The participating GPs comprised a mix of males and females, aged 30 to 70 years and from a variety of ethnic and language backgrounds. The comments from focus groups were spread across participants in groups rather than being attributed to individuals.
Awareness of child and adolescent overweight and obesity
Participating GPs were aware that child and adolescent overweight is a serious public health problem. All of the GPs were familiar with and concerned about the medical and social consequences of obesity:
‘It's so profound — it's self-esteem, it's everything else — the correlation with obesity and just about every medical condition, heaps of cancer, it's asthma, it's injury, it's everything.’ (Focus group 4)
How this fits in
The increasing prevalence of child and adolescent overweight and obesity is well-documented and there is universal endorsement that a comprehensive approach to prevention and management is required. However, little is known about the perceptions and responses of community members and professional groups, and the ways in which primary health care has responded. This research investigated and documented GPs' responses, as part of a larger investigation of community attitudes and perceptions. This is of direct relevance to clinicians in allowing them to compare their views and experiences, and to gain insight into approaches adopted by others in similar settings.
All but one of the participating GPs reported that they dealt with childhood overweight and obesity in their clinical practice, including some children with type 2 diabetes.
Causes of child and adolescent overweight and obesity
While the GPs in this study were concerned about the medical consequences, they were also strongly aware that the development of overweight and obesity among young people had many social causes, and was more than just a medical issue. They cited structural and social issues such as increasingly sedentary leisure pursuits, neighbourhood safety concerns, costs of sport, the availability of and exposure to energy-dense food, and advertising. GPs also discussed parental influences, including parents' lack of knowledge on some issues (for example, portion sizes), parental attitudes that link nurturing and eating, and parental modelling of poor eating practices (for example, skipping breakfast).
Assessing weight status
While routinely incorporating weight assessment into standard medical consultations might be ideal, it was thought to be impractical. Some GPs reported weighing and measuring all children regularly, while the majority did so primarily when calculating dosages of medication or when they had a particular concern about a child's growth or development. Some of the factors that entered into GPs' decisions about whether or not to measure height and weight at a specific consultation included the reason for the visit, time factors, and whether the family members were established or new patients. GPs reported that children's weight was a sensitive topic and that there were real risks of alienating families or losing them altogether by simply raising the issue of weight.
Weighing and measuring a child because of a concern about overweight or obesity specifically was often prompted by a parent raising the issue or because the GP was concerned:
‘I actually do the good old eyeball test and if I'm concerned what I do is I say, “Let's see how you are growing and how big you are going to be when you're 18”, and I measure their height and then say, “Let's see how much you weigh”, and we go “beep beep beep” on Medical Director [desk-top medical software], and then you have a chat.’ (Focus group 4)
There was considerable discussion (and some disagreement) in the groups about the appropriateness of body mass index (BMI) categories for children, and in particular for population groups from different cultural and ethnic backgrounds. Some GPs preferred using growth charts rather than BMI, because it seemed to make more intuitive sense to parents:
‘If they are on the 50th percentile for their height but the 100th percentile for their weight, most parents realise there is a problem, so I tend to do that rather than give a number.’ (Focus group 1)
Communicating with parents about children's weight
While it was fairly unusual, some parents did raise concerns with the GPs about their child's weight, often prompted by teasing at school, weight-related problems, or where the parents were specifically seeking the authority of the GP to motivate behavioural change in their child:
‘I think they come after they fail and tell the child not to eat that, and come to us just for confirmation from a medical man, to tell him that what he eats is wrong. That is what it is — they want [us] to confirm. It's a scaring technique.’ (Focus group 3)
More often it was the GP who had to decide whether to raise the issue. GPs recognised that children's weight is a sensitive issue because of its link to parenting behaviours, and that many mothers equate feeding with nurturing:
‘It is very hard to tell a mother to stop feeding their child so much … It's a deeply psychological thing … Yes, it's sort of “love and food”.’ (Focus group 4)
Other barriers experienced by GPs included the parents' own weight issues, and parental denial or defensiveness about their children's weight. Others felt that it was difficult to raise an issue for which there was no service available for the family:
‘How often do you get these people back? What infrastructure do you offer them? You send them out back into the wilderness really … We really need a lot more resources.’ (Focus group 4)
For these reasons, some GPs did not raise the issue independently:
‘I would invariably not talk about it, unless patients come in and talk to me about it.’ (Focus group 2)
However, the majority of the focus group participants did attempt to discuss the issue with parents, in spite of barriers, using a variety of approaches. One strategy was to discuss weight in the context of a clearly associated health problem:
‘Sometimes opportunities come, like the child is obese, and they come with some aches and pains in joints and … asthma [and ask] how do we prevent that? … Say “you do this” and she [the mother] is more likely to do it.’ (Focus group 2)
Other strategies included using humour, using a staged approach over several visits, using family histories of metabolic disorders as a starting point, or talking about eating or physical activity rather than weight itself.
Communicating with adolescents about weight
GPs acknowledged that working with adolescents was different from dealing with children. There were specific circumstances where adolescents themselves may approach a GP, or where GPs have the opportunity to raise the issue (for example, when adolescent females seek prescriptions for the contraceptive pill). GPs were aware of the aesthetic and social incentives around weight that were important for adolescents, especially females. However, GPs were also aware that emotional eating issues or eating disorders may be involved. While it was felt that adolescents were often looking for a ‘quick fix’, some of the GPs were positive about dealing with adolescents, commenting that they can be motivated to make changes:
‘It's easier with adolescents, they are a bit more aware of things and a bit more conscious of things around them and perhaps they understand better.’ (Focus group 2)
Managing overweight and obesity among children and adolescents
It was common for GPs to conduct tests and health checks as part of an assessment process, to be sure that there were no (other) serious problems and to reassure patients. Generally, GPs were confident about handling health problems associated with overweight and obesity. They felt that they were well equipped to provide factual advice and explain the health consequences of overweight and obesity.
GPs also recognised that assisting children and adolescents to manage their weight was difficult because they were dealing with the family as a whole rather than an individual patient, and that many environmental influences supported weight gain:
‘We are swimming against a huge tide …’ (Focus group 4)
Some GPs reported being actively involved in providing weight management advice to young people and their families, and felt that this was both part of their role and was expected by the families:
‘I don't refer them. I try and handle the situation. I am the family doctor. I know their family setup.’ (Focus group 2)
Some GPs reported that they provided advice on food, family food habits, and physical activity, including issues such as fats, carbohydrates, portion sizes, glycaemic index, calories, advising parents not to use food as a reward, and giving ‘lifestyle prescriptions’ to adolescents for a certain amount of physical activity. One GP asked his patients to compose a food diary and then went over it with them.
However, other GPs saw their role as more of a gatekeeper, and thought that it was not feasible for them to provide detailed dietary or physical activity advice for a variety of reasons, including limited consultation time, cost to families, and low expectations for patient compliance and success:
‘It's difficult for GPs to charge GPs' fees and to sit down and talk about kids’ diet and exercise.’ (Focus group 4)
Instead, they expressed that:
‘The GP is there to give more information to people coming in, wanting more information and details, and maybe orchestrate access to other appropriate resources.’ (Focus group 4)
GPs wanted smooth processes for referring patients to dietitians, and physical activity facilitators and systems for reimbursement for weight management.
While many GPs often suggested that the families see a dietitian, they were aware of barriers, including cost to the families and limited availability of public and private dietitian services. While perceiving that patients may consider that much dietary advice is simply ‘common sense’, GPs thought there were specific benefits from frequent contact with dietitians that could not generally occur through GPs:
‘Without the dietitians, we'd be overwhelmed, and I think it's pretty important — we can tell people what not to eat, and you need people to offer choices and offer parents, not tricks, but solutions, and a few things like that. I think it needs to be a joint process.’ (Focus group 1)
Ideal role of the GP
In spite of the perceived difficulties that surround preventing and managing childhood overweight and obesity, these GPs genuinely felt they had an important role to play. They expressed the desire to provide direct, honest advice and for this to be perceived as acceptable and helpful:
‘In an ideal world, perhaps being more proactive in helping parents identify their kid is at risk, because there is this whole like “my 3-year old, it's just puppy fat, they'll grow out of it,” when do you finally say, “it's not puppy fat, they've got a problem”, and so we maybe need to help parents identify that. So be more proactive in helping diagnose, but then also helping to steer treatment as well, and whether that is getting dietitians on board or whether it is getting schools to have a bit more focus on education and physical activity. So probably gatekeepers, helping to identify and give parents options, treatment strategies, and steering them in the right way.’ (Focus group 1)
GPs cited a number of factors that would help them to play this role. Suggestions included strategies that would help break down the barriers about discussing weight with parents and young people, including community education campaigns to normalise GPs' involvement with weight, so that people would expect them to raise the issue and provide advice as part of medical care. The idea of screening programmes in schools that referred parents of at-risk children to their GP was raised on a number of occasions. A further suggestion was for the introduction of Well Child checks as part of primary health care:
‘I think for us as GPs, a Well Child check looking beyond 5 years, where you weigh and measure kids once a year, and it's a way of getting kids in and checking for other things — like we do with our over 70s.’ (Focus group 4)
GPs also suggested the value of more professional education, more appropriate patient education materials, and increased availability of subsidised and accessible dietary and physical activity programmes to which they could refer their patients.
Beyond the GP
GPs were aware that in the current social context it is difficult for people to change their behaviours and manage their weight. There was a strong perception that GPs can be only one part of a broad set of solutions, including community education, food labelling, limiting food advertising to children, improving access to sport and recreation programmes, and safe playgrounds and open spaces. In particular, GPs saw that child care centres, preschools, schools, and school canteens provided important intervention points to reach children at an early stage, within a supportive context for healthy eating and physical activity.