Parents do not usually seek help for excess weight in their children except when a differential event takes place (75% of statements). This event may consist of parents noticing pronounced weight gain in their children after a routine checkup or some type of health problem (difficulty breathing, especially after physical activity, or hyperglycaemia) or, in most cases, comments from relatives or friends or episodes of bullying at school or in the peer group of the child, especially in preadolescents. If the message came from more than one source, parents were more likely to seek and accept the help of the paediatric care team. Some examples of the most representative sentences in the data extraction process were:

“When something happens in school (for instance, someone has told them something), when children express their aversion…” (R3).

“They rarely come. It usually happens when there is an abrupt change in weight” (R5).

“It commonly happens when a member of the family has excess weight and has a serious health problem, other times because children comment that they come at them, so the dimension of the problem changes, it is not the weight itself, but the consequences of obesity that children start to experience” (R6).

“Usually it is in preadolescent kids, when we measure the weight and fear it may be the tendency seen in the future. Other times they are anxious about food or engage in secretive eating, or other people are told that the child is obese” (R22).

This section explored how paediatric care teams broached the subject of childhood obesity with parents. The codes were classified into 2 subthemes: “approach to the problem: the interview with the parents” and “joint solution-seeking”.

Fifty-eight percent of paediatric health care workers reported they usually had no problems openly addressing the issue of overweight or obesity in a child with the parents or caregivers; each case is a challenge they are willing to take on and always with the intention of helping parents and children. The subject is brought up with empathy and tact, from a positive angle emphasising the improvement of the child’s health and facilitating engagement in the issue, trying not to create guilt or anxiety. A representative sentence in data extraction was:

“I don’t have an issue discussing obesity, but I try to use euphemisms (depending on the case) so that they do not feel ‘attacked’, because in my experience, referring bluntly to obesity may alienate the family” (R23).

The optimal attitude described by paediatric health care workers (100% of statements) that managed children with excess weight involved empathy, trust, respect, a lack of superiority, support and active listening, communicating without judgment or pressure, without forbidding or blaming, to promote awareness and acceptance of the problem, involving every agent in the family and, above all, helping them come up with possible solutions and offering positive reinforcement to their suggestions. Respondents considered addressing the individual responsible for shopping and cooking in the household essential. When all these aspects were fulfilled, management could be successful. The following are examples of the most representative sentences in the extract:

“I think that empathy, respect, establishing a horizontal communication pattern rather than presenting ourselves as being in charge, can also be helpful in working with caregivers” (R15).

“The presence of the adult that lives with the child, or primary caregiver, who plans and prepares the main meals of the day, is important” (R22).

“Changing lifestyle habits is very difficult, and are only possible with adequate motivation and positive reinforcement. From the clinic, we can offer support and provide that positive reinforcement, but the motivation of patients and families is key” (R23).

Most surveyed paediatric care workers highlighted the organizational barriers in the health care system, including the limited time allotted to visits, the insufficient cooperation with other health professionals and the lack of family involvement. We classified the different aspects on this topic (codes) into 2 subthemes: “improving teamwork and health care management” and “family involvement in the management and study of childhood obesity”.

Since the trust of patients and families in paediatric health care workers is essential, these professionals (46% of statements) demand more training, not on clinical knowledge but rather on motivational skills. One of the most representative sentences used in data extraction was:

“In this century, health professionals should know how to perform motivational interviewing, we should know how to investigate and address social determinants of health in these patients, because that is where 80% of the health problems of individuals concentrates, something that is much more evident when it comes to childhood overweight and obesity. Primary care is meant to be comprehensive, and our job is to work on everything surrounding our patients” (R15).

Seventy-seven percent of respondents stated that the lack of awareness about childhood obesity, a health care problem that, given that it does not immediately manifest with clear morbidity and is not directly associated with mortality, is not considered a serious health problem by patients (parents/caregivers and children/adolescents) or health professionals. In addition, 25% of respondents considered that the cultural level of the family was an important determinant, as a higher educational attainment corresponded to greater involvement and willingness to act. Some of the most representative sentences in the extract were:

“There is little awareness of this problem in Spain, not only in patients but also in the health care community, and there are also social and economic barriers due to their direct and indirect impact” (R1).

“The educational level of families is very important” (R7).

Our study explored the attitude and feelings of paediatric health care workers as regards childhood obesity, a serious public health problem that is not sidestepped by paediatric health professionals, but confronted openly, despite their awareness of the complexity of its management and the limited tools they have available to address it.

The survey of paediatric health care workers allowed us to identify 3 broad themes: “parental attitude toward obesity in their children” (subthemes: “parental awareness”, “parental demand for help”), “paediatric health workers and childhood obesity” (subthemes: “approach to the problem: the interview with parents” and “joint solution-seeking”) and “system barriers” (subthemes: “improving teamwork and health care management”, “family involvement in the management and study of childhood obesity”). We found that addressing childhood obesity is no easy task, as it requires that parents be aware of the problem and, above all, the establishment of rapport between the paediatric care team and patients and their families. In turn, both aspects may be influenced by many other factors, such as parental educational attainment, the structural situation of families and external conditions, such as parents or caregivers lacking time or the difficulty of introducing changes in household habits, and the health care and motivational skills of paediatric health care workers.

Parental awareness of the problem. The failure of parents or children to recognise excess weight is one of the main barriers to the management and resolution of childhood overweight and obesity.12,27–32 Previous studies have demonstrated that parents tend to underestimate their children’s weight,14,33 especially parents with excess weight12,32 and parents of young children,34 which contributes to the neglect of excess weight in children.32 There is evidence that 70.8% of children and 64.9% of parents in Spain do not generally perceive excess weight as a health problem.35 This denial may also stem from feelings of guilt for not knowing how to adequately care for the child, a fear of being judged by others36 or the stigma associated with excess weight that may affect both them and their children.19–21 When parents notice excess weight in their children, they tend not to worry, as it is more likely to become a problem when they reach school age, mainly on account of potential bullying or social exclusion.32,37 Parents and children accept help from health professionals after their concerns related to the excess weight reach a certain threshold.38 Motivating patients and families should be one of the first steps taken by paediatric care teams and is actually the first medical intervention required to successfully treat excess weight in children.12,32

Addressing the problem. Once trust between parents/children and the paediatric care team has been established, respondents considered important to show respect, refraining from authoritarian attitudes, offer support and active listening listening, without judging, scaring, prohibiting or blaming to facilitate the recognition and acceptance of the problem, adapting to the circumstances and health literacy of the family and offering different options, establishing short-term and attainable goals, and allowing parents to come up with possible solutions. Effective communication between the paediatric care team and parents and children is the cornerstone of treatment of childhood obesity12,39 that make it possible for the usual interventions (changes in diet and lifestyles habits, promotion of physical activity, changes in family habits, reduction of sedentary activity) to be truly effective, as they will have served to establish rapport with parents and children, overcoming the usual social and family-related barriers (lack of motivation, lack of involvement in management, blaming or mutual blaming of parents/children, quitting).12,35 It is also important to identify and speak to the person responsible for shopping and cooking in the household, as the diet of the child and family depends on this person. Approximately one third of paediatricians believed that children should be present in the conversations, even if it means that the discussion is less smooth or its contents get narrowed down, as they can come up with solutions and, in doing so, become more motivated to improve their weight.

How do paediatric health care workers feel? The sensitive nature of excess weight in children makes many professionals uncomfortable in broaching the subject, which is consistent with the findings of previous qualitative research.12,17 However, most of the health care workers surveyed in our study reported feeling comfortable and confident, no hesitation to bring up the subject and considerable willingness to intervene, mainly on account of their health care skills, which was consistent with the previous literature12,35,40 showing that previous training of paediatric care teams on the subject of obesity was essential to address this problem and overcome barriers. This attitude of paediatric health care workers in Spain, who feel capable of approaching this problem, stands in contrast to the findings in other countries, where professionals wait for the other party to bring up the subject of excess weight in children.16 Our findings also differ compared to those of another study conducted in Spain in 2008 in which 28.7% of professionals reported having little experience in the management of obesity,35 something that could be explained by the fact that the risk factors for obesity, both at the individual and social levels, have since been well defined, and there are now treatment guidelines to apply.12,41 This knowledge has been documented extensively and is available to paediatric health care workers in Spain. The adequate training of Spanish paediatric care staff differs substantially from the situation described by paediatric care workers in Sweden, where paediatric nurses, the professionals who are usually in charge of managing and monitoring children with overweight or obesity, report deficient training on both obesity and communication and motivational skills,16 educational deficits that have also been described by paediatric care professionals in other countries, who have openly expressed the need to improve training on childhood obesity.42–44

However, both physicians and nurses agree on the need for training in motivational skills that would unquestionably facilitate the development of rapport between them and parents and children and above all reinforce trust, which, as we noted above, are essential to the success of therapeutic interventions in this area.12 Along these lines, our research group recently found that a multi-session programme for management of preschool-age children with obesity that applied motivational techniques improved both the attitude of parents in relation to overweight and obesity in their children and the lifestyle and habits of children toward healthier patterns, while also achieving significant reductions in the BMI of the children.45,46 Other studies conducted in Australia, although not in the early childhood period, had similar outcomes, although with a lesser reduction in BMI.47,48

Improving the system. Despite the excellent disposition and qualifications for care delivery of paediatric health care workers, the system does not facilitate the management of childhood obesity. The health care system is a barrier in itself, due to the lack of time and excessive workloads of paediatric health care staff, the lack of educational materials, the limited access to specialists, the lack of collaboration with other health care professionals and the lack of awareness on the part of administrators of the importance of the problem.35 Still, the health care system cannot fight childhood obesity in isolation, as this is a global problem that requires the involvement of all social agents, including the education system, the administration and the mass media, as established in the official Strategy for Nutrition, Physical Activity and Obesity Prevention (NAOS).49 Therefore, the need to develop complementary activities as an intrinsic part of paediatric care must be acknowledged and efforts toward that end redoubled, so that they are integrated in primary care delivery with the collaboration of other social agents, such as teachers, exercise and sports professionals (individual or group coaching) and the mass media. In addition, health care administrations should encourage, facilitate and improve the participation of paediatric health professionals in studies on childhood obesity with the involvement of parents and caregivers, which would undoubtedly improve our knowledge of the effectiveness of therapeutic interventions used for management of obesity and also increase social awareness of this important public health problem, as lack of awareness is one of the greatest barriers faced by paediatric health care workers in their approach to the management of childhood obesity.

Lastly, we ought to comment on the homogeneity of the perceptions and attitudes of paediatric health care workers, independently of their professional category and their years of experience.

Strengths and limitations. This is one of the few studies conducted in Spain on the attitudes and perceptions of paediatric health care workers regarding childhood obesity and related barriers and conditions. A second strength is that since the questionnaire used consisted of open-ended questions, participants were able to explain their personal perspective on the issue without restrictions. A third strength was the methodological approach, thematic analysis, a flexible method that allows the systematic analysis and interpretation of large amounts of data, 25 including a careful analysis of the questionnaire responses, data extraction and subsequent discussion until a consensus is reached for definition of thematic categories and perceptions. Another strength is that we have contributed to the published evidence on the communication between paediatric health care workers and the parents or caregivers of children with excess weight, which is generally relevant. Among the limitations of the study were those intrinsic to its qualitative methodology, although the number of interviews performed (n = 57) exceeded the minimum established as necessary to achieve an integral understanding of the subject of interest (n = 16) but did not result in an excessively large amount of data, which would have made an exhaustive analysis difficult.50,51 Another limitation is the geographical scope of the study, as it was limited to the island of Mallorca, due to which the extrapolation of the data would require performance of additional studies with the same exact methodology in other areas. Yet another is that the health care workers that chose to participate may have been those most interested in childhood obesity, so that the sample may not be representative. We also did not investigate variables related to clinical practice, as that was not the objective of the study.

Paediatric health care workers feel confident in approaching childhood obesity, as they have been trained to manage this problem, although motivational skills are also required, for it is essential that parents recognise the problem and, above all, that good rapport is established between health care workers and parents/children. Effective communication between the paediatric care team and parents and children is the foundation of the management of childhood obesity and necessary for applied interventions to be effective. The health care system poses barriers to the activity of paediatric care teams that must be addressed.

This study was conducted in the framework of the STOP project (The Science and Technology in Childhood Obesity Policy) funded by the Horizon 2020 research and innovation programmeof the European Commission (ref. 774548), and the health care research fund(Fondo de Investigación en Salud, FIS) of the Instituto de Salud Carlos III through the Department of Health, cofunded by the European Regional Development Fund(ERDF) through project PI17/01827 and the CIBEROBN research network (CB12/03/30038), as well as competitive research grants including grant 35/2011 from the Government of the Balearic Islands and the European Cooperation in Science and Technology(EU-COST) programme (COST action CA16112). CB received a Fernando Tarongí Bauzàdoctoral grant. The above funding institutions were not involved in the design of the study, data collection and analysis or the writing of the manuscript.

EA, CB and JAT contacted paediatric care teams with the collaboration of all other authors, carried out the interviews and contributed to their analysis. EA, CB and JAT wrote the initial draft of the manuscript. All authors reviewed and approved the final manuscript.

The authors have no conflicts of interest to declare.