Discussing overweight in children during a regular consultation in general practice: a qualitative study

Childhood overweight and obesity is known as a globally rising problem with serious health consequences later in life [1, 2]. In 2016, 12% of the Dutch children aged 4 to 12 years were diagnosed with overweight, and 3% with obesity [3]. Weight status is classified by the Body Mass Index (BMI) and is a measure used to determine childhood overweight and obesity. Overweight is defined as a BMI at or above the 85th percentile and below the 95th percentile for children and teens of the same age and gender. Obesity is defined as a BMI at or above the 95th percentile for children and teens of the same age and gender [4, 5]. Children with obesity have an increased risk for insulin resistance, hypertension and dyslipidaemia, which predisposes them to cardiovascular morbidity in adulthood. In addition, orthopaedic and psychological problems are associated with childhood obesity as well [6, 7].

Primary care professionals are expected to have an important role in the prevention of overweight in The Netherlands [8] as they provide continuity of care [9]. For children aged 0–4 years a designated youth health care physician regularly monitors their health in general, with a limited follow up by the youth health care physician for children aged 4 to 12 years, i.e. only at the age of 5 and 10 [8]. In the past, a general practitioner (GP) would discuss patients’ lifestyle only when symptoms appeared [9]. Nowadays, a more proactive attitude is expected of GPs, especially for children. Some even state it is a GP’s duty to discuss a child’s lifestyle because of the dependent position of the child [10]. However, scarce earlier research in Europe by Paulis et al. (2012) showed that 42% experience barriers in raising the topic of obesity [11]. Although most GPs agreed on having a role in discussing and treating overweight and obesity in children [12, 13], earlier research in 2012 and 2016 showed only 26–38% of GPs discussed the child’s weight during any consultation [11, 12, 14]. GPs appeared reluctant discussing the overweight due to sensitivity of the topic. They feared for a negative influence on the self-esteem of the child and on the relationship with the parents [13, 14]. Therefore, acknowledging the potential consequences of raising the topic regardless of the reason of consultation and tools to raise the topic appropriately is of great importance. Other recognized barriers were lack of motivation and ignorance of parents [12‐15], a lack of knowledge and expertise of the GP, and lack of time. International studies also identified these barriers and additionally differences in cultural beliefs and lack of resources as barriers [16‐18].

Back in 2010, the ‘Obesity’ guideline from The Dutch College of General Practitioners was introduced [19]. This guideline state that every obese looking child should be examined regardless of the reason of consultation. Whereas the guideline primarily focuses on diagnostics and treatment of overweight and obesity in children, we conducted this study to, get insight in GPs perceived barriers in discussing overweight and obesity during a regular consultation in children aged 4–12 years since the implementation of the guideline in The Netherlands and to what extent they discuss the topic. Furthermore, we attempt to get more insight in the specific needs and ideas for improvement among GPs with a broad range of demographics.

In total, interviews with 10 GPs were included in the data analysis. Demographics of the participating GPs, i.e. graduation year, gender, structure and location of the general practice, are presented in Table 1. The duration of the interviews varied from 42 to 71 min. Sixty percent of the participating GPs was female, of whom one in her last year of GP training. Overall, the median of experience in the profession as a GP was 7.5 years. GPs in relatively rural areas with an urbanization rate of N < 40.000 had a median of 8 years of experience (n = 4), whereas for the relatively urban areas with an urbanization rate of N ≥ 40.000 the median of years’ experience was 6 (n = 6) [20].

This qualitative study explored the different challenges of GPs in addressing overweight in children during regular consultations. Despite the introduction of the diagnostic and therapeutic tools provided by the Dutch guideline ‘Obesity’ for GPs in 2010 [19], GPs experience barriers in discussing overweight. We identified four themes of the interview: absence of physical or mental complaints, internal barriers of the GP, the child’s family background and logistics. The major barriers eventually identified were a low consultation rate, the sensitivity of the topic (e.g. fear for patient’s reaction and/or disturbance of the relation, influence on the self-esteem of the child, resistance in the parents), the absence of a long-standing relation between the general practitioner and the child or parent, the background of the child and lack of time or prioritizing. These findings are consistent with previous literature [11‐14] and are in this study still identified after the implementation of the guideline back in 2010. Besides, a newly identified barrier concerns the consultation rate of children aged 4 to 12 years. As mentioned before, signalling and providing preventive healthcare might be a task specific for the GP, given the continuity of their care in the general practice. Although GPs in this study agreed on being part of this process, they also emphasize that Dutch children aged 4 to 12 years do not have a high consultation rate due to lack of physical complaints in this age group. In 2015, children aged 4 to 12 years had a consultation rate of about two visits per year [21]. Furthermore, they mostly do not have weight-related complaints which make acknowledging overweight in children challenging in general practice. Therefore, the absence of physical or mental complaints is an important, newly identified, barrier. In international literature, the length of interval between visits of children is also mentioned by health care professionals in general as a barrier [16]. Therefore, the prior focus might be raising awareness among parents concerning overweight in children aged 4 to 12 years and, thereby, stressing the potential supporting role of primary care professionals in tackling the overweight of their child. Despite the introduction of the diagnostic and therapeutic tools provided by the Dutch guideline ‘Obesity’ for GPs in 2010 [19], lack of knowledge and skills was mentioned as a barrier in this study. Paulis et al. (2012) mentioned length and weight are often not measured during non-weight related visits and that GPs do not feel comfortable in treating overweight because of lack of skills or knowledge [11]. GPs stated that the youth health care physician should play an active role as well [12]. However, the continuity of care for these professionals is limited to two consultations in the context of preventive healthcare at the age of 5 and 10 and, therefore, a barrier as well [13]. The barrier of limited routine contact opportunities by preventive healthcare professionals is mentioned in international literature as well [16]. As Schalkwijk et al. (2016) reported, youth health care physicians suggest a yearly check-up as a solution [13]. The sensitivity of the topic overweight appeared as one of the major barriers. This is in line with previous Dutch [11‐14] and international research [16, 18, 21‐24]. As explained before, the sensitivity lies in the fear of a negative influence on the self-esteem or happiness of the child [13] as well as resistance one may encounter with the parents [11‐14, 16, 25]. However, this fear might be unnecessary as uninvited advice might also be appreciated by patients. In a fairly representative sample (n = 969) of the Dutch population, 68% agrees on the important role of the GP to give uninvited advice concerning overweight [9]. However, the National Child Measurement Programme (NCMP), a child weight monitoring system in England encountered resistance and concerns from parents about discussing the child’s overweight during regular consultations [25]. This strengthens the thought of raising awareness among parents concerning overweight in children aged 4 to 12 years and the need for tools to raise the topic appropriately. Concerning the barrier of ‘lack of time or prioritizing’ different results have been found in previous studies. While we showed ‘lack of time or prioritizing’ as a barrier in discussing overweight, Paulis et al. (2012) reported that GPs do not experience lack of time as a barrier in raising the subject of ‘overweight’, but do so in the diagnostic work-up [11, 12]. Other studies reported it also as time consuming to discuss [14] or treat overweight [13]. Interestingly, in our study, the doctor-patient relation was mentioned both as barrier and facilitator. GPs are reluctant due to their fear to disturb the relation, which is in line with previous studies [13, 14]. GPs in the present study also referred to the absence of a long-standing relation between the GP and the child or parent as a barrier, and therefore, the lack of knowledge of the patients’ social and medical situation. This might be explained by the inclusion of acting GPs in this study implicating the absence of a longstanding doctor-patient relation. Investment in a firm relationship accompanied by more knowledge as mentioned before might facilitate discussing overweight. Barriers that were previously mentioned, but not identified in this study are, for example, lack of effective interventions and lack of resources and reimbursement [18, 22‐24, 26]. This might be explained by the organization of the health care systems in different countries [27, 28]. For example, rural areas are more common in certain regions of Western countries such as the United States of America (USA), Canada or Australia, where lack of resources is more likely to be a barrier. The access to overweight related projects and/or healthcare providers might be limited therefore. However, Dutch GPs mention a lack of (effective) overweight related projects as well [14]. Furthermore, nurse practitioners have an important role in preventive health care in the USA. They provide general health visits or yearly check-ups and may have more specialized knowledge and skills on addressing these sensitive issues than Dutch GPs have [27]. Therefore, the applicability of these results is limited to the Dutch population.

In conclusion, Dutch general practitioners seem to experience barriers in discussing overweight during regular consultations despite the availability of the diagnostic and therapeutic tools in the Dutch guideline ‘Obesity’ for general practitioners introduced in 2010 [19]. The limited consultation rate in children aged 4 to 12 years due to lack of physical complaints is one of the newly and most important barriers hindering the signalling role of the GP. Other newly identified barriers were a patient’s background (e.g. culture) and the absence of a long-standing relation between the GP and the child or parent. Important barriers as the sensitivity of the issue and lack of time or prioritizing were identified once again. This study implicates room for improvement in discussing overweight during regular consultations. Improvement of GPs’ knowledge and/or skills and awareness in parents may lead to decreasing the sensitivity of the topic. However, due to absence of physical complaints in children aged 4 to 12 years, the prior focus might be raising awareness among parents concerning overweight in children aged 4 to 12 years and, thereby, stressing the potential supporting role of primary care professionals in tackling the overweight of their child.