Childhood overweight – let’s talk about it

Childhood overweight is a major health issue. This paper describes research conducted with Irish GPs on their role in childhood overweight. The role of GPs remains undefined, is agreed to be important, and is directly referred to in policy, and a growing body of research. We explore the role of the GP through two studies, conducted with Irish GPs, parents and children aged five to 12 years. We describe an ICGP blended learning consultation skills elearning module, launched in 2014, which is now available on a 32 county basis, the content of which has been informed by the research.

Childhood overweight – what do GPs think and do about it?

We conducted a cross-sectional postal survey, using a randomly generated sample of 20% of Irish GPs (n=527). The survey instrument was a modified version of that used by Helen Dettori, sent in three mailings. Dettori originally surveyed Australian GPs to ascertain their reluctance to engage systematically with childhood overweight in practice.¹

We obtained a final response rate of 80.2%. A majority (64.4%) of GPs responding strongly agree childhood obesity is a medical problem, but believe that parents do not share this view. Only a very small minority (3.7%) indicated they consistently check weight in routine consulting. Most do not consistently use age adjusted centile charts in their identification of overweight children, with only a minority (16.28%) doing so consistently. GPs do not consistently raise this matter in consultation with overweight children and their parents, with only a minority (8.14%) doing so always. Most GPs (89.8%) indicate they find it difficult broaching this subject when consulting with overweight children and their parents. When consulting with an overweight child, less than one in 10 GPs consistently raise the issue in the consultation. GPs do not view dietitian referral as useful (less than 10% report it to be always useful). Only a minority (11.4%) report consistent improvement in their level of confidence during the previous five years. Most (67.2%) strongly agree additional guidelines would be useful, and most (59.7%) believe availability of age/gender adjusted BMI centile charts embedded in electronic medical records would be useful. 

Summarising, GPs are very concerned, but feel unable to act systematically on this issue. Concern regarding upsetting the child and parent, and uncertainty regarding what can be done about the problem, are clearly important for the GPs surveyed. 

We wondered what would happen if we started to systematically check the weight of children.

Childhood overweight – can Irish GPs even talk about it to parents and children?

We set about systematically checking the weight of 500 children, aged five to 12 years, in 10 practices, assisted by 11 GPs. Participating GPs took a simple (30 minute) module on using correct weighing technique and on the research methodology. They proceeded to ask the parents of every five to 12 year old coming in for routine care if they would agree to checking the weight of the child as part of their consultation. Ethical approval was obtained (ICGP Ethics Committee), and funding was obtained from the National Children’s Research Centre, equivalent to e10 per parent/child recruited.

Fewer than two or less parents declined at each practice, with almost all agreeing. As expected, over one quarter of the children were overweight, with 46 being obese. After the consultation, an external research assistant conducted a telephone survey to ask parents how they felt about having their child weighed by their GP in this unexpected manner. An overwhelming majority (98.6%) of parents clearly indicated that it had been useful to do so.² A minority of all parents (4.1% or less than 1 in 20) indicated that the action may have caused their child to have become anxious, angry or upset. Interestingly, almost three out of four parents of obese children indicated that their child was not upset by their GP checking the weight of the child. We looked to see which children were most likely to be upset, and found this more likely to be older children, and that five- to six-year-olds were all reported by parents to have reacted positively (ie. were felt by parents to have been neutral, relieved, pleased, or happy).

We concluded that an overwhelming proportion of these parents welcomed GPs’ screening for overweight, and that children aged five to six years were among the most receptive and least likely to respond negatively.

Childhood overweight – how to discuss it in the consultation

Taking elements from both studies, we concluded that even though GPs are clearly apprehensive about checking the weight of children, when they began to do so systematically, it fitted easily into consultations, and was appreciated by parents, even among parents of most overweight children. Though the level of upset reported among parents was low (one-in-10 of all children and one-in-four of obese children), we now believe that while GPs are clearly skilful at communicating in this sensitive area, a blended learning module on further reducing the low level of upset reported in this study would be appropriate.

GPs enjoy the trust and confidence of parents and children who attend them. Given the impact of concerted public information campaigns during the past two years, it is apparent that almost all parents are now receptive to raising this in the consultation. The good communication skills of GPs can be further enhanced in this area of care by considering some additional pointers.

Checking the weight of children regularly will result in GPs and nurses becoming more efficient, relaxed and competent at the task. There are certain words best left out of the dialogue. It may be better to talk about checking weight, about ‘finding a better weight,’ and to avoid the words ‘fat’, ‘heavy’ and ‘obese.’ Simply referring to overweight, or ‘finding a better weight’ may be a more acceptable and effective way to go in the consultation, and to back this up with high quality and appropriate written information and web-based resources (eg. www.safefood.eu). 

Finally, it is perhaps best to focus on the family, as it is usual that parents of overweight children are themselves overweight. Consider solutions for the whole family, as opposed to a problem-orientated focus on any individual child.

The ICGP elearning module on consultation skills is now available. It includes  a comprehensive literature review, with emphasis on the ICGP-HSE algorithm for childhood overweight, as well as reliable patient information resources. It includes several video consultations and discussions relating to checking the weight of schoolchildren, and is suitable for GPs, the practice team, medical students and GP registrars. It can be used as stand alone CME, or as shared learning exercise for practice teams, CME groups and GP training schemes. The module was supported by Safefood, and includes input from general practices on both sides of the border.

The next steps

You might consider and discuss with your practice team if you wish to become more active in this area of care. Based on our studies, parents are likely to be appreciative. It is a suitable and important area for audit and practice-based research. Augment the trust and confidence in your communication skills by engaging with the e learning module. Consider coding for overweight in your electronic medical record, see what local referral resources are available to your practice, and consider having your practice nurse engage in brief interventions with obesogenic families over time. 

Full authors details: Brendan O’Shea, Emma Ladewig, Prof Tom O’Dowd, Department of Public Health and Primary Care, TCD, and TCD HSE GP Training Scheme, Tallaght Hospital, Dublin

Acknowledgements: Safefood, The National Children’s Research Centre, GPs, parents and children who participated.

The ICGP elearning module on consultation skills is now available - see www.icgp.ie

References

1. Dettori H, Elliott H, Horn J. Barriers to the management of obesity in children: A cross sectional survey of GPs. Australian Family Physician 2009; 38(6): 60-64
2. O’Shea B, Ladewig EL, Kelly A, Reulbach U, O’Dowd T. Weighing children; parents agree, but GPs conflicted. Archives of Disease in Childhood. 2014 January 15, 2014