To our knowledge, ours is the first large-scale study to evaluate the frequency and patterns of clinicians communicating with youth about possible abuse of OTC products for weight control. Findings suggest clinicians rarely note suspicion or communication about the use of these products and likely are missing indicators of possible abuse of OTC products for weight control. Though self-report survey data from representative community-based samples estimate more than 5% of U.S. adolescents abuse OTC products for weight control each month, in our study of over 53,000 adolescent patients’ records, only 0.8% of patients’ notes documented suspicion or communication about these products. Even when patients presented with suspicious metabolic disturbances, such as hypokalemia and hyponatremia, very few notes indicated any clinician attention to possible OTC product abuse. Out of 130 youth presenting with suspicious metabolic disturbances, only four had records indicating the clinician communicated with the patient about possible abuse of OTC products for weight control at the time the disturbance was identified. All four of these adolescents had a previous eating disorder diagnosis, suggesting that the previous diagnosis, rather than the metabolic disturbance alone, might have prompted clinician attention.
Our study was in part designed to examine differences in clinician communication practices associated with patient gender and weight status among youth presenting with metabolic disturbances. Because so few patients with metabolic disturbances were queried, we were unable to conduct statistical tests to compare patterns within youth with these disturbances.
In secondary analyses, we identified youth whose clinical note included mention of OTC product terms used in our search, regardless of presence or absence of a metabolic disturbance. In support of our hypothesis about gender bias in clinician communication practices, we found a 3:1 (i.e., 1.2:0.4) female-to-male gender ratio in the prevalence of clinicians documenting communicating with patients regarding OTC products used for weight control. This gender ratio should be considered in light of results from representative, community-based research mentioned above, which estimates the female-to-male ratio in past-month diet pill use as approximately a 1.4:1 . Our finding is consistent with prior research documenting primary care physician underrecognition of mental health problems in men compared to women patients . In addition, our findings suggest clinician gender bias in communication practices may in part explain the results of another study documenting that when adolescent boys and girls with commensurate eating disorders symptom severity were compared, boys were much less likely than girls to have ever received treatment for their symptoms . In contrast to our hypotheses, however, we found no difference by patient gender in clinician documentation of suspicion of use.
In addition, we found an inverse gradient of communication about OTC products associated with patient weight status, where the prevalence of documented clinician communication was highest among underweight youth and lowest among overweight and obese youth. This finding provides support for our hypothesis regarding weight-related bias in clinician communications and is consistent with prior research that eating disorder symptoms are underrecognized in clinical settings, especially among overweight and obese individuals who may be offered treatment for their weight but not for their underlying eating disorder symptoms [18, 21, 29].
Our study has several limitations. One, data were gathered from extensive electronic medical records and administrative claims for services; however, clinical notes may be incomplete because providers may not document all communications with patients for a variety of reasons, including time pressure in the clinical visit and concerns about confidentiality if providers believe parents or caregivers may have access to their minor child’s electronic records. Providers may do a complete review of systems, asking questions about weight control methods, yet document the communication only as a negative review of systems. As incomplete documentation has been a long-standing concern within healthcare systems generally [30–32], Group Health offers regular trainings for providers and conducts coding audits to improve quality and completeness of documentation of clinical encounters. Two, it was not possible to determine how many of the patients abused OTC products for weight control, as records capture only those whose clinicians documented both asking patients and the patients’ response. Furthermore, patients who use OTC products may deny use when asked in an effort to conceal stigmatized behavior . Three, our search terms were deliberately inclusive with the goal of capturing all clinician notes related to OTC products used for weight control, yet it is possible some clinicians used different terms in their notes when communicating about these products. Four, while we found evidence to support our hypotheses regarding clinician bias in communication practices associated with patient gender and weight status, we were not able to examine the other possible types of clinical bias, such as bias related to patient race/ethnicity or socioeconomic position, as has been observed in other studies [34–37]. Five, we excluded patients who had been diagnosed with major illnesses in which the disease or its treatment may cause metabolic disturbances; however, in some cases, providers may have reasonably assumed the observed metabolic disturbances were explained by another known illness, such as gastroenteritis, rather than abuse of OTC products. That said, when we individually reviewed notes for patients with metabolic disturbances, we found only one case in which the clinician documented a gastroenteritis-like condition, specifically noting “viral syndrome.”
Survey research with U.S. adolescent girls and boys has well-documented abuse of OTC products for weight control. Representative, community-based research has estimated that more than 5% of youth report past-month use of OTC products for weight control, such as diet pills, laxatives, and diuretics . Only a small percentage of youth with these and other eating disorder symptoms receive treatment [16, 17], which may in part relate to our finding that clinicians rarely communicate about abuse of these products. Though abuse of OTC products for weight control can precipitate serious conditions requiring medical attention [7–14], they are widely and easily available to youth in pharmacies and online . One important strategy proposed to reduce the harm these products pose to young people is to impose age restrictions on purchases . Clinicians can also play an important role given that they are in a unique position to recognize signs and symptoms of OTC product abuse in patients and to help these youth adopt more healthful behaviors related to weight and shape.