Childhood Obesity: Knowledge, Attitudes, and Practices of European Pediatric Care Providers
OBJECTIVE: To determine and compare attitudes, skills, and practices in childhood obesity management in 4 European countries with different obesity prevalence, health care systems, and economic situations.
METHODS: A cross-sectional survey was distributed to primary health care providers from France, Italy, Poland, and Ukraine. The questionnaire was returned by 1119 participants with a response rate of 32.4%.
RESULTS: The study revealed that most of the primary health care providers were convinced of their critical role in obesity management but did not feel sufficiently competent to perform effectively. The adherence to recommended practices such as routine weight and height measurements, BMI calculation, and plotting growth parameters on recommended growth charts was poor. Most primary health care providers recognized the need for continuing professional education in obesity management, stressing the importance of appropriate dietary counseling.
CONCLUSIONS: The study underlines insufficient implementation of national guidelines for management of obesity regardless of the country and its health system. It also makes clear that the critical problem is not elaboration of guidelines but rather creating support systems for implementation of the medical standards among the primary care practitioners.
- CI —
- confidence interval
- GP —
- general practitioner
What’s Known on This Subject:
Health care professionals face problems managing obesity and often fail to follow guidelines for its management in practice. Only a few single-country reports are available describing delivery of primary care to children with obesity.
What This Study Adds:
Nearly all primary pediatric care providers from 4 European countries recognize the importance of obesity in pediatric practice, but only half use BMI clinically, and many lack the confidence and the infrastructure needed for providing care to patients with obesity.
The obesity epidemic affects all age groups including very young children and is a serious and growing problem for public health systems worldwide.1–3 The rapid rise in the prevalence of obesity is accompanied by the increasing number of comorbidities such as type 2 diabetes, hypertension, hyperlipidemia, and metabolic syndrome.3 Children have become a major focus of prevention and early treatment and therefore pediatric primary care practitioners have a crucial role in public health interventions. Their frequent contact with patients and families enable them to play an important role in the prevention, early diagnosis, and treatment of childhood obesity. A vast majority of patients trust primary care providers and believe in their competence.4,5 However, recent studies reveal that obesity management in primary care settings is inadequate,6 with only half of obese patients receiving a diagnosis and only one-third receiving proper additional counseling.7–9
Almost all studies focus on adult populations,5,7–10 and studies that do involve children are from single countries (United States, France, and Israel).11–14 Existing differences between countries’ health care systems, physician training, economic situation, and rate of overweight and obesity may significantly influence pediatric obesity management in the primary care setting. There has been no international, comparative study describing the approach of primary care providers toward the management of childhood obesity.
The objective of our study was to document and compare attitudes, skills, and practices in childhood obesity management between primary care providers in 4 European countries (Poland, France, Italy, and Ukraine) that have different obesity and overweight prevalence, health care systems, and economic situations.
We used a 26-question, self-administered questionnaire validated for length, clarity, and sustainability of the answers in a pilot group of 15 pediatricians. Questionnaires were distributed between 2008 and 2009 to primary care providers in France, Italy, Poland, and Ukraine. The request to participate in the study included reassurance that no personal or practice information would be released and that data would be used only for aggregate statistical analysis and a statement that returning the questionnaire implied consent to participate as a subject of the study. The study was approved by institutional review boards in all participating centers. Of the 3464 primary care providers contacted, 1119 (32.4%) agreed to participate. The first 5 questions concerned demographic data: country, age, gender, type of health care provider, and years in practice. The next parts of the questionnaire covered the following items:
routine measurement of height and weight during each visit;
routine BMI calculation;
anthropometric data plotting on appropriate charts;
perception of childhood obesity as a medical problem relevant to primary care;
availability of a weight-management program;
feeling of competence in obesity management;
referral pattern for childhood obesity;
duration of visits for both general pediatric and obesity reasons;
ability to deal with several aspects of obesity management in children;
perceived needs for advanced training.
Participants responded either “yes” or “no” or gave answers on a 5-point Likert scale (from “never” to “always”). Data analysis began with simple frequency counts. Confidence intervals were calculated on the basis of normal or binomial distribution (as appropriate). Data were screened for codependent variables. We used χ2 tests to examine differences between the primary care physicians by countries and to test differences in management for obesity in children. P values <0.05 were considered statistically significant. In every statistical analysis, Statistica software (version 8.0 PL; Statsoft Inc, Tulsa, OK) and SPSS 18.0 (IBM SPSS Statistics, IBM Corporation, Armonk, NY) was used.
Completed questionnaires were returned by 1119 primary care providers: 358 from Ukraine, 343 from France, 271 from Poland, and 147 from Italy. Women were overrepresented among survey responders (63.1%; 95% confidence interval [CI]: 60.2%–65.9%) in all countries except for France. In Poland, 77.9% (95% CI: 72.9%–82.8%) of the respondents were female, in the Ukraine 84.1% (95% CI: 80.3%–87.8%) of respondents were female, but in France female responders were in the minority (31.8%; 95% CI: 26.8%–36.7%). Respondents were split between pediatricians and family practitioners in the group as a whole; however, most health care providers from France were family doctors (99.1%; 95% CI: 98.1%–100%) and in Italy the majority were pediatricians (99.3%; 95% CI: 97.9%–100%). The difference between all of the countries was statistically significant for both gender and specialty. Information regarding number of primary care providers and gender composition in specific countries is included in Table 1. Almost 70% of the primary care providers (95% CI: 67.2%–72.6%) were older than 40 years; however, in the Ukraine only 46.6% (95% CI: 41.4%–51.7%) were older than 40 years (P < .0001). In the Ukraine 19.6% (95% CI: 15.5%–23.7%) of physicians had practiced for <5 years (P < .0001) compared with 13.7% (95% CI: 9.6%–17.8%) in Poland, 8.5% (95% CI: 5.5%–11.4%) in France, and 2.0% (95% CI: 0.0%–4.2%) in Italy.
Routine Measurement of Height and Weight During Each Consultation
Routine measurement of height and weight varied from 53.5% (95% CI: 48.2%–58.7%) of physicians in Poland to 69.7% (95% CI: 64.8%–74.6%) in France (P = .001) (Fig 1A).
Routine BMI Calculation
Only 50.3% (95% CI: 47.4%–53.2%) of respondents who recorded weight and height always or usually calculated BMI. Routine BMI calculation was reported by significantly fewer health care providers in Poland (36.1%; 95% CI: 30.3%–41.8%) and the Ukraine (36.9%; 95% CI: 31.9%–41.9%) than in Italy (72.8%; 95% CI: 65.6%–80.0%) (P < .0001) (Fig 1B).
Routine Plotting of Anthropometric Data and Use of Appropriate Charts
The highest use of appropriate growth charts was reported by respondents from Italy (Fig 1C). Almost 80% (95% CI: 69.3%–83.1%) of Italian doctors always used charts to plot weight and height and 43.5% (95% CI: 35.4%–51.5%) used charts to plot BMI (Fig 1D). The lowest use of growth charts was reported in Ukraine (6.1%; 95% CI: 3.6%–8.6%) (P < .001).Weight and height rather than BMI plotting was preferred by physicians from France (weight and height plotting: 48.7%; 95% CI: 39.2%–56.2%; BMI plotting: 14.6%; 95% CI: 9.9%–17.9%) and Poland (weight and height plotting: 32.5%; 95% CI: 24.2%–41.3%; BMI plotting: 12.2%; 95% CI: 8.9%–16.3%) (Fig 1 C and D). Italian doctors more often assessed children’s nutritional status by using BMI charts (61.1%; 95% CI: 53.2%–69.0%).
In each country, physicians used mostly national rather than International Obesity Task Force charts for BMI interpretation.
Duration of Visits for Evaluation of Obesity
Both general pediatric and obesity evaluation visits were shortest in Poland. However, the time spent for a visit related to obesity evaluation was significantly longer than for a general pediatric visit in every country surveyed (P < .0001) (Table 2).
Perception of Childhood Obesity as a Medical Problem Relevant to Primary Care
Appreciation of the relevance of obesity in primary care in France, Italy, and Poland was high at 94.2% (95% CI: 91.7%–96.7%), 100% (95% CI: 99.9%–100%), and 87.6% (95% CI: 83.7%–91.5%), respectively. However, only 60.3% (95% CI: 55.2%–65.3%) of Ukrainian doctors agreed that their role included childhood obesity management (P < .0001) (Fig 2A).
Availability of Weight-Management Program
Approximately two-thirds of physicians from Italy (69.4%; 95% CI: 61.9%–76.8%) and the Ukraine (68.2%; 95% CI: 63.3%–73.0%) declared that a weight-management program for children was available in their practices, whereas in France and Poland the availability of such a program was reported by 17.6% (95% CI: 13.5%–21.6%) and 18.9% (95% CI: 14.2%–23.6%), respectively (P < .0001) (Fig 2B).
Feeling of Competence
Only 21.4% (95% CI: 19.0%–23.8%) of primary care physicians regarded themselves competent in managing childhood obesity effectively (Fig 2C). In France and Italy, 31.2% (95% CI: 26.3%–36.1%) and 31.3% (95% CI: 23.8%–38.7%), respectively, felt they had a sufficient level of competence compared with physicians in Poland (18.5%; 95% CI: 13.9%–23.1%) and the Ukraine (10.1%; 95% CI: 6.9%–13.1%).
Referral Patterns in Childhood Obesity Management
Approximately 70% (95% CI: 68.1%–73.5%) of health care providers declared that they attempted to treat obese children in their office, and a majority (62.3%; 95% CI: 59.4%–65.1%) referred them if therapy proved unsuccessful. The highest percentage of referrals without any attempt to treat was noted in the Ukraine (39.4%; 95% CI: 34.3%–44.5%) (Fig 2D).
Ability to Deal With Obesity Management
The etiology and diagnosis of childhood obesity were the areas in which physicians from the Ukraine reported insufficient levels of comfort. Respondents from France, Italy, and Poland were more uncomfortable with dietary treatment and psychological care. French providers reported discomfort in communication with obese children and their parents (Table 3).
Need for Advanced Training
The need for advanced training in dietary counseling was reported as an important matter in every country surveyed. However, the needs between countries were significantly different. Ukrainian physicians needed more training in etiology and diagnostic procedures concerning childhood obesity. For French, Italian, and Polish primary health care providers, education in psychological care and interpersonal communication were more important (Table 2).
Primary care practitioners play a fundamental role in the majority of health care systems. In the World Health Report released in 2008, with the motto “primary healthcare, now more than ever,” the World Health Organization reinforced the importance of a well-organized primary health care system.15 With a dramatic increase in the prevalence of childhood obesity, primary care physicians are placed in the front line of providing health services to obese/overweight children and adolescents. Our study revealed that most of the primary health care providers, regardless of their country’s health care system, were convinced of their important role in obesity management but did not feel sufficiently competent enough to perform it effectively.
The outcomes of the different models existing in European countries for health care and disease prevention are not easy to compare and have not been extensively studied. However, the assessment of quality of health care at the primary level may be essential for future health care planning in Europe.16 Three different health care delivery systems for children were identified: pediatric-based, general practitioner (GP)–based, and combined services.16,17 Moreover, there is a variation in the definition of pediatric age in different countries.16 The Ukrainian health care system includes pediatricians as the only primary care practitioners for all children (ages 0–18 years). In Italy, the pediatrician-based system covers only younger children, whereas children older than 6 years are managed by a combined system, even though the majority of the children stay with their pediatricians until 14 years of age. Combined pediatrician/GP systems are the norm in France and Poland (Table 1).
Although somewhat difficult to compare, due to different methodologies in data collection and interpretation, obesity and overweight prevalence in French, Polish, and Ukrainian children seems to be very similar, ranging from ∼3% to 4% and 11% to 15%, respectively, in children aged 7 to 9 years.18–20 However, in Italy, obesity prevalence is almost twice as high, particularly in the southern region.21 It therefore comes as no surprise that most primary care physicians in our survey agreed that childhood obesity management is relevant for primary care and that the highest rates were reported among the Italian physicians.
A very common explanation given by primary care providers who have no interest in management of obesity is the belief that obesity is mainly a parental problem. Others quoted the lack of educational and financial support for obesity treatment and poor response to therapeutic interventions. Many physicians have a stereotypical and negative approach to a patient with obesity, although the negative attitude seems to have declined over the past 30 years.22
Our study also reveals a significant difference in availability of weight-management programs among the countries studied, although the national guidelines for management of obesity are, in principle, similar. All countries in our study share a low level of implementation of national guidelines. The adherence to recommended practices such as routine weight and height measurements, BMI calculation, and plotting growth parameters on recommended growth charts was rather poor, although adherence was overall best in Italy and worst in the Ukraine. This finding is consistent with research from other countries that reports that recommended guidelines are not commonly implemented. An Australian study revealed that less than one-third of GPs used existing guidelines in their practice, even if they believed that childhood obesity is a significant problem.23 Another Australian study found that most surveyed primary care providers did not routinely measure children’s height or weight or calculate BMI.24 The LEAP (Live, Eat, and Play) study revealed that only 50% of children were weighed and measured during their visit to a primary care provider’s office.10,11 The literature provides some insights into potential reasons for that phenomenon. Australian GPs expressed the opinion that routine height and weight measurement is impractical and time consuming. They measured children only for the drug-dose calculation or if signs or symptoms suggested a developmental problem.25 Another reason was lack of time and support of other staff members (nurses).
A low rate of guideline adherence for childhood obesity by primary care providers was also reported in Israel and the United States.26,27 Collection of data are important, but only proper interpretation can result in appropriate interventions. In our study a majority of health care practitioners used weight and height charts. Physicians in every country surveyed used mainly national and not International Obesity Task Force–recommended charts for BMI interpretation. The use of BMI charts in our survey was higher than in other studies.23,28 The Kinder Overweight Activity Lifestyle Actions (KOALA) study revealed that even after primary care practitioners have been trained in BMI calculation and interpretation, there was no significant improvement in BMI chart usage.29 It may suggest that the main barrier is not the lack of knowledge but adherence to routine practices.
Duration of visit may be crucial for the ability of the provider to perform recommended tasks. The respondents to our survey reported significant differences in visit duration. For example, in Poland, 31.7% of doctors spend <10 minutes for a routine general pediatric visit. In our opinion, such a short visit does not provide an opportunity to complete the tasks recommended in obesity guidelines.
The perception of competency is necessary for building a proactive attitude toward guideline implementation. In our study this perception was higher in France and Italy than in Poland and the Ukraine.
Preventing and managing childhood obesity in primary care is a complex and difficult task, requiring close collaboration between parents and practitioners. No wonder that communication with obese children and their parents was identified as an important issue. More than 70% of respondents expressed a need to be trained in better communication techniques.
An encouraging finding of our study is that most primary health care providers recognized the need for professional education in obesity management. The need for training in dietary counseling was most frequently reported. Our results complement a study by Walker et al30 who reported that the lack of training is a barrier to proper management of obesity in primary care. Crawford et al31 pointed out that regular training in management of obesity can improve knowledge, attitudes, and effectiveness of treatment.
The limitation of the study was a relatively low percentage of respondents (32.4%). It may be that those who responded could be more motivated and interested in childhood obesity problems than those who did not respond. It is possible that adherence to guidelines could have been even worse if nonresponders had been included. The use of self-reported data are susceptible to bias. The respondents might have overemphasized their lack of competence and need for professional training as an excuse for lack of attention to the management of obesity in children. Factors other than insufficient training could have played a role, ie, obesity management may be frustrating, not sufficiently gratifying, or too time consuming.
Prevention and treatment of childhood obesity is a complex and burdensome process that includes family involvement, behavior and dietary modification, as well as encouragement of increased physical activity (or discouraging sedentary behavior). Our study reveals that the comprehensive approach to such lifestyle modifications is certainly beyond the current capacity of primary health care providers. The strategy of obesity prevention should be coordinated by governments and addressed to the entire society. Tackling the obesity problem should involve not only the health care system but also schools, communities, and the media.
Our study is the first to our knowledge that, with the same protocol, describes and compares childhood obesity approaches among different European countries. It underlines insufficient implementation of national guidelines for management of obesity regardless of the present health care system, but it also makes clear that the critical problem is not development of guidelines but implementation of the medical standards among the primary care practitioners. It shows the weakness of the medical health system in which prevention and early diagnosis of common diseases are not regarded as principal tasks.
It is obvious that there is an urgent need for developing health care structures to support adequate time and resources for evaluation of obesity during pediatric visits at the state/country level. Training and support should be developed to improve the engagement and competency of primary health care providers in prevention and management of childhood obesity.
- Accepted March 21, 2013.
- Address correspondence to Artur Mazur, MD, PhD, Warszawska 26a, Rzeszów, Poland. E-mail:
Dr Mazur conceptualized and designed the study and revised and approved the final manuscript as submitted, Dr Malecka-Tendera participated in the study concept and made substantial contribution in revision and final approval of the manuscript as submitted, Dr. Telega conceptualized and designed the study, performed data analysis, and approved the final manuscript as submitted, Dr Malecka-Tendera and Dr Telega had equal contribution as senior authors, Dr Matusik drafted the initial manuscript, carried out the initial analysis and approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
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- Copyright © 2013 by the American Academy of Pediatrics