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Original Research |
1 All authors: Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229.
Received October 5, 2004;
accepted after revision February 7, 2005.
Address correspondence to J. L. Strife.
Abstract
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MATERIALS AND METHODS. Over 1 million radiology reports dictated at a large pediatric hospital from 1994 to 2002 were analyzed for several keywords relating to obesity. The number of cases in which the keywords appeared was recorded for each year, and a percentage was calculated. Reports done in 1999 and 2000 were further analyzed to determine where the keywords were positioned within the report.
RESULTS. The number of reports containing a keyword ranged from 131 to 456 per year. During each year, documentation of obesity occurred in less than 0.4% of all reports. During that same time period, the national prevalence of pediatric obesity ranged from 6-16%. Detailed examination of the 1999 and 2000 reports showed that even in the reports that mentioned obesity, it was usually not listed in the diagnostic impression.
CONCLUSION. Despite the increase in public awareness of obesity and increasing recognition of obesity-related disease, this study did not find a similar awareness among radiologists at a large pediatric radiology department. The reason for this discrepancy is speculative and likely multifactorial. Regardless, radiologists may be missing an opportunity to play a role in disease prevention and early recognition by documenting findings of obesity and thereby bringing them to the attention of referring physicians.
Keywords: obesity • pediatric radiology • radiology practice
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Significant effort is being made by the medical community to develop a treatment plan to combat this epidemic in children. However, effective treatment is and will continue to be dependent on the recognition of obese patients by their care providers. Radiologists are trained to identify potential health risks on imaging studies and report these findings to referring physicians.
The purpose of this study was to review the current practice of radiologists at a large pediatric institution with respect to dictating the presence of obesity in the imaging report. The results were then compared with the national prevalence of pediatric obesity.
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Reports on imaging studies done on children under 1 year old were eliminated from review because of the large number of premature infants and the exceedingly low incidence of obesity in that age group. All other reports were subjected to a word search for the following keywords: obesity, obese, excessive soft tissue(s), heavy, overweight, abnormal body habitus, and excessive fat. The number of cases in which the keywords appeared in the report was recorded for each year. The number of reports containing a keyword was then divided by the total number of reports dictated during that same year, then multiplied by 100 so that a percentage could be calculated.
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When the 1999 and 2000 reports were further examined, it was found that a significant number of the dictated reports contained false-positives and relatively few included obesity as part of the diagnostic impression (Table 1). False-positives were included in the overall data and, thus, there was actually underrepresentation of the percentage of time that keywords were used to describe an obese or overweight child. Table 2 describes the distribution of modality-specific volume and the percentage of cases where keywords were used. Radiography contributes to 73% of the volume of cases, and it also was the most common imaging technique where keywords were used to recognize obesity.
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Although childhood obesity frequently affects self-esteem and quality of life, it can also result in dysfunction of multiple organ systems even in the pediatric population [5]. Approximately 60% of overweight children and adolescents have at least one additional risk factor for cardiovascular disease, such as elevated blood pressure, hyperlipidemia, or hyperinsulinemia [6]. More than 25% have two or more of these risk factors. Liver steatosis, obstructive sleep apnea, and early pubertal maturity are all associated with obesity in children [7, 8]. Orthopedic problems may result as well, including slipped capital femoral epiphysis and tibia vara [9, 10].
The childhood years are a critical time for obesity management. In their review of the literature, Serdula et al. [11] found that about one third of obese preschool children were obese as adults, and about half of obese school-age children were obese as adults. Overall, the risk for adult obesity was at least twice as high for obese children as for non-obese children. Dietz [12] also stated that approximately 50% of obese adolescents with a body mass index at or above the 95th percentile become obese adults.
In addition, treating obesity during childhood may be easier than during adulthood. Unhealthy eating and activity patterns have not been in place as long, family support is usually more consistent, and treatment of obese children can take advantage of increases in lean body mass as the child grows. Early treatment can also prevent the development of excess adipose cells instead of shrinking them [13].
Pediatric obesity that persists into adulthood brings myriad complications. Glucose intolerance, type 2 diabetes, hypertension, dyslipidemia, and coronary heart disease are all closely associated with obesity [14]. As in children, liver disease, gallbladder disease, and obstructive sleep apnea are all comorbid conditions [15]. Obesity in adults has also been associated with menstrual irregularity and infertility, osteoarthritis, gout, venous insufficiency, and certain forms of cancer [16-18]. Weight loss can and often does eliminate many of these conditions, and a reduced mortality among weight-reduced individuals has also been recently reported [19].
It is clear that pediatric obesity is epidemic and that prevention and treatment of this disease are of paramount importance. However, it is also clear that at-risk children are not consistently being identified. One review of pediatric charts showed that providers documented obesity in only 53% of obese patient visits (ranging from 31% in preschoolers to 76% of adolescents) [20]. In the same study, obesity was only documented at the physical examination 39% of the time. Another report of surveyed doctors indicated that only 50-61% routinely initiated treatment in overweight children with no obesity-associated medical conditions [21]. Many obese children who are at high risk for serious comorbid conditions now and during future adulthood are being missed.
Radiologists are relied on to examine imaging studies for findings that may reflect disease or potential disease and to report those to the referring physician. Much of what is reported is subjective, with the impressions based on the radiologist's experience and training. It is expected that subjective findings such as osteoporosis will be looked for, documented, and reported to the referring physician because of the relation to potential health risk. However, our study found that radiologists reported obesity in fewer than 0.4% of cases, while the incidence of obesity in the pediatric population during that time period approached 16%. Even in cases where obesity was documented, it was frequently not included in the diagnostic impression.
The reason for this discrepancy between the incidence of obesity in pediatric patients and the notation in the radiology reports is speculative and likely multifactorial. It could be argued that no standard measurements for imaging obesity currently exist. However, radiologists routinely document other observations that are not based on an actual measurement, such as osteopenia, peribronchial cuffing, and heart size. The negative social connotation of obesity may deter some from documenting it in a report. Others may avoid it because of fear of medical liability, although we would argue that there is a danger of medical liability in not reporting it. Some radiologists may avoid listing obesity as a diagnosis for fear of affecting the patient's insurance status, although clinicians often list tobacco use and other high-risk behaviors as diagnoses.
Finally, many radiologists self-report that their primary reason for not documenting obesity is that it is fairly obvious on physical examination (Strife JL, unpublished data). However, just because something is obvious on examination does not mean that it is being addressed. The patient who presents with gallstones and who is obese with CT findings of fatty liver needs to have the obesity reported because of its relation to the disease process. The obese adolescent patient who presents to the emergency department with knee or hip pain should not be told that the radiographs are "normal," especially if there are inches of soft-tissue fat. There is a well-known association between slipped capital femoral epiphysis and the immature skeleton and obesity. It is the radiologist's responsibility to try to prevent further disease by reminding the clinical care providers of the morbidity and potential risk associated with obesity in that patient.
The limitations of the study include the fact that not all reports were actually interpreted. The computer searched for keywords indicating obesity and other terms may have been used in addition to those specified. In this respect, it would lead to an underestimation of obesity indicating a disease. On the other hand, false-positives were included in the overall data and, thus, there is actual underrepresentation of the percentage of time that certain keywords were used to describe an obese child. In addition, the distribution of radiology modality-specific work volume is relevant. In certain studies such as neuroimaging and nuclear medicine imaging, appreciation for obesity may be limited. In this respect, these volumes of cases contribute to an overestimation of obesity. Regardless of the limitations, a big discrepancy exists in the notation of obesity and the well-known increase in prevalence of the disease. No substantial change has occurred in the notation of obesity in radiology reporting over the past 8 years despite the increase in prevalence and recognition by other subspecialties.
Former Surgeon General C. Everett Koop stated that obesity is the number one medical issue the nation faces and warns that it is difficult to justify complacency in the face of this growing epidemic now affecting more than 58 million Americans [19]. The American Academy of Pediatrics [3] has stated that it is incumbent on the pediatric community to take a leadership role in prevention and early recognition of pediatric obesity. Radiologists can and should be involved in early recognition by documenting findings of obesity and thereby bringing them to the attention of the referring physician.
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