The World Health Organization has labelled obesity as “the 21st century epidemic.” In recent decades, there has been a progressive increase in the prevalence of obesity with a negative impact on morbidity, mortality, quality of life and health care costs,1,2 and childhood obesity is associated with an increased risk of obesity in adulthood.3,4 Comorbidities may be present from the first years of life, and patients often present with several risk factors for cardiovascular disease.5,6 Furthermore, obese children use health care services more than children with normal weight.7 Therefore, preventive interventions must be implemented at the family, school, health care and community levels to promote healthy lifestyle habits and behavioural changes in regards to diet and physical activity, along with the measures taken to manage obesity and its comorbidities.8–10

While evidence-based guidelines and protocols for the management of childhood obesity have been developed, there is insufficient data on the challenges met in their implementation, which will vary by health care setting. The aim of our study was to describe the approach of paediatric endocrinologists to the clinical management of childhood obesity, with emphasis on differences in management between levels of care.

We received 125 completed questionnaires, with representation of every autonomous community in Spain (Fig. 1A); 94% of respondents were employed in secondary or tertiary care level hospitals (Fig. 1B). The primary level of care is the point of entry to the health care system, the secondary level of care is the care delivered at regional hospitals (general medicine, general dental care, clinical laboratories, radiology, emergency care, inpatient care and low-complexity maternity care) and general hospitals (medical clinics, inpatient wards, basic emergency care, intermediate-complexity maternity care and caesarean sections, general and specialised dental care, outpatient nutrition, psychology and rehabilitation services), and the tertiary level of care is the care delivered in referral hospitals (advanced diagnosis and treatment of patients with complex diseases referred from primary and secondary level facilities).

Figure 1.

(A) Distribution of survey responses by: autonomous community where respondent practised and (B) level of care. (“Other” includes private clinics and primary care centres).

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Initial assessment and follow-up appointments

The distribution of the number of visits related to obesity per month was similar for every level of care (Fig. 2A). We found differences between levels of care in the proportion of facilities that received more than 20 visits by patients with a new diagnosis of obesity. None of the respondents employed in a secondary level hospital reported having more than 20 new obesity patients a month, compared to 5.5% of respondents in tertiary level hospitals (P=.02) (Fig. 2B).

Figure 2.

First childhood obesity-related visits and follow-up visits by level of care.

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When it came to new patients, most respondents (67.2%) reported devoting between 15 and 30min to the first visit, and there were no differences based on level of care (Fig. 3A). As for the frequency of follow-up visits, 34% reported scheduling them “every 3 months”, 17% “every 6 months”, 15% “every 2 months”, 14% “monthly or more than once a month” and 11% “based on the patient's condition”.

Figure 3.

Level of care and availability of resources.

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We found a significant association between level of care and the frequency of follow-up evaluation of obese patients (P=.036). The proportion of respondents that scheduled monthly follow-up visits was 67% at the primary care level (with follow-up visits more than once a month in 11%), 15% at the secondary care level and 7% at the tertiary care level, while the proportion of respondents that scheduled follow-up visits every 6 months was 11% at the secondary care level and 23% at the tertiary care level (none of the primary care paediatricians reported scheduling follow-up evaluations at 6-month intervals).

Successful treatment of obesity depends on the training and approach of health care professionals as well as the availability of health care resources and the involvement of multidisciplinary teams.11 Despite the availability of clinical practice guidelines published in Spain and abroad with the aim of optimising health care for paediatric patients with obesity, we found considerable variability in the management of this condition among respondents.

The surveys found in the literature, such as the Encuesta Nacional de Salud (National Health Survey), were designed to determine the prevalence and incidence of obesity12 or addressed to general paediatricians and physicians.13,14 However, there are no studies describing real-life clinical practice in the management of paediatric patients with obesity by paediatricians specialised in endocrinology.

The response rate usually achieved in surveys of health care professionals by means of online questionnaires ranges between 17% and 51%.15,16 In our study, it was 49.4%, which is considered adequate based on studies regarding the response rate obtained in this type of online survey.17 Thus, we obtained a representative sample of paediatric endocrinologists in Spain, with respondents from every autonomous community and employed in every level of care.

Nearly 50% of respondents met with 10–30 patients a month for follow-up of overweight or obesity. These data were consistent with the increased prevalence of this disease in Spanish children and adolescents.18 There was variability in the number of patients managed by respondents, which may have been due to differences in the size of the catchment population, population density or health care infrastructure between autonomous communities.19,20

Most respondents reported spending 15–30min with each patient (67.5%), and 6% reported spending fewer than 10min. Based on current recommendations8–10 for the initial assessment and followup of these patients, which include a comprehensive anthropometric evaluation, psychological evaluation with exploration of family dynamics, and administration of questionnaires regarding dietary, physical activity and other lifestyle habits, an appointment duration of fewer than 30min seems insufficient, although there are no specific recommendations on the duration of appointments.

Few facilities had nutritionists on staff (29%), and these specialists were more frequently available in tertiary care hospitals. A nutritional assessment by professionals specialising in children with chronic disease is essential,1,10,21 and should be included in management protocols. This assessment is key to prevent potential complications, such as malnutrition, and to develop an appropriate treatment plan for each patient.

Our survey found very small differences in dietary management. Almost 89% of paediatricians made modifications to the current diet of the patient, and paediatricians were most frequently responsible for providing nutritional guidance. Studies on the effectiveness of dietary management have generally been of poor methodological quality, had short durations of followup, and had not assessed long-term weight loss,22 so at present we do not know which diet is most effective for management of overweight and obesity in the paediatric population,23–25 and low-glycaemic index diets with carbohydrate restriction seem to be as effective as low-calorie diets for short-term weight loss.26 In adults, a 15–30% reduction in energy intake compared to the previous diet is recommended based on baseline energy requirements.27 Actual clinical practice adhered to recommendations,28 as only 4% of respondents used fixed low-calorie diets, and 6.4% customised low-calorie diets for each patient.

Based on level B evidence, psychological support is recommended for the management of overweight and obesity in children and adolescents, as is the use of stress management interventions and other psychological approaches.29,30 However, in our survey, only 30% of respondents reported such support being available, and only 13.6% worked in facilities that had a behavioural therapy protocol. Contrary to what we expected, the proportion of paediatric endocrinologists that could refer patients to cognitive behavioural therapy was greater in those employed in secondary care hospitals, although we found no differences between levels of care in the proportion of facilities that had a child psychologist or psychiatrist on staff.

Psychotherapy is probably the area in which the management and follow-up of these patients is most deficient. It would be helpful to assess whether the recent official recognition of child psychiatry as a distinct specialty31 helps remediate this lack and raise awareness on the care needs of this population. In fact, an expert psychological evaluation is absolutely indispensable in morbidly obese adolescents in whom surgical treatment is being considered. Furthermore, recent studies have shown that the use of stress management interventions in the treatment of these patients is associated with a reduction in BMI and an improvement in depression and anxiety symptoms.32,33

Clinical practice guidelines do not recommend routine use of pharmacotherapy for treatment of obesity in children aged less than 12 years.8–10 In our study, 30% of respondents had prescribed drugs for treatment of childhood obesity. The drug prescribed most frequently was metformin, which has been found to achieve reductions in BMI of less than 5% in children with obesity and insulin resistance aged 10–14 years.34 Both metformin and orlistat are off-label drugs. The law35 stipulates that physicians must inform patients or their legal guardians of the benefits and risks of off-label drug use and obtain written informed consent for such treatment. However, 67% of respondents that prescribed drugs did not seek informed consent. Our findings were consistent with the 2012–2013 national survey on the use of these drugs in paediatrics practice.36

Based on our data, treatment of childhood obesity with bariatric surgery is nearly incidental, as few patients fulfil the eligibility criteria.37 Indeed, clinical practice guidelines both in Spain and abroad assert that bariatric surgery in the paediatric age group should be restricted to very specific and carefully selected cases.8–10 In addition, only 36% of facilities in our survey offered this surgery, which would explain why most paediatricians were not acquainted with the different bariatric surgery techniques. The technique used most frequently to date is gastric bypass, which achieves the greatest weight loss and on which the evidence is of higher quality.38 Some autonomous communities have stated a need to regulate bariatric surgery, including specific stipulations for surgery in adolescents.39

We also found differences as to the management of patients that do not respond to initial treatment: hospital admission (14.2%), referral to psychiatry or mental health services (12.8%) or discharge (43.2%), depending on the availability of different resources. However, only 12.8% reported referring these patients to psychiatry or mental health services, when one third report that these services are available to their patients. It is worth wondering whether there is any other disease in which over 40% of patients that do not respond to initial treatment would be discharged and considered to be treatment failures. Perhaps this percentage is this high because obesity is not quite considered a disease and because paediatricians may feel ineffective and discouraged in the treatment of obesity.13,40

Selection bias is one of the potential limitations affecting the relevance of our study, as we only analysed responses submitted by paediatricians members of the SEEP that chose to complete the questionnaire, and not having included other paediatricians specialised in the management of childhood obesity in other health care settings (primary care, gastroenterology or nutrition services, etc.).

There is also a risk of information bias due to the presence of incomplete responses and the limited number of variables under study. Thus, our study did not specifically assess interventions involving physical activity, as the Spanish health care system does not offer any services in this area, and such interventions are usually organised in the community, and sports activities offered by educational and recreational facilities.

Future research on this subject could include performance of the same survey on SEEP members to assess changes in current clinical practice, surveys of other paediatricians devoted to the management of obesity, who usually remain in the field, and also assessment of the success rate of treatment and the recommendations on physical activity or other interventions related to obesity that were not included in this study.

In conclusion, few paediatric endocrinology units adhere to the recommendations of the Clinical Practice Guideline for the Prevention and Treatment of Obesity in Children and Adolescents included in the quality assurance plan of the Public Health System of the Ministry of Health and Social Policy of Spain. The heterogeneity of clinical practice is probably due to a lack of standardised protocols and resources for the multidisciplinary management of these patients. Pharmacological treatment is rarely used in childhood obesity, and there is limited experience in bariatric surgery. We did not find many differences in the approach to childhood obesity between secondary and tertiary level hospitals, although the latter usually had larger caseloads of these patients and (at least reportedly) had nutritionists and/or psychologists on staff more frequently than secondary level hospitals. Thus, the care of paediatric patients with obesity falls to the paediatrician, as the multidisciplinary treatment approach has yet to be truly established in Spain.

The authors have no conflicts of interest to declare.