RESEARCH ARTICLE

Lack of Recognition, Diagnosis, and Treatment ofOverweight/Obesity in Children Hospitalized forAsthmaAnne Borgmeyer, DNP,a Patrick M. Ercole, PhD,b Angela Niesen, MPH,a Robert C. Strunk, MDc,†

A B S T R A C T OBJECTIVES: Information is lacking regarding recognition and treatment of overweight andobesity in children hospitalized for asthma. The study objectives were to determine the currentpractice of recognition, diagnosis, and treatment of overweight and obesity for children hospitalizedfor asthma and to describe demographic, asthma, and weight characteristics for these patients.

METHODS: A retrospective record review was conducted for children admitted to the hospital withasthma in 2012. Charts were reviewed for evidence of recognition, diagnosis, and treatment ofoverweight and obesity. Subjects were classified into age-adjusted Centers for Disease Control andPrevention weight categories based on BMI percentile and chronic asthma severity categoriesaccording to National Asthma Education and Prevention Program guidelines.

RESULTS: A total of 510 subjects aged 3 to 17 years were studied. Obesity was present in 19.6% andoverweight in 13.3% of subjects. BMI percentile was recorded in only 3.3% of all charts, in only 11%of subjects with obesity, and in 0% of subjects with overweight. BMI percentile was documentedmore often in subjects with severe obesity (P 5 .013) and with moderate to severe persistent asthma(P 5 .035). Only 9 of 168 subjects who were overweight or obese (5.6%) were given a dischargediagnosis indicating overweight or obesity, and 14 (8.3%) received treatment. Chronic asthmaseverity differed by BMI weight category (P , .001), with a significant relationship between obesitystatus and chronic asthma severity in older subjects (P5 .033). There were no differences in severityof acute episodes based on weight group.

CONCLUSIONS: Overweight and obesity were underrecognized, underdiagnosed, andundertreated in children hospitalized for asthma.

aSt Louis Children’sHospital, St Louis,Missouri; bSansom

Consulting LLC, Glendale,Arizona; cDivision of

Allergy, Immunology, andPulmonary Medicine,

Department of Pediatrics,Washington University

School of Medicine,St Louis, Missouri

www.hospitalpediatrics.orgDOI:10.1542/hpeds.2015-0242Copyright © 2016 by the American Academy of Pediatrics

Address correspondence to Anne Borgmeyer, DNP, St Louis Children’s Hospital, 8E 6, 1 Children’s Place, St Louis, MO 63110. E-mail:aborgmeyer@bjc.org

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: Anne Borgmeyer received an internal grant from the St Louis Children’s Hospital Foundation to support paymentof the staff nurse research assistant and statistician for this project. The St Louis Children’s Hospital Foundation did not have a role inthe study design; collection, analysis, and interpretation of the data; writing of the report; or the decision to submit the paper forpublication. Patrick Ercole was compensated for the statistical analysis of the data. Robert Strunk and Angela Niesen have indicatedthey have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

†Deceased.

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Asthma and overweight are 2 of the mostcommon chronic health problems inchildren. According to data from theNational Center for Health Statistics, theprevalence of asthma in children in theUnited States was 9.3% in 2012.1 In2012 there were 123 100 asthmahospitalizations for children in the UnitedStates, making asthma the third mostcommon reason for admission in children.2

Also notable is a report from the Centers forDisease Control and Prevention (CDC),based on the data from the National Healthand Nutrition Examination Survey, that17.2% of children in the United States wereobese and 14.5% were overweight in thatsame time period.3

There is an association between asthmaand overweight or obesity; however, themechanisms for the relationship are poorlyunderstood. Production of preinflammatorycells and hormones due to adiposity anddeconditioning due to inactivity have beenproposed as mechanisms; however, studiesare inconclusive.4–6 Despite lack of clarity inthe cause of the relationship, studies haveshown that children with overweight orobesity are more likely to be diagnosed withasthma,7,8 have more severe asthmasymptoms,9,10 and have higher likelihood ofhospitalization.10,11 Children admitted forasthma who are overweight have beenshown to need more therapy and havelonger hospital stays.7–9,12–14 However, thereis inconsistency in the literature, and somestudies have not found that higher BMIpercentile predicts admission or effectshealth care outcomes in children withasthma.15–17 There remains a lack of data onthe prevalence of overweight and obesityamong children with asthma in the inpatientsetting and, more importantly, a lack ofinformation about the clinical practicesrelated to this population.

The guidelines for asthma care by theNational Asthma Education and PreventionProgram (NAEPP) Guidelines18 and theGlobal Initiative for Asthma (GINA) Strategyfor Asthma Management and Prevention19

recommend weight loss to improve themanagement of asthma for patients whohave overweight or obesity, but there is notspecific direction for monitoring and

managing childhood overweight and obesityin the inpatient setting in those guidelines.The Joint Commission Children’s AsthmaCare metrics also do not addressmanagement of overweight and obesityfor children hospitalized with asthma.20

There are also guidelines for themanagement and treatment of childhoodoverweight and obesity. The AmericanMedical Association, in collaboration withthe Health Resources and ServiceAdministration and the CDC, convened theExpert Committee that developed analgorithm to assess obesity risk andoutlined steps for prevention andtreatment.21 Identifying, plotting, andmonitoring BMI percentile are essentialsteps in the algorithm22 and arerecommended for all hospitalized childrenby the National Association of Children’sHospitals and Related Institutions,23 butstudies have shown that providers in bothprimary care and inpatient settings arefailing to measure and monitor BMIpercentile.24–26 A recent study by King et al27

described lack of identification andtreatment of overweight and obesity inhospitalized children; however, only a smallnumber of patients with asthma wereincluded, and results specific to the patientswith asthma were not described.

Recommendations by the ExpertCommittee21 and the recent Children’sHospital Association Consensus Statementfor Comorbidities of Childhood Obesity28 areaimed at management of overweight andobesity in the primary care setting and arenot specific to children admitted withasthma. Providers are recommended toimplement overweight and obesityprevention strategies for all children.Thorough history, patient and familyeducation for healthy eating and increasedactivity, and referral to a weightmanagement program are recommendedweight management strategies that wouldbe appropriate for providers in any healthcare setting, including the inpatient setting.The importance of assessing for weightstatus and initiating treatment ofoverweight and obesity during admission issupported by recent studies thatdemonstrate an improvement in asthma

symptoms and less use of health careresources with diet-induced weight loss forchildren with asthma who have overweightor obesity.29–31

The primary purpose of this study was todetermine whether overweight or obesitywas recognized, diagnosed, and treatedin children hospitalized with asthma.A secondary purpose of the study was todescribe the demographic, BMI, and asthmacharacteristics of the children in this studywho were hospitalized with asthma.

METHODS

Institutional review board approval wasgranted before start of the study. This studyused a retrospective cross-sectional design.The setting was a 250-bed urban tertiarychildren’s hospital in the Midwest. Thechildren’s hospital is part of an academicmedical center. All male and female childrenaged 3 to 17 years admitted with a primarydiagnosis of asthma from January 1, 2012 toDecember 31, 2012 were included. Children,3 years of age were excluded to avoidconfusion about the diagnosis of asthmaand to ensure reliability of the use of BMIpercentile as an indicator of weight status.Only the first admission for each subjectduring the study period was included in thesample to avoid bias. The electronic medicalrecords were queried for InternationalClassification of Diseases, Ninth Revisioncodes for asthma, 493.01, 492.02, 493.81,493.82, 493.90, 493.91, and 493.92. Subjectswith diagnoses that would alter the courseof asthma treatment or make the diagnosisof asthma uncertain were excluded,including the diagnoses of vocal corddysfunction, bacterial pneumonia, cysticfibrosis, bronchopulmonary dysplasia,sickle cell disease, cardiac disease, andrheumatologic disease. Patients withdiagnoses of other chronic diseasesaffecting growth and subjects withoutheight or weight measurements orimplausible growth data were alsoexcluded. Chart review was used to gatherquantitative data for the baselineevaluation. The electronic medical recordwas queried to gather the date of birth, age,gender, race, insurance source, chronicasthma severity, overall length of stay (LOS),LOS in intensive care, primary discharge

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diagnoses, order for dietitian consult ordietitian consult note, height, and weight.Subjects were grouped by age according tothe age groups as defined by the NAEPPAsthma Guidelines18: 3 to 4 years, 5 to11 years, and $12 years.

The primary investigator calculated BMI andBMI percentile, based on height, weight, age,and gender of the subject, by using theonline CDC BMI calculator.32 Subjects weregrouped by CDC guidelines for weightcategories21 as follows: BMI ,5th percentilewas considered underweight, BMI 5th to84th percentile was considered healthyweight, BMI 85th to ,95th percentile wasconsidered overweight, and BMI $95thpercentile was considered obese. Asubanalysis was conducted on subjects withBMI $95th percentile, excluding those withmissing values of proper BMI recognition orasthma severity. In the subanalysis of thosewith obesity, severe obesity was defined asBMI $99th percentile.

Overall LOS and admission to the PICUserved as indicators of the severity of theacute episode. The average LOS for asthmaat the study hospital was 1.79 days for 2012.LOS was recoded at the median of 1.00 toform a binary variable: 0 to 1 day and$2 days. The indicators for chronic asthmaseverity were the categories as defined bythe NAEPP Asthma Guidelines18: intermittent,mild persistent, moderated persistent, andsevere persistent. All house staff physiciansand nurse practitioners receive training todetermine chronic asthma severity basedon the NAEPP Asthma Guidelines. Chronicasthma severity was determined by theprovider based on history obtained duringthe admission and documentedelectronically in the discharge instructions.Severity of the acute episode and chronicseverity were compared between the weightcategories of underweight, healthy weight,overweight, and obese.

The scanned notes in the electronic healthrecords (EHRs) of all subjects werereviewed manually to determine whetherthe provider recognized the BMI percentilefor the subject during the admission or atdischarge. The indicator for recognition ofBMI percentile was the recording of the BMIpercentile by the provider in the admission

note, any daily progress note, dischargeinstructions, or discharge letter. The EHRs ofthe patients with overweight and obesitywere manually reviewed to determinewhether the provider diagnosed overweightor obesity or provided or recommendedtreatment of overweight or obesity.Diagnosis of overweight or obesity wasdefined as provider documentation of adischarge diagnosis of overweight orobesity as determined by manual chartreview. Any terminology for increasedweight was accepted for diagnosis.Diagnostic coding of overweight or obesitywas not accepted as a diagnosis because itindicated coding status, not providerdiagnosis of obesity or overweight. Previousstudies have shown inaccuracy and errorsin International Classification of Diseases,Ninth Revision coding for obesity.33,34

Treatment of obesity was defined as referralto a dietitian or consultation by a dietitianduring the hospitalization or at discharge,evidence of instructions for healthy eatingor exercise during the hospitalization or atdischarge, or referral to a weightmanagement program at discharge.Referral to a dietitian, a healthy eatingrecommendation, or referral to anoutpatient weight management programwas determined by a consultation order, adietitian note, a provider note, or adischarge recommendation in the EHR.

The nurse research assistant, the primaryinvestigator, and an unbiased researcherreviewed data collection in 20 random chartsto ensure lack of bias and reliability of themanually gathered project data. Diagnosis ofoverweight or obesity, dietitian consultation,and recognition of BMI percentile had 100%agreement between the 3 reviewers. Fleiss’s kanalysis indicated that there was substantialagreement between the 3 reviewersregarding diet or exercise counseling by theprovider (k 5 0.747, P 5 .036).

Univariate summary statistics werecompiled for demographic and clinicalpatient characteristics. Bivariate andmultivariate categorical comparisons of BMIcategory, asthma severity, LOS category, andICU admission were compared via Pearson’sx2 test of association or Fisher’s exact test,assessing post hoc significance between

column proportions via z test. Multivariatecomparison of BMI category and continuousLOS by asthma severity was assessed via2-way analysis of variance and Fisher’s LSDpost hoc test.

RESULTSDemographic Factors

Five hundred ten subjects met the criteriafor inclusion in the sample; 59 admittedwith a diagnosis of asthma were excludedfrom the analysis (Fig 1). Demographiccharacteristics of the subjects are listed inTable 1. Mean age of subjects was 8.4 years(SD 5 3.8). Median age was 7.77 years. Inall, 23.3% of patients were 3 to 4 years ofage, 58.2% of patients were 5 to 11 years ofage, and 18.4% of patients were 12 to17 years of age. The majority of the subjectswere male (62.9%), were African American(75.9%), and had government healthinsurance (66.5%).

Weight Category Distribution of theSample According to BMI Percentile

Distribution of the sample by weightcategory is shown in Table 1. Demographiccharacteristics of the subjects across theweight category distribution are also shownin Table 1. There were no significantdifferences by gender, race or ethnicity, orinsurance status across weight categories;however, patient age differed statisticallyby weight category (P , .001). Healthyweight subjects averaged 1.7 years youngerthan overweight subjects (P 5 .008) and2.3 years younger than obese subjects(P , .001). Underweight subjects were3.0 years younger than overweight subjects(P , .001) and 3.6 years younger thanobese subjects (P , .001).

Recognition of BMI Percentile andDiagnosis of Overweight and Obesity

Review of the records revealed thatdocumentation of BMI percentile by theprovider was missing in 493 (96.7%) of therecords of the total sample. Compared withsubjects without documentation of BMIpercentile, those with documentation hadhigher average BMI percentiles (79.9 vs60.3, P 5 .001), more often had LOS of$2 days (P 5 .046), were ages 12 to17 years (P 5 .010), and had severepersistent asthma (P 5 .007).

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For the 168 subjects with overweight orobesity, BMI percentile was documented inonly 11 (6.5%) of the charts. BMI percentilewas not documented for any of the68 subjects with overweight (0%). For the100 subjects with obesity, BMI percentile wasdocumented in 11 (11%) of the charts.Among subjects with obesity, those withrecognition of BMI percentile had higheraverage BMI percentile (99.1 vs 97.7,P 5 .016) and more often had severeobesity (BMI percentile $99) than subjectswith BMI 95th to 98th percentile (22.3% vs4.7%, P 5 .013).

Only 9 of the 168 (5.4%) subjects withoverweight or obesity were given adischarge diagnosis by the providerreflecting overweight or obesity in additionto the primary diagnosis of asthma. Onlysubjects with obesity were given a diagnosisof overweight/obesity. None of the subjectswith overweight were diagnosed withoverweight/obesity.

Treatment of Obesity and Overweight

Of 168 overweight or obese subjects, only 14(8.3%) received treatment of obesity andoverweight. All 14 of the subjects whoreceived weight treatment were in theobese weight group (14%). Subjects

received treatment consisting of $1 ofthe following: diet instruction orcounseling (n 5 13), instruction forincreased activity (n5 3), inpatient dietitianconsultation (n 5 8), and referral for anoutpatient weight management program(n 5 3).

Asthma Characteristics

Chronic Asthma Severity

Data on chronic asthma severity are listedin Table 1. Chronic severity was found to beassociated with BMI weight category (P #

.001) (Table 1). As a result of the significantoverall association between chronic severityand BMI weight category, pairwise post hoctesting was completed between each BMIweight category. Intermittent severity wasdifferent from both moderate persistent(P , .001) and severe persistent asthma(P , .001). Mild persistent severity wasdifferent from both moderate persistent(P , .001) and severe persistent asthma(P , .001).

Because of the significant difference in agebetween the weight categories, analyseswere conducted stratifying by age. As shownin Fig 2, when the relationship of chronicasthma severity and weight category isadjusted for age category, there was a

significant association between severepersistent chronic asthma and obesity forchildren in the oldest age group (P 5 .033).Children with obesity in the 12- to 17-yearage group demonstrated 2 times moresevere persistent asthma than those withobesity in the 5- to 11-year age group and5 times more than those with obesity in the3- to 4-year age group.

Severity of the Acute Episode

A x2 analysis of binary LOS and BMIpercentile group suggests a lowerproportion of underweight and healthyweight patients with LOS of $2 days ascompared with subjects with overweightand obesity, but the difference fell short ofstatistical significance (P 5 .055). Whenadjusted for chronic asthma severity, LOSdoes not differ by BMI category, nor doesBMI category have an interactive effect withasthma severity. However, LOS differs bychronic asthma severity when BMIcategory is accounted for (P 5 .007).When age was adjusted, LOS and BMIcategory did not show a statisticallysignificant association.

Of the 510 subjects in the sample, 110were admitted to the PICU (21.6%). Table 1shows the comparison of admission to the

FIGURE 1 Flow of participants.

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PICU by weight group. Because of thesignificant difference in age between theweight categories (P , .001), thecomparison of PICU status by weightcategory was also stratified by age group.When age was adjusted, the comparisons of

admission to the PICU and weightcategory also did not indicate anystatistically significant association. Whenwe adjusted for chronic asthma severity,admission to the PICU did not differ byBMI category.

DISCUSSION

This retrospective chart audit of childrenadmitted to the hospital for treatment ofasthma finds a striking absence ofrecognition, diagnosis, and treatment ofobesity and overweight, important

TABLE 1 Demographics and Asthma Characteristics of Children Hospitalized With Asthma by Weight Group (N 5 510)

Variable Total Sample Underweight Healthy Weight Overweight Obese P

510 100.0 28 5.5 314 61.6 68 13.3 100 19.6

n % n % n % n % n %

Demographics

Age ,.001*

3–4 y 119 23.3 9 32.1 88 28.0 13 19.1 9 9.0

5–11 y 297 58.2 19 67.9 178 56.7 39 57.4 61 61.0

12–17 y 94 18.4 0 0.0 48 15.3 16 23.5 30 30.0

Gender .500

Female 189 37.1 7 3.7 122 64.6 25 13.2 35 18.5

Male 321 62.9 21 6.5 192 59.8 43 13.4 65 20.2

Race or ethnicity .962a

Caucasian 98 19.2 7 7.1 61 62.2 13 13.3 17 17.3

African American 387 75.9 20 5.2 238 61.5 52 13.4 77 19.9

Asian 3 0.6 0 0.0 2 66.7 0 0.0 1 33.3

Other 17 3.3 1 5.9 11 64.7 2 11.8 3 17.6

Unknown 5 1.0 0 0.0 2 40.0 1 20.0 2 40.0

Insurance statusb .441a

Government 339 66.5 20 5.9 207 61.1 43 12.7 69 20.4

Commercial 150 29.4 7 4.7 96 64.0 19 12.7 28 18.7

Self-pay 19 3.7 1 5.3 10 52.6 6 31.6 2 10.5

Missing 2 0.4 0 0.0 1 50.0 0 0.0 1 50.0

Asthma characteristics

LOS .055

0–1 d 265 52.0 14 5.3 177 66.8 33 12.5 41 15.5

$2 d 245 48.0 14 5.7 137 55.9 35 14.3 59 24.1

PICU admission .179

Yes 110 21.6 7 6.4 59 53.6 15 13.6 29 26.4

No 400 78.4 21 5.3 255 63.7 53 13.3 71 17.8

Chronic asthma severityb .001*

Intermittent 88 17.3 7 8.0 60 68.2 10 11.4 11 12.5

Mild persistent 114 22.4 10 8.8 82 71.9 6 5.3 16 14.0

Moderate persistent 211 41.4 9 4.3 124 58.8 32 15.2 46 21.8

Severe persistent 88 17.3 1 1.1 46 52.3 19 21.6 22 25.0

Missing 9 1.8 1 11.1 2 22.2 1 11.1 5 55.6

Variable Total Sample Underweight Healthy Weight Overweight Obese P

Mean SD Mean SD Mean SD Mean SD Mean SD

Age, y 8.4 3.8 6.5 2.5 7.8 3.6 9.5 3.9 10.1 3.7 ,.001*

*P , .05.a Fisher’s exact test.b Missing category excluded from analysis with weight group.

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comorbidities of asthma. In the totalsample, only 3.3% of all children hadevidence of provider documentation of BMIpercentile. For the children with overweightor obesity, only 6.5% had a BMI percentiledocumented in the record, only 5.4% werediagnosed with overweight or obesity atdischarge, and only 8% had a treatmentrecommendation related to weightmanagement.

The importance of monitoring BMIpercentile is supported in the literature21,23;however, investigators have reported a lackof monitoring BMI percentile of all childrenin all settings, including the inpatientsetting.24,26,28 Young et al23 recommendconsistent identification and treatment ofoverweight and obesity as the standard ofcare for all children admitted to children’shospitals. This is the first study tospecifically examine recognition, diagnosis,and treatment of overweight and obesity inchildren hospitalized for asthma. BMIpercentile was recognized in some subjectswith obesity (11%). Of the subjects with

obesity, those with severe obesity weresignificantly more likely to have BMIpercentile recognized (P 5 .016). It ispossible that providers are able torecognize severe obesity by physicalexamination or that extreme obesity wasprioritized as a significant health issue bythe provider. More remarkable is the lack ofrecognition of overweight in this study. Noneof the patients with overweight wererecognized (0%). Missing identification ofthose with overweight may be a missedopportunity to prevent development ofobesity and reduce the severity of asthmasymptoms and comorbidities associatedwith weight.

In the overall sample BMI percentile wassignificantly more likely to be recognized inolder subjects (P 5 .010). Although it isimportant that BMI percentile wasrecognized in the older subjects, there isevidence that recognizing overweight andobesity in younger children may affecthealth outcomes. A longitudinal study ofhealthy children by Cunningham et al35

demonstrated that younger children withoverweight were more likely to have obesityas teens. A recent study by Aragona et al36

demonstrated that overweight and obesepreschool children admitted with asthmawere .2 times as likely to have repeatemergency visits as lean preschool children.Strunk et al37 showed that subjects in theChildhood Asthma Management Programwho became obese in young adulthood hadlower lung function compared with thosewho remained normal weight. Although ourstudy design is not longitudinal, the resultssuggest that an association of asthmaseverity and weight becomes morepronounced among older children, and theysupport the importance of recognizing andtreating overweight in younger children.Additional longitudinal studies of childrenwith asthma and overweight are needed toanalyze the impact of asthma on thedevelopment of obesity with age.

In the overall sample, obesity was also morelikely to be recognized in those with severechronic asthma (P 5 .007). The NAEPP

FIGURE 2 Asthma severity by BMI percentile group stratified by age category.

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Guidelines recommend addressing weight inpatients with overweight or obesity anduncontrolled asthma.18 Studies demonstrateimprovement in asthma symptoms withweight loss and thus support theimportance of recognizing and treatingthose with severe chronic asthma andoverweight or obesity.29–31 The results alsodemonstrate a relationship of chronicasthma severity and weight group that wassignificant in the older age category.Although a large prospective study byPeters38 demonstrated no significantdifference in chronic severity betweenweight groups, other studies have shownthat children with asthma who areoverweight or obese have more asthmamorbidity.39–42 Future studies may supportstronger recommendations in the NAEPPand Global Initiative for Asthma guidelinesrelated to weight recognition andmanagement in all health care settings andin all age groups for children with asthma.The urban setting and prevalence ofgovernment-insured subjects in this study(66.7%) lends support to capitalizing on theopportunity to recognize and treatoverweight and obesity in the inpatientsetting. Children living in poverty have beenshown to have higher utilization of urgentand acute care, lower utilization of primaryand specialist care, and higher prevalenceof both asthma and obesity.42–44

Even when obesity was recognized in thisstudy, the provider did not always identify itas a discharge diagnosis. At the time ofdischarge only 5.4% of subjects withoverweight or obesity received a diagnosisthat indicated overweight or obesity. Otherstudies have noted underdiagnosis ofoverweight and obesity in hospitalizedchildren.27,33,45 Some studies indicate error orinaccuracy in overweight and obesity coding14;however, others, as in our study, demonstratelack of provider diagnosis.27,45 There could bemany reasons for lack of diagnosis. Providerand patient sensitivity and bias have beenshown to influence provider diagnosis andtreatment of overweight and obesity.21,46,47 Inour study, to avoid possible provider orpatient sensitivity to the word obesity, anyterm indicating overweight or obesity wasaccepted for diagnosis, and accuracy of theterm according to BMI percentile was not

studied. It is interesting that a study ofhospitalized children by Bradford et al48

showed that parents underestimate theirchild’s weight status, but almost all parents inthe study expected that providers wouldmonitor BMI during admission and informthem of the results. The use of BMI percentileto spur additional assessment and diagnosiscannot be overlooked in the health care of allchildren in any setting.

In our study, only 8% of those withoverweight and obesity had evidence oftreatment, and subjects receiving treatmentwere in the obese group. Guidelines fortreatment of overweight and obesity forchildren hospitalized with asthma arelacking; however, components of the ExpertCommittee21 guidelines are appropriate forthe inpatient setting. Nearly all patients inthe study, regardless of weight status, weregiven instructions to “resume usual diet.”Recommendations for healthful eating andincreased activity, as recommended by theExpert Committee for children with BMIpercentile $85, could become standardpractice for children admitted with asthma.In addition, delivery of a written weightmanagement plan could be part of thedischarge instructions for those with BMIpercentile $95. And those with severeobesity or failure to lose weight could bereferred to outpatient managementprograms. Unfortunately, lack of resourcesin the community or limitations in insurancecoverage may influence the provider’sability to refer patients for needed care.

Some elements of Expert Committeerecommendations cannot be done in theinpatient setting because of the effects ofthe medications needed to treat the acuteexacerbation. Results of inpatient screeningof lipids and glucose are confounded bysystemic corticosteroids, and bloodpressure measurement is unreliablebecause of the effects of albuterol andcorticosteroids. Laboratory screening, bloodpressure measurement, and long-termmonitoring of weight and asthma outcomesare best provided in the primary caresetting; therefore, communication with theprimary care team is crucial. Although thedischarge instructions are faxed to allprimary care providers, we did not assess

for specific communication with theprimary care provider regarding weightstatus or plan for management.

A recent study by Cygan et al49 suggests thatoutcomes of pediatric overweight andobesity management in the primary caresetting are improved with a systematicapproach including use of an EHR thatalerts providers to practice protocols,patient education, and provider training.There was limited capability of the EHR inthe study hospital at the time of the study.BMI was available in the growth chartapplication, but BMI percentile had to becalculated with the CDC calculator.Recognition of weight status may haveimproved if BMI percentile were set toappear automatically in the EHR. Also, theelectronic discharge instructions gave theprovider a default option for resumingusual diet or an option for “other” thatrequired manual entry of specific dietdirections. Nearly all subjects in the studyregardless of weight category were givendirections to resume usual diet. Thisfinding could be attributed to ease ofentering the default option. As in theCygan et al study,49 optimizing the EHR hasthe potential to improve inpatient care.More studies are needed to determineeffective use of the EHR to improve careof children with asthma and overweightor obesity.

This study adds to our knowledge of thedisease process in children with overweightand obesity who are hospitalized withasthma. The prevalence of overweight andobesity in this sample (32.9%) is similar tothe prevalence of overweight and obesity inthe general population at the time of thestudy (31.8%).50 This study, as in a recentstudy by Aragona et al,36 did not find asignificant relationship between overweightor obesity and inpatient asthma clinicaloutcomes. It should be considered that LOSand admission to the ICU may be insensitivemeasures of the severity of the episode.Carroll et al12 found that obese childrenreceived longer courses of supplementaloxygen, continuous albuterol, andintravenous steroids in the ICU. Objectiveassessment data such as oxygen saturation,peak flow measurement, asthma score, and

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pulmonary function studies were notgathered or reported in this study and mayhave contributed to the understanding ofthe severity of the episodes. Including otherobjective parameters in future studiesmight help better define the effect of weighton severity of the acute episode.

This study has several potential limitations.Demographic characteristics of the sampleshould be considered in generalizing theresults of this study. Data were gatheredfrom a convenience sample of subjectsadmitted to a single tertiary pediatrichospital in an academic setting in the year2012. Also, although the data in this studywere representative of the race andethnicity of the population cared for at thisurban Midwestern children’s hospital, itdiffered from that of the general populationin the United States at the time of the study.Specifically, it did not include many Hispanicsubjects, and race or ethnicity did not varybetween weight groups. Although theassociation has varied widely in studies,race or ethnicity has been shown toinfluence both the prevalence of asthma andasthma control.40,43,51,52

The retrospective nature of this studyinfluenced data collection and analysis. Lackof height or weight measurement orimplausible measurements madecalculating BMI percentile impossible for23 subjects. Accuracy of measurementcannot be determined. Although the authorsmade every attempt to demonstrateconsistency in data extraction, the potentialfor errors in recording data to the EHR stillexist. The unavailability of the BMI percentilein the EHR was a barrier to providers andcomplicated their ability to recognizesubjects’ weight status. In addition, it ispossible that providers recognized weightstatus but did not document recognition ortreatment. The retrospective methodinfluenced the ability to gather detailedinformation about chronic asthmacharacteristics and risk of severity for thesubjects. Chronic asthma severity wasextracted from the records as designated ina discrete electronic field by the providerwho completed the discharge instructions.Although all physicians and nursepractitioners are trained to assess chronic

severity based on the NAEPP guidelines,there could be variability due to the level ofprovider competency or completeness inassessing chronic severity. Chronic asthmaseverity was identified by providers in501 of the 510 subjects in the sample;however, other details about asthma-specific characteristics such as AsthmaControl Test score, lung function, previousadmissions, previous emergency visits,asthma quality of life scores, environmentalexposure, and family histories were notconsistently available in the EHRs. Markersof severity of the acute episode were alsochosen based on data available in therecords. Binary LOS, 0 to 1 and $2 days,was also used by Aragona et al,36 but it isnot known whether it is indicative as ameasure of severity of the admission.Spirometry has been used in other studiesas an indicator of severity of the episode,but it is not routinely performed duringadmission and therefore was not availablein the record. Obstructive sleep apnea,gastroesophageal reflux, exposure totobacco smoke, and other comorbidconditions that may have influenced LOS orchronic severity were not examined in thisstudy because of a lack of reliability incharting and coding in this retrospectivestudy.

Data were not collected in this study toexamine cost of care or readmission ratebut could be an area for additional study.Although cost of care and rate ofreadmission or return to the hospital areimportant issues in health care, a recentstudy by Bettenhausen et al17 did not show arelationship between BMI and resourceutilization or cost of care; however, Aragonaet al36 did show that obese patients weremore likely to have return visits.

The sample size proved to be a limitation inthe analyses. Power was limited by theuneven distribution of sample patientsacross categorized variables of interest.Future analyses can benefit from theobserved ratio of patient categorization anda priori power analysis.

CONCLUSIONS

In this study of children admitted to thehospital with asthma, overweight andobesity were infrequently recognized or

diagnosed and seldom prompted treatmentrecommendations by providers. BMIpercentile was more likely to be recognizedin older subjects, subjects with severeobesity, and subjects with severe persistentasthma. The results of this study will bethe basis for planning processes andestablishing practice guidelines toimprove recognition, diagnosis, andmanagement of overweight and obesity inchildren who are hospitalized with statusasthmaticus. Additional study will be neededto elucidate the barriers to recognition,diagnosis, and treatment of overweightand obesity for children admitted withasthma; the effect of optimizing the EHR toimprove recognition and management ofoverweight and obesity; and the impactof including weight management in theinpatient setting on health care outcomesfor children with asthma and overweight orobesity.

Acknowledgments

Coauthor Robert C. Strunk, MD, diedunexpectedly on April 28, 2016. He was arespected pediatric allergist, investigator,colleague, and mentor. His work as directorof the Childhood Asthma ManagementProgram was important to the care ofchildren with asthma. Dr Strunk wasinstrumental in this study and the writing ofthis manuscript. The authors thank DrLeonard Bacharier, who assisted in the finalreview of the manuscript.

REFERENCES

1. Bloom B, Jones L, Freeman G. Summaryhealth statistics for US children:National Health Interview Survey, 2012.Vital Health Stat. 2013;10(258):1–73

2. Overview of Hospital Stays for Childrenin the United States, 2012. HealthcareCost and Utilization Project statisticalbrief 187. Rockville, MD: Agency forHealthcare Research and Quality; 2014.Available at: www.hcup-us.ahrq.gov/reports/statbriefs/sb187-Hospital-Stays-Children-2012.pdf

3. Ogden CL, Carroll MD, Kit BK, Flegal KM.Prevalence of obesity and trends in bodymass index among US children andadolescents, 1999–2010. JAMA. 2012;307(5):483–490

674 BORGMEYER et al

by guest on March 19, 2021www.aappublications.org/newsDownloaded from

4. Rastogi D, Fraser S, Oh J, et al.Inflammation, metabolic dysregulation,and pulmonary function among obeseurban adolescents with asthma. Am JRespir Crit Care Med. 2015;191(2):149–160

5. Ginde AA, Santillan AA, Clark S, CamargoCA Jr. Body mass index and acuteasthma severity among childrenpresenting to the emergencydepartment. Pediatr Allergy Immunol.2010;21(3):480–488

6. Jensen ME, Collins CE, Gibson PG, WoodLG. The obesity phenotype in childrenwith asthma. Paediatr Respir Rev. 2011;12(3):152–159

7. Gilliland FD, Berhane K, Islam T, et al.Obesity and the risk of newly diagnosedasthma in school-age children. Am JEpidemiol. 2003;158(5):406–415

8. Gold DR, Damokosh AI, Dockery DW,Berkey CS. Body-mass index as apredictor of incident asthma in aprospective cohort of children. PediatrPulmonol. 2003;36(6):514–521

9. Quinto KB, Zuraw BL, Poon KY, Chen W,Schatz M, Christiansen SC. Theassociation of obesity and asthmaseverity and control in children.J Allergy Clin Immunol. 2011;128(5):964–969

10. Wiesenthal EN, Fagnano M, Cook S,Halterman JS. Asthma and overweight/obese: double trouble for urbanchildren. J Asthma. 2016;53(5):485–491

11. Manion A, Velsor-Friedrich B. Quality oflife and health outcomes in overweightand non-overweight children withasthma. J Pediatr Health Care.doi:10.1016/j.pedhc.2016.01.005

12. Carroll CL, Bhandari A, Zucker AR,Schramm CM. Childhood obesityincreases duration of therapy duringsevere asthma exacerbations. PediatrCrit Care Med. 2006;7(6):527–531

13. Shanley LA, Lin H, Flores G. Factorsassociated with length of stay forpediatric asthma hospitalizations.J Asthma. 2015;52(5):471–477

14. Woolford SJ, Gebremariam A, Clark SJ,Davis MM. Persistent gap of incremental

charges for obesity as a secondarydiagnosis in common pediatrichospitalizations. J Hosp Med. 2009;4(3):149–156

15. Hom J, Morley EJ, Sasso P, Sinert R. Bodymass index and pediatric asthmaoutcomes. Pediatr Emerg Care. 2009;25(9):569–571

16. Jay M, Wijetunga NA, Stepney C, DorseyK, Chua DM, Bruzzese JM. Therelationship between asthma andobesity in urban early adolescents.Pediatr Allergy Immunol Pulmonol. 2012;25(3):159–167

17. Bettenhausen J, Puls H, Queen MA, et al.Childhood obesity and in-hospitalasthma resource utilization. J Hosp Med.2015;10(3):160–164

18. National Heart, Lung, and Blood Institute.National Asthma Education andPrevention Program Expert Panel Report3: Guidelines for the Diagnosis andManagement of Asthma. Bethesda, MD:National Institutes of Health; 2007

19. National Institutes of Health, NationalHeart, Lung, and Blood Institute. GlobalInitiative for Asthma: Global Strategy forAsthma Management and Prevention.NIH publication no. 02-3659. Bethesda,MD: National Institutes of Health; 2002

20. Joint Commission Children’s AsthmaCare. Available at: http://jointcommission.org/children’s_asthma_care/.20112011.21.

21. Barlow S. Expert Committeerecommendations regarding theprevention, assessment, and treatmentof child and adolescent overweight andobesity: summary report. Pediatrics.2007;120(suppl 4):S164–S192

22. Murray R, Battista M. Managing the riskof childhood overweight and obesity inprimary care practice. Curr ProblPediatr Adolesc Health Care. 2009;39(6):146–165

23. Young KL, Demeule M, Stuhlsatz K, et al.Identification and treatment of obesityas a standard of care for all patients inchildren’s hospitals. Pediatrics. 2011;128(suppl 2):S47–S50

24. Larsen L, Mandleco B, Williams M,Tiedeman M. Childhood obesity:prevention practices of nursepractitioners. J Am Acad Nurse Pract.2006;18(2):70–79

25. Tanda R, Salsberry P. The impact of the2007 Expert Committeerecommendations on childhood obesitypreventive care in primary care settingsin the United States. J Pediatr HealthCare. 2014;28(3):241–250

26. Sleeper EJ, Ariza AJ, Binns HJ. Dohospitalized pediatric patients haveweight and blood pressure concernsidentified? J Pediatr. 2009;154(2):213–217

27. King MA, Nkoy FL, Maloney CG,Mihalopoulos NL. Physicians andphysician trainees rarely identify oraddress overweight/obesity inhospitalized children. J Pediatr. 2015;167(4):816–820.e1

28. Estrada E, Eneli I, Hampl S, et al;Children’s Hospital Association.Children’s Hospital Associationconsensus statements for comorbiditiesof childhood obesity. Child Obes. 2014;10(4):304–317

29. Jensen ME, Gibson PG, Collins CE, HiltonJM, Wood LG. Diet-induced weight loss inobese children with asthma: arandomized controlled trial. Clin ExpAllergy. 2013;43(7):775–784

30. Luna-Pech JA, Torres-Mendoza BM, Luna-Pech JA, Garcia-Cobas CY, Navarrete-Navarro S, Elizalde-Lozano AM.Normocaloric diet improves asthma-related quality of life in obese pubertaladolescents. Int Arch Allergy Immunol.2014;163(4):252–258

31. Willeboordse M, Kant KD, Tan FE, et al.A multifactorial weight reductionprogramme for children with overweightand asthma: a randomized controlledtrial. PLoS One. 2016;11(6):e0157158

32. Centers for Disease Control andPrevention. BMI Percentile Calculator forChild and Teen Metric Version. 2014.Available at: http://nccd.cdc.gov/dnpabmi/Calculator.aspx?CalculatorType5Metric

HOSPITAL PEDIATRICS Volume 6, Issue 11, November 2016 675

by guest on March 19, 2021www.aappublications.org/newsDownloaded from

33. Woo JG, Zeller MH, Wilson K, Inge T.Obesity identified by discharge ICD-9codes underestimates the trueprevalence of obesity in hospitalizedchildren. J Pediatr. 2009;154(3):327–331

34. Benson L, Baer HJ, Kaelber DC. Trends inthe diagnosis of overweight and obesityin children and adolescents: 1999–2007.Pediatrics. 2009;123(1). Available at:www.pediatrics.org/cgi/content/full/123/1/e153

35. Cunningham SA, Kramer MR, NarayanKM. Incidence of childhood obesity in theUnited States. N Engl J Med. 2014;370(5):403–411

36. Aragona E, El-Magbri E, Wang J, et al.Impact of obesity on clinical outcomes inurban children hospitalized for statusasthmaticus. Hosp Pediatr. 2016;6(4):211–218

37. Strunk RC, Colvin R, Bacharier LB, et al;Childhood Asthma ManagementProgram Research Group. Airwayobstruction worsens in young adultswith asthma who become obese.J Allergy Clin Immunol Pract. 2015;3(5):765–71.e2

38. Peters JI, McKinney JM, Smith B, Wood P,Forkner E, Galbreath AD. Impact ofobesity in asthma: evidence from a largeprospective disease management study.Ann Allergy Asthma Immunol. 2011;106(1):30–35

39. Belamarich PF, Luder E, Kattan M, et al.Do obese inner-city children withasthma have more symptoms thannonobese children with asthma?Pediatrics. 2000;106(6):1436–1441

40. Black MH, Smith N, Porter AH, JacobsenSJ, Koebnick C. Higher prevalence ofobesity among children with asthma.Obesity (Silver Spring). 2012;20(5):1041–1047

41. Carroll CL, Stoltz P, Raykov N, Smith SR,Zucker AR. Childhood overweightincreases hospital admission rates forasthma. Pediatrics. 2007;120(4):734–740

42. Flores G, Snowden-Bridon C, Torres S,et al. Urban minority children withasthma: substantial morbidity,compromised quality and access tospecialists, and the importance ofpoverty and specialty care. J Asthma.2009;46(4):392–398

43. Keet CA, McCormack MC, Pollack CE,Peng RD, McGowan E, Matsui EC.Neighborhood poverty, urban residence,race/ethnicity, and asthma: rethinkingthe inner-city asthma epidemic. J AllergyClin Immunol. 2015;135(3):655–662

44. Scott L, Morphew T, Bollinger ME, et al.Achieving and maintaining asthmacontrol in inner-city children. J AllergyClin Immunol. 2011;128(1):56–63

45. Azhdam DB, Reyhan I, Grant-Guimaraes J,Feinstein R. Prevalence anddocumentation of overweight andobesity in hospitalized children andadolescents. Hosp Pediatr. 2014;4(6):377–381

46. Cohen ML, Tanofsky-Kraff M, Young-Hyman D, Yanovski JA. Weight and ItsRelationship to Adolescent Perceptionsof Their Providers (WRAP): a qualitativeand quantitative assessment of teenweight-related preferences and

concerns. J Adolesc Health. 2005;37(2):

163

47. Phelan SM, Burgess DJ, Yeazel MW,

Hellerstedt WL, Griffin JM, van Ryn M.

Impact of weight bias and stigma on

quality of care and outcomes for

patients with obesity. Obes Rev. 2015;

16(4):319–326

48. Bradford K, Kihlstrom M, Pointer I,

Skinner AC, Slivka P, Perrin EM. Parental

attitudes toward obesity and overweight

screening and communication for

hospitalized children. Hosp Pediatr. 2012;

2(3):126–132

49. Cygan HR, Baldwin K, Chehab LG,

Rodriguez NA, Zenk SN. Six to success:

improving primary care management of

pediatric overweight and obesity.

J Pediatr Health Care. 2014;28(5):

429–437

50. Ogden CL, Carroll MD, Kit BK, Flegal KM.

Prevalence of childhood and adult

obesity in the United States, 2011–2012.

JAMA. 2014;311(8):806–814

51. Borrell LN, Nguyen EA, Roth LA, et al.

Childhood obesity and asthma control in

the GALA II and SAGE II studies. Am J

Respir Crit Care Med. 2013;187(7):

697–702

52. Joseph M, Elliott M, Zelicoff A, Qian Z,

Trevathan E, Chang JJ. Racial disparity in

the association between body mass

index and self-reported asthma in

children: a population-based study.

J Asthma. 2016;53(5):492–497

676 BORGMEYER et al

by guest on March 19, 2021www.aappublications.org/newsDownloaded from

DOI: 10.1542/hpeds.2015-0242 originally published online October 12, 2016; 2016;6;667Hospital Pediatrics 

Anne Borgmeyer, Patrick M. Ercole, Angela Niesen and Robert C. StrunkChildren Hospitalized for Asthma

Lack of Recognition, Diagnosis, and Treatment of Overweight/Obesity in

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