The prevalence (36%) of overweight in this multiethnic inner-city pediatric clinic population exceeded the reported national data from NHANES III. Among the ethnic populations, and between male and female children, the prevalence of overweight was similar. This study shows that 29% (17 of 58) of the overweight children (2 to 18 years of age) had their diagnoses and intervention (15 of 17) documented in the medical record. In these 17 subjects, nutrition, exercise, and/or behavioral counseling were used, alone, or in combination, as an intervention with nutrition counseling being the most frequent therapy used by the providers. Further analysis revealed that blood pressure and cholesterol determinations were measured more frequently in the not documented overweight children than in those with normal weight. The rea son for this finding is not clear, and only leaves to speculation that the providers perhaps recognized an increased body weight, but failed to document the finding in the medical record. Medical documentation of overweight increased with increasing level of residency training. Higher blood pressure values were recorded in the overweight children than in normal weight children irrespective of the presence or absence of documentation. The average cholesterol level was also increased in overweight children between two and 18 years of age as compared to normal weight children, but the difference did not reach significance.

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The ethnic distribution of the 208 study subjects was 76% Hispanic, 20% African American, and 4% other. In 159 (76%) of 208 subjects between two and 18 years of age, the BMI was < 90th percentile in 101 (64%) and > 90th percentile for age and gender in 58 (36%). The mean ages (X+SD) were 6.8 years + 4.3 for subjects in < 90th percentile group, and 7.2 years ±4.1 for those in >90th percentile group (t= -0.6, p=0.55). By gender, overweight was identified in 37 (35%) of 94 males, and 21 of 65 (32%) females (X² =0.82, p=0.4). According to ethnicity, overweight was found in 36.4% of the Hispanics, and 34.4% African American, (X²=0.043, p=0.83). In the remaining 49 (24%) of 208 subjects who were < two years of age, 10 had BMI or weight/height ratios at or above the 90th percentile. These 10 patients had no documentation indicating provider awareness, planned evaluation, or intervention for suspected increase in body weight.

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Patient Population

This retrospective review of medical records was conducted in a community health clinic in the Southwest Region of Los Angeles County, and was approved by the Institutional Review Board of Human Investigations. The median household income for the region was approximately $29,501 (1995 LAC/DHS Data Collection and Analysis). The ethnic distribution of this geographic area was 59.7% Hispanic, 23.3% African American, 11.5% White non-Hispanic, and 5.4% other.

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Overweight among children and adolescents in the United States is now the most common nutritional health problem, and continues as an upward trend in the current decade. National Health and Nutrition Examination Surveys (NHANES) III, the Bogalusa Heart Study, and baseline data from the National Heart, Lung and Blood Institute’s Growth and Health Study show increases in overweight prevalence among children and adolescents between the years 19631994 with the highest increase seen occurring between 1980 and 1994.

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We found that among Medicaid children in a managed care program, who were assigned to a primary care case manager physician, up-to-date immunization rates at 18 months were still low. Age appropriate immunization rates were even lower. The temporal patterns of immunizations indicated that compliance with the immunization schedule faltered after the second month of life (See Figure 1). By 18 months of age AAI status declined from 37% to 6%. UTD status declined from 37% to 19% at 15 months and then increased to 28% at 18 months and to 46% by 2 years of age. Other studies of low-income urban populations have found similar rates.

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Among the 5,598 children studied, most were African-American (73.4%), approximately one-half were male (51%), and most mothers were in the 20 years and over age group. The designated primary care providers included public health providers (9.3%), and private providers (90.7%). Private providers included family practitioners (10.7%), pediatricians (78.3%), and other specialists. Of the 5,598 children, 2,583 (46.1%) were immunized (4:3:1 series) by 24 months of age and 1,582 (28.3%) were classified as UTD at 18 months. Of the UTD children, 351 (22.2%) were classified as AAI at 18 months. Thus 6.3% of all children were AAI. (See Table 1.)

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Rates of immunization for 5,598 children who were moved from fee-for-service care to a newly implemented primary care case management managed care program were reviewed in 1995 as part of the Quality Assessment and Improvement Project for Medicaid Managed Care in Virginia. Managed care was implemented for Virginia’s Medicaid population through a staged geographic approach. This project studied managed care as implemented in the first geographic area to be included in Medicaid managed care. The managed care program assigned each Medicaid recipient to a primary care physician (PCP) who, in exchange for a monthly per-patient management fee, was responsible for preventive services and functioned as a gatekeeper for access to medical care.

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