Effectiveness of obesity-related recognition and management in pediatric primary care settings
OA Version
Citation
Abstract
Obesity is a complex, chronic disease that affects over 14 million children in the United States (1). Whereas the public health crisis of pediatric obesity has been recognized for over two decades, we have made little progress toward effective management strategies to prevent or treat obesity. Even with the recent emergence of effective weight loss medications that target satiety pathways, which are currently approved only for those aged 12 years and older, the mainstay of pediatric obesity treatment is lifestyle counseling within the primary care setting. Given the multiple demands on primary care providers, along with limited time for each patient visit, the expectation that primary care providers can effectively manage obesity through counseling and referral may be unreasonable. We conducted two analyses to investigate the effectiveness of obesity management in the primary care setting, followed by an analysis investigating the effects of sociopolitical stress on body mass index (BMI) in children. In the first study, we used a regression discontinuity design to address the hypothesis that primary care provider recognition of overweight and obesity and associated counseling at well-child visits would not impact subsequent BMI. Using electronic medical record data from children ages 5-18 years who had at least two annual well-child visits within the Massachusetts General Hospital (MGH) system, we assessed changes in percent of 95th percentile BMI (%BMIp95) following a well-child visit based upon the exposure of eligibility for overweight/obesity related care, defined as being just above versus just below 85th percentile BMI. In the primary analysis, the intent to treat estimate of the impact of having a BMI at or above the 85th percentile threshold on change in %BMIp95 was 0.04% (95% CI -1.39% to 1.11%). Adjusting for the discontinuity in provider recognition and treatment of obesity at the 85th percentile threshold, the complier average causal effect of the primary care provider addressing obesity was a change in %BMIp95 of 0.37% (95% CI -14.2% to 11.4%). Our conclusion based on this analysis is that there is no or minimal effectiveness of primary care providers recognizing overweight/obesity and addressing it within the context of a well-child visit.
In the second study, we used the same dataset to emulate a target trial investigating the effect of primary care referral of children with obesity to subspecialty obesity care on subsequent %BMIp95, with the hypothesis that referral to subspecialty care also would not affect BMI. Using a linear mixed effects model with inverse probability weighting to account for probability of treatment and censoring, we estimated that the effect of referral on subsequent change in %BMIp95 was 0.7% (95% CI -0.1, 1.4). It is important to note that these data were collected before the recent availability of effective weight loss medications for those ages 12 and older. Our conclusion is that referral to obesity-related care before the era of weight loss medications did not effectively reduce subsequent BMI.
The third study was designed in recognition of the multiple societal and structural influences on BMI that are beyond the scope of management in a medical setting. We used a difference-in-differences analysis to assess the effect of the 2016 presidential election on %BMIp95 among children who were exposed to the discriminatory and anti-immigrant rhetoric that surrounded and followed the election. Utilizing publicly available National Health and Nutrition Examination Survey (NHANES) data as well as the MGH data used the first two studies, we did not find consistent evidence of an effect of the election to increase %BMIp95 among children of Hispanic background, although the NHANES data suggested a post-election increase in %BMIp95 of 3.4% (95% CI 0.5, 6.2) among those whose family’s primary language was Spanish as compared to those whose primary language was English.
Our findings highlight the complexity of obesity management and suggest that it may be unreasonable to expect primary care providers to prevent or treat obesity effectively. Although additional studies will need to be performed now that effective weight loss medications are available to older children, our analysis suggests that recognition and counseling of obesity in the primary care setting is not effective in lowering subsequent BMI, nor is referral to obesity-related care, at least before the advent of obesity medications. Further studies of the societal causes of obesity, including discrimination, stress, and lack of adequate resources, are needed.
Description
2025