Evaluation of Obesity Management Recorded in Electronic Clinical History: A Cohort Study

Abstract

Background: The prevalence of obesity is increasing worldwide. Because of their close proximity to the population, primary care physicians and nurses are in a unique position to motivate and advise patients with obesity on a healthy diet and increased physical activity. Drawing from information recorded in electronic clinical records, we evaluated how the general recommendations included in obesity guidelines are being implemented in routine clinical practice. Methods: This study drew from the following data from a cohort of 209 patients with obesity that attended primary care consultations: electronic clinical records, body mass index (BMI), waist circumference (WC), cardiovascular risk factors, comorbidities and whether their health professional documented compliance with the recommendations of the evidence-based obesity guidelines in their electronic history. Results: Only 25.4% of the clinical records met all the criteria established in the therapeutic guidelines regarding diet prescription, 1.4% for physical activity and 1.5% for behavioral change activities. The patients whose records mentioned diet prescription and physical activity and who received follow-up consultations for both factors had lower average BMI and WC, although this relationship was not significant after adjusting for baseline. Conclusions: We found that only a small number of records in the electronic clinical histories followed the evidence-based obesity guidelines. Recording dietetic prescription and physical exercise in the patient’s clinical record is associated with better control of obesity.