Electronic phenotypes to distinguish clinician attention to high body mass index, hypertension, lipid disorders, fatty liver and diabetes in pediatric primary care: Diagnostic accuracy of electronic phenotypes compared to masked comprehensive chart review

BACKGROUND/OBJECTIVES

Electronic phenotyping is a method of using electronic-health-record (EHR) data to automate identifying a patient/population with a characteristic of interest. This study determines validity of using EHR data of children with overweight/obesity to electronically phenotype evidence of clinician 'attention' to high body mass index (BMI) and each of four distinct comorbidities.

METHODS

We built five electronic phenotypes classifying 2-18-year-old children with overweight/obesity (n = 17,397) by electronic/health-record evidence of distinct attention to high body mass index, hypertension, lipid disorders, fatty liver, and prediabetes/diabetes. We reviewed, selected and cross-checked random charts to define items clinicians select in EHRs to build problem lists, and to order medications, laboratory tests and referrals to electronically classify attention to overweight/obesity and each comorbidity. Operating characteristics of each clinician-attention phenotype were determined by comparing comprehensive chart review by reviewers masked to electronic classification who adjudicated evidence of clinician attention to high BMI and each comorbidity.

RESULTS

In a random sample of 817 visit-records reviewed/coded, specificity of each electronic phenotype is 99%-100% (with PPVs ranging from 96.8% for prediabetes/diabetes to 100% for dyslipidemia and hypertension). Sensitivities of the attention classifications range from 69% for hypertension (NPV, 98.9%) to 84.7% for high-BMI attention (NPV, 92.3%).

CONCLUSIONS

Electronic phenotypes for clinician attention to overweight/obesity and distinct comorbidities are highly specific, with moderate (BMI) to modest (each comorbidity) sensitivity. The high specificity supports using phenotypes to identify children with prior high-BMI/comorbidity attention.

A Longitudinal Effectiveness Study of a Child Obesity Electronic Health Record Tool

BACKGROUND

Primary-care providers, clinic staff, and nurses play an important role in reducing child obesity; yet time restraints and clinical demands compete with effective pediatric weight management and prevention.

METHODS

To investigate the potential impact of an electronic health record (EHR) enabled tool to assist primary care teams in addressing child obesity, we conducted a controlled effectiveness study of FitTastic compared with usual care on the BMI pattern of 291 children (2 to 17 years) up to 4 years later.

RESULTS

Per χ2 analysis, a greater proportion of children with baseline overweight/obesity in the EHR tool group than the control group had a favorable BMI pattern (32% vs 13%, P = .03). In logistic regression, FitTastic children were more likely than control children to have a favorable BMI pattern at follow-up (OR 3.8, 95% CI 1.1 to 13.2), adjusted for age, gender, race, and parental education.

CONCLUSION

Study findings suggest that EHR-enabled tools to assist primary care teams in managing child obesity may be useful for helping to address the weight in children with overweight/obesity, especially in younger children (2 to 5 years). Digital and EHR-enabled technologies may prove useful for partnering health care teams and families in the important tasks of setting positive, family-centered healthy lifestyle behavioral goals and managing child overweight and obesity.

Clinical Decision Support for the Diagnosis and Management of Adult and Pediatric Hypertension

PURPOSE OF REVIEW

To review literature from 2016 to 2019 on clinical decision support (CDS) for diagnosis and management of hypertension in children and adults.

RECENT FINDINGS

Ten studies described hypertension CDS systems. Novel advances included the integration of patient-collected blood pressure data, automated information retrieval and management support, and use of CDS in low-resource/developing-world settings and in pediatrics. Findings suggest that CDS increases hypertension detection/control, yet many children and adults with hypertension remain undetected or undercontrolled. CDS challenges included poor usability (from lack of health record integration, excessive data entry requests, and wireless connectivity challenges) and lack of clinician trust in blood pressure measures. Hypertension CDS has improved but not closed gaps in the detection and control of hypertension in children and adults. The studies reviewed indicate that the usability of CDS and the system where CDS is deployed (e.g., commitment to high-quality blood pressure measurement/infrastructure) may impact CDS's ability to increase hypertension detection and control.

Pediatrician Communication About High Blood Pressure in Children With Overweight/Obesity During Well-Child Visits

OBJECTIVE

Despite recognition that hypertension is associated with childhood obesity, data suggest that high blood pressure (BP) is infrequently diagnosed in children. This study sought to examine provider communication with overweight school-age children regarding BP measurements that were high at well-child visits.

METHODS

Cross-sectional mixed-methods analysis of audio-recorded communication from well-child visits with overweight 6-12-year-olds. Data from the subset of children with elevated BPs were used for this study. Three BP measures obtained at the audio-recorded visit were averaged, paired with historical BPs stored in the health record, and compared to contemporary/Fourth-Report thresholds to determine if children had elevated/hypertensive BPs only at the audio-recorded visit or met hypertension-diagnostic criteria (hypertension-level BP ≥3 separate visits). Two reviewers used visit transcripts to categorize communication about BP as "absent," "unclear," or "direct." Provider use of a billing diagnosis for elevated BP/hypertension in visits with direct-BP-communication was explored.

RESULTS

In 36 of 126 (29%) visit-audio-recordings, children had elevated/hypertensive BPs. Thirty-three of the 36 eligible (92%) had intelligible audio-recordings. Of these, 9 (25%) were overweight and 24 (75%) had obesity. Seventeen (52%) had elevated BPs, and 16 (48%) hypertensive BPs. Ten (30%) met criteria for hypertension diagnosis. BP communication was absent in 20 visits (61%), unclear in 8 (24%), and direct in 5 visits (15%). Billing diagnoses for elevated BP/hypertension were entered at 4 of 5 (80%) visits with direct-BP communication.

CONCLUSIONS

Most overweight children with elevated BPs did not receive communication that BP is high at well-child visits. Relevant billing diagnoses may indicate direct-BP communication.

Algorithm to detect pediatric provider attention to high BMI and associated medical risk

We developed and validated an algorithm that uses combinations of extractable electronic-health-record (EHR) indicators (diagnosis codes, orders for laboratories, medications, and referrals) that denote widely-recommended clinician practice behaviors: attention to overweight/obesity/body mass index alone (BMI Alone), with attention to hypertension/other comorbidities (BMI/Medical Risk), or neither (No Attention). Data inputs used for each EHR indicator were refined through iterative chart review to identify and resolve modifiable coding errors. Validation was performed through manual review of randomly selected visit encounters (n = 308) coded by the refined algorithm. Of 104 encounters coded as No Attention, 89.4% lacked any evidence (specificity) of attention to BMI/Medical Risk. Corresponding evidence (sensitivity) of attention to BMI Alone was identified in 96.0% (of 101 encounters coded as BMI Alone) and BMI/Medical Risk in 96.1% (of 103 encounters coded as BMI/Medical Risk). Our EHR data algorithm can validly determine provider attention to BMI alone, with Medical Risk, or neither.

Prevalence of hyperfiltration among US youth/young adults with overweight and obesity: A population-based association study

OBJECTIVE

Determine prevalence of hyperfiltration (high estimated glomerular filtration rate "eGFR" >95th percentile for age/sex) among youth and association with BMI classification.

METHODS

With the use of 1999 to 2016 National Health and Nutrition Examination Survey data from 12- to 29-year-olds, data for serum creatinine and thresholds for high eGFR were normed using a metabolically healthy subsample (no albuminuria, healthy weights, normal blood pressures, blood glucoses, lipids, and liver enzymes). Logistic regression examined the association of BMI classification (healthy weight, overweight, and obesity classes 1-3) with hyperfiltration (eGFR > 95th percentile for age/sex), adjusted for diabetes and other covariates.

RESULTS

Of 12- to 29-year-olds (N = 18 698), 27.4% (n = 5493) met criteria for entry into the "healthy subsample" and contributed data to derive normative values for serum creatinine/hyperfiltration thresholds. In the full sample, hyperfiltration prevalence in 12- to 29-year-olds classified as healthy-weight, overweight, and obesity classes 1 to 3 was 4.9%, 4.7%, 6.5%, 8.7%, and 11.8%, respectively (P < .001). In multivariable analysis, obesity classes 2 and 3 were associated with greater likelihood of hyperfiltration (adjusted ORs for class 2: 1.5, 95% CI, 1.1-2.1; and for class 3, 2.1, 95% CI, 1.5-2.9). Diabetes also was associated with hyperfiltration (AOR, 4.0; 95% CI, 2.2-7.4).

CONCLUSION

Obesity classes 2 to 3 are associated with hyperfiltration in youth. Age/sex-specific norms for creatinine and hyperfiltration thresholds may aid recognition of kidney dysfunction early.

Association of Clinician Behaviors and Weight Change in School-Aged Children

INTRODUCTION

This study uses clinical practice data to determine whether recommended weight management clinician behaviors are associated with weight status improvement in children aged 6-12 years who are overweight or obese.

METHODS

Electronic health record data (2009-2014) from 52 clinics were used. Weight status was examined from 1 visit to the next as dichotomous improvement (versus worsening or no change) and change in percentage overweight (over sex/age-specific BMI95). The primary predictor was a clinician behavior variable denoting attention to high BMI alone or with assessment of medical risk/comorbidities and was defined using combinations of diagnostic codes and electronic health record orders. Covariates included time between visits and medications associated with weight gain or loss. Adjusted multilevel regression models examined the association of the clinician behavior variable with weight status improvement. Analyses were conducted from 2015 to 2018.

RESULTS

Children (n=7,205) had a mean age of 8.9 years; 45.5% were overweight, 54.5% obese, and 81.1% publicly insured. For 62% of overweight children, and 38%, 21%, and 11% of those in obesity classes 1-3, respectively, no attention to high BMI/medical risk assessment at any visit was identified. Children with evidence of clinician attention to high BMI alone and who underwent a medical risk assessment had significantly greater AOR of improvement in percentage of BMI95 and percentage of BMI95 change: BMI alone, AOR=1.2 (p<0.001) and β= -0.3 (p>0.05); BMI/medical risk, AOR=1.2 and β= -0.5 (both p<0.001). Other factors associated with weight status improvement included prescription medications (1 or more prescriptions associated with either weight loss or none associated with weight gain) and fewer months between visits.

CONCLUSIONS

This is the first study to use electronic health record data to demonstrate that widely recommended clinician behaviors are associated with weight status improvement in children aged 6-12 years who are overweight or obese.

Childhood and Adolescent Adversity and Cardiometabolic Outcomes: A Scientific Statement From the American Heart Association

Adverse experiences in childhood and adolescence, defined as subjectively perceived threats to the safety or security of the child's bodily integrity, family, or social structures, are known to be associated with cardiometabolic outcomes over the life course into adulthood. This American Heart Association scientific statement reviews the scientific literature on the influence of childhood adversity on cardiometabolic outcomes that constitute the greatest public health burden in the United States, including obesity, hypertension, type 2 diabetes mellitus, and cardiovascular disease. This statement also conceptually outlines pathways linking adversity to cardiometabolic health, identifies evidence gaps, and provides suggestions for future research to inform practice and policy. We note that, despite a lack of objective agreement on what subjectively qualifies as exposure to childhood adversity and a dearth of prospective studies, substantial evidence documents an association between childhood adversity and cardiometabolic outcomes across the life course. Future studies that focus on mechanisms, resiliency, and vulnerability factors would further strengthen the evidence and provide much-needed information on targets for effective interventions. Given that childhood adversities affect cardiometabolic health and multiple health domains across the life course, interventions that ameliorate these initial upstream exposures may be more appropriate than interventions remediating downstream cardiovascular disease risk factor effects later in life.

Discrepancies in Communication Versus Documentation of Weight-Management Benchmarks: Analysis of Recorded Visits With Latino Children and Associated Health-Record Documentation

To examine gaps in communication versus documentation of weight-management clinical practices, communication was recorded during primary care visits with 6- to 12-year-old overweight/obese Latino children. Communication/documentation content was coded by 3 reviewers using communication transcripts and health-record documentation. Discrepancies in communication/documentation content codes were resolved through consensus. Bivariate/multivariable analyses examined factors associated with discrepancies in benchmark communication/documentation. Benchmarks were neither communicated nor documented in up to 42% of visits, and communicated but not documented or documented but not communicated in up to 20% of visits. Lowest benchmark performance rates were for laboratory studies (35%) and nutrition/weight-management referrals (42%). In multivariable analysis, overweight (vs obesity) was associated with 1.6 more discrepancies in communication versus documentation (P = .03). Many weight-management benchmarks are not met, not documented, or performed without being communicated. Enhanced communication with families and documentation in health records may promote lifestyle changes in overweight children and higher quality care for overweight children in primary care.

Pediatricians' communication about weight with overweight Latino children and their parents

OBJECTIVE

To examine pediatrician weight-management communication with overweight Latino children and their parents and whether communication differs by pediatrician-patient language congruency.

METHODS

Mixed-methods analysis of video-recorded primary care visits with overweight 6- to 12-year-old children. Three independent reviewers used video/transcript data to identify American Academy of Pediatrics-recommended communication content and establish communication themes/subthemes. Language incongruence (LI) was defined as pediatrician limited Spanish proficiency combined with parent limited English proficiency (LEP). Bivariate analyses examined associations of LI with communication content/themes.

RESULTS

The mean child age (N = 26) was 9.5 years old; 81% were obese. Sixty-two percent of parents had LEP. Twenty-seven percent of pediatricians were Spanish-proficient. An interpreter was used in 25% of LI visits. Major themes for how pediatricians communicate overweight included BMI, weight, obese, chubby, and no communication (which only occurred in LI visits). The pediatrician communicated child overweight in 81% of visits, a weight-management plan in 50%, a culturally relevant dietary recommendation in 42%, a recommendation for a follow-up visit in 65%, and nutrition referral in 50%. Growth charts were used in 62% of visits but significantly less often in LI (13%) versus language-congruent (83%) visits (P < .001).

CONCLUSIONS

Many overweight Latino children do not receive direct communication of overweight, culturally sensitive dietary advice, or follow-up visits. LI is associated with a lower likelihood of growth chart use. During primary care visits with overweight Latino children, special attention should be paid to directly communicating child overweight, formulating culturally sensitive weight-management plans, and follow-up. With LEP families, vigilance is needed in providing a trained interpreter and using growth charts.

Branched chain amino acids are novel biomarkers for discrimination of metabolic wellness

OBJECTIVE

To identify novel biomarkers through metabolomic profiles that distinguish metabolically well (MW) from metabolically unwell (MUW) individuals, independent of body mass index (BMI).

MATERIALS/METHODS

This study was conducted as part of the Measurement to Understand the Reclassification of Disease of Cabarrus/Kannapolis (MURDOCK) project. Individuals from 3 cohorts were classified as lean (BMI<25kg/m²), overweight (BMI≥25kg/m², BMI<30kg/m²) or obese (BMI≥30kg/m²). Cardiometabolic abnormalities were defined as: (1) impaired fasting glucose (≥100mg/dL and ≤126mg/dL); (2) hypertension; (3) triglycerides ≥150mg/dL; (4) HDL-C <40mg/dL in men, <50mg/dL in women; and (5) insulin resistance (calculated Homeostatic Model Assessment (HOMA-IR) index of >5.13). MW individuals were defined as having <2 cardiometabolic abnormalities and MUW individuals had≥two cardiometabolic abnormalities. Targeted profiling of 55 metabolites used mass-spectroscopy-based methods. Principal components analysis (PCA) was used to reduce the large number of correlated metabolites into clusters of fewer uncorrelated factors.

RESULTS

Of 1872 individuals, 410 were lean, 610 were overweight, and 852 were obese. Of lean individuals, 67% were categorized as MUW, whereas 80% of overweight and 87% of obese individuals were MUW. PCA-derived factors with levels that differed the most between MW and MUW groups were factors 4 (branched chain amino acids [BCAA]) [p<.0001], 8 (various metabolites) [p<.0001], 9 (C4/Ci4, C3, C5 acylcarnitines) [p<.0001] and 10 (amino acids) [p<.0002]. Further, Factor 4, distinguishes MW from MUW individuals independent of BMI.

CONCLUSION

BCAA and related metabolites are promising biomarkers that may aid in understanding cardiometabolic health independent of BMI category.

Prevalence of vitamin D deficiency among overweight and obese US children

OBJECTIVE

Adequate vitamin D is essential for skeletal health in developing children. Although excess body weight is associated with risk of vitamin D deficiency, the national prevalence of and risk factors associated with vitamin D deficiency in overweight and obese children are unknown.

METHODS

The prevalence of vitamin D deficiency (defined as 25-hydroxyvitamin-D <20 ng/mL) was determined in a sample of 6- to 18-year-old children who were enrolled in a cross-sectional study (the 2003-2006 National Health and Nutrition Examination Survey) in which body weight and height were measured directly. Children were classified as healthy-weight, overweight, obese, or severely obese by using recommended age- and gender-specific BMI-percentile cut points. Associations between BMI-percentile classification and vitamin D deficiency were examined after adjustment for relevant confounders. Sample weights were used to generate nationally representative estimates.

RESULTS

The prevalence of vitamin D deficiency in healthy-weight, overweight, obese, and severely obese children was 21% (20%-22%), 29% (27%-31%), 34% (32%-36%), and 49% (45%-53%), respectively. The prevalence of vitamin D deficiency in severely obese white, Latino, and African-American children was 27% (3%-51%), 52% (36%-68%), and 87% (81%-93%), respectively. Compared with healthy-weight children, overweight, obese, and severely obese children had significantly greater adjusted odds of vitamin D deficiency. Modifiable factors associated with vitamin D deficiency in overweight/obese children were identified.

CONCLUSIONS

Vitamin D deficiency is highly prevalent in overweight and obese children. The particularly high prevalence in severely obese and minority children suggests that targeted screening and treatment guidance is needed.

Low HDL predicts differential blood pressure effects from two weight-loss approaches: a secondary analysis of blood pressure from a randomized, clinical weight-loss trial

Examining predictors of blood-pressure (BP) response to weight-loss diets might provide insight into mechanisms and help guide clinical care. We examined whether certain baseline patient characteristics (e.g. diet, medical history and laboratory tests) predicted BP response to two weight-loss diet approaches that differ in macronutrient content. One hundred and forty-six overweight adult outpatients were randomized to either a low-carbohydrate diet (N = 72) or orlistat plus a low-fat diet (N = 74) for 48 weeks. Predictors of BP reduction were evaluated using a structured approach and random effects regression models. Participants were 56% African-American, 72% male and 53 (±10) years-old. Of the variables considered, low baseline high-density lipoprotein (HDL) predicted greater reduction in BP in those patients who received the low-carbohydrate diet (p = 0.03 for systolic BP; p = 0.03 for diastolic BP and p = 0.02 for mean arterial pressure). A low HDL level may identify patients who will have greater BP improvement on a low-carbohydrate diet.

Branched-chain amino acid levels are associated with improvement in insulin resistance with weight loss

AIMS/HYPOTHESIS

Insulin resistance (IR) improves with weight loss, but this response is heterogeneous. We hypothesised that metabolomic profiling would identify biomarkers predicting changes in IR with weight loss.

METHODS

Targeted mass spectrometry-based profiling of 60 metabolites, plus biochemical assays of NEFA, β-hydroxybutyrate, ketones, insulin and glucose were performed in baseline and 6 month plasma samples from 500 participants who had lost ≥4 kg during Phase I of the Weight Loss Maintenance (WLM) trial. Homeostatic model assessment of insulin resistance (HOMA-IR) and change in HOMA-IR with weight loss (∆HOMA-IR) were calculated. Principal components analysis (PCA) and mixed models adjusted for race, sex, baseline weight, and amount of weight loss were used; findings were validated in an independent cohort of patients (n = 22).

RESULTS

Mean weight loss was 8.67 ± 4.28 kg; mean ∆HOMA-IR was -0.80 ± 1.73, range -28.9 to 4.82). Baseline PCA-derived factor 3 (branched chain amino acids [BCAAs] and associated catabolites) correlated with baseline HOMA-IR (r = 0.50, p < 0.0001) and independently associated with ∆HOMA-IR (p < 0.0001). ∆HOMA-IR increased in a linear fashion with increasing baseline factor 3 quartiles. Amount of weight loss was only modestly correlated with ∆HOMA-IR (r = 0.24). These findings were validated in the independent cohort, with a factor composed of BCAAs and related metabolites predicting ∆HOMA-IR (p = 0.007).

CONCLUSIONS/INTERPRETATION

A cluster of metabolites comprising BCAAs and related analytes predicts improvement in HOMA-IR independent of the amount of weight lost. These results may help identify individuals most likely to benefit from moderate weight loss and elucidate novel mechanisms of IR in obesity.

Adipose tissue mass and location affect circulating adiponectin levels

AIMS/HYPOTHESIS

Plasma levels of adiponectin are inversely associated with body mass. We hypothesised that adipose tissue distribution and body composition influences adiponectin levels.

METHODS

We assessed plasma adiponectin concentrations and dual-energy X-ray absorptiometry (DEXA) measurements of body composition among 2,820 participants from the Dallas Heart Study.

RESULTS

Among both women and men, adiponectin levels were higher in whites than in either Hispanics or African-Americans (for women: median 9.99 μg/ml [25th,75th percentile 7.11, 13.77] vs 7.56 μg/ml [5.05, 9.98] vs 6.39 μg/ml [4.37, 9.41], respectively, p < 0.0001; for men: 6.43 μg/ml [4.66, 9.19] vs 5.55 μg/ml [3.64, 7.50] vs 5.03 μg/ml [3.39, 7.28], p < 0.0001). In univariate analysis, each individual component of body mass was inversely associated with adiponectin. After multivariate analysis, adiponectin levels were found to be positively associated with lower extremity fat, whether expressed in absolute mass (for women: β = 0.055, p < 0.0001; for men: β = 0.061, p < 0.0001), or as a relative proportion (for women: β = 0.035, p < 0.0001; for men: β = 0.034, p < 0.0001). This association was consistent across ethnicities. Conversely, adiponectin was negatively correlated with truncal fat, both in absolute (for women: β = -0.039, p < 0.0001; for men: β = -0.044, p < 0.0001) and relative terms (for women: β = -0.027, p < 0.0001; for men β = -0.033, p < 0.0001). At the extreme of body mass, higher degrees of lower extremity and truncal adiposity were associated with higher levels of adiponectin.

CONCLUSIONS/INTERPRETATION

These data suggest that the location of adipose depots differentially influences circulating adiponectin concentrations-a finding observed across ethnicity and sex. Gross measures of body mass alone do not adequately account for adiponectin levels. This supports a role of adiponectin as a mediator of the positive effects of lower extremity adiposity on improvements in insulin sensitivity.