Identification and Assessment of Childhood Obesity by School-based Health Center Providers

Heather Aldrich, PhD; Bonnie Gance-Cleveland, PhD, RNC, PNP, FAAN; Sarah Schmiege, PhD; Danielle Dandreaux, PhD

J Pediatr Health Care. 2014;28(6):526-533.

Abstract and Introduction

Abstract

Introduction School-based health centers (SBHCs) serve many overweight/obese children, yet little is known about provider adherence to obesity guidelines. The purpose of this descriptive study was to evaluate obesity care assessment practices of SBHC providers prior to completing training on obesity guidelines.

Method Providers (n = 33) from SBHCs in six states (AZ, CO, NM, MI, NY, and NC) completed The International Life Science Institute Research Foundation Assessment of Overweight in Children and Adolescents Survey.

Results Most providers reported using body mass index percentile (93.9%) to assess weight. In caring for overweight/obese children, providers reported screening for hypertension 100% of the time and cardiovascular disease 93.9% of the time, and approximately two thirds reported requesting total cholesterol and lipid profile laboratory assessments. Some assessment guidelines were not routinely followed.

Discussion SBHCs serve a high-risk population, and providers in this study may benefit from additional training on assessment guidelines and quality improvement processes to improve adherence to current guidelines.

Introduction

Childhood obesity continues to be a challenging health problem. One third of children 6 to 11 years old in the United States are overweight or obese (body mass index [BMI] ≥85th percentile), and 18% are obese (BMI ≥95th percentile; Ogden, Carroll, Kit, & Flegal, 2014). Significant health disparities exist with regard to the prevalence of childhood obesity and related chronic conditions, with 46% of Hispanics and 38% of non-Hispanic Blacks classified as overweight or obese compared with 29% of non-Hispanic White children aged 6 to 11 years old (Ogden et al., 2014).

With the increasing prevalence of obesity in the previous four decades, particularly among ethnic minority youth, expert panels have published evidence-based guidelines for the prevention and treatment of childhood obesity (Barlow, 2007; National Association of Pediatric Nurse Practitioners [NAPNAP], 2006). These guidelines include routine screening for cardiovascular risk factors and medical comorbidities, as well as use of family-centered counseling, including motivational interviewing and culturally sensitive approaches to care. In addition, use of the chronic care model (Barlow, 2007) is encouraged with health care system changes to facilitate identification, assessment, self-management support, and clinical decision support. Despite the publication of these guidelines, research suggests that adherence to the obesity guidelines is poor among primary care providers (Mazur et al., 2013; Rausch, Perito, & Hametz, 2011; Sharifi et al., 2013). Adherence to the childhood obesity guidelines is complicated by a lack of consistency with some recommendations. For example, expert groups have different criteria for laboratory assessment recommendations, making it difficult for providers to know what guidelines to follow (Benson, Baer, & Kaelber, 2011).

School-based health centers (SBHCs) are clinics housed in or linked to a school that provide access to care for poor, underserved, and minority youth who are at highest risk of obesity and related chronic conditions. Chart audits from this study reveal that 43% of youth seen by the providers in these SBHCs are overweight or obese. By increasing accessibility to health care on school grounds, SBHCs have been shown to positively influence a variety of physical and mental health outcomes for children and adolescents including immunizations, oral health, asthma, reproductive health, health promotion, and illness prevention (Keeton, Soleimanpour, & Brindis, 2012). According to the most recent survey by the School-Based Health Alliance, there are 1,930 SBHCs in the United States (Lofink et al., 2013). These SBHCs provide integrated care with comprehensive medical, mental health, social services, and sometimes dental health services on the school campus, making this an ideal setting for reaching children most affected by obesity-related health disparities (Keeton et al., 2012).

SBHC providers work with an especially vulnerable youth population, yet little is known about their adherence to obesity guidelines. The purpose of this study was to describe the self-reported assessment practices of SBHC providers in six states prior to an intervention training providers on the current obesity care guidelines.

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Abstract and Introduction
Methods
Results
Discussion
Conclusions
References

Table 1. Provider demographics ( n = 33)
Characteristic	n	%
Gender
Female	31	94.0
Male	1	3.0
Did not answer	1	3.0
Ethnicity
Non-Hispanic White	25	75.8
Hispanic	3	9.1
Non-Hispanic Black	1	3.0
Native Hawaiian/Pacific Islander	1	3.0
Did not answer	3	9.1
Credentials
Nurse practitioner	23	69.7
Physician assistant	5	15.2
Medical doctor	4	12.1
Registered nurse	1	3.0
Length in practice
< 5 years	9	27.3
5–10 years	11	33.3
11–20 years	7	21.2
> 20 years	6	18.2
Specialty area
Pediatrics	15	45.5
General practice (adults and children)	16	48.5
Other	2	6.0
Patients seen per week
1–30	10	30.3
31–60	16	48.5
61–100	6	18.2
> 100	1	3.0
Body mass index*
Underweight	1	3.0
Normal weight	19	57.7
Overweight	8	24.2
Obese	4	12.1
Did not answer	1	3.0

*Calculated from providers' self-reported height and weight based on the Centers for Disease Control and Prevention (CDC) formula and classifications (CDC, 2011).

Table 2. Provider screening for related medical conditions when evaluating overweight/obese children and adolescents
	n*	Most of the time or often (%)	Sometimes (%)	Rarely or never (%)
Hypertension	33	100	—	—
Type 2 diabetes mellitus or insulin resistance	33	72.7	24.3	3.0
Endocrinologic disorders	33	45.4	36.4	18.2
Sleep disorders	33	39.4	30.3	30.3
Orthopedic problems	33	27.3	48.5	24.2
Gastrointestinal disorders	33	27.3	54.5	18.2
Pseudotumor cerebri	32	3.1	15.6	81.3
Genetic syndromes	33	3.0	21.2	75.8

*Thirty-three school-based health care providers completed the survey, but because of missing responses, the number of providers who completed each question is listed in the n column.

Table 3. Laboratory evaluations obtained by providers when caring for overweight/obese children and adolescents
	n*	Most of the time or often (%)	Sometimes (%)	Rarely or never (%)
Total cholesterol	32	69.7	24.3	6.0
Lipid profile	33	66.7	33.3	—
Glucose	32	59.4	34.4	6.2
Liver enzymes	32	56.3	34.4	9.3
Glycohemoglobin	32	31.4	37.5	28.1
Thyroid function tests	32	31.3	46.8	21.9
Insulin	33	24.3	27.2	48.5
Cortisol	33	9.1	6.1	84.8
Glucose tolerance test	33	3.0	12.1	84.9

*Thirty-three school-based health care providers completed the survey, but because of missing responses, the number of providers who completed each question is listed in the n column.

Table 4. Provider report of family history for the following conditions when evaluating children and adolescents for overweight/obesity
	n*	Most of the time or often (%)	Sometimes (%)	Rarely or never (%)
Diabetes mellitus	33	100	—	—
Cardiovascular disease	33	93.9	6.1	—
Hypertension	33	90.9	9.1	—
Dyslipidemia	33	81.8	12.1	6.1
Overweight/obesity	33	72.7	18.2	9.1
Other endocrine abnormalities	32	37.5	18.8	43.7
Gallbladder disease	33	24.2	21.2	54.6
Eating disorders in the parents	33	12.1	9.1	78.8

*Thirty-three school-based health care providers completed the survey, but because of missing responses, the number of providers who completed each question is listed in the n column.

Table 5. Provider report of psychological and emotional related considerations when evaluating children and adolescents for overweight/obesity
	n*	Most of the time or often (%)	Sometimes (%)	Rarely or never (%)
Patient concern about weight	33	90.9	6.1	3.0
Readiness to make changes to manage weight	33	78.8	21.2	—
Parent concern about weight	33	69.7	24.2	6.1
Poor self-esteem	33	66.6	27.3	9.1
Depression	33	66.6	27.3	6.1
Being teased about weight	33	66.6	18.2	15.2
Family dynamics	33	57.5	27.3	15.2
History of abuse	33	42.4	27.3	30.3
Eating disorders	33	27.3	57.5	15.2