Aim: The aim of this study is to investigate the attitude of the health care providers working in main referral hospitals in Riyadh city regarding management of overweight and obesity among children and adolescents and to identify the main barriers of implementing prevention and control program. Methods: This is a cross-sectional survey targeting all paediatric practitioners including paediatric physicians and nurses who were available during the study period. A self-administered questionnaire was used which include demographic characteristics and the measures of attitudes, barriers, information source, previous training, future continuous training about management of obesity and overweight among child and adolescent. Data analysis was performed using SPSS package. Results: findings showed that most physicians and nurses reported that childhood overweight and obesity are important public health problems and needs proper management (67.5%- 76.5%) and considered as a future chronic disease risk (71.1%, 73.0%) that would affect the future quality of life (85.0%, 73.9%). Paediatricians were less likely to report low proficiency in behavioural management, providing guidance in parenting techniques and in addressing family conflicts (32.4%, 34.3, 37.8%, respectively); For nurses, very low proficiency were also reported in almost all the statements related to perceived skills, ranging from 8.5% to 17.6%, with a significant differences in proficiency when compared between paediatricians and nurses (p<0.05). Conclusion: The study findings might help to identify several areas to be improved in promoting engagement of health care professionals in managing overweight and obesity among children. Raising burden of overweight and obesity require integration and collaboration between different key partners to empower direct role of health care providers at health care settin
|Obesity, overweight, childhood, adolescents, Paediatrician, Saudi Arabia
|Childhood obesity and overweight are one of the most
serious public health challenges of the 21st century.
Globally in 2010 the number of overweight children under
the age of five is estimated to be 42 million; close to 35
million of them are living in developing countries 
However, the actual estimated prevalence of overweight
and obese children is substantially lower than what is
usually reported[2,3]. Overweight and obesity are not
a matter of adults only, but boys and girls, children and
adolescents have become victims too, with significant reported rates . Consequently, it is expected that the
rates of coronary artery disease, type 2 DM, hypertension,
dyslipidaemia, and fatty liver, obstructive sleep apnoea,
and certain types of cancer will increase in the coming
decades particularly in developing countries [5-9].
|Studies of paediatric health care providers and their
way of managing obese children show indications of
inadequate management in different international settings
. Some authors referred it to the inadequate training
of the health care providers in the management of obese
children or adolescents which further leads to either under-diagnose or under-treatment of the obese subject .
Consequently, many recommendations were developed to
show the importance of training for the health providers
in concern with this issue and to empower them for better
management and prevention of overweight and obese
children and adolescents [12,13].
|Several studies have been conducted in Saudi Arabia
highlighting the high rates of obese and overweight
children and adolescents as well as in adults; however,
none of these studies showed the gap in the management
process, particularly from the point of view of health
providers; thus, it has not been investigated yet. Moreover,
many healthcare providers, including those in obesity
work, are unaware of the high prevalence of obesity in
children and adults in Saudi Arabia and the other Gulf
states . The epidemic in this location is more severe
than in any other part of the world,  so the study of
the problem and potential solutions in Saudi Arabia is of
great importance. aim of this study is to investigate the
attitude of the health care providers working in main
referral hospitals in Riyadh city in managing overweight
and obese child or adolescents and to identify the main
barriers of implementing an obesity prevention program.
Material and Method
Study Population and Design
|This is a cross-sectional survey targeting all paediatric
practitioners including paediatric physicians and nurses
who were available during the study period. The setting
of the study included the three main tertiary hospitals in
Riyadh City, Saudi Arabia: King Abdul Aziz Medical City
at the National Guard Health Affairs, King Fahad Medical
City which is run by the Ministry of Health, and the Army
Forces Hospital. The study proposal was approved by the
IRB in the King Abdullah International Medical Research
Center (KAIMRC). All the participants in this survey were
consented and the objectives of the study were clearly
|The data collection tool (self-administered questionnaire)
was the same English validated questionnaire used in a
similar previous studies conducted in the USA [16,17].
However, some questions were excluded from the
original instrument where found not applicable to the
local context of Saudi Arabia. Our pilot study of the final
version of questionnaire did not show significance effect
of the removed questions from the original one where the
Cronbach alpha reliability test was 0.76. The final version
of the self-administered questionnaire consists of two main
sections: the first section about the personal demographic
and background characteristics; and the second section
aim to measure paediatric practitioners and nurses on
management of obesity and overweight among child
and adolescent. These measures consist of five domains
addressing their attitudes, barriers, information source,
previous training, and their future continuous training. For
most domains, the level of respondents were measured on five points Likert scale as ?most of the times?, ?often?,
?sometimes?, ?rarely? and ?never?. The cut-off point of
accepted positive response for each domain as reported by
the respondents on the scale was ?often? or ?most of the
|The following section describes the domains/items of the
|This domain has been assessed by set of questions asking
participants about ?the need of treatment for children and
adolescents?; ?overweight children and adolescents will
outgrow their overweight?; ?children and adolescents
are more amenable to treatment than adult overweight?;
?overweight childhood and adolescent have an effect on
chronic diseases and quality of life in future?.
|Nine items were used to assess and identify the perceived
barriers on treatment approaches, including the lack of
one or more of the following: patient motivation, parent
involvement in treatment, clinician?s time, reimbursement,
clinician?s knowledge about treatment, treatment skills,
support services and concern about precipitating eating
disorders. Participants were also asked how they assess the
importance of each barrier to reach an effective treatment.
Source of Information
|In this domain, participants were asked about the most
frequently used sources of information to help in assessing
the level of overweight and obese children or adolescent
and the approach applied for the treatment. These sources
included questions related to their under graduate/post
graduate training program previously received, reading
specifically and professionally related journals or articles,
attending workshops/seminars/programs, using some
reference textbooks, using their past experience or making
benefit of the available mass media, utilizing the web sites
or even sessions from pharmaceutical companies.
Preferred method of education
|Participants were asked to answer ?Yes? or ?No?
responses for their preferred method of education. These
include questions about their preferred professional and
institutional guidelines; continuous medical education
(CME) courses at national and local meetings; web sites;
telephone conferences; televised lectures; videotapes and
Proficiency and interest in future training
|A set of questions were used to assess perceived skills
of the participants for treating overweight children.
These include items related to the uses of management
strategies, modification of patient diet, modification of
patient physical activity, modification of patient sedentary
behaviours, using some guidance in parenting technique,
addressing family conflicts and assessment of the degree of overweight. In this domain, the participants? responses
were measured on three points Likert scale as ?low?,
?moderate?, and ?high?.
|Data analysis was performed using SPSS statistical
computing package (SPSS software, version 20, USA).
Frequency distributions and percentage of respondents
were calculated for all domains. Then, the Chi Square (X2)
statistic was used to test if there is a statistical significant
differences between physicians versus nurses for the
domains i.e. attitudes, barriers, perceived management
skills /training interests, and preferred education methods,
and statistical significant p value were set at < 0.05.
|From the total of 210 questionnaires distributed to the
professionals in concern at these three hospitals, 154
were collected with a response rate of around 73%; 40
were paediatricians and 114 were nurses. Moreover, the
response rate was lower among paediatricians than among
nurses (66.6% versus 75.2%, respectively).
|The majority of respondents in the two studied professional groups (paediatricians and nurses, respectively) felt
that adolescent overweight was a condition that needed
treatment (67.5%-76.5%), and considered as a future
chronic disease risk (71.1%?73.0%) as well it would affect
the future quality of life (85.0%?73.9%), as seen in table 1.
More than half of the health providers felt that childhood
overweight was a condition that needed treatment (57.5%-
58.8%) and either childhood or adolescent overweight was
more amenable to treatment than adult overweight (85.3%,
56.4% and 55.0%, 58.9%, respectively). Around one third
of participants felt that overweight children or adolescents
would outgrow being overweight. However, no significant
differences were found among paediatricians compared
to nurses in all of the attitude statements (p>0.05).
Paediatricians were less likely to agree with some of the
statements particularly those related to the need of treatment
for overweight adolescents. In general term, regarding the
attitudes it shows no statistically significant differences
between physicians versus nurses, as seen in table 1.
|Table 2 show the most frequent barriers cited by
practitioners. The overall barriers cited by them were lack
of patient motivation (84.1%) or lack of parent involvement
(77.3%), and followed with the lack of support services (60.3%). Near half of paediatricians and nurses cited that
the lack of clinician time, lack of reimbursement, lack of
clinical knowledge and eating disorder concerns were the
important barriers. Around two thirds of the paediatricians
and over half of the nurses identified treatment futility as
a barrier either most of the time or often. In general, lower
percentages of nurses mainly identified treatment barriers
compared with paediatricians. No statistical significant
differences found between physicians and nurses
regarding their perception of barriers in managing obesity
and overwrite among children and adolescents (p >0.05).
Perceived skill level and interest in training
|Overall, paediatricians were less likely to report low
proficiency in behavioural management, providing
guidance in parenting techniques and in addressing family
conflicts(32.4%, 34.3, 37.8%, respectively); likewise, they
reported very lower proficiency in addressing patient diets
and eating practices, patients physical activities, patient
sedentary behaviour and the assessment of the overweight
degrees (19.4%, 22.9%, 19.4%, 20.0, respectively). For
nurses, very low proficiency were also reported in almost
all the statements related to perceived skills, ranging
from 8.5% to 17.6%. The significant differences (p<0.05)
were found in proficiency when compared between
paediatricians and nurses mainly in those aspects related
to the use of behavioural management strategies, guidance
in parenting techniques, and addressing family conflicts,
as shown in table 3.
|As long as the interest in training is concerned, both
groups expressed moderate interest in additional training
for all of the skill areas, and were more among nurses
than paediatricians (Table3). Over half of the nurses?
respondents expressed interest in additional training in
the use of behavioural management strategies and patient
diet or eating practices. Paediatricians were less likely
interested in training related to obesity management.
The differences were significant between nurses and
paediatricians in most of the categories (p<0.05).
Preferred continuous education methods
|Respondents were asked which methods they would use
to improve their ability to treat overweight children and
adolescents. Across the two professional groups, the
preferred method was professional guidelines (91.0%),
followed by computer-based programs (88.8%), text
books (86.6%) and CME courses at national meetings
(82.6%), while the least preferred method was telephone
conferences (29.9%), as seen in table 4. Significant
differences in preferred methods were also observed
between paediatricians and nurses in both computer
programs and telephone conferences as sources of
information on evaluation and treatment of paediatric
|With the tremendous development in technology in the 21st century, the world faces an urgent challenge of
overweight and obesity . The burden of the this public
health problem start each year increases to affect heavily
children and adolescents .
|In this study, findings showed that physicians and nurses
agree that childhood overweight and obesity are important
public health problems and they would like getting more
training in methods to tackle this health problem; however,
they are still facing a number of barriers to manage this
conditions effectively. It has been reported that, although
health professionals should play an important role in the
prevention and treatment of excess weight and obesity,
their capabilities to manage such cases with overweight
or obesity is limited . The study findings showed
that Paediatric practitioners expressed that child and
adolescent obesity needs urgent interventions to overcome
the barriers that prevent them from providing effective
treatment, specifically the expressed concern of paediatric
practitioner in our study is still lower than findings reported
in other study by Story et al., (2002) in the United State
. This is likely to be a cultural difference between
Saudi Arabia and the US in whether childhood/adolescent
overweight is accepted in our local as a normal part of
child development where, some people locally considered
obesity and overweight as desirable and sign of beauty and
in some as a feature of affluence .
|Our respondents? perceived low proficiency in counselingrelated
skills needed to manage obesity and overweight
effectively. Physicians who were aware of the low
proficiency level in obesity management were significantly
less likely to express the needs for training in this part.
It seems that topics related to assessment and counseling
strategies and behavioural management techniques for
paediatric obesity treatment and management are not
given enough attention in the medical and nursing schools
curricula or professional continuous training. Some
researchers have indicated to the significance of obesity
and how medical school curricula should reflect the
management and treatment of this issue [19,22], showing
an improvement need in the knowledge and resources to
manage and treat obese children, but some barriers still exist
including for example the lack of time and compensation
for the practitioners . A recent study in the United
State have illustrated that the importance of education
and training evidence-based assessment and counseling
techniques . Therefore, directions and priorities for
training, education, and advocacy efforts are necessary
mainly for nurses as well as for health practitioner. This
type of information could be incorporated into preprofessional
education programs. In our study a high
proportion of practitioners identified continuing education
at local and national meetings and professional guidelines
or standards of practice as preferred educational methods.
|Among the most prominent barriers identified and cited by
the majority of paediatricians and nurses in this study were
lack of patient motivation and lack of family involvement.
|Other barriers such as lack of support services, lack of
clinician time, lack of reimbursement, lack of clinical
knowledge and eating disorder are considered of less
important barrier. Tershakovec and colleagues , has
found that paediatricians in a paediatric obesity referral
clinics were reimbursed for the treatment of obesity with
low frequency of the time. Other survey also has found
that reimbursement is a major deterrent to the treatment
of obesity . Thus, modification in the current
management care policies in child obesity and adolescence
are commented by the health care professionals to be
changed . The reason for this is that no enough time
and resources were given to provide obesity services for
children and adolescents. Thus, more advocacy efforts and
legislative initiatives are needed to ensure coverage for the
delivery of both preventive and treatment services with
adequate skills and number of health providers in concern
|Our study found that both paediatricians and nurses agreed
that childhood/adolescent overweight is an important
public health problem. Nevertheless, there was a larger
percentage among paediatricians than nurses expressed
having a low skill level in management strategies for
patients and their families. Both paediatricians and nurses
expressed moderate interest in additional training for all of
the skill areas, mainly is more among paediatricians who
expressed less interest in training than nurses.
|It was not explained why many practitioners did not
express their interest in training regarding obesity
assessment. This is perhaps because paediatricians see
their health provider role is more as a clinician practitioner
than as a behaviour management expert . A study
conducted among the Child Health Care (CHC) nurses
conceptions of their preventive work with childhood
overweight and obesity in CHC centers in Sweden showed
that personal priorities, knowledge, responsibility and
the absence of resources and cooperation, as well as the
lack of uniform guidelines for preventing and managing
childhood overweight and further a deficient management
organization.12 Other reports have shown the importance
of having community programs that include schools
and dieticians, among other resources, can be effective
in promoting behaviour change in overweight children/
adolescents and their families [30,31]. Unfortunately,
such programs are not yet established in Saudi Arabia;
however, if it exists at the level of the schools for example,
it would be likely effective in altering behaviour with
parent?s participation in these programs. Such programs
allow other professionals to share the responsibility for
motivating behaviour change in overweight children/
adolescents including paediatricians and nurses.
|Although, training and continues education sessions in the
treatment and prevention of obesity and overweight are of
paramount important , physicians expressed low rank
on lack of having effective obesity treatment as one of the
top three barriers.
|Overall, paediatricians were less likely to cite low
proficiency in behavioural management, providing
guidance in parenting techniques and in addressing family
conflicts but more likely to identify low proficiency in
addressing patient leading behaviours to gain weight
and become obese. Significant differences were found
in proficiency between paediatricians and nurses as to
the use of behavioural management strategies, guidance
in parenting techniques, and addressing family conflicts.
Similar findings were shown in other studies where
practitioners commonly expressed low proficiency
and confidence in their ability to help patients change
behaviours [16, 32, 33]. However, better and more
consistent assessment of obesity could increase awareness
of the extent of the obesity problem, provide a basis for
monitoring individuals and populations, and provide early
prevention and treatment efforts.
|Although the results of this study identify issues in the
provision of care to overweight children and adolescence
and highlight areas for additional training, we need further
study to be conducted to assess the attitudes and training
needs of physicians and nurses working in primary care
practices where they would encounter and treat overweight
children/adolescents on a more regular basis. Moreover,
educational programs those teach counseling techniques
in medical and residency training for physicians and in
undergraduate and graduate training for nurses will help
develop skills of future practitioners. In addition, short
courses are needed to provide opportunities for current
practitioners to improve proficiency. Continuing education
could provide a readily accessible forum for training in
these topic areas.
|Additional research that replicates and extends the findings
from this study should be conducted. Consequences
of widespread and severe obesity for Saudi society are
serious, and the effectiveness of the Saudi medical system
to respond will be extremely important for the rest of the
world. In the face of a frightful crisis, Saudi healthcare
providers have an opportunity to light the way for their
colleagues worldwide. Thus, we also recommend studying
attitudes of these very important front-line providers.
|The findings in this study might help to target several areas
in which training and enhancement of having effective
approach in promoting engagement of health care
professional in managing overweight and obese children.
Thus, adequate and consistent assessment of obesity
and obesity- related health conditions will improve the
identification of children at risk. Improved treatment
will depend on the development of therapies that can
be applied effectively and efficiently in any health care
settings which should also extend to include the primary
health care settings.
|To control the raising burden of overweight and obesity
will require integration and collaboration between different key partners including community, schools and
to control the environment in addition to enforce the direct
role of health care providers at health care settings.
Conflict of Interest Statement
|No conflict of interest was declared.
|Special thanks to KAIMRC for support conduct the
research and for Mr. Mutaz Amin for his English editing.
|1. Brownson RC, Chriqui JF, Burgeson CR, Fisher MC, Ness RB. Translating epidemiology into policy to prevent childhood obesity: the case for promoting physical activity in school settings. Ann Epidemiol. 2010; 20: 436-444.
2. Wijnhoven TM, van Raaij JM, Spinelli A, Rito AI, Hovengen R, Kunesova M, et al. WHO European Childhood Obesity Surveillance Initiative 2008: weight, height and body mass index in 6-9-year-old children. Pediatr Obes. 2013; 8: 79-97.
3. Caterson ID, Gill TP. Obesity: epidemiology and possible prevention. Best Pract Res Clin Endocrinol Metab. 2002; 16: 595-610.
4. El-Hazmi MA, Warsy AS. The prevalence of obesity and overweight in 1-18-year-old Saudi children. Ann Saudi Med. 2002; 22: 303-307.
5. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med. 1992; 327: 1350-1355.
6. Block JP, DeSalvo KB, Fisher WP. Are physicians equipped to address the obesity epidemic? Knowledge and attitudes of internal medicine residents. Prev Med. 2003; 36: 669-675.
7. Barlow SE, Richert M, Baker EA. Putting context in the statistics: paediatricians' experiences discussing obesity during office visits. Child Care Health Dev. 2007; 33: 416-423.
8. Cali AM, Caprio S. Obesity in children and adolescents. J Clin Endocrinol Metab. 2008; 93(11 Suppl 1): S31-6.
9. Weigel C, Kokocinski K, Lederer P, Dotsch J, Rascher W, Knerr I. Childhood obesity: concept, feasibility, and interim results of a local group-based, long-term treatment program. J Nutr Educ Behav. 2008; 40: 369-373.
10. Gupta N, Goel K, Shah P, Misra A. Childhood obesity in developing countries: epidemiology, determinants, and prevention. Endocr Rev. 2012; 33: 48-70.
11. Jay M, Gillespie C, Ark T, Richter R, McMacken M, Zabar S, et al. Do internists, pediatricians, and psychiatrists feel competent in obesity care?: using a needs assessment to drive curriculum design. J Gen Intern Med. 2008; 23: 1066-1070.
12. Isma GE, Bramhagen AC, Ahlstrom G, Ostman M, Dykes AK. Obstacles to the prevention of overweight and obesity in the context of child health care in Sweden. BMC Fam Pract. 2013; 14: 143-144.
13. Wolff MS, Rhodes ET, Ludwig DS. Training in childhood obesity management in the United States: a survey of pediatric, internal medicine-pediatrics and family medicine residency program directors. BMC Med Educ. 2010; 10: 18-26.
14. Musaiger AO. Overweight and obesity in eastern mediterranean region: prevalence and possible causes. J Obes. 2011; 407237.
15. Ahmed HG, Ginawi IA, Elasbali AM, Ashankyty IM, Al-Hazimi AM. Prevalence of obesity in Hail region, KSA: in a comprehensive survey. J Obes. 2014; 961861.
16. Story MT, Neumark-Stzainer DR, Sherwood NE, Holt K, Sofka D, Trowbridge FL, et al. Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics. 2002; 110: 210-214.
17. Barlow SE, Dietz WH. Management of child and adolescent obesity: summary and recommendations based on reports from pediatricians, pediatric nurse practitioners, and registered dietitians. Pediatrics. 2002; 110: 236-238.
18. James WP. The challenge of childhood obesity. Int J Pediatr Obes. 2006; 1: 7-10.
19. WHO. Obesity: preventing and managing the global epidemic. Genava: World Health Organization; 2004.
20. Al-Baghli NA, Al-Ghamdi AJ, Al-Turki KA, El-Zubaier AG, Al-Ameer MM, Al-Baghli FA. Overweight and obesity in the eastern province of Saudi Arabia. Saudi Med J. 2008; 29: 1319-1325.
21. El-Hazmi MA, Warsy AS. A comparative study of prevalence of overweight and obesity in children in different provinces of Saudi Arabia. J Trop Pediatr. 2002a; 48: 172-177.
22. Banasiak M, Murr MM. Medical school curricula do not address obesity as a disease. Obes Surg. 2001; 11: 677-679.
23. Kolasa KM, Rickett K. Barriers to providing nutrition counseling cited by physicians: a survey of primary care practitioners. Nutr Clin Pract. 2010; 25: 502-509.
24. Vine M, Hargreaves MB, Briefel RR, Orfield C. Expanding the role of primary care in the prevention and treatment of childhood obesity: a review of clinic- and community-based recommendations and interventions. J Obes. 2013; 172035-52.
25. Tershakovec AM, Watson MH, Wenner WJ, Jr., Marx AL. Insurance reimbursement for the treatment of obesity in children. J Pediatr. 1999; 134: 573-578.
26. Berg-Smith SM, Stevens VJ, Brown KM, Van Horn L, Gernhofer N, Peters E, et al. A brief motivational intervention to improve dietary adherence in adolescents. The Dietary Intervention Study in Children (DISC) Research Group. Health Educ Res. 1999; 14: 399-410.
27. Raj M, Kumar RK. Obesity in children & adolescents. Indian J Med Res. 2010; 132: 598-607.
28. Vitolins MZ, Crandall S, Miller D, Ip E, Marion G, Spangler JG. Obesity educational interventions in U.S. medical schools: a systematic review and identified gaps. Teach Learn Med. 2012; 24: 267-272.
29. Chan RS, Woo J. Prevention of overweight and obesity: how effective is the current public health approach. Int J Environ Res Public Health. 2010; 7: 765-783.
30. Kropski JA, Keckley PH, Jensen GL. School-based obesity prevention programs: an evidence-based review. Obesity (Silver Spring). 2008; 16: 1009-1018.
31. Story M. School-based approaches for preventing and treating obesity. Int J Obes Relat Metab Disord. 1999; 23 Suppl 2: S43-51.
32. Martino S, Haeseler F, Belitsky R, Pantalon M, Fortin AHt. Teaching brief motivational interviewing to Year three medical students. Med Educ. 2007; 41: 160-167.
33. Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare quality. J Natl Med Assoc. 2008; 100: 1275-1285.