Original Article

Underdiagnosis and Lower Rates of Office Visits for Overweight/Obese Pediatric Patients in Rural Compared with Urban Areas

Authors: Christine SanGiovanni, MD, James McElligott, MD, MSCR, Kristen Morella, MPH, William Basco, MD, MS


Objectives: This study compared the number of children enrolled in Medicaid in rural and urban areas of South Carolina with an overweight/obesity diagnosis and the mean rates of office visits with overweight/obesity diagnosed.

Methods: Medicaid claims data from 2012 for children in three South Carolina counties, categorized as urban, rural high resource, and rural low resource, were used to identify those who had been diagnosed as being overweight/obese during any encounter. Logistic and Poisson regressions were performed to predict whether overweight/obese children in each county would receive an overweight/obesity visit diagnosis and to calculate the mean rate of total office visits with an overweight/obesity diagnosis in each county.

Results: A total of 1233 children enrolled in Medicaid were diagnosed as being overweight/obese at any encounter in the designated counties. Well visits with overweight/obesity diagnosed varied significantly, with 42.6%, 28%, and 11% in urban, rural high-resource counties, and rural low-resource counties, respectively (P < 0.01). In the logistic regression rural high-resource children (adjusted odds ratio 0.58, 95% confidence interval 0.38–0.88) and rural low-resource children (adjusted odds ratio 0.16, 95% confidence interval 0.09–0.28) were less likely than urban children to be diagnosed as being overweight/obese at a well visit. All of the children had a low number of total office visits with overweight/obesity diagnosed. When comparing the counties, urban children (1.22 visits per year) had more visits than rural low-resource children (0.75 visits per year, P < 0.01) and rural high-resource children (0.89 visits per year, P < 0.01).

Conclusions: Overweight/obesity is underdiagnosed in rural children enrolled in Medicaid in South Carolina, which affects the number of children who receive help to manage their weight. Interventions to overcome barriers of diagnosis and management are necessary to address childhood obesity properly.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Ogden CL, Carroll MD, Lawman HG, et al. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA 2016;315:2292-2299.
2. Barlow SE, Expert Committee. Expert committee recommendations regarding the prevention, assesment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120( Suppl 4 ):S164-S192.
3. Spear BA, Barlow SE, Ervin C, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics 2007;120( Suppl 4 ):S254-S288.
4. Spivack JG, Swietlik M, Alessandrini E, et al. Primary care providers' knowledge, practices, and perceived barriers to the treatment and prevention of childhood obesity. Obesity (Silver Spring) 2010;18:1341-1347.
5. Story MT, Neumark-Stzainer DR, Sherwood NE, et al. Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics 2002;110( 1 Pt 2 ):210-214.
6. Liang L, Meyerhoefer C, Wang J. Obesity counseling by pediatric health professionals: an assessment using nationally representative data. Pediatrics 2012;130:67-77.
7. Findholt NE, Davis MM, Michael YL. Perceived barriers, resources, and training needs of rural primary care providers relevant to the management of childhood obesity. J Rural Health 2013;29( Suppl 1 ):s17-s24.
8. Holt N, Schetzina KE, Dalton WT, 3rd et al. Primary care practice addressing child overweight and obesity: a survey of primary care physicians at four clinics in southern Appalachia. South Med J 2011;104:14-19.
9. Johnson JA, 3rd Johnson AM. Urban-rural differences in childhood and adolescent obesity in the United States: a systematic review and meta-analysis. Child Obes 2015;11:233-241.
10. Lutfiyya MN, Lipsky MS, Wisdom-Behounek J, et al. Is rural residency a risk factor for overweight and obesity for U.S. children? Obesity (Silver Spring) 2007;15:2348-2356.
11. Mustillo S, Worthman C, Erkanli A, et al. Obesity and psychiatric disorder: developmental trajectories. Pediatrics 2003;111(4 Pt 1):851-859.
12. Vieweg VR, Johnston CH, Lanier JO, et al. Correlation between high risk obesity groups and low socioeconomic status in school children. South Med J 2007;100:8-13.
13. Wang Y, Beydoun MA. The obesity epidemic in the United States-gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev 2007;29:6-28.
14. Dilley KJ, Martin LA, Sullivan C, et al. Identification of overweight status is associated with higher rates of screening for comorbidities of overweight in pediatric primary care practice. Pediatrics 2007;119:e148-e155.
15. Barlow SE, Bobra SR, Elliott MB, et al. Recognition of childhood overweight during health supervision visits: does BMI help pediatricians? Obesity (Silver Spring) 2007;15:225-232.
16. Riley MR, Bass NM, Rosenthal P, et al. Underdiagnosis of pediatric obesity and underscreening for fatty liver disease and metabolic syndrome by pediatricians and pediatric subspecialists. J Pediatr 2005;147:839-842.
17. Cook S, Weitzman M, Auinger P, et al. Screening and counseling associated with obesity diagnosis in a national survey of ambulatory pediatric visits. Pediatrics 2005;116:112-116.
18. McElligott JT, Summer AP. Health care utilization patterns for young children in rural counties of the I-95 corridor of South Carolina. J Rural Health 2013;29:198-204.
19. Lacey L, Micka B, McCleary N, (Eds). South Carolina Health Professions Data Book. Charleston, SC:Office for Healthcare Workforce , 2012.
20. Patel AI, Madsen KA, Maselli JH, et al. Underdiagnosis of pediatric obesity during outpatient preventive care visits. Acad Pediatr 2010;10:405-409.
21. Lim CS, Janicke DM. Barriers related to delivering pediatric weight management interventions to children and families from rural communities. Children' Health Care 2013;42:214-230.
22. Shaikh U, Nettiksimmons J, Romano P. Pediatric obesity management in rural clinics in California and the role of telehealth in distance education. J Rural Health 2011;27:263-269.
23. Davis AM, James RL, Curtis MR, et al. Pediatric obesity attitudes, services, and information among rural parents: a qualitative study. Obesity (Silver Spring) 2008;16:2133-2140.
24. Klein JD, Sesselberg TS, Johnson MS, et al. Adoption of body mass index guidelines for screening and counseling in pediatric practice. Pediatrics 2010;125:265-272.
25. Cygan HR, Baldwin K, Chehab LG, et al. Six to success: improving primary care management of pediatric overweight and obesity. J Pediatr Health Care 2014;28:429-437.
26. Ziv A, Boulet JR, Slap GB. Utilization of physician offices by adolescents in the United States. Pediatrics 1999;104( 1 Pt 1 ):35-42.
27. Walsh CO, Milliren CE, Feldman HA, et al. Sensitivity and specificity of obesity diagnosis in pediatric ambulatory care in the United States. Clin Pediatr (Phila) 2013;52:829-835.