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Original article
Health profiles of overweight and obese youth attending general practice
  1. Winifred D Paulis1,
  2. Millicent Palmer2,
  3. Patty Chondros2,
  4. Sylvia Kauer2,
  5. Marienke van Middelkoop1,
  6. Lena A Sanci2
  1. 1Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
  2. 2General Practice and Primary Health Care Academic Centre, The University of Melbourne, Melbourne, Australia
  1. Correspondence to W D Paulis, Department of General Practice, Erasmus MC, P.O. Box 2040, Rotterdam 3000 CA, The Netherlands; w.paulis{at}erasmusmc.nl

Abstract

Background Literature suggests that overweight and obese young people use healthcare services more often, but this awaits confirmation in primary care.

Objective To identify health profiles of underweight, overweight and obese young people attending general practice and compare them to normal-weight youth and also to explore the weight-related health risks of eating and exercise behaviour in the four different weight categories.

Methods This study used a cross-sectional design with baseline data from a trial including 683 young people (14–24 years of age) presenting to general practice. Through computer-assisted telephone interviews data were obtained on number and type of health complaints and consultations, emotional distress, health-related quality of life (HRQoL) and eating and exercise behaviour.

Results General practitioners (GPs) were consulted more often by overweight (incidence rate ratio (IRR): 1.28, 95% CI (1.04 to 1.57)) and obese youth (IRR: 1.54, 95% CI (1.21 to 1.97), but not for different health problems compared with normal-weight youth. The reason for presentation was seldom a weight issue. Obese youth reported lower physical HRQoL. Obese and underweight youth were less likely to be satisfied with their eating behaviour than their normal-weight peers. Exercise levels were low in the entire cohort.

Conclusions Our study highlights the need for effective weight management given that overweight and obese youth consult their GP more often. Since young people do not present with weight issues, it becomes important for GPs to find ways to initiate the discussion about weight, healthy eating and exercise with youth.

Trial registration number ISRCTN16059206.

  • Adolescent Health
  • Obesity
  • General Practice
  • Quality of Life

https://doi.org/10.1136/archdischild-2016-311404

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    What is already known on this topic?

    • Literature suggests that overweight and obese young people use health services more often, but this awaits confirmation in populations attending primary care.

    • Primary care is considered an appropriate setting for weight management.

    What this study adds?

    • There is need for effective weight management given that overweight and obese youth consult their general practice more often.

    • Overweight and obese young people do not consult their general practitioner (GP) for different reasons than other youth.

    • Since youth do not usually present with weight issues, GPs need to find ways to initiate the discussion about weight and healthy lifestyle.

    Introduction

    The worldwide prevalence of overweight and obesity among children, adolescents and adults has increased enormously since the 1970s.1 Data from the Australian National Health Survey (ANHS) demonstrate that obesity rates in Australia are high, with more than one quarter of its adolescents currently overweight or obese.2 Adolescent overweight and obesity are linked to an increased risk of developing chronic obesity in adulthood, which increases the likelihood of weight-related adult morbidities and mortality.3

    Specialist services designed to manage obesity are limited and lack the capacity to deal with the current level of overweight and obese patients.4 It is therefore important that effective management can also occur in primary care settings.5 Literature shows that general practitioners (GPs) acknowledge their potential role in the management of childhood obesity, but the majority of GPs do not address weight in regular consultations.6 Barriers include the limited evidence base for effective management7 and perceptions held by primary care providers that parents and children lack the motivation to change.8 Notwithstanding these issues, with young people attending primary care at least annually there are many opportunities for detection of weight issues and preventive health advice.9

    Other work has suggested that overweight and obese young people use health services more often,10 and have lower quality of life or experience more emotional distress than normal-weight youth11 but this awaits confirmation in studies of populations attending primary care. Understanding the clinical profile of these young people could help in the design of new effective approaches for this group in primary care.

    This study is a secondary analysis of baseline data collected from patients attending Australian general practice enrolled in a cluster randomised trial of a training intervention for primary care clinicians in screening and counselling young people for health risks. With this epidemiological study, we aim to describe the health profiles of underweight, overweight and obese youth and compare them to young people of normal weight. In addition, we will explore the weight-related health risks of eating and exercise behaviour among young people in the different weight categories.

    Methods

    Study design

    We used a cross-sectional design, drawing on data from the Prevention, Access and Risk Taking In Young People (PARTY) project. The PARTY project was a stratified cluster randomised controlled trial involving 40 general practices in Victoria, Australia. The study was designed to assess the effectiveness and acceptability of an intervention for general practice clinicians (GPs and practice nurses) addressing risk-taking behaviour in youth. The full protocol for this project has been published.12 After practices were randomised, data from young people were collected at three time points: immediately after the recruitment consultation (‘exit interview’) and at 3 months and 12 months after consultation. To answer the current research questions, only the ‘exit interview’ data were used (see figure 1).

    Figure 1
    Figure 1

    Flow chart of study design and inclusion, derived from the flow chart of the main outcome paper.32 BMI, body mass index; CATI, computer-assisted telephonic interview.

    Participants

    All young people aged between 14 and 24 years attending the participating general practices between 2007 and 2010 were eligible for participation. Youth and young people are used as composite terms to combine adolescence (14–19 years old) and young adulthood (20–24 years old).13 Youth were excluded from the study if they were very unwell (vomiting, febrile, weak, psychotic or cognitively impaired), could not speak English or if they were unable to give informed consent and unwilling to obtain consent from guardians.

    Procedure

    Young people were approached in the clinical setting after their consultation by their clinician who provided a brief overview of the study and asked for permission to pass on their contact details to the study researchers. The researchers phoned each young person and provided a detailed explanation of the study and obtained informed consent. As an incentive for participating, all young people were given the option to enter a draw for an iPod valued at A$200.

    However, clinicians were inconsistent with approaching all eligible youth and with timelines under threat, research assistants were placed in the remaining practices to systematically recruit, following the same procedure as the clinicians.12

    Researchers conducted a computer-assisted telephone interview (CATI) with the consenting young people. The duration of the interview was approximately 50 min. All researchers were masked to the allocation status of the practices and young people also were not informed of their practice's allocation status.

    Measures

    The interview contained self-reported measures of the young person's experience with the clinic and clinician(s), quality of life and emotional distress, engagement in risky behaviours, willingness and readiness to change health behaviours, utilisation of health services and basic demographics.12

    For the present analyses, we used the following data:

    • basic demographics (age, gender, birth country, education (student yes/no) and employment (employed yes/no))

    • self-reported height and weight

    • practice billing type (private, national healthcare funded or community health centres) and socioeconomic status of general practice (based on Socio-Economic Indexes for Areas14 (dichotomised in advantaged/disadvantaged)).

    Presentations to general practice:

    • number of consultations in the last 12 months

    • reason(s) for presentation at current consultation

    Broader health profile

    • emotional distress (anxiety and depressive symptoms, measured with the Kessler-10, K-10, questionnaire;15 a higher score indicates more emotional distress)

    • Health-related quality of life (HRQoL, measured with the SF-12 questionnaire;16 a higher score indicates better HRQoL).

    Weight-related health risks (exact questions in online supplementary appendix A1)

    • self-reported amount of exercise

    • satisfaction with current eating behaviour.

    Data management and analyses

    All statistical analyses were done using STATA/SE V.12.0 (StataCorp, College Station, Texas, USA). Body mass index (BMI) was calculated and young people were categorised as underweight, normal weight, overweight or obese. For patients younger than 18 years of age, international gender and age-specific BMI cut-off values were used to determine the weight status.17 ,18 These values correspond to a BMI under 18.5 kg/m2 for underweight, 18.5–25 kg/m2 normal weight, 25–30 kg/m2 overweight and over 30 kg/m2 obese, which were used for young people from 18 years onwards.

    The reasons for presentation to the practice were coded into categories of complaints by a trained nurse using the second edition of the International Classification of Primary Care (ICPC-2).19 Type of complaints were analysed in the ICPC categories separately and in three broad categories: physiological/general/well visit, sexual/reproductive health and psychosocial.

    Data on exercise behaviour were dichotomised into yes/no variables (see online supplementary appendix A1, eg, at least 20 min of moderate vigorous activity (like walking) every day).

    Demographic data were presented as means and SDs for continuous data, and numbers and percentages for categorical data. Pearson χ2 tests were used to evaluate between-weight category differences in categorical demographic variables. We conducted linear regression analyses for continuous outcome variables, logistic regression analyses for dichotomous variables and Poisson regression for count variables (number of consultations and complaints) to test the associations between the outcome of interest and weight status. Normal weight was used as reference category. Regression analyses were adjusted for age, gender, education level of youth, socioeconomic status and billing type of the general practice, study arm and recruitment method (by clinician or research assistant). All analyses used robust SEs to adjust for clustering at general practice level. The strength of the association between weight category and outcome was determined using ORs for dichotomous measures, incidence rate ratios (IRRs) for the number of consultations and complaints and difference in means (β) for continuous outcomes, all with 95% CIs.

    Results

    Data on height and weight were available from 683 participants of the sample (901) (75.8%). A total of 122/683 (17.9%) young people were classified as overweight and 44/683 (6.4%) as obese. Table 1 shows the demographic characteristics of the participants within the different weight categories. Most youth were female (76.4%) and consulted general practices in advantaged areas. Obese youth were less likely to be a student (p=0.02).

    View this table:
    Table 1

    Demographic characteristics by weight status

    Presentations to general practice

    On average young people consulted the general practice six times in the last year (SD 6.6, median 5 and IQR 6). Both overweight (IRR: 1.28, 95% CI (1.04 to 1.57)) and obese young people (IRR: 1.54, 95% CI (1.21 to 1.97)) visited their practice more often compared with normal-weight youth, but they did not report more complaints at one consultation (see table 2). Underweight young people did not differ from their normal-weight peers in frequency of consultations.

    View this table:
    Table 2

    Number of presentations to the general practice by weight status

    Youth consulted the general practice for very diverse reasons: from headaches to advice on contraceptives. The reason for presentation to the practice did not differ between the weight categories (see online supplementary appendix A2). From the 1229 reported reasons for presentation, only eight were for a weight issue (one from an underweight, five from normal weight and two from overweight individuals).

    Broader health profile

    Underweight, overweight and obese youth did not differ in their levels of emotional distress as measured by the K-10 or in the mental component of the HRQoL questionnaire (SF-12) from normal-weight youth (see table 3). However, obese individuals had significantly lower scores on the physical component of the SF-12 compared with normal-weight youth (β: −3.41, 95% CI (−5.96 to −0.86)).

    View this table:
    Table 3

    Broader health profile; emotional distress (Kessler-10) and health-related quality of life (SF-12) by weight status

    Weight-related health risks

    Both underweight (OR: 0.53, 95% CI (0.31 to 0.92)) and obese young people (OR: 0.48, 95% CI (0.28 to 0.83)) are less likely to be satisfied with their eating behaviour than normal-weight youth (see table 4).

    View this table:
    Table 4

    Eating and exercise behaviour by weight status

    Approximately 35% of all young people reported having at least 20 min of moderate vigorous activity (like walking) 7 days a week. In addition, 64% of all young people reported having at least 20 min of vigorous activity (like sports) at least twice a week. There were no significant differences between moderate and vigorous exercise levels between the weight categories.

    Discussion

    Summary of main findings

    Our results show that overweight and obese young people consult their general practice more often but not for different health problems than normal-weight youth. The reason for presentation was seldom a weight issue. The physical component score of HRQoL of the obese individuals was lower compared with normal-weight youth. In addition, results show that obese and underweight young people were less likely to be satisfied with their eating behaviour than their normal-weight peers. The exercise levels did not differ between the groups.

    Strengths and limitations

    We are not aware of previous reports that have investigated health profiles and opportunities for treatment of overweight and obese youth in general practice.

    We used self-reported measures of height and weight to determine the weight status of youth. This might have led to a misclassification; presumably an underestimation of the percentages determined as overweight and obese.20 This could explain the lower prevalence of overweight and obesity found in our study compared with the prevalence in the ANHS.2 However, any misclassifications of the weight status are not likely to affect the direction of the associations found.

    In addition, height and weight data were not available for all participants of the PARTY project. Height and weight were not included in the questionnaire at the start of the study and were added after the inclusion of the first 219 participants. Since the reason for the missing values is procedural, we assume that the missing data would not bias our results.

    Comparison with existing literature

    The higher frequency of visits in the overweight and obese groups compared with the normal-weight group found in our study is consistent with the finding from Wijga et al that obese adolescents reported greater healthcare needs.10 The average number of consultations per year of all young people in this study is relatively high (6.0, SD 6.6) compared with the average in the population of young people in Australia (3.2 consultations per year).21 The high consultation rate in our study might be explained by the fact that all participants had to visit the practice at least once to be included in the study and, in addition the chance to be invited for participation in the study increased for youth with a higher frequency of visits to general practice.

    In contrast to our findings, previous literature reports that excess weight at a young age is already associated with specific health problems like musculoskeletal complaints22 and asthma.23 However, Wake et al24 also found that overweight and obese adolescents do not report specific health complaints that might prompt them to see their doctor. This may also explain our finding that overweight and obese youth do not tend to consult their GP for weight issues. Another explanation for why we did not find an association between weight status and reason for presentation might be lack of study power. The reason for presentation was only recorded for the current consultation and not for all consultations in the previous 12 months. Therefore, the number of reasons for presentation might be too small to detect differences between the different weight categories. If the reason for presentation was reported at more consultations, an association might have been found.

    In contrast to our expectations and previous literature11 no association was found between emotional distress or psychosocial HRQoL and weight status. However, similar results were seen in Dutch adolescents where no association was found between mental health and weight status, while obesity was related to poorer self-perceived physical health and more health visits.25 A recent large cohort study also confirms that with increasing weight participants report poorer physical QoL.26 It could be argued that the increased number of consultations is related to obesity because of this decreased self-perceived physical health. However, when we adjusted for HRQoL the number of consultations was still significantly higher for obese youth compared with those with normal weight (data not shown).

    The WHO recommends at least 60 min of moderate-to-vigorous activity every day for children (until 18 years) and 150 min of moderate-to-vigorous activity a week for adults.27 In our study, only 35% of all participants reported at least 20 min of moderate physical activity every day. Therefore, the majority of young people did not meet the WHO guideline, which is in line with prior data from a national study among young people in Australia.21

    Since a previous study showed that low level of physical activity was associated with both health complaints and lower HRQoL,28 one might have expected obese youth to report lower amounts of physical activity. However, in this study, there were no differences found in amount of exercise between youth of different weight categories. One explanation might be that there were no differences since the activity level of all youth in our cohort was low. Another explanation might be that the dichotomised outcome measure was not sensitive enough to detect differences.

    Implications for practice and research

    Primary care is considered as an appropriate setting for embedding weight management programmes. Since overweight and obese youth consult their general practice more often, this highlights the need for effective weight management. However, given that overweight and obese young people do not present with weight issues, it becomes important for GPs to find ways to initiate the discussion with youth on healthy lifestyle and preventing weight gain in future. There is some evidence that screening and intervening on health risk behaviours in young people improves health outcomes.29 The effects of such a proactive approach in the management of excessive weight are, however, still unknown. Notwithstanding, body shape, eating and exercise together with acne are the most common health topics adolescents report wanting to discuss with their primary healthcare provider.30 Besides, literature shows that patients who were told by their physician that they were overweight had more realistic perceptions of their own weight, had the desire to lose weight and had recent attempts to lose weight.31 The above finding underlines the need for clinicians to initiate the discussion with young people on healthy lifestyle and weight. A discussion alone is not an effective intervention and of course this is no guarantee for success, but a non-judgemental conversation is a start. More tailored interventions for effective weight management are needed in primary care. Future studies should investigate how primary care can effectively help young people improve their eating and exercise behaviour. But it may take decades before we know how effective prevention strategies really are and the question is if we are willing to wait that long before we take action.

    Acknowledgments

    The authors thank the young people, general practitioners, practice nurses and practice support staff of Victoria, without their participation this research would not have been possible.

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    Footnotes

    • Contributors WDP analysed the data and drafted the manuscript. MP analysed the data and helped to draft the manuscript. PC participated in the design of the study and helped do draft the manuscript. SK participated in the design of the study and helped do draft the manuscript MvM revised the manuscript critically for important intellectual content LAS participated in its design, coordinated the study and has been involved in drafting the manuscript. All authors read and approved the final manuscript.

    • Funding Australian Health Ministers' Advisory Council Australian Primary Health Care Research Institute. National Health and Medical Research Council.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Ethics approval Ethics approval for the party study and all analyses were obtained from the University of Melbourne Human Research Ethics Committee.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The design paper shows which data are available. LAS is coordinator of the project and data belong at the University of Melbourne.

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