It is known that puberty is a critical time for the development of overweight,19 and unfortunately, these adolescents were not being monitored with BMI-for-age or growth charts.
The evaluation of education was based on the physician chart note and is a limitation that may underestimate the true amount of education that was provided. It is very possible that education was given but not documented. However, these were all routine well visits. It would be difficult to implement and follow up on a plan to address weight, diet, or exercise without documenting the education that was provided.
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Conflict of interest: none declared.
Received for publication July 31, 2006. Revision received November 28, 2006. Accepted for publication December 8, 2006.
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