Identification and counseling for obesity among children on psychotropic medications in ambulatory settings

Authors

  • Ihuoma U. Eneli,

    Corresponding author
    1. Department of Pediatrics; Ohio State University, Nationwide Children's Hospital, Columbus, OH, USA
    • Center for Healthy Weight and Nutrition; Nationwide Children's Hospital, Columbus, OH, USA
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  • Wei Wang,

    1. Center for Innovation in Pediatric Practice, Nationwide Children's Hospital, Columbus, OH, USA
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  • Kelly Kelleher

    1. Department of Pediatrics; Ohio State University, Nationwide Children's Hospital, Columbus, OH, USA
    2. Center for Innovation in Pediatric Practice, Nationwide Children's Hospital, Columbus, OH, USA
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  • Disclosure: The authors declare no conflict of interest.

Correspondence: Ihuoma U. Eneli (ihuoma.eneli@nationwidechildrens.org)

Abstract

Objective

To examine identification and counseling for obesity at pediatric office visits associated with psychotropic medications.

Design and Methods

Analysis of ambulatory care visits by children 2-17 years in the National Ambulatory Medical Care Surveys and outpatient component of the National Hospital Ambulatory Medical Care Surveys from 2005 to 2008. Physician identification of obesity was determined using ICD-9 CM diagnostic codes.

Results

In 2005-2008, there were 38,539 pediatric ambulatory care visits weighted to represent 600 million pediatric visits nationally. Psychotropic medications were associated with 5.2% of visits. The prevalence of overweight/obesity (BMI ≥ 85th%tile) was 15.9% for visits without psychotropic medication, 19.4% and 16.8% for visits associated with nonobesogenic and obesogenic psychotropic medications, respectively. Controlling for age, gender, and BMI, obesity was more likely to be identified at visits associated with psychotropic medications (OR 5.2, 95% CI 3-8.8), among females (OR 1.6, 95% CI 1.1-2.3) and non-Hispanics (OR 1.5, 95% CI 1.0-2.4). At visits with psychotropic medications, dietary counseling was provided at 11.4%, while blood pressure and cholesterol screening were obtained at 6.9% and 6.8% of these visits, respectively.

Conclusions

Our results indicate suboptimal identification and counseling for obesity children who are prescribed psychotropic medications, despite their increased risk for weight gain.

Introduction

As greater numbers of children and adolescents are diagnosed with mental health disorders in the last 10 years, the use of psychotropic drugs in the pediatric population has increased [1]. Many of the medications prescribed are the newer psychotropic drugs, such as Risperidone, and Quetiapine, oftentimes referred to as second-generation antipsychotics. Compared to the older drugs like Haldol and Thorazine, second-generation antipsychotics boast an improved safety profile, with fewer side effects such as tardive dyskinesia, extra pyramidal symptoms, and hyperprolactinemia [4, 5]. This advantage has led to providers prescribing antipsychotics more frequently not only for psychotic conditions, but also for other behavioral problems such as oppositional defiant disorder, irritability in autism, bipolar disorder, and schizophrenia [4]. In addition, several of these newer drugs are now approved and indicated for use in the pediatric population by the Food and Drug Administration.

A troublesome side effect of many of these medications is weight gain [4, 6]. Children can gain as much as 4-10 kg in a 10-week period [6]. Excessive weight gain has ominous implications for the emotional and physical health of the child. Childhood obesity is associated with metabolic abnormalities such as dyslipidemia, glucose intolerance, insulin resistance, type 2 diabetes, and hypertension [9, 10]. Obese children are also at increased risk for psychosocial sequelae, including low self-esteem [11].

To counteract the adverse side effect of weight gain, providers are to educate the patient on the risk of weight gain, and provide dietary and physical activity counseling when any psychotropic medication is initiated [12, 13]. These lifestyle recommendations, when adhered to, have been shown to reduce psychotropic-induced weight gain [12, 14, 15]. In a 6-month medical weight management program based on lifestyle changes alone, participants lost an average of 6 kg, with a decline of 2.1 units in BMI [15].

The increase in the use of the psychotropic medication particularly second-generation antipsychotics, burden of obesity as a disease, and encouraging outcome with diet and physical activity counseling underscore the need for healthcare providers who care for these children to screen, prevent and treat weight-related problems. Using a national representative population of office visits, we examined current provider practice patterns associated with screening for obesity, as well as diet and physical activity counseling for a vulnerable subset of children whose treatment for mental illness put them at a higher risk to become or remain obese.

Methods

The National Center for Health Statistics (NCH) conducts two national surveillance surveys [16, 17], the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), to track healthcare provider practices in ambulatory settings within the United States.

Study database

The National Ambulatory Medical Care Survey (NAMCS) conducted annually since 1989 is an office-based survey of patient-physician encounters. It uses multistage stratified random sampling by geographic area, physician specialty, and patient visits within a 52-week randomized period. Nonfederally funded, office-based physicians, principally involved with patient care, are selected from the master lists of the American Medical Association and American Osteopathic Association. For each physician, patient encounters are systematically sampled from a sequential list of patients seen in the physician's office during an assigned week. The sampling rate varies from 20% to 100% depending on the size of the practice.

The National Hospital Ambulatory Medical Care Survey (NHAMCS) is conducted in emergency and outpatient departments in nonfederal general and short stay hospitals located in the 50 states and the District of Columbia. Clinics are eligible if they are attached to the sample hospital and care is provided under the supervision of a physician. Patients are randomly selected from a sample of visits that occur during a randomly assigned 4-week reporting period. The sampling rate employed is 1 in 20 visits or a maximum of 200 visits.

Survey instrument

For both NAMCS and NHAMCS, the unit of analysis is the patient visit. For each visit, physicians or staff completed a one-page survey instrument detailing patient demographics, insurance data, patient complaint, physician diagnoses and services provided, current over-the-counter and prescription medications, visit disposition, and duration of visit. Up to three patient-complaints for a visit and three physician diagnoses are coded according to the NAMCS Code and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), respectively.[18] A check box allows physicians or staff to indicate when blood pressure or cholesterol screening, diet/nutrition, and exercise counseling are performed. In 2005, the survey began collecting height and weight measures. The survey design and estimation procedures are described in-depth elsewhere [16, 17].

Study population

We identified all office visits by patients 2-17 years between 2005 and 2008 in the NAMCS and the outpatient component of the NHAMCS database. We excluded any visit made to emergency departments from the sample.

Case definitions

An obesity-related visit was defined as a visit with a physician identification of overweight/obesity using the diagnostic codes, ICD-9-CM 278.0-278.3 Overweight/obesity was defined as a BMI >85th percentile for age and gender [19]. The presence of any of the following obesity-related condition was classified as a cardiovascular and metabolic (CVM) condition: (1) hyperlipidemia ICD-9 272.0-272.5; (2) hypertension ICD-9 401.1 or 401.9 or NAMCS code 2510.0; and (3) type 2 diabetes ICD-9 stem codes 250 with fifth-digit subclassification 0 or 2. Most of the obesity-related conditions occurred with low frequency; thus, we were unable to examine each comorbid condition separately.

Using the National Institute of Mental Health index of medications, psychotropic medications were initially categorized into four categories: antimanic, antipsychotic, antidepressants, and antianxiety drugs. Then, two authors (IUE and KK) independently subcategorized each medication as obesogenic or nonobesogenic using side effects reported in the extant literature and review of the 2008 Physician Desk Reference (Table 1). Both authors resolved areas of disagreement together, and input from two psychiatrists was used to settle any remaining differences.

Table 1. Classification of psychotropic medications
Obesogenic psychotropic medicationsNon-obesogenic psychotropic medications
AntidepressantsAntidepressants 
SertralineBupropionImipramine HCL
AmitriptylineVenlafaxineDoxapram HCL
NortriptylineTrazadoneDesipramine HCL
ParoxetineBuspironeTrimipramine Maleate
CitralopramFluvoxamine
DoxepinProtriptyline HCL
Fluoxetine
Escitalopram
Mood stabilizers/AntimaniaMood stabilizers/Antimania
LithiumTopiramate
ValproateLamotrigine
CarbamazepineZonisamide
Gabapentin
Antipsychotics Antipsychotics
MirtazapineRisperidoneMolindone
HaloperidolQuetiapinePimozide
PerphenazineZiprasidone
ClozapineAripiprazole
OlanzapineThioridazine
AnxiolyticsAnxiolytics
None applicableAlprazolam
Lorazepam
PsychostimulantsPsychostimulants
None applicableMethylphenidate
Amphetamine
Dextroamphetamine sulfate

Reliability of data

The NCHS suggests combining the NAMCS and outpatient component of the NHAMCS surveys when ambulatory care is assessed. Combining both surveys allows for inclusion of select populations, such as Medicaid, African-American, and adolescent groups with different healthcare access patterns [20]. The reliability criteria for validity and generalizability of data from the NAMCS and NHAMCS data is a minimum 30 unweighted cases and a relative standard error <30%. We report results only when reliability criteria for the data were met.

Statistical analysis

To obtain national estimates, we used the NCHS provided weights, calculated from physician and visit sampling rates and adjusted for nonresponse for each patient encounter [16, 17]. Statistical significance for bivariate categorical data, for example, differences between patient demographics, physician identification of obesity, use of psychotropic medication, presence of cardiovascular and metabolic conditions, counseling for diet and physical activity, were assessed using the Chi-square test. We used logistic regression analysis to determine predictor for identification of obesity. The independent variables in the model were age, sex, race/ethnicity, overweight status, and obesogenic psychotropic medication.

Results

In 2005-2008, there were an estimated 38,539 pediatric ambulatory care visits weighted to represent 600 million pediatric visits nationally. At these visits, the mean age was 9 years, 49% were females and 72.4% Caucasian. Almost half (44.2%) had private insurance and 44% had Medicaid/State Children's Insurance Health Plan. Psychotropic medications were associated with 5.2% of all the visits (n = 3383). Of these visits 18.8% were antidepressants, 10.4% were antimanic drugs, 25.4% at antipsychotic drugs, 6.9% antianxiety drugs, and 37.9% stimulants. Two or more psychotropic drugs were reported at 27.9% of the visits, with second-generation antipsychotics at 22.8% of visits.

Obesity identification and prevalence rates

The prevalence rate for overweight/obesity (BMI ≥ 85th percentile) was 15.9% for all ambulatory visits. Table 2 summarizes the characteristics of office visits based on use of psychotropic medications. The prevalence rates for overweight/obesity were highest at visits with nonobesogenic psychotropic medications (19.4%). Obesity was identified as a diagnosis by the provider at 8.6% of visits with obesogenic psychotropic medications, 6.9% of visits with nonobesogenic psychotropic medications, and 1.4% of visits without any psychotropic medications. Of the visits with the BMI ≥ 85th percentile, obesity was identified by the provider at 38.5% of visits with obesogenic psychotropic medications, 29.8% of visits with nonobesogenic psychotropic medications, and 15.6% of visits without any psychotropic medications (Figure 1). At visits with two or more psychotropic medications, the unadjusted odds of being overweight/obese (BMI >85th percentile) was increased (OR 4.0, 95% CI 1.8-8.9). In a logistic regression analysis, controlling for age, gender, and BMI, obesity was more likely to be identified at visits associated with psychotropic medications (OR 5.2, 95% CI 3-8.8), among females (OR 1.6, 95% CI 1.1-2.3) and non-Hispanics (OR 1.5, 95% CI 1.0-2.4).

Figure 1.

Prevalence of obesity and rate of physician identification

Table 2. Characteristics of study population
 Obesogenica Psychotropic Medication (%) (n = 1365)Nonobesogenic Psychotropic Medication (%) (n = 2,018)No Psychotropic Medication (%) (n = 35,156)
  1. aVisit where any obesogenic medication was identified.
Mean age (years)12.2 ± 0.211.8 ± 0.28.9 ± 0.1
Male Gender61.859.750.3
Race
African American14.614.811.8
White81.582.882.2
Other3.92.46.0
Insurance
Private49.952.461.1
Medicaid37.132.128.1
Other13.018.512.8
Med use
Antidepressant45.830.9N/A
Antimanic24.010.4-
Antipsychotic73.110.3-
Antianxiety3.612.0-
Stimulants9.560.9-
Number of meds:  -
154.581.2-
236.113.4-
3 or more9.25.4
BMI ≥ 85th%tile16.819.415.7

Counseling pattern and rates

The frequency of diet or physical activity counseling during the study years 2005, 2006, 2007, and 2008 were 0.08%, 0.05%, 0.05%, and 0.07% respectively. Across the years, there were no statistically significant differences in counseling rates (P = 0.59). Diet counseling was provided at only 0.27% of all visits, whereas blood pressure and cholesterol screening occurred at 36.5% and 1.2 % of visits, respectively. For visits associated with psychotropic medications, dietary counseling was provided at 11.4% of the visits. Blood pressure and cholesterol screening were obtained at 6.9% and 6.8% of these visits, respectively. The highest rates of any counseling (0.7%) occurred at visits where there was a psychotropic medication and the BMI was >85th percentile (Figure 2). The rates for physical activity counseling alone did not meet NAMCS/NHAMCS reliability because of the extremely low unweighted numbers (<30) and, therefore, are not reported.

Figure 2.

Frequency of diet or physical activity counseling at pediatric ambulatory visits 2005-2008

Cardiovascular and metabolic comorbidity

The prevalence of cardiovascular and metabolic (CVM) complications at all the visits was 0.96% (n = 597). In a logistic regression analysis controlling for age, gender, race (Table 3), the odds of a CVM condition being identified by the provider at the visit was higher when the subject was overweight or obese (OR 2.6, 95% CI 1.5-4.5). There was no significant association between the presence of a CVM condition and visits with an obesogenic psychotropic medication (OR 1.7, 95% CI 0.5-5.3).

Table 3. Independent predictors of cardiometabolic complication (CVM) among children and adolescents 2-17 years in NAMCS and NHAMCS 2005-2008 (N = 38,539)
VariableAdjusted OR95% CI
Ethnicity
Hispanic1.080.54-2.15
Non-Hispanic (referent)
Gender
Female1.400.86-2.27
Male (referent)
Age
12-17 yrs1.220.73-2.02
6-11 yrs (referent)
2-5 yrs0.680.32-1.40
BMI >85th percentile (overweight or obese)
Yes2.651.56-4.51
No (referent)
Obesogenic psychotropic medication
Yes1.670.52-5.33
No (referent)

Discussion

Our results indicate suboptimal identification and counseling for obesity at pediatric ambulatory visits associated with psychotropic medications despite increased vulnerability for weight gain in these children. This trend is similar to low rates of provider identification of obesity [23] and discordant with how most physicians report they view childhood obesity [24]. In a survey of pediatricians and other health providers, 75-93% felt childhood and adolescent obesity was a serious condition that needed to be addressed [24].

Despite the overall low identification rates reported in our study, it is encouraging that the odds of identifying obesity was significantly higher at visits associated with a psychotropic medication (OR 5.2, 95% CI 3-8.8). Perhaps healthcare providers are more sensitive to weight gain among this subset of children. Other positive predictors for identification included female gender and non-Hispanic ethnicity. A higher rate of physician identification for obesity has been reported previously among females [25]. Females may be more likely than males to share their concerns about their weight with their physicians, thus prompting greater identification. We did not find increased identification of obesity at visits with blacks or Hispanics reported in other studies [25, 28]. It is probable that racial/ethnic distribution may differ depending on the pattern of prescribing psychotropic medication, or the etiology of the weight gain, that is, whether it is exogenous or induced by psychotropic medications. Thus, our finding of increased identification among non-Hispanics needs to be interpreted with caution and further analysis recommended.

Correll and colleagues[5] have put forth a set of criteria to define clinically significant psychotropic-induced weight gain in children and adolescents. The criteria include (i) ≥5% increase in over baseline weight in 3 months, (ii) increase in BMI Z-score of 0.5 standard deviation or more above appropriate growth, (iii) crossing into the 95th percentile for BMI, or (iv) crossing into the 85-94th percentile for BMI plus one obesity related co-morbidity. For a child to meet these criteria there has been considerable deviation from their normal growth trajectory. The criteria align with recognized definitions for overweight and obesity in children [19]. The excess weight gain noted with psychotropic medications is associated with an increased risk for hyperglycemia, insulin resistance, exacerbation or onset of diabetes, elevated triglycerides and cholesterol levels [7, 8, 29]. Other associated conditions of obesity include low self-esteem, which increases the likelihood of high-risk behaviors that can worsen underlying mental health conditions [11].

For children who require psychotropic medication, the excess weight gain and the burden of disease associated with obesity signal an urgency to examine provider counseling practices. When healthcare providers prescribe psychotropic medications with known influences on weight, the patient should receive preemptive counseling prior to initiation and during treatment. Lifestyle counseling remains the first line of defense for addressing excess weight gain. Although healthcare providers sometimes perceive lifestyle counseling as ineffective [24], studies have shown healthcare providers can be effective agents for change [34, 35]. Overweight adolescents who are counseled by their physician report attempting weight loss strategies at rates similar to recommendations [35]. Families also look to physicians as a primary resource for addressing weight concerns [36]. However, the efficacy of counseling for psychotropic-induced weight gain in an ambulatory setting to reduce or prevent obesity in children is largely unknown [12, 14, 15].

A possible barrier for lifestyle counseling at office visits is the lack of reimbursement for obesity-related services [37], especially as counseling for a potential side effect that is yet to occur does not usually qualify as a stand-alone billable office visit diagnosis. When preemptive counseling is provided at visits for medication monitoring, a modifier code can be used to indicate the additional preventive care provided depending on the scope of the counseling. Alternatively, lifestyle counseling can be coded and billed under the diagnostic code of “abnormal weight gain” (ICD-9 code 783.1) in addition to the mental health diagnostic code if the child has demonstrated weight gain because of the medication.

There are limitations to our study. The cross-sectional nature of the study design precludes our ability to access care provided over time to an individual patient; thus, it is conceivable that obesity or counseling has been identified at a prior visit. Although the NAMCS/NHAMCS form is completed independent of billing, our estimates of obesity recognition and counseling may be conservative as low reimbursement rates for the diagnosis of obesity may decrease the likelihood of a physician coding for obesity. Despite these limitations, the study has several strengths. In using a large nationally representative sample of pediatric office visits, we offer some insight on management of obesity in a vulnerable segment of children in the United States. Including data from the outpatient clinics in the NHAMCS allowed us to capture a broader spectrum of ambulatory care visits than those that occur only in the physician's office, providing a more representative national sample.

In summary, our findings suggest poor recognition and counseling for obesity for all children regardless of whether they are on psychotropic medication. That healthcare providers identify obesity most often in children on obesogenic medications is encouraging and an area for further study. We need to investigate the challenges to instituting preventive counseling on a consistent basis when any psychotropic medications, especially second-generation antipsychotics are prescribed for children. This is particularly relevant given diagnostic criteria for psychotropic-induced weight gain includes children who may not yet have a BMI above the 85th percentile, the trigger for a diagnosis of obesity [19]. Finally, this study provides national and generalizeable baseline data on which to track physician practice patterns in managing children on psychotropic medications over time.

Ancillary