Association of Clinician Behaviors and Weight Change in School-Aged Children

Abstract

Introduction: This study uses clinical practice data to determine whether recommended weight management clinician behaviors are associated with weight status improvement in children aged 6-12 years who are overweight or obese.

Methods: Electronic health record data (2009-2014) from 52 clinics were used. Weight status was examined from 1 visit to the next as dichotomous improvement (versus worsening or no change) and change in percentage overweight (over sex/age-specific BMI₉₅). The primary predictor was a clinician behavior variable denoting attention to high BMI alone or with assessment of medical risk/comorbidities and was defined using combinations of diagnostic codes and electronic health record orders. Covariates included time between visits and medications associated with weight gain or loss. Adjusted multilevel regression models examined the association of the clinician behavior variable with weight status improvement. Analyses were conducted from 2015 to 2018.

Results: Children (n=7,205) had a mean age of 8.9 years; 45.5% were overweight, 54.5% obese, and 81.1% publicly insured. For 62% of overweight children, and 38%, 21%, and 11% of those in obesity classes 1-3, respectively, no attention to high BMI/medical risk assessment at any visit was identified. Children with evidence of clinician attention to high BMI alone and who underwent a medical risk assessment had significantly greater AOR of improvement in percentage of BMI₉₅ and percentage of BMI₉₅ change: BMI alone, AOR=1.2 (p<0.001) and β= -0.3 (p>0.05); BMI/medical risk, AOR=1.2 and β= -0.5 (both p<0.001). Other factors associated with weight status improvement included prescription medications (1 or more prescriptions associated with either weight loss or none associated with weight gain) and fewer months between visits.

Conclusions: This is the first study to use electronic health record data to demonstrate that widely recommended clinician behaviors are associated with weight status improvement in children aged 6-12 years who are overweight or obese.

Figure 1.

Sample flow. Notes: EHR data were extracted in 2014. The study sample was drawn from a population with 47% of children aged 6–12 years who had EHR evidence of overweight or obesity at one or more primary care visits. Final sample included 7,205 children aged 6–12 years with overweight or obesity and one or more well-child visits. The study team only received data for children with overweight and obesity (n=11,451). EHR was adopted by academic/teaching clinics in November 2009 and community-based and private clinics at different time-points from 2010–2012. ^aInclusion required two elevated BMI percentiles to increase the likelihood that children in the cohort truly had overweight/obesity (e.g., did not have a single BMI elevation due to error). Because the study team received all visit data for children, including for visits when child age was <6 years, one of the two BMI elevations needed for inclusion could come from a visit prior to age 6 years. EHR, electronic health record.

Figure 2.

Proportions of children aged 6–12 years with overweight and obesity (N=7,205) with evidence of attention to overweight/obesity/high BMI alone, attention to both BMI and medical risk/presence of obesity comorbidities, and no attention at visits^a in study cohort, by BMI category.^b Notes: Rates of clinician behaviors improve directly with BMI category. For example, the proportion of children with overweight/obesity lacking evidence of attention to both high BMI and medical risk is 62% among children with overweight and improves to 11% of children with obesity Class 3. ^aThe highest weight management practice behavior ever performed at a visit during time in cohort. “No Attention” indicates no evidence of attention to high BMI alone or with medical risk at any visit. Children coded as “BMI Alone” lacked evidence of attention to both BMI and medical risk at the same visit or at any visit. Children coded as “BMI/Medical Risk” had evidence of attention to both BMI and medical risk at one or more visits; these children may also have had one or more visits with evidence of attention to high BMI alone. Children coded as having attention to medical risk without attention to high BMI were included in “No Attention” category. ^bBMI category is the baseline BMI category at each child’s first visit documented in the electronic health record at which child met study inclusion criteria.