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Michael Weitzman, MD
Strong Children's Research Center
Department of Pediatrics
University of Rochester School of Medicine and Dentistry
Rochester, NY 14642
Department of Pediatrics
New York University
New York, NY 10016
Sarah Barlow, MD, MPH
Division of Gastroenterology and Hepatology
St Louis University School of Medicine
St Louis, MO 63104
We thank Drs Eneli and Davies for their letter, and we appreciate the concern they expressed about the generalizability of the National Ambulatory Medical Care Survey (NAMCS) findings. Some of the issues they raise about accurate measurement of physician behavior were the impetus for our examination of these data. The purpose of this article was to look for alternative descriptions of pediatric practice patterns in regards to childhood obesity. Few disagree that physicians have an important role in the identification of childhood obesity, but each method to assess physician behavior has potential issues with validity.1–4
The NAMCS represents an established research methodology for describing ambulatory clinical care in the United States. We acknowledge that the low sample size puts statistical limitation on some of these findings, primarily when subgroups are examined as they were in our Table 1.5 Of note, our results represent the combination of 4 years of surveys pooled together. This weighted collection, which represents 130 million ambulatory visits, documented obesity diagnosis in <1% of visits with children, although obesity is a very common chronic condition. We acknowledged possible contributions to the low diagnosis rate, including failure to document a diagnosis that was made, but noted that this strategy also avoided the overreporting that may occur because of social desirability in surveys. Use of the NAMCS provided several benefits including unbiased sampling and unbiased reporting. The instructions for the list of diagnoses included obesity as an example of a chronic condition that should be listed if addressed. The discrepancy between diagnosis rate and obesity prevalence was so marked that we felt it raised serious concerns about underdiagnosis.
Our findings are consistent with those of other investigations that used different methods. Recent studies reviewing medical charts in pediatric primary care practices have also revealed low rates of obesity identification.6–8 The documented identification rates on those studies were higher than in the NAMCS, but each of these other studies examined only a small number of offices, many of which were academic, and thus lacked the representativeness of the NAMCS. Similar to our results, these studies showed that visits with obesity identified were far more likely to include recommendations for treatment that incorporated changing diet and physical activity behaviors. The more frequent diet and exercise counseling suggests the potential treatment benefits of diagnosis. Identification of all children with excess weight will allow treatment to begin earlier in the disease course. Behaviors during these earlier phases may be changed more easily with simple counseling measures delivered in the primary care setting.
We agree that the absolute rates of diagnosis and counseling in the NAMCS may not reflect exact rates in offices. However, this study, as well as others, strongly suggests that diagnosis rates are low and that better diagnosis rates will lead to higher rates of intervention.
REFERENCES
Related articles in Pediatrics:
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