Weight Status of Children and Adolescents
in a Telepsychiatry Clinic
Shayna Marks, M.A.,1Ulfat Shaikh, M.D., M.P.H.,2Donald M.
Hilty, M.D.,3and Stacey Cole, M.B.A.4
1Department of Psychology and Social Behavior, University of
California at Irvine School of Social Ecology, Irvine, California.
2Department of Pediatrics, University of California Davis School
of Medicine, Sacramento, California.
3Rural Program in Medical Education, University of California
Davis School of Medicine, Sacramento, California.
4University of California Davis Center for Health and Technology,
The prevalence of overweight and obesity is approximately 32%
among children and adolescents in the United States. Comorbid
conditions associated with pediatric overweight and obesity include
psychiatric conditions. The purpose of this study was to determine
the prevalence of overweight and obesity among children and ado-
lescents presenting for consultation from rural communities to the
UC Davis Telemedicine Program (UCDTP), as well as to collect
preliminary data to design an integrated disease management pro-
gram for children and adolescents with obesity and mental illness.
Patients aged 21 and under seen for psychiatric consultation at the
UCDTP between 2004 and 2006 were included. Retrospective med-
ical record review was conducted to determine the major psychiatric
diagnoses, height, weight, body–mass index, and weight status
(underweight=at risk for underweight, normal weight, overweight, or
obese) for each patient. Of the 230 patients referred, a total of 121
patients had both height and weight values documented. Three pa-
tients were underweight; 51 were normal weight; 28 were over-
weight; 39 were obese. The most common psychiatric diagnoses in
the 121 patients were attention deficit=hyperactivity disorder
(ADHD; n¼40), bipolar disorder (n¼36), and depression (n¼31).
The most common psychiatric diagnoses in patients with available
weight and height data who were overweight and obese were bipolar
disorder (n¼20), depression (n¼18), and ADHD (n¼17). Ap-
proximately 55% of child and adolescent patients seen for tele-
psychiatry consultation whose charts documented height and weight
measurements were overweight or obese. Psychiatric diagnoses in
overweight youngsters need to be researched further to determine
whether the weight change is primary or secondary to mood and=or
to treatments, such as medication. At such a high rate of co-
morbidity, monitoring the weight status of young psychiatric patients
in this population is indicated.
Key words: telepsychiatry, rural children, pediatric overweight and
obesity, psychiatric medications
Control and Prevention indicate that the prevalence of childhood
overweight and obesity is approximately 32%.1–3Additionally, the
overall prevalence of obesity in children residing in rural areas is
higher than the prevalence of obesity in the general pediatric pop-
ulation. In studies conducted in rural settings, the range of obesity is
28% (southwestern Oklahoma4) to 33% (rural Appalachia5) to 54%
(Mississippi, overweight or obese6). More recently, data from the
National Survey of Children’s Health (NSCH) demonstrated that
overweight or obese children were more likely to live in rural com-
pared to urban areas (OR¼1.252; 95% confidence interval, 1.248,
Rural location or residence may not be the only contributing factor
in the high prevalence of overweight and obesity in children.7,8
Obesity has long been associated with low socioeconomic status
(SES).9Indeed, characteristicsofhealthand healthcare associatedwith
low SES may be true of residents of both rural areas and inner-city
he prevalence of pediatric overweight and obesity in the
United States has reached epidemic proportions over the
past 3 decades. Although its prevalence shows some vari-
ation between age groups, data from the Centers for Disease
970 TELEMEDICINE and e-HEALTH
DECEMBER 2009 DOI: 10.1089=tmj.2008.0150
urban areas.10However, the NSCH showed that rural children were
more likely than their urban counterparts to live in poverty, have
no health insurance, have lower preventive healthcare, have more
sedentary habits, and have a greater risk of comorbidities.9Due to
the contributions of socioeconomic, geographic, and health-related
challenges faced by residents of rural communities, rural children are
at increased risk for obesity and its consequences,11possibly even
beyond that faced by children in inner-city urban areas.10
Obesity and overweight have long been associated with psychi-
atric and psychological disorders in children. In one study, 58% of
obese children studied were diagnosed with at least one psychiatric
disorder, especially anxiety disorders.12Obese children are at in-
by adults, decreased self-esteem, and depression.13Psychosocial
consequences of obesity are especially concerning in children be-
cause of the impact on their emotional well-being as young
adults.13,14Further complicating the issue is the finding that the
prevalence of psychiatric disorders may be higher in rural areas
compared to urban areas,15a pattern that has been associated with a
number of factors, including geographical isolation, increased rates
of substance use, disability, and unemployment, as well as decreased
access to medical and mental healthcare.
Technology plays a critical role in the delivery of mental health
services to rural areas, which have lower access to psychiatrists and
psychologists. Telemedicine use has expanded rapidly since the
1990s and is becoming an effective means for increasing access to
healthcare. Several studies have shown the usefulness of tele-
medicine in linking experts to rural communities.16–18The American
Academy of Child and Adolescent Psychiatry has written practice
guidelines for the use of telecommunications technologies in work-
ing with children and adolescents in the mental health setting.19In
one such tele-endocrinology service, more than 80% of patients
treated by the pediatric weight management specialist showed im-
provements in their diet, activity level, or weight.20
The goal of this present study is to determine the prevalence of
overweight and obesity among a group of children and adolescents
from rural communities, as defined by the California Office of
Statewide Health Planning and Development,21presenting for psy-
chiatric consultation delivered by telemedicine; height and weight
values were recorded for these youngsters. This study will pro-
vide preliminary data to inform the development of an integrated
care model for the treatment of comorbid obesity and psychiatric
disorder among rural children and their families using telecommu-
Materials and Methods
UC DAVIS TELEMEDICINE PROGRAM AND SITES
The University of California Davis Health System (UCDHS) has
developed one of the nation’s leading telemedicine programs work-
ing across over 30 medical specialties. The program provides over 80
outpatient clinics and hospital sites, mostly in rural Northern Cali-
fornia, with access to more than 30 medical specialties and has
completed over 10,000 video-based clinical consultations to date.
Telepsychiatry has accounted for over 2,000 of these consults, de-
livered to over 28 sites in rural California.
In addition to telepsychiatry consultations, the UCDHS tele-
medicine program also provides telemedicine weight management
consultations to children and adolescents living in rural areas of
California. Since 2000, over 500 children and adolescents at 18 rural
clinics in California received such consultations from a UCDHS pe-
diatric weight management specialist and dietitian. An earlier med-
ical record review of 99 children and adolescents who received
telemedicine weight management consultations revealed that the
majority of consultations were associated with changes or additions
to diagnoses, diagnostic evaluation, and treatment plans.
Individuals ages 21 and under (mean age¼13 years, range¼4–21,
standard deviation – 4.84; 40.6% female) who were seen for psychi-
atric consultation in the UC Davis Telemedicine Program between
2004 and 2006 were identified using the UCDHSTelemedicine Clinical
Telepsychiatry consultations were performed in accordance with
the UCDHS telemedicine policies and procedures.22Video consulta-
tions were performed at 384 kilobits per second by either Internet
Protocol or Integrated Services Digital Network.23,24Medical records
from these visits were reviewed to determine major psychiatric di-
agnoses, height, and weight for each patient. Only those individuals
defined as children by the National Institutes of Health25who were
under 21 years of age at the time of consultation and had complete
information in their consultative record regarding their psychiatric
diagnoses, height, and weight were included. Following abstrac-
tion of this information, body–mass index (BMI), BMI percentile,
and weight status were calculated using the U.S. Department of
Agriculture=Agricultural Research Service (ARS) Children’s Nutri-
tion Research Center’s online BMI calculator.26
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ª M A R Y A N N L I E B E R T , IN C . . VOL. 15NO. 10 . DECEMBER 2009
TELEMEDICINE and e-HEALTH 971
Patient weight status was classified by BMI percentile into under-
weight, at risk for underweight, normal weight, overweight, or obese
according to the Children’s Nutrition Research Center’s guidelines.26
bivariate analyses were conducted to determine the association be-
tween presence of psychiatric disorders and weight category (under-
weight, at risk for underweight, normal, overweight, and obese).
A total of 230 patients, less than 21 years of age, identified by the
Telemedicine Consultation Database had been seen by a UCDHS
psychiatrist. At the time of this study, medical records of 161 patients
were available for review. Of these 161 patients, a total of 121 pa-
tients had psychiatric diagnostic information as well as both height
and weight values documented at their telepsychiatry visit. Of the
121children and adolescents includedinour analyses,46(38%)were
female. The mean age of patients included in the study was 13 years
(SD – 4.07, age range¼4–21 years).
WEIGHT CATEGORY AND PSYCHIATRIC DIAGNOSES
for underweight. Fifty-one patients (42%) were of normal weight for
age and sex. Twenty-eight patients (23%) were overweight, and 39
(32%) were obese. Psychiatric diagnoses in overweight and obese
patients included attention deficit=hyperactivity disorder (ADHD),
impulse control disorder, oppositional defiant disorder, conduct
disorder, Tourette’s syndrome, depression, dysthymia, bipolar dis-
order, schizoaffective disorder, schizophrenia, psychotic disorder not
otherwise specified (NOS), autism, Asperger’s syndrome, obsessive–
compulsive disorder, post-traumatic stress disorder, generalized
anxiety disorder, substance abuse disorder, mental retardation, eat-
ing disorder NOS, and cognitive disorder NOS. The most common
psychiatric diagnosis documented was ADHD, in 40 (33%) of pa-
tients. The next most frequently made diagnoses were bipolar dis-
order (n¼36; 30%) and depression (n¼32; 26%). These rates did not
data were available; the most common diagnoses in the group with
control disorders (27%), and bipolar disorder (27%). The frequency of
psychiatric diagnoses by weight category for the 121 patients with
available weight and height data is presented in Table 1.
Patients with available weight and height data were categorized
by weight status, as either underweight=normal weight or over-
weight=obese. Independent samples t-tests were computed between
weight status and psychiatric diagnoses. Analyses indicate that un-
derweight or normal weight children are significantly more likely to
have ADHD than are overweight or obese children (t(106.379)¼
1.991, p¼0.049). There was a trend toward increased rates of con-
duct disorder among overweight or obese children compared to
normal or underweight children (t(98.297)¼?1.788, p¼0.077).
Although more overweight and obese individuals had diagnoses of
bipolar disorder or depression than did normal weight or under-
weight individuals, these differences were not significant. No other
relationships between psychiatric diagnosis and weight status were
Table 1. Frequency of Psychiatric Diagnosis by Weight Category
FOR UNDERWEIGHTNORMAL WEIGHT OVERWEIGHT OBESE
ADHD2 66.6721 41.187 25.00 1025.64 40
Bipolar disorder0 0.00 16 31.378 28.57 1230.77 36
Depression1 33.33 12 23.537 25.00 1128.21 31
Other psychiatric diagnoses0 0.002 3.926 21.436 15.38 14
Total3 2.47%5142.15%28 23.14% 3932.23% 121
ADHD, attention deficit=hyperactivity disorder.
MARKS ET AL.
972 TELEMEDICINE and e-HEALTH
significant. When individuals were categorized either as obese
or not obese, only psychotic disorders differed by weight status
(t(81)¼2.293, p¼0.024). No other psychiatric diagnoses differed
between obese and nonobese children.
Our study found that among patients seen for telepsychiatry
consultation, for whom data on psychiatric diagnoses, height, and
weight were available, the prevalence of overweight and obesity was
55%. This high prevalence of overweight and obesity seen in our
subjects may be reflective of population characteristics in rural areas
of California, or in other resource-limited populations who com-
monly utilize telepsychiatric services.
Published studies indicate a link between obesity and psychiatric
disorders, specifically ADHD in adolescents.27,28Explanations that
havebeen positedfor thisrelationship are that ADHDsymptomscould
be correlated with binge eating, bulimia, and emotionally induced
eating, which in turn results inobesity.29,30Contrary tothese findings,
our results indicate that in a sample seen for psychiatric consultation,
there was a significantly higher rate of ADHD among normal and
underweight individuals than among overweight and obese individ-
uals. This is more in line with Curtin and colleagues’ finding that
the prevalence of obesity in children with ADHD is similar to that of
the general population.31In our study, there were no statistically
significant differences in the rates of the most common psychiatric
diagnoses—ADHD, depression, and bipolar disorder—between indi-
viduals who were obese and those who were not. Nonetheless, rates of
depression and bipolar disorder were higher in overweight and obese
children than innormal and underweight children, and a trend toward
increased rates of conduct disorder in overweight children compared
to normal weight children was observed.
A partial explanation for the relationship of obesity and psychi-
atric disorders may be that genetic linkage between these disorders
exists.32–34In addition, it is plausible, as mentioned above, that
obesity alters a patient’s emotional trajectory due to stigma or that
coping=‘‘interventions’’ from parents misdirects a patient’s attempts
to cope. On the other hand, mood and other disorders may lead to
obesity. Finally, medication treatments (e.g., atypical antipsychotics
impact on metabolism and obesity.
telepsychiatry consultations may facilitate identification and treat-
ment of excess weight that may be common in this population.
Additionally, identifying children and adolescents with specific psy-
chiatricdiagnosesthat may beassociated with overweight and obesity
may help promote an integrative approach to mental and physical
sample size was small. Second, children and adolescents referred to
the telepsychiatry clinic may have unique characteristics compared to
either their rural peers or their urban and suburban counterparts. For
example, children referred to telepsychiatry may be more likely to be
underinsured than other children in the community, and therefore
may face additional obstacles to maintaining their health than their
peers. Third, because the present study was a retrospective review
rather than a prospective trial, our data only indicate an association
between specific mental health issues and obesity in the population
included, and do not infer causality. Another important limitation is
that medical records of 30% of the patients eligible for inclusion in
this study were unavailable for review.
Approximately 55% of children and adolescents presenting for
consultation to the UC Davis telepsychiatry clinic, with available data
on psychiatric diagnoses, height, and weight, were overweight or
obese. Among these patients, underweight or normal weight children
children. Obese children were more likely to have conduct disorder
than underweight or normal weight children. Although overweight
and obese children were somewhat more likely than under- or normal
weight children to have depression or bipolar disorder, these differ-
ences were not significant. While identifying these relationships
provides preliminary data to develop an integrative model of treat-
ment for children with comorbid psychiatric issues and obesity seen
in telemedicine clinics, further prospective studies are warranted.
Dr. Shaikh’s research is funded by a K12 award from the UC Davis
Clinical and Translational Science Center (grant # UL1 RR024146
from the National Center for Research Resources [NCRR], National
Institutes of Health).
No competing financial interests exist.
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Address correspondence to:
Shayna Marks, M.A.
Department of Psychology and Social Behavior
University of California at Irvine School of Social Ecology
3340 Social Ecology Building II
Irvine, CA 92697
Received: November 20, 2008
Revised: May 13, 2009
Accepted: July 13, 2009
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974 TELEMEDICINE and e-HEALTH