Obesity Research & Clinical Practice (2014) 8, e140—e148

ORIGINAL ARTICLE

GPs, families and children’s perceptions of childhood obesity Kay M. Jones ∗, Maureen E. Dixon, John B. Dixon Monash University, Department of General Practice, 270 Ferntree Gully Road, Notting Hill, Victoria, Australia Received 19 April 2012 ; received in revised form 25 January 2013; accepted 12 February 2013

KEYWORDS Qualitative; Perceptions; Parents; Diet; Lifestyle

Summary Background: Childhood obesity has a high risk of becoming a chronic disease requiring life-long weight management. Evidence based guidelines were developed and distributed to GPs throughout Australia by the NHMRC, but current application falls short. Measuring height and weight, and calculating BMI for children appears to be rare. Some general practitioners (GPs) perceive significant barriers to managing this patient cohort, and patients report not having confidence in their GPs. Aim: To explore perceptions and experiences of treating childhood obesity of (i) GPs, (ii) families involved in a childhood obesity study in general practice’ and (iii) families not involved in the project, but who had concerns about childhood obesity. Methodology: Supported by the literature, a semi-structured schedule was developed to address the aims. Ten GPs and eight families involved, and four families previously not involved in the project participated in interviews in 2009. All family interviews were audio-taped and transcribed verbatim. Data were thematically analyzed. Findings: Five themes emerged: (1) raising the topic, (2) frustrations experienced by GPs and families, (3) support available for GPs to provide to families and/or anticipated by families, (4) successes from involvement in the project and (5) sustaining improvements — the GPs’ and family’s perspectives. Discussion and conclusion: All acknowledged that childhood obesity is a sensitive issue with both GPs and parents preferring the other to raise the topic. GPs reported successes in practice and patient management such as improved patient records. For families, the GPs dedication and support were major factors sought. © 2013 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.

Introduction ∗ Corresponding author. Tel.: +61 3 9902 4485; fax: +61 3 8575 2233. E-mail address: [email protected] (K.M. Jones).

Obesity in childhood has a high risk of becoming a chronic disease that will require lifelong weight management [1—4]. Incidence and

1871-403X/$ — see front matter © 2013 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.orcp.2013.02.001

Childhood obesity prevalence rates have increased dramatically over the past two decades [5]. In Australia, an estimated 8% of children aged between 5 and 17 years are obese and a further 17% overweight [6]. At the current rate, it is predicted that 65% of young Australians will be overweight or obese by 2020 [7]. There is a growing body of evidence that links obesity to short-term and long-term health, psychosocial and economic consequences [8]. The costs to the Australian economy are both financial and non-financial [9]. The financial cost of obesity in Australia in 2005 was estimated as $3767 billion. Of this, productivity costs were estimated as $1.7 billion (45%), health system costs were $873 million (23%) and carer costs were $804 million (21%). Of the financial costs 29% are borne by individuals, 16% by families, 37% by the federal government, 5% by state governments, 1% by employers and 12% by the rest of society [9]. Non-financial costs include individuals being subjected to bias, discrimination [10] and stigmatization [3] but this discrimination may result in financial cost through, for example, increased use of the health system or loss of employment opportunities. Evidence based guidelines, ‘Overweight and obesity in adults. A guide for General Practitioners’ and ‘Overweight and obesity in children and adolescents; A guide for General Practitioners’ were developed by the National Health and Medical Research Council (NHMRC) and distributed to GPs throughout Australia [11,12]. GPs have the opportunity to screen children during consultations, but current practice appears to fall short of these guidelines [13]. Training for GPs in child anthropometry [14] and the use of age-gender body mass index percentile (BMI) charts is unusual for children [14] including pre-schoolers [15]. BMI percentile calculators are not available in most current medical software [16]. Evidence also suggests that primary care physicians rarely use weight management counselling strategies [17] such as family therapy or cognitive behaviour therapy (CBT), possibly because of their low confidence in their ability to counsel, and possibly because they question the efficacy of behavioural counselling [18]. While GPs agree they have a role in managing overweight and obesity in children, not all assess children, suggesting there may be barriers [19]. Some practitioners suggest there are significant barriers to patient compliance [20], including lack of knowledge about treatment options [21,22], negative attitudes towards overweight and obese individuals [23], time constraints, lack of resources and remuneration [24] and their perception that they did not see many overweight and obese children [19]. Poor efficacy and unrealistic expectations in

e141 treating young obese patients with, for example, diet instruction, dietitian referral and supportive therapy [25] has demonstrated limited success and leads to therapeutic inertia. Some patients report similar perceptions, including not having confidence in their GPs for weight management, preferring other health professionals [26] because the health professionals’ support and attitude is important to the patient [27]. Although GPs’ and practice nurses’ roles include raising the issue of a child’s weight, they report that ultimately this is a social and family problem [28], thus, they may miss valuable opportunities to raise the issue and manage this problem [5]. For some, childhood obesity was not seen as being within their professional domain [29]. Parents believe GPs have a role and can help children manage weight, but few report that GPs discuss the child’s weight with them [30], or spend time providing effective weight management advice [31], and rarely develop a programme and follow up [32]. Family involvement is critical [33—37] as families shape food choices, eating behaviours, leisure time activities and sedentary behaviours. But factors can influence parents’ receptivity to hearing their child is overweight or obese [38]; not all parents recognize their child has a weight problem [39] or that the problem may be a threat to health and wellbeing [40]. Others recognize the issue but lack concern [41]. Children provide another perspective; they describe humiliation and exclusion as the main reason for wanting to lose weight [42], along with gains in quality of life and self -esteem, yet families often undermine or fail to support lifestyle changes [43]. Other barriers include language, culture, and motivation to change [44]. On the other hand, parents’ concerns can be met by health professionals with implications of poor parenting, or the parents’ concerns dismissed as unnecessary, simply ignored [45] or being treated disrespectfully by members of the medical profession [46]. Targeting children aged 4—10 years, this primary care project ‘‘Developing and implementing best childhood obesity strategies in general practice’’ focussed on working with GPs and their teams to improve the assessment, management and treatment of childhood obesity. This work is novel as it includes the perspectives and experiences of three groups, particularly a small group of families who were not involved in the project. The aim of this part of the study was to explore the perceptions and experiences of treating childhood obesity of (i) GPs, (ii) families involved in this project and (iii) families not involved in the project, but who had concerns about childhood obesity.

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Methodology Study sample and recruitment A convenience sample was recruited from the 10 GPs and 15 families involved in the study for the purpose of exploring GPs’ perceptions and experiences of treating childhood obesity and families and children’s perceptions, concerns and experiences of treating childhood obesity [47,48]. GPs were invited to participate during education workshops and to invite the families involved in this project to participate in a semi-structured interview. All 10 GPs (100% response rate) and eight of the 15 families agreed and participated (53% response rate). In addition, families not involved in this project were recruited via advertisements placed in local newspapers inviting them to participate in an interview; four families responded and all participated in an interview (100% response rate). The purpose of interviewing the second cohort of families was to explore whether their perceptions, concerns and experiences of treating childhood obesity were similar or different to families who were involved in the project. GPs and families were compensated for their involvement in this project.

Data collection and analysis Supported by the literature, a semi-structured schedule was developed to address the aims (Table 1). Data were collected from GPs during workshops and from families during face-to-face or telephone interviews. All interviews were conducted in 2009. Workshops lasted approximately 1.5—2 h and interviews approximately 30—45 min. All interviews were audio-taped and transcribed verbatim. Data were thematically analyzed independently by two investigators (KJ, MD). Key themes were compared and when there was a difference of opinion, issues were discussed until agreement was reached [47,49,50]. Data are reported under the five themes that emerged from the data analysis [47]. Generally, numbers are not used to describe data [51], but where relevant, numbers are used [52]. Comments made by GPs are identified as (GP1—GP10), comments made by participating families are identified as (F1—F8), and comments made by families who were not involved in the study are identified as (FN1—FN4). This project was approved by the Monash University Standing Committee on Ethics in Research Involving Humans.

K.M. Jones et al. Table 1 Semi-structured interviews.

schedule

for

family

1. Would you like to tell me about your experience when visiting your doctor, in particular about your child’s weight problem [45] 2. Is there anything else that you think your doctor could have talked about/discussed [30] 3. Is there anything else that you think your doctor could have done? (for example, provide more help [30]) 4. Does your GP regularly weigh and measure your child/ren [14] 5. Do you think your GP has a responsibility to raise this issue [21,31], or 6. Do you think it is up to you to raise the topic [21] 7. If your GP has raised the issue, have they discussed a. Health risks b. Exercise recommendations c. Diet recommendations d. Setting realistic weight goals [30] 8. Is there anything else that you think your doctor could have talked about/discussed 9. Is there anything else that you think your doctor could have done? (for example, provide more help [30])

Findings Demographics of families Of the 12 interviews, eight were conducted face-toface and four by telephone. Children were present at five of the eight face-to-face interviews. Two of the children were from ‘study’ families and three were from ‘non-study’ families. Children commented during four interviews. Two children from one non-study family were present at one of the face-to-face interviews. No children were present and/or participated in the four telephone interviews. The group comprised eight females and five males with an age range of 8—16 years (Table 2).

Raising the topic (of obesity) GPs Of the ten GPs, seven asked the parents about their child’s obesity without the child being present, one discussed the topic with the parents and the

Childhood obesity Table 2

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Demographics and family involvement in the semi-structured interviews.

Family

Study/non study family

Age (years)

Gender

Child present at interview

F1 F2 F3 F4 F5 F6 F7 F8 FN 1 (a,b) FN 2 FN 3 FN 4

Study Study Study Study Study Study Study Study Non-study Non-study Non-study Non-study

8 7 7 10 4 9 8 8 16, 14 10 13 12

M M M F F F F F F+M F F M

N Y N N N N Y N Y Y N Y

child (GP2) and one did so ‘‘sometimes’’ (GP4). For some, the topic was not seen as an important issue. Nonetheless, GPs used a range of approaches including ‘‘clinical impression triggers’’ (GP1) ‘‘a gentle, subtle approach’’ (GP5), in a ‘‘non-confrontational way’’ (GP6) and ensuring to ‘‘always include the family in the child’s management plan’’ (GP8). Four GPs indicated they had difficulty raising the topic due to various reasons including ‘‘the sensitivity of the topic’’ (GP1) or ‘‘the possibility of leading to conflict’’ (GP3), thus, chose not to discuss the issue in front of the child because ‘‘it could lead to an eating disorder or depression’’ (GP3). One suggested that it ‘‘depended on the age of the child’’ (GP9), another felt ‘‘the older the child, the less likely [the GP] would be to discuss the child’s weight in their presence’’ (GP4). Difficulties were also encountered because of parents ‘‘ignoring, dismissing, or being offended when the matter was raised’’ (GP10). While GPs reported finding it easier to talk frankly if the parent raised the issue, ‘‘because the parent already has a concern’’ (GP4), this indicated that ‘‘the aspect of appearing judgemental is removed’’ (GP2). But, some parents felt that their child ‘‘being chubby represented good health’’ (GP10). Whether these beliefs were ethnicity or culturally based, or there were other reasons, it was noted these beliefs may be potential barriers: ‘‘one must consider racial and educational status and readiness to change’’ (GP6). Practice nurses were employed in seven of the 10 practices, although in one practice, ‘‘the practice nurse was not available to help’’ (GP7) and in another, the practice nurse was, ‘‘only available for two sessions [per week]’’ (GP6). GPs felt ‘‘the practice nurse is in a good position to measure all children’’ (GP2, GP8) and ‘‘can work with the GP

Children comment

Y Y Y Y

Interview f-2-f or by phone f-2-f f-2-f f-2-f Phone Phone Phone f-2-f Phone f-2-f f-2-f f-2-f f-2-f

to tailor the child’s management plan’’ (GP1), particularly as few of these GPs reported they had measured and recorded height and weight, calculated BMI or used BMI percentile charts. Although five GPs had recorded family history, only (GP2) had recorded the parents’ height, weight and BMI.

Families Not surprisingly, when asked whether they had noticed any differences in the consultation and/or whether the GP spent more time with the family, participants described the GP as being ‘‘more interested in the children’s life and wellbeing and has a better understanding of the family unit’’ [F1]. For one family, the GP: ‘‘scheduled specific visits to discuss the topic’’ [F3], for another, ‘‘the GP . . . talks more about routine, what we are eating and the activity we are involved in’’ [F5]. However, when families not involved in the project were asked to describe their experience when visiting their GP about their child’s weight; responses varied considerably. One parent felt the topic ‘‘is fairly sensitive, but appreciated when [the GP] did bring it forward’’ [F1]. For another, the experience was less positive, ‘‘since my daughter was 18 months old she has always been around 10 per cent above the healthy weight limit for her age. When she was four and a half, the doctor said to maintain her weight, so the ball was put back in my court. The GP wasn’t really worried about it’’ [F2]. One parent stated that she ‘‘tries to make sure she [her daughter] is not in a consultation when [the topic] is brought up because I’ve had a weight problem all my life and I don’t want her to start to think like that already’’ [F3]. Generally, the children from families not involved in the project reported that discussing the

e144 issue with the GP was not a positive experience: one felt, ‘‘regardless of scales being tucked around a corner out of sight of other people, I wouldn’t want to do it, I’d just feel awkward about it’’ [FN1b]. A second commented that, ‘‘the GP usually says something about weight before asking why you’re there, and I don’t like talking about it. It puts you in a really awkward spot as a person’’ [FN2]. A third commented: ‘‘I don’t really like talking about my weight, I feel awkward. Suggesting something I can do to keep my weight down and stuff is OK, I generally listen, I just feel uncomfortable. They don’t really talk to me properly about it’’ [FN4]. None of the children from either group had used any other treatments or natural remedies for losing weight; ‘‘my wife is into natural remedies, but our daughter hates the taste so refuses to take them’’ [F8].

Frustrations experienced by the GPs and families GPs Issues around family dynamics and/or a lack of compliance and follow up, particularly when parents give in to children’s demands were frustrating for the GPs. Both GPs and families found it frustrating when GPs ‘‘were unable to find relevant information to hand to families’’ (GP6). External influences such as such as television advertising, the television turned on at meal time, marketing toys with food, convenience fast food and hectic lifestyle were challenges for GPs and families. For example, ‘‘parents controlling their children’s diet and exercise’’ (GP4), ‘‘parents unwilling to make changes’’ (GP1), ‘‘don’t adhere to plans or give into children’s demands’’ (GP9) ‘‘no recognition there is a problem’’ (GP10) or ‘‘not bring the child back for a check’’ (GP7). One GP was concerned about ‘‘exposure to unhealthy product advertising’’ and another expressed ‘‘a sense of helplessness’’ when endeavouring to manage childhood obesity (GP3). Practice-based issues identified by GPs included ‘‘motivating staff and maintaining interest’’ (GP1), ‘‘the practice nurse not being available’’ (GP7) ‘‘few resources available to help parents’’ (GP2, GP3, GP6), ‘‘time’’ (GP3), ‘‘other issues more pressing’’ (GP4) including ‘‘staff turnover’’ (GP 1, GP3, GP8) ‘‘being a solo’’ (GP3). BMI charts were not in the medical software, and financial matters were double-edged with a lack of government funded financial incentives to compensate GPs who manage weight related problems.

K.M. Jones et al.

Families For families involved in the project, few mentioned practice-based issues, such as whether the nurse or other staff spent more time with the child. Change of staff was an issue for one family, ‘‘we started seeing one nurse, she left, and there was a period where there was nobody else’’ (F1). ‘Who’ assisted the family was an issue for another; ‘‘the dietitian did most of the work, she did the whole thing’’ (F6). Referral was also raised; one family mentioned being provided with a referral (F2) but ‘‘decided not to go now, but maybe later if there is still a problem’’ (F2). Whereas, another family was hoping for a referral to a paediatrician, ‘‘but it never happened’’ (F8). For the four families not involved in the project when asked whether they could think of anything else the GP could have talked about, or done, the GP not approaching the subject was a concern: ‘‘it would be great if the doctors raised the subject and weighed and measured the kids’’ (FN1). Additionally: ‘‘it would be great if the GPs had a programme or something, something to follow or something to write down and measure the weight and the activities, to go by’’ (FN2, FN3). One parent felt the GP had simply dismissed her concerns (FN4). Children also had a point of view about the GPs involvement: ‘‘[the GP] did not bring up the issue of health risks initially, but it was raised at school in PE; food, healthy development, each term was a different theme. At school we are not allowed to bring any fast food onto the property’’ (FN1a). ‘‘Yeah, PE, healthy food, healthy development; the whole canteen was re-done and they got rid of the finger buns and all that kind of stuff’’ (FN1b). School was a source of information for another: ‘‘we have a healthy eating ‘thing,’ we have a bus every Thursday that comes around with fruit that is free and we have 10 min of running on the fitness track’’ (FN2). Another suggested: ‘‘f they [the GP] could like, try to help more than just telling me what to do, if they know of any places or things that would help me and show me and how to get in contact with them, that kind of stuff’’ (FN4).

Support available for GPs to provide to families and/or anticipated by families GPs All GPs reported that specialists including the Royal Children’s Hospital, allied health professionals such as dietitians and psychologists, community

Childhood obesity programmes and sport such as football, hockey, cycling, affiliations with schools, and gymnasiums were available in the various areas where the GPs were located. Nonetheless, one GP was unsure ‘‘of any community services available’’ (GP1), another felt ‘‘specialists may feel the matter is too trivial for paediatric review’’ (GP2) and another suggested that ‘‘for families from the sub-continent (South Asia) there are religious and cultural barriers in accessing services’’ (GP9). Regarding the use of the guidelines developed and circulated by the NHMRC about managing childhood obesity, given the GPs joined this project because of the topic it was surprising that two GPs were not aware of them, seven were aware of them but did not use them, and one had used them but ‘not often’.

Families The eight families involved in the project reported changes in how they managed their child’s weight as a consequence of their involvement. Of note was a change in awareness, particularly around ‘‘purchasing food and involving children in cooking’’ (F1, F2, F4), ‘‘physical activity’’ (F1, F3), ‘‘interacting more with the kids’’ (F5) and ‘‘being more conscious of family activities’’ (F8). For those not involved in the project, all families felt the GP has a responsibility to raise the issue rather than them (the family). Along with appreciating GPs raising the issue (FN1), they appreciated ‘‘being taken seriously’’ (FN3) and ‘‘being provided with any practical assistance that may be available, including information about physical activity and games that make it fun for the kids’’ (FN2). On child felt that: ‘‘it is probably their responsibility, they know all about it but they don’t really help. And to talk about some of the dangers of very low calorie diets; help you to plan what to do’’ (FN4). However, sensitivity was an issue, one child commented ‘‘we had a ‘‘You Can Do It’ day at school but I didn’t want to do it with a boy!’’(FN2) Two others mentioned the layout in supermarket aisles: ‘‘they should have lolly free aisles . . . it’s stacked against you’’ (FN1a, FN1b).

Successes from involvement in the project GPs While varying degrees of success were reported for children reducing BMI for age and gender,

e145 and modifying lifestyles, GPs’ felt there were significant successes from involvement in the project which were both practice and patient related. From the practice perspective, there was ‘‘increased discussion among clinic doctors and nurses’’ (GP1), ‘‘more aware that childhood obesity is a major health problem’’ (GP2), and ‘‘staff working together’’ (GP5) ‘‘as a team’’ (GP 9). There were also improvements in children’s records and a better understanding of lifestyle and family dynamics including changes in children and families’ behaviour. From the perspective of patient/family outcomes, ‘‘changing behaviour in two families’’ (GP4), being able to record ‘‘a suitable response from the family’’ (GP6), such as, ‘‘patients committed to lifestyle changes’’ (GP7, GP8). GPs indicated they felt their attitude was more positive and generally, they were taking a more proactive approach by, for example, including measurements as a standard part of the consultation.

Families For families involved the most important changes were related to sedentary behaviour and physical activity (F1, FN1), food and portion size (F2, F3, F5, FN3), and children asking questions (F4). Since seeing the doctor, one child thought that ‘‘seeing the doctor was helpful, I feel different now, it’s easier to run around the oval, I feel really good and fit and all that. And at school we have a fruit break’’ (F7). For families not involved in the project, important issues included; ‘‘the doctors need to talk about health risks of being overweight’’ (FN1a) and ‘‘the doctors need to talk about health risk dangers’’ (FN2), because ‘‘health risks being discussed at school in PE’’ (FN1a).

Sustaining improvements — the GPs’ and family’s perspectives GPs Sustaining improvement revolved around continuing to ‘‘measure the children regularly’’ (GP2, GP7) and ‘‘educate them to have a healthy diet’’ (GP9), ensuring a ‘‘more methodical approach’’ (GP4) with ‘‘measures as imperatives’’ (GP6), ‘‘talk to parents’’ (GP7) and ‘‘continue 2-monthly appointments for the child’’ (GP3). Easy access to measuring tools such as BMI charts being available on medical software [16], education for GPs and the

e146 use of a general practice management plan (GPMP) were all seen as important. However, at the time of this study, childhood obesity did not meet the criteria for a GPMP.

Families Study families identified issues for sustaining improvement of weight management for their child as including ‘‘ancillary staff [in the practice] helping, perhaps a dietitian could have helped’’ [F1]. Others commented that if the problem returned, they would do the programme again [F2, F4]. Annual check-ups were also important as was the GP’s dedication; ‘‘he really cares about our child, so it’s a good thing for everyone to adopt’’ [F5], and ‘‘in general GPs reinforce the basics, diet exercise because GPs are a natural source of information’’ [F1]. One child commented, ‘‘we have less takeaway, now mum and I cook together, my favourite is mum’s homemade pizzas!’’ (F4). For families not involved, suggestions for sustaining improvement of weight management for their child included, the GP regularly weighing and measuring the child. While ‘‘the doctor sits, takes time, sees the real problem that maybe it is not food but something else’’ (FN1), ‘‘GPs did not regularly weigh and measure their children . . . it was not done regularly; probably a one-off’’ (FN1, FN3). One family felt it would be better ‘‘if health professionals were the ones to raise the issue’’ (FN1). For another, ‘‘although the dietitian resolved that this was a genetic issue, the GP didn’t follow up’’ (FN2). Another family ‘‘wanted to be taken seriously and to be told you can go to a paediatrician’’ (FN3).

Discussion The GPs and all families provided significant feedback about their experiences, openly discussing sensitive issues, frustrations, support, successes and how to sustain improvements. Generally, childhood obesity was described as a sensitive issue and raising the topic was a challenge, notwithstanding each group preferred ‘the other’ to raise the topic [13]. Frustrations expressed were generally around issues that individuals were unable to change, such as government and school policy. From the GPs perspective, challenges also to add to the list included practice issues around staff, medical software and financial issues [16,24]. While some GPs indicated that generally, they did not

K.M. Jones et al. see childhood obesity as an important health issue, involvement in this study made them more aware of the issues they may not have considered in the past including additional referral options available in their areas [19]. In addition, all had made improvements in practice and patient management and these could be sustained by being proactive. Access to children’s BMI charts on medical software and developing management plans were two examples that could be taken up in the immediate future [16]. Of interest, while guidelines are available [12], none of the GPs used them. The twelve families who participated in this component of the project had similar views about managing childhood obesity. The issues most frequently mentioned by families included (a) the GPs’ dedication and (b) the GPs having knowledge about managing childhood obesity and knowledge about programmes available to refer children [30,31]. All families expressed concern about their children’s health and wellbeing and had sought assistance from GPs. Some felt they met with success, other felt their endeavours were thwarted. The outcomes of this study support previous work [14,19,26,40—42,53] but the study may not be generalizable because participants were all from metropolitan Melbourne thus the experiences of GPs and families in rural Australia have not been taken into account.

Conclusion Given the topic, it is not surprising that the three groups were all seeking similar outcomes and support, albeit from a different perspective. Supporting GPs through education programmes, updating medical software and recognition of obesity as a chronic disease by the federal government would all assist GPs to work with families to improve the assessment, management and treatment of childhood obesity in general practice.

Conflict of interest statement The authors have no conflicts of interest.

Acknowledgements This project was funded by the Commonwealth Government through the General Practice Clinical Research Programme (Round 2) — Priority Driven Research Grants administered by NHMRC (491116).

Childhood obesity We are grateful to the GPs, parents and children who participated in the study and the parents and children who responded to advertisements and took part in the ‘interview’ component of the study. We also acknowledge Maureen Dixon’s contribution who was a valued member of the team who conducted this research. John Dixon receives research support through a senior research fellowship from the NHMRC and Baker IDI Heart and Diabetes Institute is supported in part by the Victorian Government’s OIS Programme.

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GPs, families and children's perceptions of childhood obesity.

Childhood obesity has a high risk of becoming a chronic disease requiring life-long weight management. Evidence based guidelines were developed and di...
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