Screening and counseling for childhood obesity: results from a national survey.

PURPOSE: To examine family physicians' beliefs and practices about using body mass index (BMI) percentiles to screen for childhood overweight and obesity. METHODS: Surveys about management of childhood overweight were mailed to 1800 American Academy of Family Physician members in 2006. RESULTS: 729 surveys were returned; 445 were eligible. Most (71%) members were familiar with BMI guidelines; 41% were familiar with American Academy of Family Physician recommendations about overweight. Most (78%) had tools available to calculate BMI; fewer have enough time for overweight screening (55%), and only 45% reported computing BMI percentile at most or every well visit for children older than 2. Having an electronic health record increased BMI screening rates. Family physicians felt prepared to discuss weight, but only 43% believed their counseling was effective and many (55%) lack community or referral services. Most (72%) wanted simple diet and exercise recommendations for patients. Reimbursement for weight-related services is insufficient: 86% say that patients cannot pay for services not covered by insurance. Factor analysis identified clinician self-efficacy, resources, and reimbursement as factors related to calculating BMI percentiles. CONCLUSIONS: BMI is underutilized by family physicians. Most believe they should try to prevent overweight and have tools to use BMI, but clinicians have few resources available for treatment, have low self-efficacy, and report inadequate reimbursement.

Adoption of body mass index guidelines for screening and counseling in pediatric practice.

OBJECTIVE: The purpose of this study was to examine pediatrician implementation of BMI and provider interventions for childhood overweight prevention and treatment. METHODS: Data were obtained from the American Academy of Pediatrics (AAP) Periodic Survey of Fellows No. 65, a nationally representative survey of AAP members. Surveys that addressed the provision of screening and management of childhood overweight and obesity in primary care settings were mailed to 1622 nonretired US AAP members in 2006. RESULTS: One thousand five (62%) surveys were returned; 677 primary care clinicians in active practice were eligible for the survey. Nearly all respondents (99%) reported measuring height and weight at well visits, and 97% visually assess children for overweight at most or every well-child visit. Half of the respondents (52%) assess BMI percentile for children older than 2 years. Most pediatricians reported that they do not have time to counsel on overweight and obesity, that counseling has poor results, and that having simple diet and exercise recommendations would be helpful in their practice. Pediatricians in large practices and those who had attended continuing medical education on obesity were more familiar with national expert guidelines, were more likely to use BMI percentile, and had higher self-efficacy in practices related to childhood and adolescent overweight and obesity. Multivariate analysis revealed that pediatricians with better access to community and adjunct resources were more likely to use BMI percentile. CONCLUSIONS: BMI-percentile screening in primary pediatric practice is underused. Most pediatricians believe that they can and should try to prevent overweight and obesity, yet few believe there are good treatments once a child is obese. Training, time, and resource limitations affect BMI-percentile use. Awareness of national guidelines may improve rates of BMI-percentile use and recognition of opportunities to prevent childhood and adolescent obesity.

Measuring quality of adolescent preventive services of health plan enrollees and school-based health center users.

PURPOSE: To evaluate whether quality of care provided to adolescents enrolled in a community-based managed care plan was better for those who also received some care at school-based health centers (SBHCs). METHODS: The Young Adult Health Care Survey (YAHCS) was administered to 374 adolescents (commercially insured, Medicaid-insured, and SBHC users) to assess risk behaviors, provision of preventive screening and counseling, and quality of care. RESULTS: SBHC users were most likely to report that their provider told them their discussions were confidential, and that they received screening/counseling on sexually transmitted diseases (STDs), HIV/AIDS, condom use, and birth control. Commercially insured adolescents were least likely to report discussion of sexual health issues. SBHC users had the highest mean YAHCS quality measure scores for screening/counseling on pregnancy/STDs, diet and exercise, and helpfulness of counseling provided; Medicaid-insured teens had the lowest scores on four of seven measures. Regression models controlled for demographics, use of screener, and site of care showed that use of a screener had a significant impact on six of seven quality measure models. Younger age predicted screening for risk behaviors; being female, African-American, and an SBHC user predicted screening on pregnancy/STDs. CONCLUSIONS: SBHCs may increase adolescents' access to confidential care, and SBHC providers may be more likely than those in other settings to screen and counsel patients about sexual health. Overall quality of preventive care reported by commercially insured adolescents may be better in some health content areas and worse in others compared with care reported by Medicaid-insured youth and SBHC users.

Use of complementary medicine and dietary supplements among U.S. adolescents.

PURPOSE: Use of complementary and alternative medicine (CAM) is increasing, but some dietary supplements have potentially negative side effects. This study examines CAM and dietary supplement use among a national sample of adolescents. METHODS: A total of 1280 adolescents 14-19 years old completed an online survey in 2002 about lifetime and past-30-day use of all CAM modalities, and specifically about use of herbal medicines and dietary supplements. We e-mailed invitations to 12,353 members of Harris Interactive's national Youth Query panel, and filled age/gender quotas sample targets. Data were then weighted to reflect the U.S. adolescent population by gender, race/ethnicity, urbanicity, region, parents' education, propensity to be online, and likelihood of nonresponse. Chi-square and logistic regression analyses were done using SPSS. RESULTS: Seventy-nine percent of adolescents had used CAM in their lifetime, 48.5% in the previous month; 46.2% had used dietary supplements in their lifetime, 29.1% in the previous month; 9.3% reported concurrent use of supplements and prescription medication in the previous month. Factors associated with CAM and supplement use included being female, positive attitudes towards CAM, and being age 16-17 years (rather than in younger or older age groups). Commonly used supplements included ginseng, zinc, echinacea, ginkgo, weight loss supplements, and creatine. CONCLUSIONS: Many adolescents use CAM and dietary supplements, including a significant number concurrent with prescription medications. Commonly used supplements (weight loss supplements and creatine) are closely linked to attempts to change body shape. Health care providers should be aware of CAM and supplement use by adolescents.

Adolescents' knowledge of and beliefs about herbs and dietary supplements: a qualitative study.

OBJECTIVE: To explore adolescents' knowledge of and beliefs about dietary supplements, including herbs, and over-the-counter (OTC) medications. METHODS: Eighteen focus groups with 81 adolescents in Monroe County, New York, explored teens' familiarity with and beliefs about CAM, specifically dietary supplements. We asked about general health beliefs and opinions of OTC medications to provide a framework for understanding how dietary supplements are conceptualized. Groups were conducted with suburban adolescents, urban minority adolescents, adolescents with chronic illness, (asthma, eating disorders, and diabetes), and patients of complementary/alternative practitioners ("CAM practitioners"). Transcripts were analyzed for themes relating to prevention ("staying healthy") and treatment of illness ("getting better"); direct quotations are used to illustrate adolescents' views. RESULTS: Most adolescents are familiar with "herbal medicine," "herbal remedies," or "nutritional supplements," and are able to name specific products or complementary/alternative medicine (CAM) therapies; however, many are unfamiliar with the term "alternative medicine." Adolescents are more familiar with remedies or CAM therapies commonly used by people from their own cultural or ethnic background. Older suburban females and those with chronic illnesses are more familiar with herbs and supplements than other adolescents. Most supplement use is conceptually linked with treating illness rather than with preventive care. CONCLUSIONS: Most adolescents are familiar with culturally based herbal products and nutritional supplements, used for treatment of illnesses, and not for preventive care. Providers and researchers should consider chronic illness status and culture/family tradition, and clarify terms, when asking adolescents about self-care, OTCs, or CAM.

The Internet: a window on adolescent health literacy.

PURPOSE: Adolescents are well served by the Internet through school access, but they will only derive maximum benefit from this information resource if they are able to search for, evaluate, and use its online information effectively. Internet use, however, requires significant literacy skills, and little is known about the health literacy of adolescents. The aim of this paper is to describe functional, critical, and interactive health literacy challenges experienced by adolescent students when using the Internet for online health information. METHODS: Twenty-six focus groups with 157 adolescent students, aged 11-19, conducted within a convenience sample of middle and high schools in diverse geographical and socioeconomic settings in the United Kingdom (UK) and United States of America (US) between May 2001 and May 2002. RESULTS: Many students cited difficulties in accessing health information online. Functional health literacy challenges included, for example, spelling medical terms correctly and being able to construct questions describing symptoms accurately. Critical challenges included discerning relevance of information retrieved by search engines and knowing which sites to trust. Interactive challenges included the appropriate application of health information to address personal health concerns within their local neighborhood. CONCLUSIONS: Exploring the challenges faced when adolescents search for online health information indicates deficiencies regarding health literacy skills. Difficulties regarding functional, critical, and interactive skills were all present. The Internet may offer opportunities for identifying such deficiencies and building better health literacy skills among adolescents, as part of health curriculum interventions to improve the population's future health.

Health information-seeking behaviour in adolescence: the place of the internet.

The internet is one of a range of health information sources available to adolescents. It is recognised that young people have difficulties accessing traditional health services; in theory, the internet offers them confidential and convenient access to an unprecedented level of information about a diverse range of subjects. This could redress adolescents' state of relative health 'information poverty', compared to adults. This paper seeks to explore United Kingdom (UK) and United States (US) adolescents' perceptions and experiences of using the internet to find information about health and medicines, in the context of the other health information sources that are available to them. The study involved a series of 26 single-gender focus groups with 157 English-speaking students aged 11-19 years from the UK and the US. Many students reported that the internet was their primary general information source. Information sources were defined during analysis in terms of previous experience of the source, saliency of the available information, and credibility of the source (defined in terms of expertise, trustworthiness and empathy). Most focus group participants had extensive personal experience with the internet and some information providers therein (notably search engines). Internet health information was regarded generally as salient. Its saliency was increased through active searching and personalisation. Perceived credibility of the internet varied because expertise and trustworthiness were sometimes difficult to determine, and empathy could be facilitated through online communities but the individual could control disclosure. The internet combines positive features of traditional lay and professional, personal and impersonal sources. Although it is unlikely to supplant the role of trusted peers and adults, the internet has found an important place among adolescents' repertory of health information sources.

Improving adolescent preventive services through state, managed care, and community partnerships.

PURPOSE: To develop and evaluate a multipronged, guideline-based initiative to improve quality of adolescent preventive care. METHODS: Activities included: (a) academic institution-based grand rounds and insurance company-sponsored community rounds continuing education sessions on preventive care for primary care clinicians, (b) academic detailing during chart review visits to practices by nurse reviewers, to encourage adolescent-specific confidentiality policies and use of screener or trigger questionnaires during well visits, and (c) partnerships with community corporate leaders to promote awareness of quality preventive services. Interventions were evaluated by comparing 2000 and 2001 chart reviews for rates of tobacco use, substance use, and human immunodeficiency virus (HIV) prevention screening and counseling. RESULTS: A total of 285 clinicians attended continuing education (CE) sessions and 96 offices received detailing visits. Improvements in adolescent preventive health services delivery were noted in both commercial and Medicaid populations. We found the following when comparing 2001 results with those from 2000: Tobacco use screening or counseling increased from 42.5% to 45.5% for the commercial population and from 32.0% to 43.5% for the Medicaid population; substance use screening increased from 42.5% to 44.0% for the commercial population and from 32.0% to 43.5% for the Medicaid population. HIV counseling increased from 26.5% to 35.5% for the commercial population, and from 28.0% to 40.0% for the Medicaid population (all Medicaid and HIV differences are significant at p <.05). CONCLUSIONS: These activities have been successful in improving adolescent preventive services for Medicaid populations in New York. Academic detailing can assist health plans in promoting preventive care improvements by primary care clinicians. Further measurement is needed to assess the effect on commercially insured populations.